If the pandemic served as a window into our health, what it revealed was a U.S. population that is not only sick but also seemingly only getting sicker. Life expectancy is falling precipitously. Three-fourths of Americans are overweight or obese, half have diabetes or prediabetes, and a majority are metabolically unhealthy. Furthermore, the rates of allergic, inflammatory, and autoimmune diseases are rising at rates of 3%-9% per year in the West, far faster than the speed of genetic change in this population.

Of course, diet and lifestyle are major factors behind such trends, but a grossly underappreciated driver in what ails us is the role of environmental toxins and endocrine-disrupting chemicals. In years past, these factors have largely evaded the traditional Western medical establishment; however, mounting evidence now supports their significance in fertility, metabolic health, and cancer.

Although several industrial chemicals and toxins have been identified as carcinogens and have subsequently been regulated, many more remain persistent in the environment and continue to be freely used. It is therefore incumbent upon both the general public and clinicians to be knowledgeable about these exposures. Here, we review some of the most common exposures and the substantial health risks associated with them, along with some general guidance around best practices for how to minimize exposure.
 

Microplastics

“Microplastics” is a term used to describe small fragments or particles of plastic breakdown or microbeads from household or personal care products, measuring less than 5 mm in length.

Plastic waste is accumulating at alarming and devastating proportions – by 2050, it is estimated that by weight, there will be more plastic than fish in the oceans. That translates into hundreds of thousands of tons of microplastics and trillions of these particles in the seas. A recent study demonstrated that microplastics were present in the bloodstream in the majority of 22 otherwise healthy participants.

Since the 1950s, plastic exposure has been shown to promote tumorigenesis in animal studies, and in vitro studies have demonstrated the toxicity of microplastics at the cellular level. However, it is not well known whether the plastic itself is toxic or if it simply serves as a carrier for other environmental toxins to bioaccumulate.

According to Tasha Stoiber, a senior scientist at the Environmental Working Group, “Microplastics have been widely detected in fish and seafood, as well as other products like bottled water, beer, honey, and tap water.” The EWG states there are no formal advisories on fish consumption to avoid exposure to microplastics at the moment.

Pressure also is mounting for a ban on microbeads in personal care products.

Until such bans are put in place, it is advised to avoid single-use plastics, favor reusable tote bags for grocery shopping rather than plastic bags, and opt for loose leaf tea or paper tea bags rather than mesh-based alternatives.
 

Phthalates

Phthalates are chemicals used to make plastics soft and durable, as well as to bind fragrances. They are commonly found in household items such as vinyl (for example, flooring, shower curtains) and fragrances, air fresheners, and perfumes.

Phthalates are known hormone-disrupting chemicals, exposure to which has been associated with abnormal sexual and brain development in children, as well as lower levels of testosterone in men. Exposures are thought to occur via inhalation, ingestion, and skin contact; however, fasting studies demonstrate that a majority of exposure is probably food related.

To avoid phthalate exposures, recommendations include avoiding polyvinyl chloride plastics (particularly food containers, plastic wrap, and children’s toys), which are identifiable by the recycle code number 3, as well as air fresheners and fragranced products.

The EWG’s Skin Deep database provides an important resource on phthalate-free personal care products.

Despite pressure from consumer advocacy groups, the U.S. Food and Drug Administration has not yet banned phthalates in food packaging.
 

Bisphenol A (BPA)

BPA is a chemical additive used to make clear and hard polycarbonate plastics, as well as epoxy and thermal papers. BPA is one of the highest-volume chemicals, with roughly 6 billion pounds produced each year. BPA is traditionally found in many clear plastic bottles and sippy cups, as well as in the lining of canned foods.

Structurally, BPA acts as an estrogen mimetic and has been associated with cardiovascular disease, obesity, and male sexual dysfunction. Since 2012, BPA has been banned in sippy cups and baby bottles, but there is some debate as to whether its replacements (bisphenol S and bisphenol F) are any safer; they appear to have similar hormonal effects as BPA.

As with phthalates, the majority of ingestion is thought to be food related. BPA has been found in more than 90% of a representative study population in the United States.

Guidance advises avoiding polycarbonate plastics (identifiable with the recycling code number 7), as well as avoiding handling thermal papers such as tickets and receipts, if possible. Food and beverages should be stored in glass or stainless steel. If plastic must be used, opt for polycarbonate- and polyvinyl chloride–free plastics, and food and beverages should never be reheated in plastic containers or wrapping. Canned foods should ideally be avoided, particularly canned tunas and condensed soups. If canned products are bought, they should ideally be BPA free.
 

Dioxins and polychlorinated biphenyls (PCBs)

Dioxins are mainly the byproducts of industrial practices; they are released after incineration, trash burning, and fires. PCBs, which are somewhat structurally related to dioxins, were previously found in products such as flame retardants and coolants. Dioxins and PCBs are often grouped in the same category under the umbrella term “persistent organic pollutants” because they break down slowly and remain in the environment even after emissions have been curbed.

Tetrachlorodibenzodioxin, perhaps the best-known dioxin, is a known carcinogen. Dioxins also have been associated with a host of health implications in development, immunity, and reproductive and endocrine systems. Higher levels of PCB exposure have also been associated with an increased risk for mortality from cardiovascular disease.

Notably, dioxin emissions have been reduced by 90% since the 1980s, and the U.S. Environmental Protection Agency has banned the use of PCBs in industrial manufacturing since 1979. However, environmental dioxins and PCBs still enter the food chain and accumulate in fat.

The best ways to avoid exposures are through limiting meat, fish, and dairy consumption and trimming the skin and fat from meats. The level of dioxins and PCBs found in meat, eggs, fish, and dairy are approximately 5-10 times higher than they are in plant-based foods. Research has shown that farmed salmon is likely to be the most PCB-contaminated protein source in the U.S. diet; however, newer forms of land-based and sustainable aquaculture probably avoid this exposure.
 

Pesticides

The growth of modern monoculture agriculture in the United States over the past century has coincided with a dramatic surge in the use of industrial pesticides. In fact, over 90% of the U.S. population have pesticides in their urine and blood, regardless of where they live. Exposures are thought to be food related.

Approximately 1 billion pounds of pesticides are used annually in the United States, including nearly 300 million pounds of glyphosate, which has been identified as a probable carcinogen by European agencies. The EPA has not yet reached this conclusion, although the matter is currently being litigated.

A large European prospective cohort trial demonstrated a lower risk for cancer in those with a greater frequency of self-reported organic food consumption. In addition to cancer risk, relatively elevated blood levels of a pesticide known as beta-hexachlorocyclohexane (B-HCH) are associated with higher all-cause mortality. Also, exposure to DDE – a metabolite of DDT, a chlorinated pesticide heavily used in the 1940s-1960s that still persists in the environment today – has been shown to increase the risk for Alzheimer’s-type dementia as well as overall cognitive decline.

Because these chlorinated pesticides are often fat soluble, they seem to accumulate in animal products. Therefore, people consuming a vegetarian diet have been found to have lower levels of B-HCH. This has led to the recommendation that consumers of produce should favor organic over conventional, if possible. Here too, the EWG provides an important resource to consumers in the form of shopper guides regarding pesticides in produce.
 

Per- and polyfluoroalkyl substances (PFAS)

PFAS are a group of fluorinated compounds discovered in the 1930s. Their chemical composition includes a durable carbon-fluoride bond, giving them a persistence within the environment that has led to their being referred to as “forever chemicals.”

PFAS have been detected in the blood of 98% of Americans, and in the rainwater of locations as far afield as Tibet and Antarctica. Even low levels of exposure have been associated with an increased risk for cancer, liver disease, low birth weight, and hormonal disruption.

The properties of PFAS also make them both durable at very high heat and water repellent. Notoriously, the chemical was used by 3M to make Scotchgard for carpets and fabrics and by Dupont to make Teflon for nonstick coating of pots and pans. Although perfluorooctanoic acid (PFOA) was removed from nonstick cookware in 2013, PFAS – a family of thousands of synthetic compounds – remain common in fast-food packaging, water- and stain-repellent clothing, firefighting foam, and personal care products. PFAS are released into the environment during the breakdown of these consumer and industrial products, as well as from dumping from waste facilities.

Alarmingly, the EWG notes that up to 200 million Americans may be exposed to PFAS in their drinking water. In March 2021, the EPA announced that they will be regulating PFAS in drinking water; however, the regulations have not been finalized. Currently, it is up to individual states to test for its presence in the water. The EWG has compiled a map of all known PFAS contamination sites.

To avoid or prevent exposures from PFAS, recommendations include filtering tap water with either reverse osmosis or activated carbon filters, as well as avoiding fast food and carry-out food, if possible, and consumer products labeled as “water resistant,” “stain-resistant,” and “nonstick.”

In a testament to how harmful these chemicals are, the EPA recently revised their lifetime health advisories for PFAS, such as PFOA, to 0.004 parts per trillion, which is more than 10,000 times smaller than the previous limit of 70 parts per trillion. The EPA also has proposed formally designating certain PFAS chemicals as “hazardous substances.”

Dr. Goel, clinical assistant professor of medicine at Weill Cornell Medicine, New York, has disclosed no relevant financial relationships. A version of this article originally appeared on Medscape.com.

If the pandemic served as a window into our health, what it revealed was a U.S. population that is not only sick but also seemingly only getting sicker. Life expectancy is falling precipitously. Three-fourths of Americans are overweight or obese, half have diabetes or prediabetes, and a majority are metabolically unhealthy. Furthermore, the rates of allergic, inflammatory, and autoimmune diseases are rising at rates of 3%-9% per year in the West, far faster than the speed of genetic change in this population.

Of course, diet and lifestyle are major factors behind such trends, but a grossly underappreciated driver in what ails us is the role of environmental toxins and endocrine-disrupting chemicals. In years past, these factors have largely evaded the traditional Western medical establishment; however, mounting evidence now supports their significance in fertility, metabolic health, and cancer.

Although several industrial chemicals and toxins have been identified as carcinogens and have subsequently been regulated, many more remain persistent in the environment and continue to be freely used. It is therefore incumbent upon both the general public and clinicians to be knowledgeable about these exposures. Here, we review some of the most common exposures and the substantial health risks associated with them, along with some general guidance around best practices for how to minimize exposure.
 

Microplastics

“Microplastics” is a term used to describe small fragments or particles of plastic breakdown or microbeads from household or personal care products, measuring less than 5 mm in length.

Plastic waste is accumulating at alarming and devastating proportions – by 2050, it is estimated that by weight, there will be more plastic than fish in the oceans. That translates into hundreds of thousands of tons of microplastics and trillions of these particles in the seas. A recent study demonstrated that microplastics were present in the bloodstream in the majority of 22 otherwise healthy participants.

Since the 1950s, plastic exposure has been shown to promote tumorigenesis in animal studies, and in vitro studies have demonstrated the toxicity of microplastics at the cellular level. However, it is not well known whether the plastic itself is toxic or if it simply serves as a carrier for other environmental toxins to bioaccumulate.

According to Tasha Stoiber, a senior scientist at the Environmental Working Group, “Microplastics have been widely detected in fish and seafood, as well as other products like bottled water, beer, honey, and tap water.” The EWG states there are no formal advisories on fish consumption to avoid exposure to microplastics at the moment.

Pressure also is mounting for a ban on microbeads in personal care products.

Until such bans are put in place, it is advised to avoid single-use plastics, favor reusable tote bags for grocery shopping rather than plastic bags, and opt for loose leaf tea or paper tea bags rather than mesh-based alternatives.
 

Phthalates

Phthalates are chemicals used to make plastics soft and durable, as well as to bind fragrances. They are commonly found in household items such as vinyl (for example, flooring, shower curtains) and fragrances, air fresheners, and perfumes.

Phthalates are known hormone-disrupting chemicals, exposure to which has been associated with abnormal sexual and brain development in children, as well as lower levels of testosterone in men. Exposures are thought to occur via inhalation, ingestion, and skin contact; however, fasting studies demonstrate that a majority of exposure is probably food related.

To avoid phthalate exposures, recommendations include avoiding polyvinyl chloride plastics (particularly food containers, plastic wrap, and children’s toys), which are identifiable by the recycle code number 3, as well as air fresheners and fragranced products.

The EWG’s Skin Deep database provides an important resource on phthalate-free personal care products.

Despite pressure from consumer advocacy groups, the U.S. Food and Drug Administration has not yet banned phthalates in food packaging.
 

Bisphenol A (BPA)

BPA is a chemical additive used to make clear and hard polycarbonate plastics, as well as epoxy and thermal papers. BPA is one of the highest-volume chemicals, with roughly 6 billion pounds produced each year. BPA is traditionally found in many clear plastic bottles and sippy cups, as well as in the lining of canned foods.

Structurally, BPA acts as an estrogen mimetic and has been associated with cardiovascular disease, obesity, and male sexual dysfunction. Since 2012, BPA has been banned in sippy cups and baby bottles, but there is some debate as to whether its replacements (bisphenol S and bisphenol F) are any safer; they appear to have similar hormonal effects as BPA.

As with phthalates, the majority of ingestion is thought to be food related. BPA has been found in more than 90% of a representative study population in the United States.

Guidance advises avoiding polycarbonate plastics (identifiable with the recycling code number 7), as well as avoiding handling thermal papers such as tickets and receipts, if possible. Food and beverages should be stored in glass or stainless steel. If plastic must be used, opt for polycarbonate- and polyvinyl chloride–free plastics, and food and beverages should never be reheated in plastic containers or wrapping. Canned foods should ideally be avoided, particularly canned tunas and condensed soups. If canned products are bought, they should ideally be BPA free.
 

Dioxins and polychlorinated biphenyls (PCBs)

Dioxins are mainly the byproducts of industrial practices; they are released after incineration, trash burning, and fires. PCBs, which are somewhat structurally related to dioxins, were previously found in products such as flame retardants and coolants. Dioxins and PCBs are often grouped in the same category under the umbrella term “persistent organic pollutants” because they break down slowly and remain in the environment even after emissions have been curbed.

Tetrachlorodibenzodioxin, perhaps the best-known dioxin, is a known carcinogen. Dioxins also have been associated with a host of health implications in development, immunity, and reproductive and endocrine systems. Higher levels of PCB exposure have also been associated with an increased risk for mortality from cardiovascular disease.

Notably, dioxin emissions have been reduced by 90% since the 1980s, and the U.S. Environmental Protection Agency has banned the use of PCBs in industrial manufacturing since 1979. However, environmental dioxins and PCBs still enter the food chain and accumulate in fat.

The best ways to avoid exposures are through limiting meat, fish, and dairy consumption and trimming the skin and fat from meats. The level of dioxins and PCBs found in meat, eggs, fish, and dairy are approximately 5-10 times higher than they are in plant-based foods. Research has shown that farmed salmon is likely to be the most PCB-contaminated protein source in the U.S. diet; however, newer forms of land-based and sustainable aquaculture probably avoid this exposure.
 

Pesticides

The growth of modern monoculture agriculture in the United States over the past century has coincided with a dramatic surge in the use of industrial pesticides. In fact, over 90% of the U.S. population have pesticides in their urine and blood, regardless of where they live. Exposures are thought to be food related.

Approximately 1 billion pounds of pesticides are used annually in the United States, including nearly 300 million pounds of glyphosate, which has been identified as a probable carcinogen by European agencies. The EPA has not yet reached this conclusion, although the matter is currently being litigated.

A large European prospective cohort trial demonstrated a lower risk for cancer in those with a greater frequency of self-reported organic food consumption. In addition to cancer risk, relatively elevated blood levels of a pesticide known as beta-hexachlorocyclohexane (B-HCH) are associated with higher all-cause mortality. Also, exposure to DDE – a metabolite of DDT, a chlorinated pesticide heavily used in the 1940s-1960s that still persists in the environment today – has been shown to increase the risk for Alzheimer’s-type dementia as well as overall cognitive decline.

Because these chlorinated pesticides are often fat soluble, they seem to accumulate in animal products. Therefore, people consuming a vegetarian diet have been found to have lower levels of B-HCH. This has led to the recommendation that consumers of produce should favor organic over conventional, if possible. Here too, the EWG provides an important resource to consumers in the form of shopper guides regarding pesticides in produce.
 

Per- and polyfluoroalkyl substances (PFAS)

PFAS are a group of fluorinated compounds discovered in the 1930s. Their chemical composition includes a durable carbon-fluoride bond, giving them a persistence within the environment that has led to their being referred to as “forever chemicals.”

PFAS have been detected in the blood of 98% of Americans, and in the rainwater of locations as far afield as Tibet and Antarctica. Even low levels of exposure have been associated with an increased risk for cancer, liver disease, low birth weight, and hormonal disruption.

The properties of PFAS also make them both durable at very high heat and water repellent. Notoriously, the chemical was used by 3M to make Scotchgard for carpets and fabrics and by Dupont to make Teflon for nonstick coating of pots and pans. Although perfluorooctanoic acid (PFOA) was removed from nonstick cookware in 2013, PFAS – a family of thousands of synthetic compounds – remain common in fast-food packaging, water- and stain-repellent clothing, firefighting foam, and personal care products. PFAS are released into the environment during the breakdown of these consumer and industrial products, as well as from dumping from waste facilities.

Alarmingly, the EWG notes that up to 200 million Americans may be exposed to PFAS in their drinking water. In March 2021, the EPA announced that they will be regulating PFAS in drinking water; however, the regulations have not been finalized. Currently, it is up to individual states to test for its presence in the water. The EWG has compiled a map of all known PFAS contamination sites.

To avoid or prevent exposures from PFAS, recommendations include filtering tap water with either reverse osmosis or activated carbon filters, as well as avoiding fast food and carry-out food, if possible, and consumer products labeled as “water resistant,” “stain-resistant,” and “nonstick.”

In a testament to how harmful these chemicals are, the EPA recently revised their lifetime health advisories for PFAS, such as PFOA, to 0.004 parts per trillion, which is more than 10,000 times smaller than the previous limit of 70 parts per trillion. The EPA also has proposed formally designating certain PFAS chemicals as “hazardous substances.”

Dr. Goel, clinical assistant professor of medicine at Weill Cornell Medicine, New York, has disclosed no relevant financial relationships. A version of this article originally appeared on Medscape.com.

If the pandemic served as a window into our health, what it revealed was a U.S. population that is not only sick but also seemingly only getting sicker. Life expectancy is falling precipitously. Three-fourths of Americans are overweight or obese, half have diabetes or prediabetes, and a majority are metabolically unhealthy. Furthermore, the rates of allergic, inflammatory, and autoimmune diseases are rising at rates of 3%-9% per year in the West, far faster than the speed of genetic change in this population.

Of course, diet and lifestyle are major factors behind such trends, but a grossly underappreciated driver in what ails us is the role of environmental toxins and endocrine-disrupting chemicals. In years past, these factors have largely evaded the traditional Western medical establishment; however, mounting evidence now supports their significance in fertility, metabolic health, and cancer.

Although several industrial chemicals and toxins have been identified as carcinogens and have subsequently been regulated, many more remain persistent in the environment and continue to be freely used. It is therefore incumbent upon both the general public and clinicians to be knowledgeable about these exposures. Here, we review some of the most common exposures and the substantial health risks associated with them, along with some general guidance around best practices for how to minimize exposure.
 

Microplastics

“Microplastics” is a term used to describe small fragments or particles of plastic breakdown or microbeads from household or personal care products, measuring less than 5 mm in length.

Plastic waste is accumulating at alarming and devastating proportions – by 2050, it is estimated that by weight, there will be more plastic than fish in the oceans. That translates into hundreds of thousands of tons of microplastics and trillions of these particles in the seas. A recent study demonstrated that microplastics were present in the bloodstream in the majority of 22 otherwise healthy participants.

Since the 1950s, plastic exposure has been shown to promote tumorigenesis in animal studies, and in vitro studies have demonstrated the toxicity of microplastics at the cellular level. However, it is not well known whether the plastic itself is toxic or if it simply serves as a carrier for other environmental toxins to bioaccumulate.

According to Tasha Stoiber, a senior scientist at the Environmental Working Group, “Microplastics have been widely detected in fish and seafood, as well as other products like bottled water, beer, honey, and tap water.” The EWG states there are no formal advisories on fish consumption to avoid exposure to microplastics at the moment.

Pressure also is mounting for a ban on microbeads in personal care products.

Until such bans are put in place, it is advised to avoid single-use plastics, favor reusable tote bags for grocery shopping rather than plastic bags, and opt for loose leaf tea or paper tea bags rather than mesh-based alternatives.
 

Phthalates

Phthalates are chemicals used to make plastics soft and durable, as well as to bind fragrances. They are commonly found in household items such as vinyl (for example, flooring, shower curtains) and fragrances, air fresheners, and perfumes.

Phthalates are known hormone-disrupting chemicals, exposure to which has been associated with abnormal sexual and brain development in children, as well as lower levels of testosterone in men. Exposures are thought to occur via inhalation, ingestion, and skin contact; however, fasting studies demonstrate that a majority of exposure is probably food related.

To avoid phthalate exposures, recommendations include avoiding polyvinyl chloride plastics (particularly food containers, plastic wrap, and children’s toys), which are identifiable by the recycle code number 3, as well as air fresheners and fragranced products.

The EWG’s Skin Deep database provides an important resource on phthalate-free personal care products.

Despite pressure from consumer advocacy groups, the U.S. Food and Drug Administration has not yet banned phthalates in food packaging.
 

Bisphenol A (BPA)

BPA is a chemical additive used to make clear and hard polycarbonate plastics, as well as epoxy and thermal papers. BPA is one of the highest-volume chemicals, with roughly 6 billion pounds produced each year. BPA is traditionally found in many clear plastic bottles and sippy cups, as well as in the lining of canned foods.

Structurally, BPA acts as an estrogen mimetic and has been associated with cardiovascular disease, obesity, and male sexual dysfunction. Since 2012, BPA has been banned in sippy cups and baby bottles, but there is some debate as to whether its replacements (bisphenol S and bisphenol F) are any safer; they appear to have similar hormonal effects as BPA.

As with phthalates, the majority of ingestion is thought to be food related. BPA has been found in more than 90% of a representative study population in the United States.

Guidance advises avoiding polycarbonate plastics (identifiable with the recycling code number 7), as well as avoiding handling thermal papers such as tickets and receipts, if possible. Food and beverages should be stored in glass or stainless steel. If plastic must be used, opt for polycarbonate- and polyvinyl chloride–free plastics, and food and beverages should never be reheated in plastic containers or wrapping. Canned foods should ideally be avoided, particularly canned tunas and condensed soups. If canned products are bought, they should ideally be BPA free.
 

Dioxins and polychlorinated biphenyls (PCBs)

Dioxins are mainly the byproducts of industrial practices; they are released after incineration, trash burning, and fires. PCBs, which are somewhat structurally related to dioxins, were previously found in products such as flame retardants and coolants. Dioxins and PCBs are often grouped in the same category under the umbrella term “persistent organic pollutants” because they break down slowly and remain in the environment even after emissions have been curbed.

Tetrachlorodibenzodioxin, perhaps the best-known dioxin, is a known carcinogen. Dioxins also have been associated with a host of health implications in development, immunity, and reproductive and endocrine systems. Higher levels of PCB exposure have also been associated with an increased risk for mortality from cardiovascular disease.

Notably, dioxin emissions have been reduced by 90% since the 1980s, and the U.S. Environmental Protection Agency has banned the use of PCBs in industrial manufacturing since 1979. However, environmental dioxins and PCBs still enter the food chain and accumulate in fat.

The best ways to avoid exposures are through limiting meat, fish, and dairy consumption and trimming the skin and fat from meats. The level of dioxins and PCBs found in meat, eggs, fish, and dairy are approximately 5-10 times higher than they are in plant-based foods. Research has shown that farmed salmon is likely to be the most PCB-contaminated protein source in the U.S. diet; however, newer forms of land-based and sustainable aquaculture probably avoid this exposure.
 

Pesticides

The growth of modern monoculture agriculture in the United States over the past century has coincided with a dramatic surge in the use of industrial pesticides. In fact, over 90% of the U.S. population have pesticides in their urine and blood, regardless of where they live. Exposures are thought to be food related.

Approximately 1 billion pounds of pesticides are used annually in the United States, including nearly 300 million pounds of glyphosate, which has been identified as a probable carcinogen by European agencies. The EPA has not yet reached this conclusion, although the matter is currently being litigated.

A large European prospective cohort trial demonstrated a lower risk for cancer in those with a greater frequency of self-reported organic food consumption. In addition to cancer risk, relatively elevated blood levels of a pesticide known as beta-hexachlorocyclohexane (B-HCH) are associated with higher all-cause mortality. Also, exposure to DDE – a metabolite of DDT, a chlorinated pesticide heavily used in the 1940s-1960s that still persists in the environment today – has been shown to increase the risk for Alzheimer’s-type dementia as well as overall cognitive decline.

Because these chlorinated pesticides are often fat soluble, they seem to accumulate in animal products. Therefore, people consuming a vegetarian diet have been found to have lower levels of B-HCH. This has led to the recommendation that consumers of produce should favor organic over conventional, if possible. Here too, the EWG provides an important resource to consumers in the form of shopper guides regarding pesticides in produce.
 

Per- and polyfluoroalkyl substances (PFAS)

PFAS are a group of fluorinated compounds discovered in the 1930s. Their chemical composition includes a durable carbon-fluoride bond, giving them a persistence within the environment that has led to their being referred to as “forever chemicals.”

PFAS have been detected in the blood of 98% of Americans, and in the rainwater of locations as far afield as Tibet and Antarctica. Even low levels of exposure have been associated with an increased risk for cancer, liver disease, low birth weight, and hormonal disruption.

The properties of PFAS also make them both durable at very high heat and water repellent. Notoriously, the chemical was used by 3M to make Scotchgard for carpets and fabrics and by Dupont to make Teflon for nonstick coating of pots and pans. Although perfluorooctanoic acid (PFOA) was removed from nonstick cookware in 2013, PFAS – a family of thousands of synthetic compounds – remain common in fast-food packaging, water- and stain-repellent clothing, firefighting foam, and personal care products. PFAS are released into the environment during the breakdown of these consumer and industrial products, as well as from dumping from waste facilities.

Alarmingly, the EWG notes that up to 200 million Americans may be exposed to PFAS in their drinking water. In March 2021, the EPA announced that they will be regulating PFAS in drinking water; however, the regulations have not been finalized. Currently, it is up to individual states to test for its presence in the water. The EWG has compiled a map of all known PFAS contamination sites.

To avoid or prevent exposures from PFAS, recommendations include filtering tap water with either reverse osmosis or activated carbon filters, as well as avoiding fast food and carry-out food, if possible, and consumer products labeled as “water resistant,” “stain-resistant,” and “nonstick.”

In a testament to how harmful these chemicals are, the EPA recently revised their lifetime health advisories for PFAS, such as PFOA, to 0.004 parts per trillion, which is more than 10,000 times smaller than the previous limit of 70 parts per trillion. The EPA also has proposed formally designating certain PFAS chemicals as “hazardous substances.”

Dr. Goel, clinical assistant professor of medicine at Weill Cornell Medicine, New York, has disclosed no relevant financial relationships. A version of this article originally appeared on Medscape.com.

Irregular sleep – such as inconsistent sleep duration or sleep timing – may increase the risk of developing atherosclerosis among adults older than age 45, a new report suggests.

In particular, variation in sleep duration of more than 2 hours per night in the same week was tied to higher rates of atherosclerosis.

“Poor sleep is linked with several cardiovascular conditions, including heart disease, hypertension, and type 2 diabetes,” lead author Kelsie M. Full, PhD, MPH, assistant professor of medicine at Vanderbilt University Medical Center, Nashville, Tenn., said in an interview.

“Overall, we found that participants who slept varying amounts of hours throughout the week (meaning that one night they slept less, one night they slept more) were more likely to have atherosclerosis than participants who slept about the same amount of time each night,” she said.

The study was published online in the Journal of the American Heart Association.
 

Analyzing associations

Dr. Full and colleagues examined data from 2032 participants in the Multi-Ethnic Study of Atherosclerosis Sleep Ancillary Study, which included adults aged between 45 and 84 years in six U.S. communities who completed 7-day wrist actigraphy assessment and kept a sleep diary between 2010 and 2013.

For subclinical markers of cardiovascular disease, participants underwent assessments of coronary artery calcium, carotid plaque presence, carotid intima-media thickness, and ankle-brachial index.

The research team assessed sleep duration, or the total number of minutes of sleep in a night, and sleep timing regularity, which was determined on the basis of the time someone initially fell asleep each night. They adjusted for cardiovascular disease risk factors and sleep characteristics, such as obstructive sleep apnea, sleep duration, and sleep fragmentation.

The average age of the participants was 68.6 years, and 53.6% were women. About 37.9% identified as White, 27.6% as Black or African American, 23.4% as Hispanic American, and 11.1% as Chinese American.

During the 7-day period, about 38% of participants experienced a change in sleep duration of more than 90 minutes, and 18% experienced a sleep duration change of more than 120 minutes. Those who had irregular sleep were more likely to be non-White, current smokers, have lower average annual incomes, have work shift schedules or did not work, and have a higher average body mass index.

For the study, sleep duration irregularity was defined as a standard deviation of more than 120 minutes. Those participants who had a greater degree of sleep irregularity were more likely to have high coronary artery calcium burden than those whose sleep duration was more more regular, defined as an SD of 60 minutes or less (> 300; prevalence ratio, 1.33; 95% confidence interval, 1.03-1.71), as well as abnormal ankle-brachial index (< 0.9, prevalence ratio, 1.75;95% CI, 1.03-2.95).

Further, those with irregular sleep timing (SD > 90 minutes) were more likely to have a high coronary artery calcium burden (prevalence ratio, 1.39; 95% CI, 1.07-1.82) in comparison with those with more regular sleep timing (SD < 30 minutes).

“The biggest surprise to me was that 30% of the participants in the study had total sleep times that varied by more than 90 minutes over the course of the week,” Dr. Full said. “This is consistent with prior studies that suggest that a large proportion of the general public have irregular sleep patterns, not just shift workers.”
 

Investigating next steps

In additional analyses, Dr. Full and colleagues found that sleep duration regularity continued to be associated with high coronary artery calcium burden and abnormal ankle-brachial index when accounting for severe obstructive sleep apnea, average nightly sleep duration, and average sleep fragmentation.

Notably, when sleep duration was added, all participants with more irregular sleep durations (SD > 60 minutes) were more likely to have a high coronary artery calcium burden, compared with those with regular sleep durations (SD < 60 minutes). The results remained when participants who reported shift work, including night shift work, were excluded.

Additional studies are needed to understand the mechanisms, the study authors wrote. Night-to-night variability in sleep duration and sleep timing can cause desynchronization in the sleep-wake timing and circadian disruption.

“A key issue highlighted in this study is that sleep irregularity itself, independent of how much sleep people were getting, was related to heart health. Sleep is a naturally recurring phenomenon, and maintaining regularity helps provide stability and predictability to the body,” Michael Grandner, PhD, associate professor of psychiatry and director of the sleep and health research program at the University of Arizona, Tucson, said in an interview.

Dr. Grandner, who wasn’t involved with this study, has researched sleep irregularity and associations with cardiovascular disease, diabetes, obesity, and many other adverse outcomes.

“When people have very irregular sleep schedules, it may make it harder for the body to optimally make good use of the sleep it is getting, since it such a moving target,” he said. “The unique angle here is the ability to focus on regularity of sleep.”

The study was supported by the National Heart, Lung, and Blood Institute and the National Center for Advancing Translational Sciences of the National Institutes of Health. One author received grants and consulting fees from pharmaceutical companies unrelated to the research. The other authors and Dr. Grandner disclosed no relevant financial relationships.

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

Irregular sleep – such as inconsistent sleep duration or sleep timing – may increase the risk of developing atherosclerosis among adults older than age 45, a new report suggests.

In particular, variation in sleep duration of more than 2 hours per night in the same week was tied to higher rates of atherosclerosis.

“Poor sleep is linked with several cardiovascular conditions, including heart disease, hypertension, and type 2 diabetes,” lead author Kelsie M. Full, PhD, MPH, assistant professor of medicine at Vanderbilt University Medical Center, Nashville, Tenn., said in an interview.

“Overall, we found that participants who slept varying amounts of hours throughout the week (meaning that one night they slept less, one night they slept more) were more likely to have atherosclerosis than participants who slept about the same amount of time each night,” she said.

The study was published online in the Journal of the American Heart Association.
 

Analyzing associations

Dr. Full and colleagues examined data from 2032 participants in the Multi-Ethnic Study of Atherosclerosis Sleep Ancillary Study, which included adults aged between 45 and 84 years in six U.S. communities who completed 7-day wrist actigraphy assessment and kept a sleep diary between 2010 and 2013.

For subclinical markers of cardiovascular disease, participants underwent assessments of coronary artery calcium, carotid plaque presence, carotid intima-media thickness, and ankle-brachial index.

The research team assessed sleep duration, or the total number of minutes of sleep in a night, and sleep timing regularity, which was determined on the basis of the time someone initially fell asleep each night. They adjusted for cardiovascular disease risk factors and sleep characteristics, such as obstructive sleep apnea, sleep duration, and sleep fragmentation.

The average age of the participants was 68.6 years, and 53.6% were women. About 37.9% identified as White, 27.6% as Black or African American, 23.4% as Hispanic American, and 11.1% as Chinese American.

During the 7-day period, about 38% of participants experienced a change in sleep duration of more than 90 minutes, and 18% experienced a sleep duration change of more than 120 minutes. Those who had irregular sleep were more likely to be non-White, current smokers, have lower average annual incomes, have work shift schedules or did not work, and have a higher average body mass index.

For the study, sleep duration irregularity was defined as a standard deviation of more than 120 minutes. Those participants who had a greater degree of sleep irregularity were more likely to have high coronary artery calcium burden than those whose sleep duration was more more regular, defined as an SD of 60 minutes or less (> 300; prevalence ratio, 1.33; 95% confidence interval, 1.03-1.71), as well as abnormal ankle-brachial index (< 0.9, prevalence ratio, 1.75;95% CI, 1.03-2.95).

Further, those with irregular sleep timing (SD > 90 minutes) were more likely to have a high coronary artery calcium burden (prevalence ratio, 1.39; 95% CI, 1.07-1.82) in comparison with those with more regular sleep timing (SD < 30 minutes).

“The biggest surprise to me was that 30% of the participants in the study had total sleep times that varied by more than 90 minutes over the course of the week,” Dr. Full said. “This is consistent with prior studies that suggest that a large proportion of the general public have irregular sleep patterns, not just shift workers.”
 

Investigating next steps

In additional analyses, Dr. Full and colleagues found that sleep duration regularity continued to be associated with high coronary artery calcium burden and abnormal ankle-brachial index when accounting for severe obstructive sleep apnea, average nightly sleep duration, and average sleep fragmentation.

Notably, when sleep duration was added, all participants with more irregular sleep durations (SD > 60 minutes) were more likely to have a high coronary artery calcium burden, compared with those with regular sleep durations (SD < 60 minutes). The results remained when participants who reported shift work, including night shift work, were excluded.

Additional studies are needed to understand the mechanisms, the study authors wrote. Night-to-night variability in sleep duration and sleep timing can cause desynchronization in the sleep-wake timing and circadian disruption.

“A key issue highlighted in this study is that sleep irregularity itself, independent of how much sleep people were getting, was related to heart health. Sleep is a naturally recurring phenomenon, and maintaining regularity helps provide stability and predictability to the body,” Michael Grandner, PhD, associate professor of psychiatry and director of the sleep and health research program at the University of Arizona, Tucson, said in an interview.

Dr. Grandner, who wasn’t involved with this study, has researched sleep irregularity and associations with cardiovascular disease, diabetes, obesity, and many other adverse outcomes.

“When people have very irregular sleep schedules, it may make it harder for the body to optimally make good use of the sleep it is getting, since it such a moving target,” he said. “The unique angle here is the ability to focus on regularity of sleep.”

The study was supported by the National Heart, Lung, and Blood Institute and the National Center for Advancing Translational Sciences of the National Institutes of Health. One author received grants and consulting fees from pharmaceutical companies unrelated to the research. The other authors and Dr. Grandner disclosed no relevant financial relationships.

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

Irregular sleep – such as inconsistent sleep duration or sleep timing – may increase the risk of developing atherosclerosis among adults older than age 45, a new report suggests.

In particular, variation in sleep duration of more than 2 hours per night in the same week was tied to higher rates of atherosclerosis.

“Poor sleep is linked with several cardiovascular conditions, including heart disease, hypertension, and type 2 diabetes,” lead author Kelsie M. Full, PhD, MPH, assistant professor of medicine at Vanderbilt University Medical Center, Nashville, Tenn., said in an interview.

“Overall, we found that participants who slept varying amounts of hours throughout the week (meaning that one night they slept less, one night they slept more) were more likely to have atherosclerosis than participants who slept about the same amount of time each night,” she said.

The study was published online in the Journal of the American Heart Association.
 

Analyzing associations

Dr. Full and colleagues examined data from 2032 participants in the Multi-Ethnic Study of Atherosclerosis Sleep Ancillary Study, which included adults aged between 45 and 84 years in six U.S. communities who completed 7-day wrist actigraphy assessment and kept a sleep diary between 2010 and 2013.

For subclinical markers of cardiovascular disease, participants underwent assessments of coronary artery calcium, carotid plaque presence, carotid intima-media thickness, and ankle-brachial index.

The research team assessed sleep duration, or the total number of minutes of sleep in a night, and sleep timing regularity, which was determined on the basis of the time someone initially fell asleep each night. They adjusted for cardiovascular disease risk factors and sleep characteristics, such as obstructive sleep apnea, sleep duration, and sleep fragmentation.

The average age of the participants was 68.6 years, and 53.6% were women. About 37.9% identified as White, 27.6% as Black or African American, 23.4% as Hispanic American, and 11.1% as Chinese American.

During the 7-day period, about 38% of participants experienced a change in sleep duration of more than 90 minutes, and 18% experienced a sleep duration change of more than 120 minutes. Those who had irregular sleep were more likely to be non-White, current smokers, have lower average annual incomes, have work shift schedules or did not work, and have a higher average body mass index.

For the study, sleep duration irregularity was defined as a standard deviation of more than 120 minutes. Those participants who had a greater degree of sleep irregularity were more likely to have high coronary artery calcium burden than those whose sleep duration was more more regular, defined as an SD of 60 minutes or less (> 300; prevalence ratio, 1.33; 95% confidence interval, 1.03-1.71), as well as abnormal ankle-brachial index (< 0.9, prevalence ratio, 1.75;95% CI, 1.03-2.95).

Further, those with irregular sleep timing (SD > 90 minutes) were more likely to have a high coronary artery calcium burden (prevalence ratio, 1.39; 95% CI, 1.07-1.82) in comparison with those with more regular sleep timing (SD < 30 minutes).

“The biggest surprise to me was that 30% of the participants in the study had total sleep times that varied by more than 90 minutes over the course of the week,” Dr. Full said. “This is consistent with prior studies that suggest that a large proportion of the general public have irregular sleep patterns, not just shift workers.”
 

Investigating next steps

In additional analyses, Dr. Full and colleagues found that sleep duration regularity continued to be associated with high coronary artery calcium burden and abnormal ankle-brachial index when accounting for severe obstructive sleep apnea, average nightly sleep duration, and average sleep fragmentation.

Notably, when sleep duration was added, all participants with more irregular sleep durations (SD > 60 minutes) were more likely to have a high coronary artery calcium burden, compared with those with regular sleep durations (SD < 60 minutes). The results remained when participants who reported shift work, including night shift work, were excluded.

Additional studies are needed to understand the mechanisms, the study authors wrote. Night-to-night variability in sleep duration and sleep timing can cause desynchronization in the sleep-wake timing and circadian disruption.

“A key issue highlighted in this study is that sleep irregularity itself, independent of how much sleep people were getting, was related to heart health. Sleep is a naturally recurring phenomenon, and maintaining regularity helps provide stability and predictability to the body,” Michael Grandner, PhD, associate professor of psychiatry and director of the sleep and health research program at the University of Arizona, Tucson, said in an interview.

Dr. Grandner, who wasn’t involved with this study, has researched sleep irregularity and associations with cardiovascular disease, diabetes, obesity, and many other adverse outcomes.

“When people have very irregular sleep schedules, it may make it harder for the body to optimally make good use of the sleep it is getting, since it such a moving target,” he said. “The unique angle here is the ability to focus on regularity of sleep.”

The study was supported by the National Heart, Lung, and Blood Institute and the National Center for Advancing Translational Sciences of the National Institutes of Health. One author received grants and consulting fees from pharmaceutical companies unrelated to the research. The other authors and Dr. Grandner disclosed no relevant financial relationships.

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

This transcript has been edited for clarity.

Hi. I’m Art Caplan. I’m at the Division of Medical Ethics at New York University’s Grossman School of Medicine, where I’m the director.

It’s flu season, yet again. For many parts of the country, we’re already in the thick of it, and for other places, we’re going to have flu outbreaks continuing and intensifying. I’ve long believed that every health care institution – nursing homes, hospitals, clinics, home care, hospice – should require flu shots for all doctors and all nurses because it is the easiest, cheapest, and most ethical way to protect the workforce, who you need to be in there when flu outbreaks take place, and to protect patients against getting the flu when they come into hospital settings and get exposed to health care workers who may have the flu already but don’t know it.

In a recent poll, I was happy to see that the majority of physicians surveyed agreed with me: 65% said they supported mandatory flu vaccination in hospitals and only 23% said they did not. I think flu vaccination is something that has already been shown to be useful and important, not only in stopping people from getting the flu but also in making sure that they don’t get as sick when they get the flu.

Just like COVID-19 vaccination, it doesn’t always prevent somebody from getting infected, but if you get it, it keeps you from winding up sick at home, or worse – from dying and winding up in the morgue. Flu kills many, many people every year. We don’t want that to happen. A flu vaccine will really help prevent deaths, help prevent the number of symptoms that somebody gets, and will get people back to work. The benefits are pretty clear.

Does the flu vaccine work equally well every year? It does not. Some years, the strains that are picked for the vaccine don’t match the ones that circulate, and we don’t get as much protection as we hoped for. I think the safety side is so strong that it’s worth making the investment and the effort to promote mandatory flu vaccination.

Can you opt out on religious grounds? Well, some hospitals permit that at New York University. You have to go before a committee and make a case that your exemption on religious grounds is based on an authentic set of beliefs that are deeply held, and not just something you thought up the day before flu vaccine requirements went into effect.

There may be room for some exemptions – obviously, for health reasons. If people think that the flu vaccine is dangerous to them and can get a physician to agree and sign off that they are not appropriate to vaccinate, okay.

On the other hand, if you’re working with an especially vulnerable population – newborns, people who are immunosuppressed – then I think you’ve got to be vaccinated and you shouldn’t be working around people who are at huge risk of getting the flu if you refuse to be vaccinated or, for that matter, can’t be vaccinated.

Would I extend these mandates? Yes, I would. I’d extend them to COVID-19 vaccination and to measles vaccination. I think physicians and nurses should be good role models. They should get vaccinated. We know that the best available evidence says that vaccination for infectious disease is safe. It is really the best thing we can do to combat a variety of diseases such as the flu and COVID-19.

It seems to me that, in addition, the data that are out there in terms of risks from flu and COVID-19 – deaths in places like nursing homes – are overwhelming about the importance of trying to get staff vaccinated so they don’t bring flu into an institutionalized population. This is similar for prison health and many other settings where people are kept close together and staff may move from place to place, rotating from institution to institution, spreading infectious disease.

I’m going to go with the poll. Let’s keep pushing for health care workers to do the right thing and to be good role models. Let’s get everybody a flu vaccination. Let’s extend it to a COVID-19 vaccination and its boosters.

Let’s try to show the nation that health care is going to be guided by good science, a duty to one’s own health, and a duty to one’s patients. It shouldn’t be political. It should be based on what works best for the interests of health care providers and those they care for.

I’m Art Caplan at the New York University Grossman School of Medicine. Thanks for watching.
 

Dr. Caplan has disclosed the following relevant financial relationships: Served as a director, officer, partner, employee, advisor, consultant, or trustee for Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position). Serves as a contributing author and advisor for Medscape. A version of this article originally appeared on Medscape.com.

This transcript has been edited for clarity.

Hi. I’m Art Caplan. I’m at the Division of Medical Ethics at New York University’s Grossman School of Medicine, where I’m the director.

It’s flu season, yet again. For many parts of the country, we’re already in the thick of it, and for other places, we’re going to have flu outbreaks continuing and intensifying. I’ve long believed that every health care institution – nursing homes, hospitals, clinics, home care, hospice – should require flu shots for all doctors and all nurses because it is the easiest, cheapest, and most ethical way to protect the workforce, who you need to be in there when flu outbreaks take place, and to protect patients against getting the flu when they come into hospital settings and get exposed to health care workers who may have the flu already but don’t know it.

In a recent poll, I was happy to see that the majority of physicians surveyed agreed with me: 65% said they supported mandatory flu vaccination in hospitals and only 23% said they did not. I think flu vaccination is something that has already been shown to be useful and important, not only in stopping people from getting the flu but also in making sure that they don’t get as sick when they get the flu.

Just like COVID-19 vaccination, it doesn’t always prevent somebody from getting infected, but if you get it, it keeps you from winding up sick at home, or worse – from dying and winding up in the morgue. Flu kills many, many people every year. We don’t want that to happen. A flu vaccine will really help prevent deaths, help prevent the number of symptoms that somebody gets, and will get people back to work. The benefits are pretty clear.

Does the flu vaccine work equally well every year? It does not. Some years, the strains that are picked for the vaccine don’t match the ones that circulate, and we don’t get as much protection as we hoped for. I think the safety side is so strong that it’s worth making the investment and the effort to promote mandatory flu vaccination.

Can you opt out on religious grounds? Well, some hospitals permit that at New York University. You have to go before a committee and make a case that your exemption on religious grounds is based on an authentic set of beliefs that are deeply held, and not just something you thought up the day before flu vaccine requirements went into effect.

There may be room for some exemptions – obviously, for health reasons. If people think that the flu vaccine is dangerous to them and can get a physician to agree and sign off that they are not appropriate to vaccinate, okay.

On the other hand, if you’re working with an especially vulnerable population – newborns, people who are immunosuppressed – then I think you’ve got to be vaccinated and you shouldn’t be working around people who are at huge risk of getting the flu if you refuse to be vaccinated or, for that matter, can’t be vaccinated.

Would I extend these mandates? Yes, I would. I’d extend them to COVID-19 vaccination and to measles vaccination. I think physicians and nurses should be good role models. They should get vaccinated. We know that the best available evidence says that vaccination for infectious disease is safe. It is really the best thing we can do to combat a variety of diseases such as the flu and COVID-19.

It seems to me that, in addition, the data that are out there in terms of risks from flu and COVID-19 – deaths in places like nursing homes – are overwhelming about the importance of trying to get staff vaccinated so they don’t bring flu into an institutionalized population. This is similar for prison health and many other settings where people are kept close together and staff may move from place to place, rotating from institution to institution, spreading infectious disease.

I’m going to go with the poll. Let’s keep pushing for health care workers to do the right thing and to be good role models. Let’s get everybody a flu vaccination. Let’s extend it to a COVID-19 vaccination and its boosters.

Let’s try to show the nation that health care is going to be guided by good science, a duty to one’s own health, and a duty to one’s patients. It shouldn’t be political. It should be based on what works best for the interests of health care providers and those they care for.

I’m Art Caplan at the New York University Grossman School of Medicine. Thanks for watching.
 

Dr. Caplan has disclosed the following relevant financial relationships: Served as a director, officer, partner, employee, advisor, consultant, or trustee for Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position). Serves as a contributing author and advisor for Medscape. A version of this article originally appeared on Medscape.com.

This transcript has been edited for clarity.

Hi. I’m Art Caplan. I’m at the Division of Medical Ethics at New York University’s Grossman School of Medicine, where I’m the director.

It’s flu season, yet again. For many parts of the country, we’re already in the thick of it, and for other places, we’re going to have flu outbreaks continuing and intensifying. I’ve long believed that every health care institution – nursing homes, hospitals, clinics, home care, hospice – should require flu shots for all doctors and all nurses because it is the easiest, cheapest, and most ethical way to protect the workforce, who you need to be in there when flu outbreaks take place, and to protect patients against getting the flu when they come into hospital settings and get exposed to health care workers who may have the flu already but don’t know it.

In a recent poll, I was happy to see that the majority of physicians surveyed agreed with me: 65% said they supported mandatory flu vaccination in hospitals and only 23% said they did not. I think flu vaccination is something that has already been shown to be useful and important, not only in stopping people from getting the flu but also in making sure that they don’t get as sick when they get the flu.

Just like COVID-19 vaccination, it doesn’t always prevent somebody from getting infected, but if you get it, it keeps you from winding up sick at home, or worse – from dying and winding up in the morgue. Flu kills many, many people every year. We don’t want that to happen. A flu vaccine will really help prevent deaths, help prevent the number of symptoms that somebody gets, and will get people back to work. The benefits are pretty clear.

Does the flu vaccine work equally well every year? It does not. Some years, the strains that are picked for the vaccine don’t match the ones that circulate, and we don’t get as much protection as we hoped for. I think the safety side is so strong that it’s worth making the investment and the effort to promote mandatory flu vaccination.

Can you opt out on religious grounds? Well, some hospitals permit that at New York University. You have to go before a committee and make a case that your exemption on religious grounds is based on an authentic set of beliefs that are deeply held, and not just something you thought up the day before flu vaccine requirements went into effect.

There may be room for some exemptions – obviously, for health reasons. If people think that the flu vaccine is dangerous to them and can get a physician to agree and sign off that they are not appropriate to vaccinate, okay.

On the other hand, if you’re working with an especially vulnerable population – newborns, people who are immunosuppressed – then I think you’ve got to be vaccinated and you shouldn’t be working around people who are at huge risk of getting the flu if you refuse to be vaccinated or, for that matter, can’t be vaccinated.

Would I extend these mandates? Yes, I would. I’d extend them to COVID-19 vaccination and to measles vaccination. I think physicians and nurses should be good role models. They should get vaccinated. We know that the best available evidence says that vaccination for infectious disease is safe. It is really the best thing we can do to combat a variety of diseases such as the flu and COVID-19.

It seems to me that, in addition, the data that are out there in terms of risks from flu and COVID-19 – deaths in places like nursing homes – are overwhelming about the importance of trying to get staff vaccinated so they don’t bring flu into an institutionalized population. This is similar for prison health and many other settings where people are kept close together and staff may move from place to place, rotating from institution to institution, spreading infectious disease.

I’m going to go with the poll. Let’s keep pushing for health care workers to do the right thing and to be good role models. Let’s get everybody a flu vaccination. Let’s extend it to a COVID-19 vaccination and its boosters.

Let’s try to show the nation that health care is going to be guided by good science, a duty to one’s own health, and a duty to one’s patients. It shouldn’t be political. It should be based on what works best for the interests of health care providers and those they care for.

I’m Art Caplan at the New York University Grossman School of Medicine. Thanks for watching.
 

Dr. Caplan has disclosed the following relevant financial relationships: Served as a director, officer, partner, employee, advisor, consultant, or trustee for Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position). Serves as a contributing author and advisor for Medscape. A version of this article originally appeared on Medscape.com.

More on ‘intellectual constipation’

Regarding your editorial, “From debate to stalemate and hate: An epidemic of intellectual constipation” (Current Psychiatry, January 2023, p. 3-4, doi:10.12788/cp.0321): fantastic and so very well put. As you (we) get older, we get more forceful in presenting our ideas. Your presentation is perfect for the times, and I hope your editorial is read by many. I have started a group of doctors (Psychiatrists of the Realm) that will be available to teach physicians and nonphysicians at no charge. It is our responsibility as the elder statesmen of medicine to make sure what wisdom we have acquired can be shared with others.

Robert W. Pollack, MD, ABPN, DLFAPA
Fort Myers, Florida

Disclosures
The author reports no financial relationships with any companies whose products are mentioned in this letter, or with manufacturers of competing products.

More on SWOT analysis of psychiatry

I loved your recent analysis of psychiatry (“Contemporary psychiatry: A SWOT analysis,” Current Psychiatry, January 2023, p. 16-19,27, doi:10.12788/cp.0320). What a great idea! It looks very complete to me. It occurs to me to consider adding a very simple but I think profound strength: the fact that one’s mental health affects every decision a person makes for their entire life. Taking this stance opens many doors and makes our input and expertise as a profession relevant to all aspects of society. Mental health is personal and matters deeply to all of us.

Paul R. Crosby, MD, MBA
President and CEO of the Frances and Craig Lindner Center of HOPE
Associate Professor and Vice Chair
Department of Psychiatry and Behavioral Neuroscience
University of Cincinnati College of Medicine
Cincinnati, Ohio

Disclosures
The author reports no financial relationships with any companies whose products are mentioned in this letter, or with manufacturers of competing products.

More on evolution’s triumphs and blunders

I enjoyed your editorial, “Is evolution’s greatest triumph its worst blunder?” (Current Psychiatry, November 2022, p. 5,10-11, doi:10.12788cp.0301). I commend you for the bravery and freshness of the view you suggest we reconsider. It is interesting that observation of humans' propensity for violence didn't cause Darwin to wonder how that fit into his survival paradigm since we were not likely to have been under threat of extinction while the human neocortex was undergoing its novel evolutionary design. Being born in 1809 would have given him enough time to have his doubts about undesired human evolutionary trajectories with potential extinction outcomes. I’m no expert, but I’ve never heard he considered that human potential could lean in that direction. You may have seen the article by Kirsch¹ about people who are advocating that humans voluntarily move toward extinction and let the planet live. I would be interested in a follow-up article on the type of comments and ideas inspired by your editorial. Kudos to you for your creativity.

Michele A. Packard, PhD
Boulder, Colorado

Disclosures
The author reports no financial relationships with any companies whose products are mentioned in this letter, or with manufacturers of competing products.

More on ‘intellectual constipation’

Regarding your editorial, “From debate to stalemate and hate: An epidemic of intellectual constipation” (Current Psychiatry, January 2023, p. 3-4, doi:10.12788/cp.0321): fantastic and so very well put. As you (we) get older, we get more forceful in presenting our ideas. Your presentation is perfect for the times, and I hope your editorial is read by many. I have started a group of doctors (Psychiatrists of the Realm) that will be available to teach physicians and nonphysicians at no charge. It is our responsibility as the elder statesmen of medicine to make sure what wisdom we have acquired can be shared with others.

Robert W. Pollack, MD, ABPN, DLFAPA
Fort Myers, Florida

Disclosures
The author reports no financial relationships with any companies whose products are mentioned in this letter, or with manufacturers of competing products.

More on SWOT analysis of psychiatry

I loved your recent analysis of psychiatry (“Contemporary psychiatry: A SWOT analysis,” Current Psychiatry, January 2023, p. 16-19,27, doi:10.12788/cp.0320). What a great idea! It looks very complete to me. It occurs to me to consider adding a very simple but I think profound strength: the fact that one’s mental health affects every decision a person makes for their entire life. Taking this stance opens many doors and makes our input and expertise as a profession relevant to all aspects of society. Mental health is personal and matters deeply to all of us.

Paul R. Crosby, MD, MBA
President and CEO of the Frances and Craig Lindner Center of HOPE
Associate Professor and Vice Chair
Department of Psychiatry and Behavioral Neuroscience
University of Cincinnati College of Medicine
Cincinnati, Ohio

Disclosures
The author reports no financial relationships with any companies whose products are mentioned in this letter, or with manufacturers of competing products.

More on evolution’s triumphs and blunders

I enjoyed your editorial, “Is evolution’s greatest triumph its worst blunder?” (Current Psychiatry, November 2022, p. 5,10-11, doi:10.12788cp.0301). I commend you for the bravery and freshness of the view you suggest we reconsider. It is interesting that observation of humans' propensity for violence didn't cause Darwin to wonder how that fit into his survival paradigm since we were not likely to have been under threat of extinction while the human neocortex was undergoing its novel evolutionary design. Being born in 1809 would have given him enough time to have his doubts about undesired human evolutionary trajectories with potential extinction outcomes. I’m no expert, but I’ve never heard he considered that human potential could lean in that direction. You may have seen the article by Kirsch¹ about people who are advocating that humans voluntarily move toward extinction and let the planet live. I would be interested in a follow-up article on the type of comments and ideas inspired by your editorial. Kudos to you for your creativity.

Michele A. Packard, PhD
Boulder, Colorado

Disclosures
The author reports no financial relationships with any companies whose products are mentioned in this letter, or with manufacturers of competing products.

More on ‘intellectual constipation’

Regarding your editorial, “From debate to stalemate and hate: An epidemic of intellectual constipation” (Current Psychiatry, January 2023, p. 3-4, doi:10.12788/cp.0321): fantastic and so very well put. As you (we) get older, we get more forceful in presenting our ideas. Your presentation is perfect for the times, and I hope your editorial is read by many. I have started a group of doctors (Psychiatrists of the Realm) that will be available to teach physicians and nonphysicians at no charge. It is our responsibility as the elder statesmen of medicine to make sure what wisdom we have acquired can be shared with others.

Robert W. Pollack, MD, ABPN, DLFAPA
Fort Myers, Florida

Disclosures
The author reports no financial relationships with any companies whose products are mentioned in this letter, or with manufacturers of competing products.

More on SWOT analysis of psychiatry

I loved your recent analysis of psychiatry (“Contemporary psychiatry: A SWOT analysis,” Current Psychiatry, January 2023, p. 16-19,27, doi:10.12788/cp.0320). What a great idea! It looks very complete to me. It occurs to me to consider adding a very simple but I think profound strength: the fact that one’s mental health affects every decision a person makes for their entire life. Taking this stance opens many doors and makes our input and expertise as a profession relevant to all aspects of society. Mental health is personal and matters deeply to all of us.

Paul R. Crosby, MD, MBA
President and CEO of the Frances and Craig Lindner Center of HOPE
Associate Professor and Vice Chair
Department of Psychiatry and Behavioral Neuroscience
University of Cincinnati College of Medicine
Cincinnati, Ohio

Disclosures
The author reports no financial relationships with any companies whose products are mentioned in this letter, or with manufacturers of competing products.

More on evolution’s triumphs and blunders

I enjoyed your editorial, “Is evolution’s greatest triumph its worst blunder?” (Current Psychiatry, November 2022, p. 5,10-11, doi:10.12788cp.0301). I commend you for the bravery and freshness of the view you suggest we reconsider. It is interesting that observation of humans' propensity for violence didn't cause Darwin to wonder how that fit into his survival paradigm since we were not likely to have been under threat of extinction while the human neocortex was undergoing its novel evolutionary design. Being born in 1809 would have given him enough time to have his doubts about undesired human evolutionary trajectories with potential extinction outcomes. I’m no expert, but I’ve never heard he considered that human potential could lean in that direction. You may have seen the article by Kirsch¹ about people who are advocating that humans voluntarily move toward extinction and let the planet live. I would be interested in a follow-up article on the type of comments and ideas inspired by your editorial. Kudos to you for your creativity.

Michele A. Packard, PhD
Boulder, Colorado

Disclosures
The author reports no financial relationships with any companies whose products are mentioned in this letter, or with manufacturers of competing products.

An investigational smartphone app that delivers cognitive behavioral therapy (CBT) to people with type 2 diabetes led to a significant 10 percentage point cut in the incidence of antihyperglycemic-drug intensification during 6 months’ follow-up, when compared with a control phone app, in the CBT app’s pivotal trial with 669 randomized patients.

Previously reported results from this trial, called BT-001, showed that people randomized to use the CBT app had a significant average 0.4 percentage point reduction in hemoglobin A1c, compared with controls, after 90 days for the trial’s primary endpoint, and a significant 0.29 percentage point reduction in A1c, compared with controls, after 180 days.

The new finding, that these incremental drops in A1c occurred while the control patients also received significantly more intensification of their antihyperglycemic medication, provides further evidence for the efficacy of the CBT app, said Marc P. Bonaca, MD, in a press conference organized by the American College of Cardiology in advance of its upcoming joint scientific sessions.

The CBT app “significantly reduced A1c despite less intensification of antihyperglycemic therapy,” noted Dr. Bonaca, a vascular medicine specialist and executive director of CPC Clinical Research, an academic research organization created by and affiliated with the University of Colorado at Denver, Aurora.

Based on positive safety and efficacy findings from the primary-endpoint phase of the BT-001 trial, reported in Diabetes Care, the company developing the CBT app, Better Therapeutics, said in a statement that the U.S. Food and Drug Administration accepted the company’s application for de novo classification and marketing approval of the app, also called BT-001. If the agency grants this classification and marketing approval, the company plans to sell the app on a prescription basis for use by people with type 2 diabetes.


 

CBT app gives patients problem-solving skills

CBT gives people with type 2 diabetes a way to better understand their unhelpful behaviors and motivations and teaches them problem-solving skills. Providing this counseling via an app addresses the challenge of making the intervention scalable to a broad range of patients, Dr. Bonaca explained.

“Clinicians are frustrated by trying to produce behavioral change” in patients. The BT-001 app “provides a new avenue to treatment,” an approach that clinicians have been “very receptive” to using “once they understand the mechanism,” Dr. Bonaca said during the press conference. “The effect at 90 days was very similar to what a drug would do. It’s not just drugs any more” for treating people with type 2 diabetes, he declared.

“CBT is an empirically supported psychotherapy for a variety of emotional disorders, and it has been adapted to target specific emotional distress in the context of chronic illness,” commented Amit Shapira, PhD, a clinical psychologist at the Joslin Diabetes Center in Boston who has not been involved in the BT-001 studies. A CBT protocol designed for diabetes, CBT for Adherence and Depression “has been shown to have a positive impact on depression symptoms and glycemic control in adults with type 2 diabetes,” Dr. Shapira noted in an interview.

“Once a physician explains this [CBT] app and patients understand how to use it, then patients will be happy to use it,” commented Julia Grapsa, MD, PhD, a cardiologist at St. Thomas Hospital in London, who moderated the press conference. “We may see an explosion of apps like this one, designed to help better control” other chronic disorders, such as elevated blood pressure or abnormal lipid levels, Dr. Grapsa predicted. “I’m very optimistic that these apps have a great future in health care.”
 

Forty percent relative cut in new antihyperglycemic drug use

The BT-001 study randomized 669 adults with smartphone access and type 2 diabetes at any of six U.S. sites. The enrolled patients had type 2 diabetes for an average of 11 years, and an A1c of 7%-10.9% with an average level of 8.2%. Participants had to be on a stable medication regimen for at least 3 months but not using prandial insulin, and their treatment regimens could undergo adjustment during the trial. At baseline, each subject was on an average of 2.1 antihyperglycemic medications, including 90% on metformin and 42% on a sulfonylurea.

The new results reported by Dr. Bonaca showed that, during follow-up, people using the app had a 14.4% rate of antihyperglycemic drug intensification compared with a 24.4% rate among the controls, a roughly 40% relative decrease in new antihyperglycemic medication use. In addition, among those using insulin at baseline, 3.8% of controls increased their insulin dose, compared with 1.5% of those using the CBT app, while insulin doses decreased in 0.9% of the control subjects and in 2.2% of those using the BT-001 app.

Further study findings, first reported by Dr. Bonaca at the American Heart Association scientific sessions in late 2022, also showed a clear dose-response pattern for the CBT app: the more CBT lessons a person completed, the greater their reduction in A1c over 180 days of app use. People who used the app fewer than 10 times had an average reduction from baseline in their A1c of less than 0.1 percentage points. Among those who used the app 10-20 times (a subgroup with roughly one-third of the people randomized to app use), average A1c reduction increased to about 0.4 percentage points, and among those who used the app more than 20 times (also about one-third of the intervention group), the average A1c reduction from baseline was about 0.6 percentage points.

“It would be interesting to learn more about the adults who engaged with the app” and had a higher use rate “to provide more targeted care” with the app to people who match the profiles of those who were more likely to use the app during the trial, said Dr. Shapira.

This “clear” dose-response relationship “was one of the most exciting findings. It helps validate the mechanism,” Dr. Bonaca said during the press conference. “We’re now modeling which patients were the most engaged” with using the app, and “looking at ways to increase app engagement.”

Better Therapeutics also announced, in December 2022, results from a separate, uncontrolled study of a similar CBT app in 19 people with nonalcoholic fatty liver disease and nonalcoholic steatohepatitis. The findings showed that use of the tested app linked with an average 16% drop from baseline in liver fat content as measured by MRI, as well as other improvements in markers of hepatic function. The company said in a statement that based on these findings it planned to apply for breakthrough-device designation with the FDA for use of a liver-specific CBT app in people with nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.

The BT-001 trial was sponsored by Better Therapeutics, the company developing the app. CPC Clinical Research receives research and consulting funding from numerous companies. Dr. Bonaca has been a consultant to Audentes, and is a stockholder of Medtronic and Pfizer. Dr. Shapira and Dr. Grapsa had no disclosures.

An investigational smartphone app that delivers cognitive behavioral therapy (CBT) to people with type 2 diabetes led to a significant 10 percentage point cut in the incidence of antihyperglycemic-drug intensification during 6 months’ follow-up, when compared with a control phone app, in the CBT app’s pivotal trial with 669 randomized patients.

Previously reported results from this trial, called BT-001, showed that people randomized to use the CBT app had a significant average 0.4 percentage point reduction in hemoglobin A1c, compared with controls, after 90 days for the trial’s primary endpoint, and a significant 0.29 percentage point reduction in A1c, compared with controls, after 180 days.

The new finding, that these incremental drops in A1c occurred while the control patients also received significantly more intensification of their antihyperglycemic medication, provides further evidence for the efficacy of the CBT app, said Marc P. Bonaca, MD, in a press conference organized by the American College of Cardiology in advance of its upcoming joint scientific sessions.

The CBT app “significantly reduced A1c despite less intensification of antihyperglycemic therapy,” noted Dr. Bonaca, a vascular medicine specialist and executive director of CPC Clinical Research, an academic research organization created by and affiliated with the University of Colorado at Denver, Aurora.

Based on positive safety and efficacy findings from the primary-endpoint phase of the BT-001 trial, reported in Diabetes Care, the company developing the CBT app, Better Therapeutics, said in a statement that the U.S. Food and Drug Administration accepted the company’s application for de novo classification and marketing approval of the app, also called BT-001. If the agency grants this classification and marketing approval, the company plans to sell the app on a prescription basis for use by people with type 2 diabetes.


 

CBT app gives patients problem-solving skills

CBT gives people with type 2 diabetes a way to better understand their unhelpful behaviors and motivations and teaches them problem-solving skills. Providing this counseling via an app addresses the challenge of making the intervention scalable to a broad range of patients, Dr. Bonaca explained.

“Clinicians are frustrated by trying to produce behavioral change” in patients. The BT-001 app “provides a new avenue to treatment,” an approach that clinicians have been “very receptive” to using “once they understand the mechanism,” Dr. Bonaca said during the press conference. “The effect at 90 days was very similar to what a drug would do. It’s not just drugs any more” for treating people with type 2 diabetes, he declared.

“CBT is an empirically supported psychotherapy for a variety of emotional disorders, and it has been adapted to target specific emotional distress in the context of chronic illness,” commented Amit Shapira, PhD, a clinical psychologist at the Joslin Diabetes Center in Boston who has not been involved in the BT-001 studies. A CBT protocol designed for diabetes, CBT for Adherence and Depression “has been shown to have a positive impact on depression symptoms and glycemic control in adults with type 2 diabetes,” Dr. Shapira noted in an interview.

“Once a physician explains this [CBT] app and patients understand how to use it, then patients will be happy to use it,” commented Julia Grapsa, MD, PhD, a cardiologist at St. Thomas Hospital in London, who moderated the press conference. “We may see an explosion of apps like this one, designed to help better control” other chronic disorders, such as elevated blood pressure or abnormal lipid levels, Dr. Grapsa predicted. “I’m very optimistic that these apps have a great future in health care.”
 

Forty percent relative cut in new antihyperglycemic drug use

The BT-001 study randomized 669 adults with smartphone access and type 2 diabetes at any of six U.S. sites. The enrolled patients had type 2 diabetes for an average of 11 years, and an A1c of 7%-10.9% with an average level of 8.2%. Participants had to be on a stable medication regimen for at least 3 months but not using prandial insulin, and their treatment regimens could undergo adjustment during the trial. At baseline, each subject was on an average of 2.1 antihyperglycemic medications, including 90% on metformin and 42% on a sulfonylurea.

The new results reported by Dr. Bonaca showed that, during follow-up, people using the app had a 14.4% rate of antihyperglycemic drug intensification compared with a 24.4% rate among the controls, a roughly 40% relative decrease in new antihyperglycemic medication use. In addition, among those using insulin at baseline, 3.8% of controls increased their insulin dose, compared with 1.5% of those using the CBT app, while insulin doses decreased in 0.9% of the control subjects and in 2.2% of those using the BT-001 app.

Further study findings, first reported by Dr. Bonaca at the American Heart Association scientific sessions in late 2022, also showed a clear dose-response pattern for the CBT app: the more CBT lessons a person completed, the greater their reduction in A1c over 180 days of app use. People who used the app fewer than 10 times had an average reduction from baseline in their A1c of less than 0.1 percentage points. Among those who used the app 10-20 times (a subgroup with roughly one-third of the people randomized to app use), average A1c reduction increased to about 0.4 percentage points, and among those who used the app more than 20 times (also about one-third of the intervention group), the average A1c reduction from baseline was about 0.6 percentage points.

“It would be interesting to learn more about the adults who engaged with the app” and had a higher use rate “to provide more targeted care” with the app to people who match the profiles of those who were more likely to use the app during the trial, said Dr. Shapira.

This “clear” dose-response relationship “was one of the most exciting findings. It helps validate the mechanism,” Dr. Bonaca said during the press conference. “We’re now modeling which patients were the most engaged” with using the app, and “looking at ways to increase app engagement.”

Better Therapeutics also announced, in December 2022, results from a separate, uncontrolled study of a similar CBT app in 19 people with nonalcoholic fatty liver disease and nonalcoholic steatohepatitis. The findings showed that use of the tested app linked with an average 16% drop from baseline in liver fat content as measured by MRI, as well as other improvements in markers of hepatic function. The company said in a statement that based on these findings it planned to apply for breakthrough-device designation with the FDA for use of a liver-specific CBT app in people with nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.

The BT-001 trial was sponsored by Better Therapeutics, the company developing the app. CPC Clinical Research receives research and consulting funding from numerous companies. Dr. Bonaca has been a consultant to Audentes, and is a stockholder of Medtronic and Pfizer. Dr. Shapira and Dr. Grapsa had no disclosures.

An investigational smartphone app that delivers cognitive behavioral therapy (CBT) to people with type 2 diabetes led to a significant 10 percentage point cut in the incidence of antihyperglycemic-drug intensification during 6 months’ follow-up, when compared with a control phone app, in the CBT app’s pivotal trial with 669 randomized patients.

Previously reported results from this trial, called BT-001, showed that people randomized to use the CBT app had a significant average 0.4 percentage point reduction in hemoglobin A1c, compared with controls, after 90 days for the trial’s primary endpoint, and a significant 0.29 percentage point reduction in A1c, compared with controls, after 180 days.

The new finding, that these incremental drops in A1c occurred while the control patients also received significantly more intensification of their antihyperglycemic medication, provides further evidence for the efficacy of the CBT app, said Marc P. Bonaca, MD, in a press conference organized by the American College of Cardiology in advance of its upcoming joint scientific sessions.

The CBT app “significantly reduced A1c despite less intensification of antihyperglycemic therapy,” noted Dr. Bonaca, a vascular medicine specialist and executive director of CPC Clinical Research, an academic research organization created by and affiliated with the University of Colorado at Denver, Aurora.

Based on positive safety and efficacy findings from the primary-endpoint phase of the BT-001 trial, reported in Diabetes Care, the company developing the CBT app, Better Therapeutics, said in a statement that the U.S. Food and Drug Administration accepted the company’s application for de novo classification and marketing approval of the app, also called BT-001. If the agency grants this classification and marketing approval, the company plans to sell the app on a prescription basis for use by people with type 2 diabetes.


 

CBT app gives patients problem-solving skills

CBT gives people with type 2 diabetes a way to better understand their unhelpful behaviors and motivations and teaches them problem-solving skills. Providing this counseling via an app addresses the challenge of making the intervention scalable to a broad range of patients, Dr. Bonaca explained.

“Clinicians are frustrated by trying to produce behavioral change” in patients. The BT-001 app “provides a new avenue to treatment,” an approach that clinicians have been “very receptive” to using “once they understand the mechanism,” Dr. Bonaca said during the press conference. “The effect at 90 days was very similar to what a drug would do. It’s not just drugs any more” for treating people with type 2 diabetes, he declared.

“CBT is an empirically supported psychotherapy for a variety of emotional disorders, and it has been adapted to target specific emotional distress in the context of chronic illness,” commented Amit Shapira, PhD, a clinical psychologist at the Joslin Diabetes Center in Boston who has not been involved in the BT-001 studies. A CBT protocol designed for diabetes, CBT for Adherence and Depression “has been shown to have a positive impact on depression symptoms and glycemic control in adults with type 2 diabetes,” Dr. Shapira noted in an interview.

“Once a physician explains this [CBT] app and patients understand how to use it, then patients will be happy to use it,” commented Julia Grapsa, MD, PhD, a cardiologist at St. Thomas Hospital in London, who moderated the press conference. “We may see an explosion of apps like this one, designed to help better control” other chronic disorders, such as elevated blood pressure or abnormal lipid levels, Dr. Grapsa predicted. “I’m very optimistic that these apps have a great future in health care.”
 

Forty percent relative cut in new antihyperglycemic drug use

The BT-001 study randomized 669 adults with smartphone access and type 2 diabetes at any of six U.S. sites. The enrolled patients had type 2 diabetes for an average of 11 years, and an A1c of 7%-10.9% with an average level of 8.2%. Participants had to be on a stable medication regimen for at least 3 months but not using prandial insulin, and their treatment regimens could undergo adjustment during the trial. At baseline, each subject was on an average of 2.1 antihyperglycemic medications, including 90% on metformin and 42% on a sulfonylurea.

The new results reported by Dr. Bonaca showed that, during follow-up, people using the app had a 14.4% rate of antihyperglycemic drug intensification compared with a 24.4% rate among the controls, a roughly 40% relative decrease in new antihyperglycemic medication use. In addition, among those using insulin at baseline, 3.8% of controls increased their insulin dose, compared with 1.5% of those using the CBT app, while insulin doses decreased in 0.9% of the control subjects and in 2.2% of those using the BT-001 app.

Further study findings, first reported by Dr. Bonaca at the American Heart Association scientific sessions in late 2022, also showed a clear dose-response pattern for the CBT app: the more CBT lessons a person completed, the greater their reduction in A1c over 180 days of app use. People who used the app fewer than 10 times had an average reduction from baseline in their A1c of less than 0.1 percentage points. Among those who used the app 10-20 times (a subgroup with roughly one-third of the people randomized to app use), average A1c reduction increased to about 0.4 percentage points, and among those who used the app more than 20 times (also about one-third of the intervention group), the average A1c reduction from baseline was about 0.6 percentage points.

“It would be interesting to learn more about the adults who engaged with the app” and had a higher use rate “to provide more targeted care” with the app to people who match the profiles of those who were more likely to use the app during the trial, said Dr. Shapira.

This “clear” dose-response relationship “was one of the most exciting findings. It helps validate the mechanism,” Dr. Bonaca said during the press conference. “We’re now modeling which patients were the most engaged” with using the app, and “looking at ways to increase app engagement.”

Better Therapeutics also announced, in December 2022, results from a separate, uncontrolled study of a similar CBT app in 19 people with nonalcoholic fatty liver disease and nonalcoholic steatohepatitis. The findings showed that use of the tested app linked with an average 16% drop from baseline in liver fat content as measured by MRI, as well as other improvements in markers of hepatic function. The company said in a statement that based on these findings it planned to apply for breakthrough-device designation with the FDA for use of a liver-specific CBT app in people with nonalcoholic fatty liver disease and nonalcoholic steatohepatitis.

The BT-001 trial was sponsored by Better Therapeutics, the company developing the app. CPC Clinical Research receives research and consulting funding from numerous companies. Dr. Bonaca has been a consultant to Audentes, and is a stockholder of Medtronic and Pfizer. Dr. Shapira and Dr. Grapsa had no disclosures.

Among professional football players, the concussion burden during years of active play is associated with post-career high blood pressure, a new study suggests.

Among more than 4,000 participants, 37% had hypertension at a median of 24 years post career and reported a median concussion symptom score (CSS) of 23 on a scale of 0 to 130.

“We have long seen an incompletely explained link between football participation and later-life cardiovascular disease,” Aaron L. Baggish, MD, of Massachusetts Hospital and Harvard Medical School, Boston, told this news organization.

“This study tested [whether] concussion burden during years of active play would be a determinant of later-life hypertension, the most common cause of cardiovascular disease, and indeed found this relationship to be a strong one.”

The study was published online in Circulation.
 

Link to cognitive decline?

Dr. Baggish and colleagues recruited former professional American-style football (ASF) players to participate in a survey administered by the Football Players Health Study at Harvard University.

Concussion burden was quantified with respect to the occurrence and severity of common concussion symptoms – e.g., headaches, nausea, dizziness, confusion, loss of consciousness (LOC), disorientation, and feeling unsteady on one’s feet – over years of active participation.

Prevalent hypertension was determined either by the participants’ previously receiving from a clinician a recommendation for medication for “high blood pressure” or by the participants’ taking such medication at the time of survey completion. Diabetes status was determined by the participants’ receiving a prior recommendation for or prescription for “diabetes or high blood sugar” medication.

Of 15,070 invited to participate in the study, 4,168 did so. The mean age of the participants was 51.8 years; 39.4% were Black; the mean body mass index was 31.3; and 33.9% were linemen. Participants played for a mean of 6.9 seasons and were surveyed at a median 24.1 years post ASF career completion. The median CSS was 23.

A total of 1,542 participants (37.3%) had hypertension, and 8.8% had diabetes.

After adjustment for established hypertension risk factors, including smoking, race, diabetes, age, and BMI, there was a graded association between CSS category and odds of later-life hypertension and between high CSS exposure and prevalent hypertension.

Results persisted when LOC, a single highly specific severe concussion symptom, was used in isolation as a surrogate for CSS, the investigators noted.

“These results suggest that repetitive early-life brain injury may have later-life implications for cardiovascular health,” they wrote. They also noted that hypertension has been shown to independently increase the risk of cognitive decline.

While premature cognitive decline among ASF players is generally attributed to chronic traumatic encephalopathy, “data from the current study raise the possibility that some element of cognitive decline among former ASF players may be attributable to hypertension,” which is potentially treatable.

“Future studies clarifying associations and causal pathways between brain injury, hypertension, and brain health are warranted,” they concluded.

Dr. Baggish added, “We hope that clinicians will now understand that head injury is an independent risk factor for high blood pressure and will screen vulnerable populations accordingly, as this may lead to better recognition of previously underdiagnosed hypertension with subsequent opportunities for intervention.”
 

Close monitoring

Commenting on the study, Jonathan Kim, MD, chair-elect of the American College of Cardiology’s Sports–Cardiology Section and chief of sports cardiology at Emory University in Atlanta, said, “They clearly show an independent association, which is not causality but is a new finding that requires more research. To me, it really emphasizes that cardiovascular risk is the most important health consequence that we should be worried about in retired NFL [National Football League] players.

“There are multifactorial reasons – not just repetitive head trauma – why this athletic population is at risk for the development of high blood pressure, even among college players,” he said.

Dr. Kim’s team has shown in studies conducted in collaboration with Dr. Baggish and others that collegiate football players who gain weight and develop increased systolic blood pressure are at risk of developing a “pathologic” cardiovascular phenotype.

Other research from this group showed links between nonsteroidal anti-inflammatory drug use among high school and collegiate ASF players and increased cardiovascular risk, as well as ASF-associated hypertension and ventricular-arterial coupling. 

The suggestion that late-life hypertension could play a role in premature cognitive decline among ASF players “warrants further study,” Dr. Kim said, “because we do know that hypertension in the general population can be associated with cognitive decline. So that’s an important future direction.”

He concluded: “It’s a matter of focusing on cardiac prevention.” After their careers, players should be counseled on the importance of losing weight and adopting heart-healthy habits. In addition to some of the traditional concerns that might lead to closer follow-up of these patients, “having a lot of concussions in the history could potentially be another risk factor that should warrant close monitoring of blood pressure and, of course, treatment if necessary.”

The study was supported by Harvard Catalyst/the Harvard Clinical and Translational Science Center and the NFL Players Association. Dr. Baggish and several coauthors have received funding from the NFL Players Association.

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

Among professional football players, the concussion burden during years of active play is associated with post-career high blood pressure, a new study suggests.

Among more than 4,000 participants, 37% had hypertension at a median of 24 years post career and reported a median concussion symptom score (CSS) of 23 on a scale of 0 to 130.

“We have long seen an incompletely explained link between football participation and later-life cardiovascular disease,” Aaron L. Baggish, MD, of Massachusetts Hospital and Harvard Medical School, Boston, told this news organization.

“This study tested [whether] concussion burden during years of active play would be a determinant of later-life hypertension, the most common cause of cardiovascular disease, and indeed found this relationship to be a strong one.”

The study was published online in Circulation.
 

Link to cognitive decline?

Dr. Baggish and colleagues recruited former professional American-style football (ASF) players to participate in a survey administered by the Football Players Health Study at Harvard University.

Concussion burden was quantified with respect to the occurrence and severity of common concussion symptoms – e.g., headaches, nausea, dizziness, confusion, loss of consciousness (LOC), disorientation, and feeling unsteady on one’s feet – over years of active participation.

Prevalent hypertension was determined either by the participants’ previously receiving from a clinician a recommendation for medication for “high blood pressure” or by the participants’ taking such medication at the time of survey completion. Diabetes status was determined by the participants’ receiving a prior recommendation for or prescription for “diabetes or high blood sugar” medication.

Of 15,070 invited to participate in the study, 4,168 did so. The mean age of the participants was 51.8 years; 39.4% were Black; the mean body mass index was 31.3; and 33.9% were linemen. Participants played for a mean of 6.9 seasons and were surveyed at a median 24.1 years post ASF career completion. The median CSS was 23.

A total of 1,542 participants (37.3%) had hypertension, and 8.8% had diabetes.

After adjustment for established hypertension risk factors, including smoking, race, diabetes, age, and BMI, there was a graded association between CSS category and odds of later-life hypertension and between high CSS exposure and prevalent hypertension.

Results persisted when LOC, a single highly specific severe concussion symptom, was used in isolation as a surrogate for CSS, the investigators noted.

“These results suggest that repetitive early-life brain injury may have later-life implications for cardiovascular health,” they wrote. They also noted that hypertension has been shown to independently increase the risk of cognitive decline.

While premature cognitive decline among ASF players is generally attributed to chronic traumatic encephalopathy, “data from the current study raise the possibility that some element of cognitive decline among former ASF players may be attributable to hypertension,” which is potentially treatable.

“Future studies clarifying associations and causal pathways between brain injury, hypertension, and brain health are warranted,” they concluded.

Dr. Baggish added, “We hope that clinicians will now understand that head injury is an independent risk factor for high blood pressure and will screen vulnerable populations accordingly, as this may lead to better recognition of previously underdiagnosed hypertension with subsequent opportunities for intervention.”
 

Close monitoring

Commenting on the study, Jonathan Kim, MD, chair-elect of the American College of Cardiology’s Sports–Cardiology Section and chief of sports cardiology at Emory University in Atlanta, said, “They clearly show an independent association, which is not causality but is a new finding that requires more research. To me, it really emphasizes that cardiovascular risk is the most important health consequence that we should be worried about in retired NFL [National Football League] players.

“There are multifactorial reasons – not just repetitive head trauma – why this athletic population is at risk for the development of high blood pressure, even among college players,” he said.

Dr. Kim’s team has shown in studies conducted in collaboration with Dr. Baggish and others that collegiate football players who gain weight and develop increased systolic blood pressure are at risk of developing a “pathologic” cardiovascular phenotype.

Other research from this group showed links between nonsteroidal anti-inflammatory drug use among high school and collegiate ASF players and increased cardiovascular risk, as well as ASF-associated hypertension and ventricular-arterial coupling. 

The suggestion that late-life hypertension could play a role in premature cognitive decline among ASF players “warrants further study,” Dr. Kim said, “because we do know that hypertension in the general population can be associated with cognitive decline. So that’s an important future direction.”

He concluded: “It’s a matter of focusing on cardiac prevention.” After their careers, players should be counseled on the importance of losing weight and adopting heart-healthy habits. In addition to some of the traditional concerns that might lead to closer follow-up of these patients, “having a lot of concussions in the history could potentially be another risk factor that should warrant close monitoring of blood pressure and, of course, treatment if necessary.”

The study was supported by Harvard Catalyst/the Harvard Clinical and Translational Science Center and the NFL Players Association. Dr. Baggish and several coauthors have received funding from the NFL Players Association.

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

Among professional football players, the concussion burden during years of active play is associated with post-career high blood pressure, a new study suggests.

Among more than 4,000 participants, 37% had hypertension at a median of 24 years post career and reported a median concussion symptom score (CSS) of 23 on a scale of 0 to 130.

“We have long seen an incompletely explained link between football participation and later-life cardiovascular disease,” Aaron L. Baggish, MD, of Massachusetts Hospital and Harvard Medical School, Boston, told this news organization.

“This study tested [whether] concussion burden during years of active play would be a determinant of later-life hypertension, the most common cause of cardiovascular disease, and indeed found this relationship to be a strong one.”

The study was published online in Circulation.
 

Link to cognitive decline?

Dr. Baggish and colleagues recruited former professional American-style football (ASF) players to participate in a survey administered by the Football Players Health Study at Harvard University.

Concussion burden was quantified with respect to the occurrence and severity of common concussion symptoms – e.g., headaches, nausea, dizziness, confusion, loss of consciousness (LOC), disorientation, and feeling unsteady on one’s feet – over years of active participation.

Prevalent hypertension was determined either by the participants’ previously receiving from a clinician a recommendation for medication for “high blood pressure” or by the participants’ taking such medication at the time of survey completion. Diabetes status was determined by the participants’ receiving a prior recommendation for or prescription for “diabetes or high blood sugar” medication.

Of 15,070 invited to participate in the study, 4,168 did so. The mean age of the participants was 51.8 years; 39.4% were Black; the mean body mass index was 31.3; and 33.9% were linemen. Participants played for a mean of 6.9 seasons and were surveyed at a median 24.1 years post ASF career completion. The median CSS was 23.

A total of 1,542 participants (37.3%) had hypertension, and 8.8% had diabetes.

After adjustment for established hypertension risk factors, including smoking, race, diabetes, age, and BMI, there was a graded association between CSS category and odds of later-life hypertension and between high CSS exposure and prevalent hypertension.

Results persisted when LOC, a single highly specific severe concussion symptom, was used in isolation as a surrogate for CSS, the investigators noted.

“These results suggest that repetitive early-life brain injury may have later-life implications for cardiovascular health,” they wrote. They also noted that hypertension has been shown to independently increase the risk of cognitive decline.

While premature cognitive decline among ASF players is generally attributed to chronic traumatic encephalopathy, “data from the current study raise the possibility that some element of cognitive decline among former ASF players may be attributable to hypertension,” which is potentially treatable.

“Future studies clarifying associations and causal pathways between brain injury, hypertension, and brain health are warranted,” they concluded.

Dr. Baggish added, “We hope that clinicians will now understand that head injury is an independent risk factor for high blood pressure and will screen vulnerable populations accordingly, as this may lead to better recognition of previously underdiagnosed hypertension with subsequent opportunities for intervention.”
 

Close monitoring

Commenting on the study, Jonathan Kim, MD, chair-elect of the American College of Cardiology’s Sports–Cardiology Section and chief of sports cardiology at Emory University in Atlanta, said, “They clearly show an independent association, which is not causality but is a new finding that requires more research. To me, it really emphasizes that cardiovascular risk is the most important health consequence that we should be worried about in retired NFL [National Football League] players.

“There are multifactorial reasons – not just repetitive head trauma – why this athletic population is at risk for the development of high blood pressure, even among college players,” he said.

Dr. Kim’s team has shown in studies conducted in collaboration with Dr. Baggish and others that collegiate football players who gain weight and develop increased systolic blood pressure are at risk of developing a “pathologic” cardiovascular phenotype.

Other research from this group showed links between nonsteroidal anti-inflammatory drug use among high school and collegiate ASF players and increased cardiovascular risk, as well as ASF-associated hypertension and ventricular-arterial coupling. 

The suggestion that late-life hypertension could play a role in premature cognitive decline among ASF players “warrants further study,” Dr. Kim said, “because we do know that hypertension in the general population can be associated with cognitive decline. So that’s an important future direction.”

He concluded: “It’s a matter of focusing on cardiac prevention.” After their careers, players should be counseled on the importance of losing weight and adopting heart-healthy habits. In addition to some of the traditional concerns that might lead to closer follow-up of these patients, “having a lot of concussions in the history could potentially be another risk factor that should warrant close monitoring of blood pressure and, of course, treatment if necessary.”

The study was supported by Harvard Catalyst/the Harvard Clinical and Translational Science Center and the NFL Players Association. Dr. Baggish and several coauthors have received funding from the NFL Players Association.

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

Men making speaker introductions at the 2022 annual scientific sessions of the American College of Cardiology were similarly likely to use professional titles regardless of gender, while women making introductions were more likely to use professional titles overall, based on a review of more than 800 videos of last year’s presentations.

“Implicit sex bias in speaker introductions at major medical conferences can foster and drive sex-driven assumptions about the competency of the speaker,” corresponding author Ankur Kalra, MD, an interventional cardiologist at Franciscan Health, Lafayette, Ind., said in an interview. “This is particularly important as recent data have shown a welcome, though gradual increase in the number of women speakers at major cardiology scientific sessions.”

In a research letter published in JACC: Advances, the researchers reviewed 1,696 videos from the ACC meeting held in Washington in April 2022 compiled by ACC Anywhere, and identified the participants as either “introducers” or “speakers.”

The final analysis included 888 speaker-introducer dyads. The introducer population was 49.4% men and 50.6% women; the speaker population included 58.8% men and 41.2% women.

Overall, 77.9% of speakers were addressed professionally in the first mention, and 71.5% were addressed professionally throughout the introduction. When making introductions, full professors were significantly more likely to use nonprofessional address than associate professors, assistant professors, and trainees (28.7% vs. 18.2%, 10.8%, and 0%, respectively).

Regardless of the sex of the speaker, women making introductions were significantly more likely than men to use professional titles for the speaker on first reference and consistently (84.2% vs. 71.5% and 78.2% vs. 64.7%, respectively; P < 0.001 for both).

Men doing introductions used professional forms of address similarly for both men and women speakers on first reference and consistently (72.2% vs. 71.1% and 65.4% vs. 64.3%, respectively).

No significant difference appeared in the use of professional address by women introducing women speakers compared to women introducing men speakers on first reference and consistently (81.9% vs. 86.1% and 75.0% vs. 80.8%, respectively).

“There was no significant association of the formality of introductions with the speaker’s sex and rank,” the researchers noted.

The findings were limited by several factors, including a lack of self-identified sex data, restriction to a binary determination of sex, and a lack of race/ethnicity analysis, the authors noted. In addition, the study could not account for prior familiarity between introducers and speakers that might influence the introduction.
 

Findings show positive trend

Dr. Kalra was surprised by the study findings, but in a good way. “A recent study on speakers presenting at Internal Medicine grand rounds demonstrated significant sex-based differences in using professional titles for formal introductions for women speakers in comparison with men speakers,” he said in an interview. The current study researchers expected to find similar differences.

“To our pleasant surprise, there was no implicit sex bias in introductions at the ACC 22, as there was no significant difference in the use of professional forms of address by men introducers of women speakers compared with men introducers of men speakers,” he said. “Similarly, the percentage of professional forms of address by women introducers was similar for men and women speakers.”
 

Setting an example

“A platform like ACC 22 is a window into the world of cardiovascular disease professionals – it’s a snapshot of who we are and what ethos/principles/values we represent,” said Dr. Kalra. “How we introduce one another is a surrogate marker of the mutual respect we behold for one another; our characters are on display, and the world and our junior colleagues are watching. Modern-day cardiology departments and practices must be completely intolerant to subtle microaggressions. The important take-away for clinicians is that it could be that our surprising findings may be attributed to the increased dialogue on sex disparities in cardiology, which has made physicians more cognizant of subtle microaggressions.”

A larger sample size is needed to replicate the study findings, and Dr. Kalra and colleagues hope to include data from ACC’s 2023 meeting, held with the World Congress of Cardiology in March, for additional research in this area.
 

Time to close inclusion gaps

“The time is now to dive into all previous and current gaps in diversity and inclusion,” Roxana Mehran, MD, said in an interview. “We must understand what the data are, and disseminate and educate all in health care on these issues.”

Dr. Mehran said she was not surprised by the findings of the current study. “This has been my own feeling for many years, watching mostly men be given important roles, such as Grand Rounds Speaking engagements. Now we have the data, and I congratulate the authors for the hard work to dig this out.

“In all aspects, we need to look at the entire talent pool to choose leadership, speakers, and key opinion leaders, as well as principal investigators in clinical trials,” said Dr. Mehran. “This has long been given to our wonderful and talented male colleagues without any effort to look for women, and non-Whites to be given the opportunity to shine and share their talent.”

Looking ahead, “we must remain vigilant and close gaps in all aspects of medicine whether in delivering care, or in the work force; this needs intentional efforts by all.”

The study was funded by makeadent.org and the Ram and Sanjita Kalra Aavishqaar Fund. Dr. Kalra is the CEO and creative director of makeadent.org. The other authors had no financial conflicts to disclose. Dr. Mehran had no financial conflicts to disclose.

Men making speaker introductions at the 2022 annual scientific sessions of the American College of Cardiology were similarly likely to use professional titles regardless of gender, while women making introductions were more likely to use professional titles overall, based on a review of more than 800 videos of last year’s presentations.

“Implicit sex bias in speaker introductions at major medical conferences can foster and drive sex-driven assumptions about the competency of the speaker,” corresponding author Ankur Kalra, MD, an interventional cardiologist at Franciscan Health, Lafayette, Ind., said in an interview. “This is particularly important as recent data have shown a welcome, though gradual increase in the number of women speakers at major cardiology scientific sessions.”

In a research letter published in JACC: Advances, the researchers reviewed 1,696 videos from the ACC meeting held in Washington in April 2022 compiled by ACC Anywhere, and identified the participants as either “introducers” or “speakers.”

The final analysis included 888 speaker-introducer dyads. The introducer population was 49.4% men and 50.6% women; the speaker population included 58.8% men and 41.2% women.

Overall, 77.9% of speakers were addressed professionally in the first mention, and 71.5% were addressed professionally throughout the introduction. When making introductions, full professors were significantly more likely to use nonprofessional address than associate professors, assistant professors, and trainees (28.7% vs. 18.2%, 10.8%, and 0%, respectively).

Regardless of the sex of the speaker, women making introductions were significantly more likely than men to use professional titles for the speaker on first reference and consistently (84.2% vs. 71.5% and 78.2% vs. 64.7%, respectively; P < 0.001 for both).

Men doing introductions used professional forms of address similarly for both men and women speakers on first reference and consistently (72.2% vs. 71.1% and 65.4% vs. 64.3%, respectively).

No significant difference appeared in the use of professional address by women introducing women speakers compared to women introducing men speakers on first reference and consistently (81.9% vs. 86.1% and 75.0% vs. 80.8%, respectively).

“There was no significant association of the formality of introductions with the speaker’s sex and rank,” the researchers noted.

The findings were limited by several factors, including a lack of self-identified sex data, restriction to a binary determination of sex, and a lack of race/ethnicity analysis, the authors noted. In addition, the study could not account for prior familiarity between introducers and speakers that might influence the introduction.
 

Findings show positive trend

Dr. Kalra was surprised by the study findings, but in a good way. “A recent study on speakers presenting at Internal Medicine grand rounds demonstrated significant sex-based differences in using professional titles for formal introductions for women speakers in comparison with men speakers,” he said in an interview. The current study researchers expected to find similar differences.

“To our pleasant surprise, there was no implicit sex bias in introductions at the ACC 22, as there was no significant difference in the use of professional forms of address by men introducers of women speakers compared with men introducers of men speakers,” he said. “Similarly, the percentage of professional forms of address by women introducers was similar for men and women speakers.”
 

Setting an example

“A platform like ACC 22 is a window into the world of cardiovascular disease professionals – it’s a snapshot of who we are and what ethos/principles/values we represent,” said Dr. Kalra. “How we introduce one another is a surrogate marker of the mutual respect we behold for one another; our characters are on display, and the world and our junior colleagues are watching. Modern-day cardiology departments and practices must be completely intolerant to subtle microaggressions. The important take-away for clinicians is that it could be that our surprising findings may be attributed to the increased dialogue on sex disparities in cardiology, which has made physicians more cognizant of subtle microaggressions.”

A larger sample size is needed to replicate the study findings, and Dr. Kalra and colleagues hope to include data from ACC’s 2023 meeting, held with the World Congress of Cardiology in March, for additional research in this area.
 

Time to close inclusion gaps

“The time is now to dive into all previous and current gaps in diversity and inclusion,” Roxana Mehran, MD, said in an interview. “We must understand what the data are, and disseminate and educate all in health care on these issues.”

Dr. Mehran said she was not surprised by the findings of the current study. “This has been my own feeling for many years, watching mostly men be given important roles, such as Grand Rounds Speaking engagements. Now we have the data, and I congratulate the authors for the hard work to dig this out.

“In all aspects, we need to look at the entire talent pool to choose leadership, speakers, and key opinion leaders, as well as principal investigators in clinical trials,” said Dr. Mehran. “This has long been given to our wonderful and talented male colleagues without any effort to look for women, and non-Whites to be given the opportunity to shine and share their talent.”

Looking ahead, “we must remain vigilant and close gaps in all aspects of medicine whether in delivering care, or in the work force; this needs intentional efforts by all.”

The study was funded by makeadent.org and the Ram and Sanjita Kalra Aavishqaar Fund. Dr. Kalra is the CEO and creative director of makeadent.org. The other authors had no financial conflicts to disclose. Dr. Mehran had no financial conflicts to disclose.

Men making speaker introductions at the 2022 annual scientific sessions of the American College of Cardiology were similarly likely to use professional titles regardless of gender, while women making introductions were more likely to use professional titles overall, based on a review of more than 800 videos of last year’s presentations.

“Implicit sex bias in speaker introductions at major medical conferences can foster and drive sex-driven assumptions about the competency of the speaker,” corresponding author Ankur Kalra, MD, an interventional cardiologist at Franciscan Health, Lafayette, Ind., said in an interview. “This is particularly important as recent data have shown a welcome, though gradual increase in the number of women speakers at major cardiology scientific sessions.”

In a research letter published in JACC: Advances, the researchers reviewed 1,696 videos from the ACC meeting held in Washington in April 2022 compiled by ACC Anywhere, and identified the participants as either “introducers” or “speakers.”

The final analysis included 888 speaker-introducer dyads. The introducer population was 49.4% men and 50.6% women; the speaker population included 58.8% men and 41.2% women.

Overall, 77.9% of speakers were addressed professionally in the first mention, and 71.5% were addressed professionally throughout the introduction. When making introductions, full professors were significantly more likely to use nonprofessional address than associate professors, assistant professors, and trainees (28.7% vs. 18.2%, 10.8%, and 0%, respectively).

Regardless of the sex of the speaker, women making introductions were significantly more likely than men to use professional titles for the speaker on first reference and consistently (84.2% vs. 71.5% and 78.2% vs. 64.7%, respectively; P < 0.001 for both).

Men doing introductions used professional forms of address similarly for both men and women speakers on first reference and consistently (72.2% vs. 71.1% and 65.4% vs. 64.3%, respectively).

No significant difference appeared in the use of professional address by women introducing women speakers compared to women introducing men speakers on first reference and consistently (81.9% vs. 86.1% and 75.0% vs. 80.8%, respectively).

“There was no significant association of the formality of introductions with the speaker’s sex and rank,” the researchers noted.

The findings were limited by several factors, including a lack of self-identified sex data, restriction to a binary determination of sex, and a lack of race/ethnicity analysis, the authors noted. In addition, the study could not account for prior familiarity between introducers and speakers that might influence the introduction.
 

Findings show positive trend

Dr. Kalra was surprised by the study findings, but in a good way. “A recent study on speakers presenting at Internal Medicine grand rounds demonstrated significant sex-based differences in using professional titles for formal introductions for women speakers in comparison with men speakers,” he said in an interview. The current study researchers expected to find similar differences.

“To our pleasant surprise, there was no implicit sex bias in introductions at the ACC 22, as there was no significant difference in the use of professional forms of address by men introducers of women speakers compared with men introducers of men speakers,” he said. “Similarly, the percentage of professional forms of address by women introducers was similar for men and women speakers.”
 

Setting an example

“A platform like ACC 22 is a window into the world of cardiovascular disease professionals – it’s a snapshot of who we are and what ethos/principles/values we represent,” said Dr. Kalra. “How we introduce one another is a surrogate marker of the mutual respect we behold for one another; our characters are on display, and the world and our junior colleagues are watching. Modern-day cardiology departments and practices must be completely intolerant to subtle microaggressions. The important take-away for clinicians is that it could be that our surprising findings may be attributed to the increased dialogue on sex disparities in cardiology, which has made physicians more cognizant of subtle microaggressions.”

A larger sample size is needed to replicate the study findings, and Dr. Kalra and colleagues hope to include data from ACC’s 2023 meeting, held with the World Congress of Cardiology in March, for additional research in this area.
 

Time to close inclusion gaps

“The time is now to dive into all previous and current gaps in diversity and inclusion,” Roxana Mehran, MD, said in an interview. “We must understand what the data are, and disseminate and educate all in health care on these issues.”

Dr. Mehran said she was not surprised by the findings of the current study. “This has been my own feeling for many years, watching mostly men be given important roles, such as Grand Rounds Speaking engagements. Now we have the data, and I congratulate the authors for the hard work to dig this out.

“In all aspects, we need to look at the entire talent pool to choose leadership, speakers, and key opinion leaders, as well as principal investigators in clinical trials,” said Dr. Mehran. “This has long been given to our wonderful and talented male colleagues without any effort to look for women, and non-Whites to be given the opportunity to shine and share their talent.”

Looking ahead, “we must remain vigilant and close gaps in all aspects of medicine whether in delivering care, or in the work force; this needs intentional efforts by all.”

The study was funded by makeadent.org and the Ram and Sanjita Kalra Aavishqaar Fund. Dr. Kalra is the CEO and creative director of makeadent.org. The other authors had no financial conflicts to disclose. Dr. Mehran had no financial conflicts to disclose.

More than 1 in 5 children worldwide are at risk of developing an eating disorder such as bulimia, anorexia, or binge eating, a new analysis suggests.

The study was published in the journal JAMA Pediatrics. Researchers analyzed data for 63,181 adolescents 6-18 years old from 16 countries to look for what is called “disordered eating.” None of the children included in the study had diagnosed physical or mental disorders, and data were not included from the COVID-19 time period.

The researchers examined results from a widely used standardized eating disorder questionnaire called the Sick, Control, One, Fat, Food (SCOFF). When someone answers yes to two or more of the questions, the person is considered to have disordered eating, which “denotes a suspicion of an existing eating disorder,” the researchers write. The five questions are:

• Do you make yourself sick because you feel uncomfortably full?
• Do you worry you have lost control over how much you eat?
• Have you recently lost more than 14 pounds in a 3-month period?
• Do you believe yourself to be fat when others say you are too thin?
• Would you say that food dominates your life?

Overall, 22% of children replied yes to two or more of the questions. The proportion of children with disordered eating is likely even higher, the researchers explain, because children may hide symptoms “due to feelings of shame or stigmatization.”

The findings are a dramatic shift from the estimation that 2.7% of people ages 13-18 have an eating disorder during their adolescent years.

In this latest study, disordered eating was more common among girls, older children, and those with a higher body mass index, or BMI, which is a combined measure of height and weight.

The analysis showed that 30% of girls had disordered eating, compared with 17% of boys. When looking at responses by age, the proportion of kids with disordered eating increased by 20 percentage points between the ages of 10 and 18.

The findings regarding children who already have a high BMI confirms previous research that many of those children are already following disordered eating behaviors while trying to lose weight, the authors write.

“Although most adolescents who develop an eating disorder do not report prior excess weight problems, some adolescents could misinterpret what eating healthy consists of and engage in unhealthy behaviors (for instance, skipping meals to generate a caloric deficit), which could then lead to development of an eating disorder,” the researchers explain.

The study points to the need for parents, caregivers, and health care professionals to be on the lookout for disordered eating symptoms in children because they are linked to the risk of developing a clinical eating disorder. The symptoms to watch for include behaviors such as weight loss dieting, binge eating, self-induced vomiting, excessive exercise, and the use of laxatives or diuretics, the researchers write.

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

More than 1 in 5 children worldwide are at risk of developing an eating disorder such as bulimia, anorexia, or binge eating, a new analysis suggests.

The study was published in the journal JAMA Pediatrics. Researchers analyzed data for 63,181 adolescents 6-18 years old from 16 countries to look for what is called “disordered eating.” None of the children included in the study had diagnosed physical or mental disorders, and data were not included from the COVID-19 time period.

The researchers examined results from a widely used standardized eating disorder questionnaire called the Sick, Control, One, Fat, Food (SCOFF). When someone answers yes to two or more of the questions, the person is considered to have disordered eating, which “denotes a suspicion of an existing eating disorder,” the researchers write. The five questions are:

• Do you make yourself sick because you feel uncomfortably full?
• Do you worry you have lost control over how much you eat?
• Have you recently lost more than 14 pounds in a 3-month period?
• Do you believe yourself to be fat when others say you are too thin?
• Would you say that food dominates your life?

Overall, 22% of children replied yes to two or more of the questions. The proportion of children with disordered eating is likely even higher, the researchers explain, because children may hide symptoms “due to feelings of shame or stigmatization.”

The findings are a dramatic shift from the estimation that 2.7% of people ages 13-18 have an eating disorder during their adolescent years.

In this latest study, disordered eating was more common among girls, older children, and those with a higher body mass index, or BMI, which is a combined measure of height and weight.

The analysis showed that 30% of girls had disordered eating, compared with 17% of boys. When looking at responses by age, the proportion of kids with disordered eating increased by 20 percentage points between the ages of 10 and 18.

The findings regarding children who already have a high BMI confirms previous research that many of those children are already following disordered eating behaviors while trying to lose weight, the authors write.

“Although most adolescents who develop an eating disorder do not report prior excess weight problems, some adolescents could misinterpret what eating healthy consists of and engage in unhealthy behaviors (for instance, skipping meals to generate a caloric deficit), which could then lead to development of an eating disorder,” the researchers explain.

The study points to the need for parents, caregivers, and health care professionals to be on the lookout for disordered eating symptoms in children because they are linked to the risk of developing a clinical eating disorder. The symptoms to watch for include behaviors such as weight loss dieting, binge eating, self-induced vomiting, excessive exercise, and the use of laxatives or diuretics, the researchers write.

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

More than 1 in 5 children worldwide are at risk of developing an eating disorder such as bulimia, anorexia, or binge eating, a new analysis suggests.

The study was published in the journal JAMA Pediatrics. Researchers analyzed data for 63,181 adolescents 6-18 years old from 16 countries to look for what is called “disordered eating.” None of the children included in the study had diagnosed physical or mental disorders, and data were not included from the COVID-19 time period.

The researchers examined results from a widely used standardized eating disorder questionnaire called the Sick, Control, One, Fat, Food (SCOFF). When someone answers yes to two or more of the questions, the person is considered to have disordered eating, which “denotes a suspicion of an existing eating disorder,” the researchers write. The five questions are:

• Do you make yourself sick because you feel uncomfortably full?
• Do you worry you have lost control over how much you eat?
• Have you recently lost more than 14 pounds in a 3-month period?
• Do you believe yourself to be fat when others say you are too thin?
• Would you say that food dominates your life?

Overall, 22% of children replied yes to two or more of the questions. The proportion of children with disordered eating is likely even higher, the researchers explain, because children may hide symptoms “due to feelings of shame or stigmatization.”

The findings are a dramatic shift from the estimation that 2.7% of people ages 13-18 have an eating disorder during their adolescent years.

In this latest study, disordered eating was more common among girls, older children, and those with a higher body mass index, or BMI, which is a combined measure of height and weight.

The analysis showed that 30% of girls had disordered eating, compared with 17% of boys. When looking at responses by age, the proportion of kids with disordered eating increased by 20 percentage points between the ages of 10 and 18.

The findings regarding children who already have a high BMI confirms previous research that many of those children are already following disordered eating behaviors while trying to lose weight, the authors write.

“Although most adolescents who develop an eating disorder do not report prior excess weight problems, some adolescents could misinterpret what eating healthy consists of and engage in unhealthy behaviors (for instance, skipping meals to generate a caloric deficit), which could then lead to development of an eating disorder,” the researchers explain.

The study points to the need for parents, caregivers, and health care professionals to be on the lookout for disordered eating symptoms in children because they are linked to the risk of developing a clinical eating disorder. The symptoms to watch for include behaviors such as weight loss dieting, binge eating, self-induced vomiting, excessive exercise, and the use of laxatives or diuretics, the researchers write.

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

A real-world analysis shows “meaningful” overall survival benefits when a cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitor is added to endocrine therapy for older women with hormone receptor (HR)–positive/HER2-negative metastatic breast cancer (MBC).

Three years after starting first-line treatment, overall survival rates were 49% with endocrine therapy alone versus 73% with endocrine therapy plus a CDK4/6 inhibitor – findings largely consistent with clinical trial data.

Treatment with endocrine therapy alone “should have a limited role in early lines of therapy for patients with HR-positive/HER2-negative MBC,” the researchers concluded.

The study was published online in the journal Cancer.

The Food and Drug Administration has approved the CDK4/6 inhibitors palbociclib, abemaciclib, and ribociclib for HR-positive/HER2-negative MBC in first and advanced therapy lines. The approval was based on phase 3, randomized, controlled trial data.

Yet gaps in evidence remain regarding survival outcomes in real-world settings for patients starting treatment with a CDK4/6 inhibitor, particularly for patients aged 65 and older, who typically aren’t included in randomized clinical trials.

To address these gaps, Ravi Goyal, PhD, with the University of Houston, and colleagues conducted a retrospective cohort study using the Survey Epidemiology and End Results Medicare database.

Dr. Goyal and coauthors identified 630 Medicare patients with HR-positive/HER2-negative MBC for whom first-line treatment was initiated within 12 months of diagnosis. Patients received either endocrine therapy alone (461 patients) or endocrine therapy plus a CDK4/6 inhibitor (169 patients), most commonly palbociclib.

The median duration of follow-up from the start of treatment was 24 months in the endocrine therapy–alone group and 30 months in the combination therapy group.

In a Kaplan-Meier analysis, the overall survival rate at 3 years after starting first-line treatment was 73% for the combination therapy group versus49% for the endocrine therapy group (P < .0001). Median overall survival from first-line therapy was not estimable in the endocrine therapy plus CDK4/6 inhibitor group; it was 34.8 months in the endocrine therapy–only group.

In multivariable Cox regression models, first-line dual therapy was independently associated with 41% lower rate of death in comparison with endocrine therapy alone (adjusted hazard ratio, 0.59).

Dr. Goyal and colleagues also performed a separate analysis of 206 patients for whom treatment was initiated in the second line; 88 received endocrine therapy alone, and 118 received endocrine therapy plus CDK4/6 inhibitor therapy.

In this setting, a similar benefit of dual therapy was observed. The 3-year overall survival rate was 68% for the combination group versus 50% for endocrine therapy alone (P = .0051). Median overall survival with second-line therapy was not estimable for the combination group; it was 30.9 months for the endocrine therapy group.

In the second line, multivariable Cox regression analysis showed that combination therapy was associated with a nearly 58% lower rate of death in comparison with endocrine therapy alone (aHR, 0.42).

The coauthors of an editorial in Cancer explain that the combination of a CDK4/6 inhibitor and endocrine therapy has become the “preferred first-line approach” in the management of HR-positive/HER2-negative MBC.

Dario Trapani, MD, and Erica Mayer, MD, with Dana-Farber Cancer Institute, Boston, noted that an overall survival benefit of similar magnitude from endocrine therapy plus a CDK4/6 inhibitor has also been reported in a recent real-world study of palbociclib and letrozole.

The work of Dr. Goyal and colleagues provides “confirmatory real-world evidence observed in clinical trials for endocrine sensitive, de novo, metastatic [breast cancer] in an older population,” Dr. Trapani and Dr. Mayer wrote.

The study had no specific funding. The authors and Dr. Trapani disclosed no relevant financial relaitonships. Dr. Mayer has consulted for Lilly, Novartis, Gilead, AstraZeneca, and Diaccurate.

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

A real-world analysis shows “meaningful” overall survival benefits when a cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitor is added to endocrine therapy for older women with hormone receptor (HR)–positive/HER2-negative metastatic breast cancer (MBC).

Three years after starting first-line treatment, overall survival rates were 49% with endocrine therapy alone versus 73% with endocrine therapy plus a CDK4/6 inhibitor – findings largely consistent with clinical trial data.

Treatment with endocrine therapy alone “should have a limited role in early lines of therapy for patients with HR-positive/HER2-negative MBC,” the researchers concluded.

The study was published online in the journal Cancer.

The Food and Drug Administration has approved the CDK4/6 inhibitors palbociclib, abemaciclib, and ribociclib for HR-positive/HER2-negative MBC in first and advanced therapy lines. The approval was based on phase 3, randomized, controlled trial data.

Yet gaps in evidence remain regarding survival outcomes in real-world settings for patients starting treatment with a CDK4/6 inhibitor, particularly for patients aged 65 and older, who typically aren’t included in randomized clinical trials.

To address these gaps, Ravi Goyal, PhD, with the University of Houston, and colleagues conducted a retrospective cohort study using the Survey Epidemiology and End Results Medicare database.

Dr. Goyal and coauthors identified 630 Medicare patients with HR-positive/HER2-negative MBC for whom first-line treatment was initiated within 12 months of diagnosis. Patients received either endocrine therapy alone (461 patients) or endocrine therapy plus a CDK4/6 inhibitor (169 patients), most commonly palbociclib.

The median duration of follow-up from the start of treatment was 24 months in the endocrine therapy–alone group and 30 months in the combination therapy group.

In a Kaplan-Meier analysis, the overall survival rate at 3 years after starting first-line treatment was 73% for the combination therapy group versus49% for the endocrine therapy group (P < .0001). Median overall survival from first-line therapy was not estimable in the endocrine therapy plus CDK4/6 inhibitor group; it was 34.8 months in the endocrine therapy–only group.

In multivariable Cox regression models, first-line dual therapy was independently associated with 41% lower rate of death in comparison with endocrine therapy alone (adjusted hazard ratio, 0.59).

Dr. Goyal and colleagues also performed a separate analysis of 206 patients for whom treatment was initiated in the second line; 88 received endocrine therapy alone, and 118 received endocrine therapy plus CDK4/6 inhibitor therapy.

In this setting, a similar benefit of dual therapy was observed. The 3-year overall survival rate was 68% for the combination group versus 50% for endocrine therapy alone (P = .0051). Median overall survival with second-line therapy was not estimable for the combination group; it was 30.9 months for the endocrine therapy group.

In the second line, multivariable Cox regression analysis showed that combination therapy was associated with a nearly 58% lower rate of death in comparison with endocrine therapy alone (aHR, 0.42).

The coauthors of an editorial in Cancer explain that the combination of a CDK4/6 inhibitor and endocrine therapy has become the “preferred first-line approach” in the management of HR-positive/HER2-negative MBC.

Dario Trapani, MD, and Erica Mayer, MD, with Dana-Farber Cancer Institute, Boston, noted that an overall survival benefit of similar magnitude from endocrine therapy plus a CDK4/6 inhibitor has also been reported in a recent real-world study of palbociclib and letrozole.

The work of Dr. Goyal and colleagues provides “confirmatory real-world evidence observed in clinical trials for endocrine sensitive, de novo, metastatic [breast cancer] in an older population,” Dr. Trapani and Dr. Mayer wrote.

The study had no specific funding. The authors and Dr. Trapani disclosed no relevant financial relaitonships. Dr. Mayer has consulted for Lilly, Novartis, Gilead, AstraZeneca, and Diaccurate.

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

A real-world analysis shows “meaningful” overall survival benefits when a cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitor is added to endocrine therapy for older women with hormone receptor (HR)–positive/HER2-negative metastatic breast cancer (MBC).

Three years after starting first-line treatment, overall survival rates were 49% with endocrine therapy alone versus 73% with endocrine therapy plus a CDK4/6 inhibitor – findings largely consistent with clinical trial data.

Treatment with endocrine therapy alone “should have a limited role in early lines of therapy for patients with HR-positive/HER2-negative MBC,” the researchers concluded.

The study was published online in the journal Cancer.

The Food and Drug Administration has approved the CDK4/6 inhibitors palbociclib, abemaciclib, and ribociclib for HR-positive/HER2-negative MBC in first and advanced therapy lines. The approval was based on phase 3, randomized, controlled trial data.

Yet gaps in evidence remain regarding survival outcomes in real-world settings for patients starting treatment with a CDK4/6 inhibitor, particularly for patients aged 65 and older, who typically aren’t included in randomized clinical trials.

To address these gaps, Ravi Goyal, PhD, with the University of Houston, and colleagues conducted a retrospective cohort study using the Survey Epidemiology and End Results Medicare database.

Dr. Goyal and coauthors identified 630 Medicare patients with HR-positive/HER2-negative MBC for whom first-line treatment was initiated within 12 months of diagnosis. Patients received either endocrine therapy alone (461 patients) or endocrine therapy plus a CDK4/6 inhibitor (169 patients), most commonly palbociclib.

The median duration of follow-up from the start of treatment was 24 months in the endocrine therapy–alone group and 30 months in the combination therapy group.

In a Kaplan-Meier analysis, the overall survival rate at 3 years after starting first-line treatment was 73% for the combination therapy group versus49% for the endocrine therapy group (P < .0001). Median overall survival from first-line therapy was not estimable in the endocrine therapy plus CDK4/6 inhibitor group; it was 34.8 months in the endocrine therapy–only group.

In multivariable Cox regression models, first-line dual therapy was independently associated with 41% lower rate of death in comparison with endocrine therapy alone (adjusted hazard ratio, 0.59).

Dr. Goyal and colleagues also performed a separate analysis of 206 patients for whom treatment was initiated in the second line; 88 received endocrine therapy alone, and 118 received endocrine therapy plus CDK4/6 inhibitor therapy.

In this setting, a similar benefit of dual therapy was observed. The 3-year overall survival rate was 68% for the combination group versus 50% for endocrine therapy alone (P = .0051). Median overall survival with second-line therapy was not estimable for the combination group; it was 30.9 months for the endocrine therapy group.

In the second line, multivariable Cox regression analysis showed that combination therapy was associated with a nearly 58% lower rate of death in comparison with endocrine therapy alone (aHR, 0.42).

The coauthors of an editorial in Cancer explain that the combination of a CDK4/6 inhibitor and endocrine therapy has become the “preferred first-line approach” in the management of HR-positive/HER2-negative MBC.

Dario Trapani, MD, and Erica Mayer, MD, with Dana-Farber Cancer Institute, Boston, noted that an overall survival benefit of similar magnitude from endocrine therapy plus a CDK4/6 inhibitor has also been reported in a recent real-world study of palbociclib and letrozole.

The work of Dr. Goyal and colleagues provides “confirmatory real-world evidence observed in clinical trials for endocrine sensitive, de novo, metastatic [breast cancer] in an older population,” Dr. Trapani and Dr. Mayer wrote.

The study had no specific funding. The authors and Dr. Trapani disclosed no relevant financial relaitonships. Dr. Mayer has consulted for Lilly, Novartis, Gilead, AstraZeneca, and Diaccurate.

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

Advanced imaging technology that uses artificial intelligence can potentially predict which patients with lung cancer are likely to experience cancer progression after surgery, according to new data.

The technology, known as highly multiplexed imaging mass cytometry (IMC), can provide cellular-level detail of the tumor immune microenvironment, which may allow clinicians to identify patients who need additional treatment, as well as those who don’t.

“It is well known that the frequency of certain cell populations within the tumor microenvironment correlates with clinical outcomes. These observations help us understand the biology underlying cancer progression,” senior author Logan Walsh, PhD, assistant professor of human genetics and the Rosalind Goodman Chair in Lung Cancer Research at McGill University’s Rosalind and Morris Goodman Cancer Institute, Montreal, said in an interview.

“We wanted to test whether using completely unbiased AI could find and use the spatial topography of the tumor microenvironment from IMC data to predict clinical outcomes,” he said. “It turns out the answer is yes! AI can predict clinical outcomes when combined with IMC with extremely high accuracy from a single 1-mm² tumor core.”

The study was published on in Nature.
 

The immune landscape

Lung cancer is the leading cause of cancer-related death in Canada, surpassing breast, colon, and prostate cancer deaths combined, the study authors write.

Lung adenocarcinoma, a non–small cell lung cancer, is the most common subtype and is characterized by distinct cellular and molecular features. The tumor immune microenvironment influences disease progression and therapy response, the authors write. Understanding the spatial landscape of the microenvironment could provide insight into disease progression, therapeutic vulnerabilities, and biomarkers of response to existing treatments.

In a collaborative study, Dr. Walsh and colleagues from McGill University and Université Laval profiled the cellular composition and spatial organization of the tumor immune microenvironment in tumors from 416 patients with lung adenocarcinoma across five histologic patterns. They used IMC to assess at samples from the universities’ biobanks that patients had provided for research purposes.

The research team detected more than 1.6 million cells, which allowed spatial analysis of immune lineages and activation states with distinct clinical correlates, including survival. They used a supervised lineage assignment approach to classify 14 distinct immune cell populations, along with tumor cells and endothelial cells.

High-grade solid tumors had the greatest immune infiltrate (44.6%), compared with micropapillary (37%), acinar (39.7%), papillary (32.8%), and lepidic architectures (32.7%). Macrophages were the most frequent cell population in the tumor immune microenvironment, representing 12.3% of total cells and 34.1% of immune cells.

The prevalence of CD163+ macrophages was strongly correlated with FOXP3+ immunoregulatory T cells in the solid pattern. This relationship was less pronounced in low-grade lepidic and papillary architectures. This finding could suggest an interplay between macrophage and T-cell populations in the tumor immune microenvironment across lung adenocarcinoma patterns.

Using a deep neural network model, the researchers also analyzed the relationship between immune populations and clinical or pathologic variables by examining the frequency of individual cell types as a percentage of total cells in each image. Each image was cross-referenced with clinical data from patients, including sex, age, body mass index, smoking status, stage, progression, survival, and histologic subtype.

Overall, the researchers found that various clinical outcomes, including cancer progression, could be predicted with high accuracy using a single 1-mm² tumor core. For instance, they could predict progression in stage IA and IB resected lung cancer with 95.9% accuracy.
 

Additional applications

“We were not surprised that AI was able to predict clinical outcomes, but we were surprised that it was able to do so with such high accuracy and precision,” said Dr. Walsh. “We were also surprised to learn that our predictions were equally accurate using only six-plex data, compared with 35-plex. This hinted to us that we could potentially scale down the number of markers to a practical number that would be amenable to technologies available in routine pathology labs.”

Dr. Walsh and colleagues are now validating the predictive tool using a lower-plex technology. In addition, they are investigating the immune landscapes of primary and metastatic brain tumors.

“This study is important, as it helps us to understand and appreciate the biological and mechanistic factors that may influence treatment outcomes. Our standard clinical predictors for predicting risk of recurrence and probability of response to therapy are not optimal,” Yee Ung, MD, an associate professor of radiation oncology at Sunnybrook Health Sciences Centre, Toronto, said in an interview.

Dr. Ung, who wasn’t involved with this study, has researched noninvasive hypoxia imaging and targeting in lung cancer. Ideally, he said, future studies should incorporate the use of noninvasive imaging predictive factors, in addition to the tumor immune microenvironment and clinical factors, to predict outcomes and provide personalized treatment.

“As we begin to investigate and understand more about cancer biology down to the cellular and molecular level, we need to strategically use AI methodologies in the processing and analysis of data,” he said.

The study was supported by the McGill Interdisciplinary Initiative in Infection and Immunity, the Brain Tumour Funders’ Collaborative, the Canadian Institutes of Health Research, and the Canadian Foundation for Innovation. Dr. Walsh and Dr. Ung have disclosed no relevant financial relationships.

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

Advanced imaging technology that uses artificial intelligence can potentially predict which patients with lung cancer are likely to experience cancer progression after surgery, according to new data.

The technology, known as highly multiplexed imaging mass cytometry (IMC), can provide cellular-level detail of the tumor immune microenvironment, which may allow clinicians to identify patients who need additional treatment, as well as those who don’t.

“It is well known that the frequency of certain cell populations within the tumor microenvironment correlates with clinical outcomes. These observations help us understand the biology underlying cancer progression,” senior author Logan Walsh, PhD, assistant professor of human genetics and the Rosalind Goodman Chair in Lung Cancer Research at McGill University’s Rosalind and Morris Goodman Cancer Institute, Montreal, said in an interview.

“We wanted to test whether using completely unbiased AI could find and use the spatial topography of the tumor microenvironment from IMC data to predict clinical outcomes,” he said. “It turns out the answer is yes! AI can predict clinical outcomes when combined with IMC with extremely high accuracy from a single 1-mm² tumor core.”

The study was published on in Nature.
 

The immune landscape

Lung cancer is the leading cause of cancer-related death in Canada, surpassing breast, colon, and prostate cancer deaths combined, the study authors write.

Lung adenocarcinoma, a non–small cell lung cancer, is the most common subtype and is characterized by distinct cellular and molecular features. The tumor immune microenvironment influences disease progression and therapy response, the authors write. Understanding the spatial landscape of the microenvironment could provide insight into disease progression, therapeutic vulnerabilities, and biomarkers of response to existing treatments.

In a collaborative study, Dr. Walsh and colleagues from McGill University and Université Laval profiled the cellular composition and spatial organization of the tumor immune microenvironment in tumors from 416 patients with lung adenocarcinoma across five histologic patterns. They used IMC to assess at samples from the universities’ biobanks that patients had provided for research purposes.

The research team detected more than 1.6 million cells, which allowed spatial analysis of immune lineages and activation states with distinct clinical correlates, including survival. They used a supervised lineage assignment approach to classify 14 distinct immune cell populations, along with tumor cells and endothelial cells.

High-grade solid tumors had the greatest immune infiltrate (44.6%), compared with micropapillary (37%), acinar (39.7%), papillary (32.8%), and lepidic architectures (32.7%). Macrophages were the most frequent cell population in the tumor immune microenvironment, representing 12.3% of total cells and 34.1% of immune cells.

The prevalence of CD163+ macrophages was strongly correlated with FOXP3+ immunoregulatory T cells in the solid pattern. This relationship was less pronounced in low-grade lepidic and papillary architectures. This finding could suggest an interplay between macrophage and T-cell populations in the tumor immune microenvironment across lung adenocarcinoma patterns.

Using a deep neural network model, the researchers also analyzed the relationship between immune populations and clinical or pathologic variables by examining the frequency of individual cell types as a percentage of total cells in each image. Each image was cross-referenced with clinical data from patients, including sex, age, body mass index, smoking status, stage, progression, survival, and histologic subtype.

Overall, the researchers found that various clinical outcomes, including cancer progression, could be predicted with high accuracy using a single 1-mm² tumor core. For instance, they could predict progression in stage IA and IB resected lung cancer with 95.9% accuracy.
 

Additional applications

“We were not surprised that AI was able to predict clinical outcomes, but we were surprised that it was able to do so with such high accuracy and precision,” said Dr. Walsh. “We were also surprised to learn that our predictions were equally accurate using only six-plex data, compared with 35-plex. This hinted to us that we could potentially scale down the number of markers to a practical number that would be amenable to technologies available in routine pathology labs.”

Dr. Walsh and colleagues are now validating the predictive tool using a lower-plex technology. In addition, they are investigating the immune landscapes of primary and metastatic brain tumors.

“This study is important, as it helps us to understand and appreciate the biological and mechanistic factors that may influence treatment outcomes. Our standard clinical predictors for predicting risk of recurrence and probability of response to therapy are not optimal,” Yee Ung, MD, an associate professor of radiation oncology at Sunnybrook Health Sciences Centre, Toronto, said in an interview.

Dr. Ung, who wasn’t involved with this study, has researched noninvasive hypoxia imaging and targeting in lung cancer. Ideally, he said, future studies should incorporate the use of noninvasive imaging predictive factors, in addition to the tumor immune microenvironment and clinical factors, to predict outcomes and provide personalized treatment.

“As we begin to investigate and understand more about cancer biology down to the cellular and molecular level, we need to strategically use AI methodologies in the processing and analysis of data,” he said.

The study was supported by the McGill Interdisciplinary Initiative in Infection and Immunity, the Brain Tumour Funders’ Collaborative, the Canadian Institutes of Health Research, and the Canadian Foundation for Innovation. Dr. Walsh and Dr. Ung have disclosed no relevant financial relationships.

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

Advanced imaging technology that uses artificial intelligence can potentially predict which patients with lung cancer are likely to experience cancer progression after surgery, according to new data.

The technology, known as highly multiplexed imaging mass cytometry (IMC), can provide cellular-level detail of the tumor immune microenvironment, which may allow clinicians to identify patients who need additional treatment, as well as those who don’t.

“It is well known that the frequency of certain cell populations within the tumor microenvironment correlates with clinical outcomes. These observations help us understand the biology underlying cancer progression,” senior author Logan Walsh, PhD, assistant professor of human genetics and the Rosalind Goodman Chair in Lung Cancer Research at McGill University’s Rosalind and Morris Goodman Cancer Institute, Montreal, said in an interview.

“We wanted to test whether using completely unbiased AI could find and use the spatial topography of the tumor microenvironment from IMC data to predict clinical outcomes,” he said. “It turns out the answer is yes! AI can predict clinical outcomes when combined with IMC with extremely high accuracy from a single 1-mm² tumor core.”

The study was published on in Nature.
 

The immune landscape

Lung cancer is the leading cause of cancer-related death in Canada, surpassing breast, colon, and prostate cancer deaths combined, the study authors write.

Lung adenocarcinoma, a non–small cell lung cancer, is the most common subtype and is characterized by distinct cellular and molecular features. The tumor immune microenvironment influences disease progression and therapy response, the authors write. Understanding the spatial landscape of the microenvironment could provide insight into disease progression, therapeutic vulnerabilities, and biomarkers of response to existing treatments.

In a collaborative study, Dr. Walsh and colleagues from McGill University and Université Laval profiled the cellular composition and spatial organization of the tumor immune microenvironment in tumors from 416 patients with lung adenocarcinoma across five histologic patterns. They used IMC to assess at samples from the universities’ biobanks that patients had provided for research purposes.

The research team detected more than 1.6 million cells, which allowed spatial analysis of immune lineages and activation states with distinct clinical correlates, including survival. They used a supervised lineage assignment approach to classify 14 distinct immune cell populations, along with tumor cells and endothelial cells.

High-grade solid tumors had the greatest immune infiltrate (44.6%), compared with micropapillary (37%), acinar (39.7%), papillary (32.8%), and lepidic architectures (32.7%). Macrophages were the most frequent cell population in the tumor immune microenvironment, representing 12.3% of total cells and 34.1% of immune cells.

The prevalence of CD163+ macrophages was strongly correlated with FOXP3+ immunoregulatory T cells in the solid pattern. This relationship was less pronounced in low-grade lepidic and papillary architectures. This finding could suggest an interplay between macrophage and T-cell populations in the tumor immune microenvironment across lung adenocarcinoma patterns.

Using a deep neural network model, the researchers also analyzed the relationship between immune populations and clinical or pathologic variables by examining the frequency of individual cell types as a percentage of total cells in each image. Each image was cross-referenced with clinical data from patients, including sex, age, body mass index, smoking status, stage, progression, survival, and histologic subtype.

Overall, the researchers found that various clinical outcomes, including cancer progression, could be predicted with high accuracy using a single 1-mm² tumor core. For instance, they could predict progression in stage IA and IB resected lung cancer with 95.9% accuracy.
 

Additional applications

“We were not surprised that AI was able to predict clinical outcomes, but we were surprised that it was able to do so with such high accuracy and precision,” said Dr. Walsh. “We were also surprised to learn that our predictions were equally accurate using only six-plex data, compared with 35-plex. This hinted to us that we could potentially scale down the number of markers to a practical number that would be amenable to technologies available in routine pathology labs.”

Dr. Walsh and colleagues are now validating the predictive tool using a lower-plex technology. In addition, they are investigating the immune landscapes of primary and metastatic brain tumors.

“This study is important, as it helps us to understand and appreciate the biological and mechanistic factors that may influence treatment outcomes. Our standard clinical predictors for predicting risk of recurrence and probability of response to therapy are not optimal,” Yee Ung, MD, an associate professor of radiation oncology at Sunnybrook Health Sciences Centre, Toronto, said in an interview.

Dr. Ung, who wasn’t involved with this study, has researched noninvasive hypoxia imaging and targeting in lung cancer. Ideally, he said, future studies should incorporate the use of noninvasive imaging predictive factors, in addition to the tumor immune microenvironment and clinical factors, to predict outcomes and provide personalized treatment.

“As we begin to investigate and understand more about cancer biology down to the cellular and molecular level, we need to strategically use AI methodologies in the processing and analysis of data,” he said.

The study was supported by the McGill Interdisciplinary Initiative in Infection and Immunity, the Brain Tumour Funders’ Collaborative, the Canadian Institutes of Health Research, and the Canadian Foundation for Innovation. Dr. Walsh and Dr. Ung have disclosed no relevant financial relationships.

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