CHEST Physician

Among adults with type 2 diabetes, the presence of preserved ratio impaired spirometry (PRISm) was significantly associated with increased risk of mortality and both macro- and microvascular complications, as well as increased mortality, based on data from more than 20,000 individuals.

PRISm occurs in approximately 10% of the general population and has been identified as a predictor of adverse health outcomes including cardiorespiratory morbidity and mortality, Guochen Li, MD, of the Medical College of Soochow University, Suzhou, China, and colleagues wrote.

“A growing number of studies have demonstrated that impaired lung function and type 2 diabetes could trigger shared pathophysiological injuries, such as microangiopathy and chronic inflammation,” they said, but the potential role of PRISm as an early predictor of adverse outcomes in patients with type 2 diabetes has not been fully examined.

In a study published in the journal Chest, the researchers reviewed data from 20,047 individuals with type 2 diabetes in the UK Biobank, a population-based cohort of adults aged 37-73 years recruited between 2006 and 2010.

The main exposure was lung function based on spirometry. PRISm was defined as predicted forced expiratory volume per second (FEV1) less than 80%, with an FEV1/ forced vital capacity (FVC) ratio of at least 0.70. Individuals with normal spirometry (defined as predicted FEV1 ≥ 80% with an FEV1/FVC ratio ≥ 0.70) served as controls.

The primary outcomes were major complications of type 2 diabetes including macrovascular events (myocardial infarction, unstable angina, coronary heart disease [CHD], ischemic stroke, and any type of stroke), microvascular events (diabetic retinopathy and diabetic kidney disease) and mortality (all-cause, cardiovascular, and respiratory).

Overall, 16.9% of study participants (3385 patients) had obstructive spirometry and 22.6% (4521 patients) had PRISm. Compared with individuals with normal spirometry, those with PRISm were more likely to be current smokers, obese, and living in economically disadvantaged areas. Individuals with PRISm also were significantly more likely to be long-term patients with diabetes who were taking glucose-lowering or lipid-lowering drugs (P < .001 for all).

The median follow-up for each of the type 2 diabetes complications and mortality was approximately 12 years. Over this time, 5.0% of patients developed incident MI, 1.3% developed unstable angina, 15.6% had CHD, 3.5% had an ischemic stroke, and 4.7% had any type of stroke. As for microvascular events, 7.8% developed diabetic retinopathy and 6.7% developed diabetic kidney disease. A total of 2588 patients died during the study period (15.1%), including 544 from cardiovascular disease and 319 from respiratory disease.

PRISm was significantly associated with increased risk of each of the complications and mortality types. These associations persisted after adjusting for lifestyle and other factors. The fully adjusted hazard ratios for PRISm versus normal spirometry were 1.23 for MI, 1.23 for unstable angina, 1.21 for CHD, 1.38 for ischemic stroke, 1.41 for any type of stroke, 1.31 for diabetic retinopathy, and 1.38 for diabetic kidney disease. Adjusted HRs for mortality were 1.34, 1.60, and 1.56 for all-cause, cardiovascular, and respiratory mortality, respectively.

The researchers also found that adding PRISm to an office-based risk score significantly improved the risk classification and predictive power for type 2 diabetes complications with the exception of unstable angina and mortality. They found little evidence for an association with sex, smoking, or PRISm duration and any mortality types. However, in subgroup analyses by age, sex, and duration of diabetes, PRISm remained associated with increased risk of macrovascular and microvascular complications, as well as mortality.

Potential mechanisms for the association between PRISm and diabetes complications include the role of insulin resistance in the exacerbation of lung damage in patients with type 2 diabetes, the increased rate of supplemental oxygen use among individuals with PRISm, and the increased prevalence of pulmonary artery enlargement in the PRISm subjects, the researchers wrote.

The findings were limited by several factors including the prospective design, the homogeneous population of individuals primarily of British or Irish ancestry, and the exclusion of diabetic neuropathy from the analysis, the researchers noted.

However, the results were strengthened by the large cohort, use of professional spirometry, and relatively long follow-up. “The findings underscore the relevance of PRISm for prognostic classification in type 2 diabetes and its potential for optimizing prevention strategies in this condition,” they concluded.

The study was supported by the National Natural Science Foundation of China, Natural Science Foundation of Jiangsu Province, and the Priority Academic Program Development of Jiangsu Higher Education Institutions. The researchers reported no relevant financial relationships.

A version of this article first appeared on Medscape.com

Among adults with type 2 diabetes, the presence of preserved ratio impaired spirometry (PRISm) was significantly associated with increased risk of mortality and both macro- and microvascular complications, as well as increased mortality, based on data from more than 20,000 individuals.

PRISm occurs in approximately 10% of the general population and has been identified as a predictor of adverse health outcomes including cardiorespiratory morbidity and mortality, Guochen Li, MD, of the Medical College of Soochow University, Suzhou, China, and colleagues wrote.

“A growing number of studies have demonstrated that impaired lung function and type 2 diabetes could trigger shared pathophysiological injuries, such as microangiopathy and chronic inflammation,” they said, but the potential role of PRISm as an early predictor of adverse outcomes in patients with type 2 diabetes has not been fully examined.

In a study published in the journal Chest, the researchers reviewed data from 20,047 individuals with type 2 diabetes in the UK Biobank, a population-based cohort of adults aged 37-73 years recruited between 2006 and 2010.

The main exposure was lung function based on spirometry. PRISm was defined as predicted forced expiratory volume per second (FEV1) less than 80%, with an FEV1/ forced vital capacity (FVC) ratio of at least 0.70. Individuals with normal spirometry (defined as predicted FEV1 ≥ 80% with an FEV1/FVC ratio ≥ 0.70) served as controls.

The primary outcomes were major complications of type 2 diabetes including macrovascular events (myocardial infarction, unstable angina, coronary heart disease [CHD], ischemic stroke, and any type of stroke), microvascular events (diabetic retinopathy and diabetic kidney disease) and mortality (all-cause, cardiovascular, and respiratory).

Overall, 16.9% of study participants (3385 patients) had obstructive spirometry and 22.6% (4521 patients) had PRISm. Compared with individuals with normal spirometry, those with PRISm were more likely to be current smokers, obese, and living in economically disadvantaged areas. Individuals with PRISm also were significantly more likely to be long-term patients with diabetes who were taking glucose-lowering or lipid-lowering drugs (P < .001 for all).

The median follow-up for each of the type 2 diabetes complications and mortality was approximately 12 years. Over this time, 5.0% of patients developed incident MI, 1.3% developed unstable angina, 15.6% had CHD, 3.5% had an ischemic stroke, and 4.7% had any type of stroke. As for microvascular events, 7.8% developed diabetic retinopathy and 6.7% developed diabetic kidney disease. A total of 2588 patients died during the study period (15.1%), including 544 from cardiovascular disease and 319 from respiratory disease.

PRISm was significantly associated with increased risk of each of the complications and mortality types. These associations persisted after adjusting for lifestyle and other factors. The fully adjusted hazard ratios for PRISm versus normal spirometry were 1.23 for MI, 1.23 for unstable angina, 1.21 for CHD, 1.38 for ischemic stroke, 1.41 for any type of stroke, 1.31 for diabetic retinopathy, and 1.38 for diabetic kidney disease. Adjusted HRs for mortality were 1.34, 1.60, and 1.56 for all-cause, cardiovascular, and respiratory mortality, respectively.

The researchers also found that adding PRISm to an office-based risk score significantly improved the risk classification and predictive power for type 2 diabetes complications with the exception of unstable angina and mortality. They found little evidence for an association with sex, smoking, or PRISm duration and any mortality types. However, in subgroup analyses by age, sex, and duration of diabetes, PRISm remained associated with increased risk of macrovascular and microvascular complications, as well as mortality.

Potential mechanisms for the association between PRISm and diabetes complications include the role of insulin resistance in the exacerbation of lung damage in patients with type 2 diabetes, the increased rate of supplemental oxygen use among individuals with PRISm, and the increased prevalence of pulmonary artery enlargement in the PRISm subjects, the researchers wrote.

The findings were limited by several factors including the prospective design, the homogeneous population of individuals primarily of British or Irish ancestry, and the exclusion of diabetic neuropathy from the analysis, the researchers noted.

However, the results were strengthened by the large cohort, use of professional spirometry, and relatively long follow-up. “The findings underscore the relevance of PRISm for prognostic classification in type 2 diabetes and its potential for optimizing prevention strategies in this condition,” they concluded.

The study was supported by the National Natural Science Foundation of China, Natural Science Foundation of Jiangsu Province, and the Priority Academic Program Development of Jiangsu Higher Education Institutions. The researchers reported no relevant financial relationships.

A version of this article first appeared on Medscape.com

Among adults with type 2 diabetes, the presence of preserved ratio impaired spirometry (PRISm) was significantly associated with increased risk of mortality and both macro- and microvascular complications, as well as increased mortality, based on data from more than 20,000 individuals.

PRISm occurs in approximately 10% of the general population and has been identified as a predictor of adverse health outcomes including cardiorespiratory morbidity and mortality, Guochen Li, MD, of the Medical College of Soochow University, Suzhou, China, and colleagues wrote.

“A growing number of studies have demonstrated that impaired lung function and type 2 diabetes could trigger shared pathophysiological injuries, such as microangiopathy and chronic inflammation,” they said, but the potential role of PRISm as an early predictor of adverse outcomes in patients with type 2 diabetes has not been fully examined.

In a study published in the journal Chest, the researchers reviewed data from 20,047 individuals with type 2 diabetes in the UK Biobank, a population-based cohort of adults aged 37-73 years recruited between 2006 and 2010.

The main exposure was lung function based on spirometry. PRISm was defined as predicted forced expiratory volume per second (FEV1) less than 80%, with an FEV1/ forced vital capacity (FVC) ratio of at least 0.70. Individuals with normal spirometry (defined as predicted FEV1 ≥ 80% with an FEV1/FVC ratio ≥ 0.70) served as controls.

The primary outcomes were major complications of type 2 diabetes including macrovascular events (myocardial infarction, unstable angina, coronary heart disease [CHD], ischemic stroke, and any type of stroke), microvascular events (diabetic retinopathy and diabetic kidney disease) and mortality (all-cause, cardiovascular, and respiratory).

Overall, 16.9% of study participants (3385 patients) had obstructive spirometry and 22.6% (4521 patients) had PRISm. Compared with individuals with normal spirometry, those with PRISm were more likely to be current smokers, obese, and living in economically disadvantaged areas. Individuals with PRISm also were significantly more likely to be long-term patients with diabetes who were taking glucose-lowering or lipid-lowering drugs (P < .001 for all).

The median follow-up for each of the type 2 diabetes complications and mortality was approximately 12 years. Over this time, 5.0% of patients developed incident MI, 1.3% developed unstable angina, 15.6% had CHD, 3.5% had an ischemic stroke, and 4.7% had any type of stroke. As for microvascular events, 7.8% developed diabetic retinopathy and 6.7% developed diabetic kidney disease. A total of 2588 patients died during the study period (15.1%), including 544 from cardiovascular disease and 319 from respiratory disease.

PRISm was significantly associated with increased risk of each of the complications and mortality types. These associations persisted after adjusting for lifestyle and other factors. The fully adjusted hazard ratios for PRISm versus normal spirometry were 1.23 for MI, 1.23 for unstable angina, 1.21 for CHD, 1.38 for ischemic stroke, 1.41 for any type of stroke, 1.31 for diabetic retinopathy, and 1.38 for diabetic kidney disease. Adjusted HRs for mortality were 1.34, 1.60, and 1.56 for all-cause, cardiovascular, and respiratory mortality, respectively.

The researchers also found that adding PRISm to an office-based risk score significantly improved the risk classification and predictive power for type 2 diabetes complications with the exception of unstable angina and mortality. They found little evidence for an association with sex, smoking, or PRISm duration and any mortality types. However, in subgroup analyses by age, sex, and duration of diabetes, PRISm remained associated with increased risk of macrovascular and microvascular complications, as well as mortality.

Potential mechanisms for the association between PRISm and diabetes complications include the role of insulin resistance in the exacerbation of lung damage in patients with type 2 diabetes, the increased rate of supplemental oxygen use among individuals with PRISm, and the increased prevalence of pulmonary artery enlargement in the PRISm subjects, the researchers wrote.

The findings were limited by several factors including the prospective design, the homogeneous population of individuals primarily of British or Irish ancestry, and the exclusion of diabetic neuropathy from the analysis, the researchers noted.

However, the results were strengthened by the large cohort, use of professional spirometry, and relatively long follow-up. “The findings underscore the relevance of PRISm for prognostic classification in type 2 diabetes and its potential for optimizing prevention strategies in this condition,” they concluded.

The study was supported by the National Natural Science Foundation of China, Natural Science Foundation of Jiangsu Province, and the Priority Academic Program Development of Jiangsu Higher Education Institutions. The researchers reported no relevant financial relationships.

A version of this article first appeared on Medscape.com

Thoracic Oncology & Chest Imaging Network

Interventional Procedures Section

The MIST-2 trial (Rahman, et al. N Engl J Med. 2011;365:518), the first randomized trial to show the benefit of intrapleural enzyme therapy (IET) with tissue plasminogen activator and deoxyribonuclease for the treatment of complicated pleural infection (cPI) is the foundational study for the use of IET. It was from this cohort that the first prospectively validated mortality prediction score for cPI was developed – the RAPID score (Rahman, et al. Chest. 2014;145[4]:848).

The RAPID score, comprised of Renal, Age, Purulence, Infection source, and Dietary factors (albumin) divides patients with cPI into three 3-month mortality groups: low (1.5%), medium (17.8%), and high (47.8%). The score was externally validated in the PILOT trial (Corcoran, et al. Eur Respir J. 2020;56[5]:2000130). Mortality outcomes were separately assessed in 1-, 3-, and 5-year follow-up by White, et al (Ann Am Thorac Soc. 2015;12[9]:1310) and found to bear out with an increased OR for mortality of 14.3 and 53.3 in the medium and high risk groups, respectively. Of note, there was a surgical referral rate of only 4% to16% in the study cohort, and the original study did not distinguish between IET use or surgery.

To look at RAPID in a purely surgical cohort, Stüben, et al (Sci Rep. 2023;13[1]:3206) applied the RAPID score to a cohort of patients with empyema all treated with initial surgical drainage. They found the RAPID score to be an accurate predictor of 90-day mortality and improved with the addition of diabetes and renal replacement therapy. Liou, et al (J Thorac Dis. 2023;15[3]:985) showed that patients with a low RAPID score who were taken to surgery early had improved length of stay and organ failure and mortality rates compared with those taken later.

Can the RAPID score differentiate between those who need IET alone, early surgery, or late surgery? Not yet, but several prospective studies are underway to help improve outcomes in this ancient disease. Until then, the RAPID score remains a useful risk-stratification tool for an increasingly broad population of patients with pleural infection.

Max Diddams, MD
Section Fellow-in-Training

Thoracic Oncology & Chest Imaging Network

Interventional Procedures Section

The MIST-2 trial (Rahman, et al. N Engl J Med. 2011;365:518), the first randomized trial to show the benefit of intrapleural enzyme therapy (IET) with tissue plasminogen activator and deoxyribonuclease for the treatment of complicated pleural infection (cPI) is the foundational study for the use of IET. It was from this cohort that the first prospectively validated mortality prediction score for cPI was developed – the RAPID score (Rahman, et al. Chest. 2014;145[4]:848).

The RAPID score, comprised of Renal, Age, Purulence, Infection source, and Dietary factors (albumin) divides patients with cPI into three 3-month mortality groups: low (1.5%), medium (17.8%), and high (47.8%). The score was externally validated in the PILOT trial (Corcoran, et al. Eur Respir J. 2020;56[5]:2000130). Mortality outcomes were separately assessed in 1-, 3-, and 5-year follow-up by White, et al (Ann Am Thorac Soc. 2015;12[9]:1310) and found to bear out with an increased OR for mortality of 14.3 and 53.3 in the medium and high risk groups, respectively. Of note, there was a surgical referral rate of only 4% to16% in the study cohort, and the original study did not distinguish between IET use or surgery.

To look at RAPID in a purely surgical cohort, Stüben, et al (Sci Rep. 2023;13[1]:3206) applied the RAPID score to a cohort of patients with empyema all treated with initial surgical drainage. They found the RAPID score to be an accurate predictor of 90-day mortality and improved with the addition of diabetes and renal replacement therapy. Liou, et al (J Thorac Dis. 2023;15[3]:985) showed that patients with a low RAPID score who were taken to surgery early had improved length of stay and organ failure and mortality rates compared with those taken later.

Can the RAPID score differentiate between those who need IET alone, early surgery, or late surgery? Not yet, but several prospective studies are underway to help improve outcomes in this ancient disease. Until then, the RAPID score remains a useful risk-stratification tool for an increasingly broad population of patients with pleural infection.

Max Diddams, MD
Section Fellow-in-Training

Thoracic Oncology & Chest Imaging Network

Interventional Procedures Section

The MIST-2 trial (Rahman, et al. N Engl J Med. 2011;365:518), the first randomized trial to show the benefit of intrapleural enzyme therapy (IET) with tissue plasminogen activator and deoxyribonuclease for the treatment of complicated pleural infection (cPI) is the foundational study for the use of IET. It was from this cohort that the first prospectively validated mortality prediction score for cPI was developed – the RAPID score (Rahman, et al. Chest. 2014;145[4]:848).

The RAPID score, comprised of Renal, Age, Purulence, Infection source, and Dietary factors (albumin) divides patients with cPI into three 3-month mortality groups: low (1.5%), medium (17.8%), and high (47.8%). The score was externally validated in the PILOT trial (Corcoran, et al. Eur Respir J. 2020;56[5]:2000130). Mortality outcomes were separately assessed in 1-, 3-, and 5-year follow-up by White, et al (Ann Am Thorac Soc. 2015;12[9]:1310) and found to bear out with an increased OR for mortality of 14.3 and 53.3 in the medium and high risk groups, respectively. Of note, there was a surgical referral rate of only 4% to16% in the study cohort, and the original study did not distinguish between IET use or surgery.

To look at RAPID in a purely surgical cohort, Stüben, et al (Sci Rep. 2023;13[1]:3206) applied the RAPID score to a cohort of patients with empyema all treated with initial surgical drainage. They found the RAPID score to be an accurate predictor of 90-day mortality and improved with the addition of diabetes and renal replacement therapy. Liou, et al (J Thorac Dis. 2023;15[3]:985) showed that patients with a low RAPID score who were taken to surgery early had improved length of stay and organ failure and mortality rates compared with those taken later.

Can the RAPID score differentiate between those who need IET alone, early surgery, or late surgery? Not yet, but several prospective studies are underway to help improve outcomes in this ancient disease. Until then, the RAPID score remains a useful risk-stratification tool for an increasingly broad population of patients with pleural infection.

Max Diddams, MD
Section Fellow-in-Training

Sleep Medicine Network

Home-Based Mechanical Ventilation & Neuromuscular Disease Section

The diaphragm plays a key a role in respiratory mechanics, particularly during the inspiratory cycle. Unilateral diaphragm paralysis (UDP) from traumatic, compressive, inflammatory, neuropathic, or iatrogenic phrenic nerve injury presents with exertional dyspnea or orthopnea, though more severe cases may present with hypoventilation, hypercapnia, and daytime fatigue. Diagnostic workup requires evaluation beyond radiography to determine if diaphragm elevation indicates paralysis with or without paradox. Severity of symptoms and degree of impairment do not consistently correlate with fluoroscopic/ultrasound findings during sniff maneuver, degree of restriction by spirometry, or supine forces. Compensatory accessory muscle use during daytime breathing can mask symptoms, and there can be severe nocturnal hypoventilation related to UDP.

For symptomatic patients, treatment recommendations require understanding of the etiology and the likelihood of resolution vs progression, or association with progressive systemic conditions. Nighttime noninvasive ventilation (NIV) is considered useful since diaphragmatic weakness worsens in supine position, and hypoventilation during REM sleep without accessory muscle support is exacerbated (Steier J, et al. Eur Respir J. 2008;32[6]:1479). However, evidence for NIV in UDP remains low quality. NIV has been proposed for ventilatory support particularly when hypercapnia is present (Wiebel M, et al. Med Klin. 1995;90[1 Suppl 1]:20). For patients with progressive neuromuscular conditions, NIV with a backup rate is strongly recommended (Steindor M, et al. Respir Care. 2021;66[3]:410; Benditt JO. Respir Care. 2019;64[6]:679), but access to respiratory assist devices is limited for isolated UDP under current reimbursement algorithms without demonstrable hypercapnia or significant restrictive spirometry. The recent ONMAP recommendations calling for use of symptom severity to support initiating NIV if FVC>80% have not yet been adopted (Morgenthaler TI, et al. Chest. 2021;160[5]:e419). Without marked spirometric restriction or hypercapnia, most patients must fail conservative PAP therapy prior to escalation to NIV, and initiation of a backup rate remains debated. Nevertheless, the only large case series evaluating the predominant features of polysomnography in UDP suggests high incidence of central apneas, suggesting a backup rate may indeed be required independent of the need to support neuromuscular function (Singh M, et al. Can J Anesthesiology. 2021;68[7]:1064). Further assessment of the features, needs, and understanding of the natural trajectory is essential to guide approach to sleep-related hypoventilation in UDP.

Landy V. Luna Diaz
Section Fellow-in-Training

Bethany L. Lussier, MD, FCCP
Section Member-at-Large

Sleep Medicine Network

Home-Based Mechanical Ventilation & Neuromuscular Disease Section

The diaphragm plays a key a role in respiratory mechanics, particularly during the inspiratory cycle. Unilateral diaphragm paralysis (UDP) from traumatic, compressive, inflammatory, neuropathic, or iatrogenic phrenic nerve injury presents with exertional dyspnea or orthopnea, though more severe cases may present with hypoventilation, hypercapnia, and daytime fatigue. Diagnostic workup requires evaluation beyond radiography to determine if diaphragm elevation indicates paralysis with or without paradox. Severity of symptoms and degree of impairment do not consistently correlate with fluoroscopic/ultrasound findings during sniff maneuver, degree of restriction by spirometry, or supine forces. Compensatory accessory muscle use during daytime breathing can mask symptoms, and there can be severe nocturnal hypoventilation related to UDP.

For symptomatic patients, treatment recommendations require understanding of the etiology and the likelihood of resolution vs progression, or association with progressive systemic conditions. Nighttime noninvasive ventilation (NIV) is considered useful since diaphragmatic weakness worsens in supine position, and hypoventilation during REM sleep without accessory muscle support is exacerbated (Steier J, et al. Eur Respir J. 2008;32[6]:1479). However, evidence for NIV in UDP remains low quality. NIV has been proposed for ventilatory support particularly when hypercapnia is present (Wiebel M, et al. Med Klin. 1995;90[1 Suppl 1]:20). For patients with progressive neuromuscular conditions, NIV with a backup rate is strongly recommended (Steindor M, et al. Respir Care. 2021;66[3]:410; Benditt JO. Respir Care. 2019;64[6]:679), but access to respiratory assist devices is limited for isolated UDP under current reimbursement algorithms without demonstrable hypercapnia or significant restrictive spirometry. The recent ONMAP recommendations calling for use of symptom severity to support initiating NIV if FVC>80% have not yet been adopted (Morgenthaler TI, et al. Chest. 2021;160[5]:e419). Without marked spirometric restriction or hypercapnia, most patients must fail conservative PAP therapy prior to escalation to NIV, and initiation of a backup rate remains debated. Nevertheless, the only large case series evaluating the predominant features of polysomnography in UDP suggests high incidence of central apneas, suggesting a backup rate may indeed be required independent of the need to support neuromuscular function (Singh M, et al. Can J Anesthesiology. 2021;68[7]:1064). Further assessment of the features, needs, and understanding of the natural trajectory is essential to guide approach to sleep-related hypoventilation in UDP.

Landy V. Luna Diaz
Section Fellow-in-Training

Bethany L. Lussier, MD, FCCP
Section Member-at-Large

Sleep Medicine Network

Home-Based Mechanical Ventilation & Neuromuscular Disease Section

The diaphragm plays a key a role in respiratory mechanics, particularly during the inspiratory cycle. Unilateral diaphragm paralysis (UDP) from traumatic, compressive, inflammatory, neuropathic, or iatrogenic phrenic nerve injury presents with exertional dyspnea or orthopnea, though more severe cases may present with hypoventilation, hypercapnia, and daytime fatigue. Diagnostic workup requires evaluation beyond radiography to determine if diaphragm elevation indicates paralysis with or without paradox. Severity of symptoms and degree of impairment do not consistently correlate with fluoroscopic/ultrasound findings during sniff maneuver, degree of restriction by spirometry, or supine forces. Compensatory accessory muscle use during daytime breathing can mask symptoms, and there can be severe nocturnal hypoventilation related to UDP.

For symptomatic patients, treatment recommendations require understanding of the etiology and the likelihood of resolution vs progression, or association with progressive systemic conditions. Nighttime noninvasive ventilation (NIV) is considered useful since diaphragmatic weakness worsens in supine position, and hypoventilation during REM sleep without accessory muscle support is exacerbated (Steier J, et al. Eur Respir J. 2008;32[6]:1479). However, evidence for NIV in UDP remains low quality. NIV has been proposed for ventilatory support particularly when hypercapnia is present (Wiebel M, et al. Med Klin. 1995;90[1 Suppl 1]:20). For patients with progressive neuromuscular conditions, NIV with a backup rate is strongly recommended (Steindor M, et al. Respir Care. 2021;66[3]:410; Benditt JO. Respir Care. 2019;64[6]:679), but access to respiratory assist devices is limited for isolated UDP under current reimbursement algorithms without demonstrable hypercapnia or significant restrictive spirometry. The recent ONMAP recommendations calling for use of symptom severity to support initiating NIV if FVC>80% have not yet been adopted (Morgenthaler TI, et al. Chest. 2021;160[5]:e419). Without marked spirometric restriction or hypercapnia, most patients must fail conservative PAP therapy prior to escalation to NIV, and initiation of a backup rate remains debated. Nevertheless, the only large case series evaluating the predominant features of polysomnography in UDP suggests high incidence of central apneas, suggesting a backup rate may indeed be required independent of the need to support neuromuscular function (Singh M, et al. Can J Anesthesiology. 2021;68[7]:1064). Further assessment of the features, needs, and understanding of the natural trajectory is essential to guide approach to sleep-related hypoventilation in UDP.

Landy V. Luna Diaz
Section Fellow-in-Training

Bethany L. Lussier, MD, FCCP
Section Member-at-Large

Diffuse Lung Disease & Lung Transplant Network

Interstitial Lung Disease Section

Idiopathic pulmonary fibrosis (IPF) is a fatal lung disease that affects an estimated 100,000 people in the United States alone. Despite the availability of two approved antifibrotic drugs, nintedanib and pirfenidone, there is still a need for effective treatments to improve patient outcomes.

The ISABELA 1 and 2 trials were two Phase III clinical trials designed to evaluate ziritaxestat, a novel autotaxin inhibitor, in patients with IPF. Unfortunately, both trials were terminated early after an interim analysis revealed a lack of efficacy and safety concerns. Specifically, neither dose of ziritaxestat showed any benefit on the rate of decline for FVC over 52 weeks. Moreover, the treatment with ziritaxestat showed no benefit on the reported secondary outcomes. Patients in the ziritaxestat groups experienced worse outcomes in terms of time to first respiratory- related hospitalization, respiratory- related mortality, and first acute IPF exacerbation. Pooled data for both trials showed higher all-cause mortality for the ziritaxestat groups in relation to placebo (Maher T, et al. JAMA. 2023;329[18]:1567).

These disappointing results highlight the challenges of developing effective treatments for IPF. The complexity of IPF as a disease, with multiple pathways contributing to its pathogenesis, makes it difficult to identify effective therapeutic targets. In addition, clinical trials for new treatments must also account for the availability of approved antifibrotic therapies, which creates an added challenge for clinical trial design.

Matthew Huang, MD
Section Fellow-in-Training

Brad Bemiss, MD
Section Member-at-Large

Diffuse Lung Disease & Lung Transplant Network

Interstitial Lung Disease Section

Idiopathic pulmonary fibrosis (IPF) is a fatal lung disease that affects an estimated 100,000 people in the United States alone. Despite the availability of two approved antifibrotic drugs, nintedanib and pirfenidone, there is still a need for effective treatments to improve patient outcomes.

The ISABELA 1 and 2 trials were two Phase III clinical trials designed to evaluate ziritaxestat, a novel autotaxin inhibitor, in patients with IPF. Unfortunately, both trials were terminated early after an interim analysis revealed a lack of efficacy and safety concerns. Specifically, neither dose of ziritaxestat showed any benefit on the rate of decline for FVC over 52 weeks. Moreover, the treatment with ziritaxestat showed no benefit on the reported secondary outcomes. Patients in the ziritaxestat groups experienced worse outcomes in terms of time to first respiratory- related hospitalization, respiratory- related mortality, and first acute IPF exacerbation. Pooled data for both trials showed higher all-cause mortality for the ziritaxestat groups in relation to placebo (Maher T, et al. JAMA. 2023;329[18]:1567).

These disappointing results highlight the challenges of developing effective treatments for IPF. The complexity of IPF as a disease, with multiple pathways contributing to its pathogenesis, makes it difficult to identify effective therapeutic targets. In addition, clinical trials for new treatments must also account for the availability of approved antifibrotic therapies, which creates an added challenge for clinical trial design.

Matthew Huang, MD
Section Fellow-in-Training

Brad Bemiss, MD
Section Member-at-Large

Diffuse Lung Disease & Lung Transplant Network

Interstitial Lung Disease Section

Idiopathic pulmonary fibrosis (IPF) is a fatal lung disease that affects an estimated 100,000 people in the United States alone. Despite the availability of two approved antifibrotic drugs, nintedanib and pirfenidone, there is still a need for effective treatments to improve patient outcomes.

The ISABELA 1 and 2 trials were two Phase III clinical trials designed to evaluate ziritaxestat, a novel autotaxin inhibitor, in patients with IPF. Unfortunately, both trials were terminated early after an interim analysis revealed a lack of efficacy and safety concerns. Specifically, neither dose of ziritaxestat showed any benefit on the rate of decline for FVC over 52 weeks. Moreover, the treatment with ziritaxestat showed no benefit on the reported secondary outcomes. Patients in the ziritaxestat groups experienced worse outcomes in terms of time to first respiratory- related hospitalization, respiratory- related mortality, and first acute IPF exacerbation. Pooled data for both trials showed higher all-cause mortality for the ziritaxestat groups in relation to placebo (Maher T, et al. JAMA. 2023;329[18]:1567).

These disappointing results highlight the challenges of developing effective treatments for IPF. The complexity of IPF as a disease, with multiple pathways contributing to its pathogenesis, makes it difficult to identify effective therapeutic targets. In addition, clinical trials for new treatments must also account for the availability of approved antifibrotic therapies, which creates an added challenge for clinical trial design.

Matthew Huang, MD
Section Fellow-in-Training

Brad Bemiss, MD
Section Member-at-Large

Airways Disorders Network

Pediatric Chest Medicine Section

For young adults with chronic health conditions, the process of transitioning to adult health care is complicated, resulting in frustration for patients and families, and clinicians, as well as increased morbidity and mortality (Varty et al. J Pediatr Nurs. 2020;55:201). As such, there have been efforts to determine practices that can minimize risk and improve satisfaction with the transition process.

The National Alliance to Advance Adolescent Health developed the “Got Transition” program with input from pediatric and adult clinicians, as well as patient advocates (White, et al. Six Core Elements of Health Care Transition™ 3.0. Washington, DC: Got Transition, The National Alliance to Advance Adolescent Health, July 2020). CF R.I.S.E is a similar program aimed specifically at improving the transition to adult care among patients with cystic fibrosis (www.cfrise.com). Got Transition provides the following recommendations pertinent to both pediatric and adult providers.

Pediatric clinics should start to assess transition readiness in early adolescence, and provide training pertinent to any skill gaps identified. This may include knowledge about condition-specific self-care skills, as well as navigation of the health care system. An individualized plan can then be developed, including timing of transition and identification of an appropriate adult provider.

The transfer should include communication between the pediatric and adult care providers prior to and, if needed, after the patient’s first appointment with the adult provider. Adult clinics can enhance the transition process by establishing a method to welcome transitioning young adult patients and orient them to the practice, addressing patient concerns regarding the transition, and assessing the patients’ self-management skills with resources provided, as needed.

Both pediatric and adult providers have a role in helping patients transition safely and smoothly from pediatric to adult care.

Sarah Cohen, MD
Section Fellow-in-Training

Airways Disorders Network

Pediatric Chest Medicine Section

For young adults with chronic health conditions, the process of transitioning to adult health care is complicated, resulting in frustration for patients and families, and clinicians, as well as increased morbidity and mortality (Varty et al. J Pediatr Nurs. 2020;55:201). As such, there have been efforts to determine practices that can minimize risk and improve satisfaction with the transition process.

The National Alliance to Advance Adolescent Health developed the “Got Transition” program with input from pediatric and adult clinicians, as well as patient advocates (White, et al. Six Core Elements of Health Care Transition™ 3.0. Washington, DC: Got Transition, The National Alliance to Advance Adolescent Health, July 2020). CF R.I.S.E is a similar program aimed specifically at improving the transition to adult care among patients with cystic fibrosis (www.cfrise.com). Got Transition provides the following recommendations pertinent to both pediatric and adult providers.

Pediatric clinics should start to assess transition readiness in early adolescence, and provide training pertinent to any skill gaps identified. This may include knowledge about condition-specific self-care skills, as well as navigation of the health care system. An individualized plan can then be developed, including timing of transition and identification of an appropriate adult provider.

The transfer should include communication between the pediatric and adult care providers prior to and, if needed, after the patient’s first appointment with the adult provider. Adult clinics can enhance the transition process by establishing a method to welcome transitioning young adult patients and orient them to the practice, addressing patient concerns regarding the transition, and assessing the patients’ self-management skills with resources provided, as needed.

Both pediatric and adult providers have a role in helping patients transition safely and smoothly from pediatric to adult care.

Sarah Cohen, MD
Section Fellow-in-Training

Airways Disorders Network

Pediatric Chest Medicine Section

For young adults with chronic health conditions, the process of transitioning to adult health care is complicated, resulting in frustration for patients and families, and clinicians, as well as increased morbidity and mortality (Varty et al. J Pediatr Nurs. 2020;55:201). As such, there have been efforts to determine practices that can minimize risk and improve satisfaction with the transition process.

The National Alliance to Advance Adolescent Health developed the “Got Transition” program with input from pediatric and adult clinicians, as well as patient advocates (White, et al. Six Core Elements of Health Care Transition™ 3.0. Washington, DC: Got Transition, The National Alliance to Advance Adolescent Health, July 2020). CF R.I.S.E is a similar program aimed specifically at improving the transition to adult care among patients with cystic fibrosis (www.cfrise.com). Got Transition provides the following recommendations pertinent to both pediatric and adult providers.

Pediatric clinics should start to assess transition readiness in early adolescence, and provide training pertinent to any skill gaps identified. This may include knowledge about condition-specific self-care skills, as well as navigation of the health care system. An individualized plan can then be developed, including timing of transition and identification of an appropriate adult provider.

The transfer should include communication between the pediatric and adult care providers prior to and, if needed, after the patient’s first appointment with the adult provider. Adult clinics can enhance the transition process by establishing a method to welcome transitioning young adult patients and orient them to the practice, addressing patient concerns regarding the transition, and assessing the patients’ self-management skills with resources provided, as needed.

Both pediatric and adult providers have a role in helping patients transition safely and smoothly from pediatric to adult care.

Sarah Cohen, MD
Section Fellow-in-Training

Since May, physicians in 21 states are no longer being asked broad mental health or substance abuse questions when they apply for a medical license. That’s a major shift that could ease doctors’ concerns about seeking treatment, according to the Dr. Lorna Breen Heroes› Foundation, a physician burnout prevention group that tracks such changes.

The foundation was named in honor of Lorna Breen, MD, an emergency medicine physician in New York City who died by suicide in April 2020 as the pandemic unfolded. The rate of suicide among physicians is twice that of the general population.

“The issue is not whether a physician may have had a serious or a mild mental illness ... but whether they have any disabilities that may affect their current work,” said Peter Yellowlees, MD, distinguished professor of psychiatry at the University of California, Davis. “Asking about any past mental illness episodes, which may have occurred years previously ... is simply discriminatory and is an example of the stigma associated with mental disorders.”

The Breen Foundation has been working with state medical boards and hospitals to remove stigmatizing mental health and substance abuse questions from licensing and credentialing applications.

Dr. Breen had told her sister and brother-in-law shortly before her suicide that she was afraid she could lose her license and the career she loved if the medical board found out that she had received inpatient mental health treatment, said J. Corey Feist, JD, MBA, her brother-in-law and cofounder and president of the foundation.

She wasn’t aware that New York was a state that didn’t ask physicians questions about their mental health, said Mr. Feist.

“That’s why we want to make it very clear to physicians which states continue to ask these questions and which ones don’t,” Mr. Feist said.

Many physicians share Dr. Breen’s concern about professional consequences.

Four in 10 physicians said that they did not seek help for burnout or depression because they worried that their employer or state medical board would find out, according to the Medscape ‘I Cry but No One Cares’: Physician Burnout & Depression Report 2023.

One Oregon emergency department physician said that informing her state medical board about an episode of mania resulted in public disclosures, a 4-month long investigation, lost income, and poorer work evaluations. Looking back on her decision to be transparent with the board, Susan Haney, MD, said that she was naive. “The board is not your friend.”

Fearing for her career, now-retired ob.gyn. Robyn Alley-Hay, MD, never disclosed on licensing applications that in the 1990s, she had been hospitalized and treated for depression. She stopped practicing medicine in 2014 and now works as a life coach.

“I hated those questions because I felt I could never tell the whole truth,” Dr. Alley-Hay said. “But I could always truthfully answer ‘no’ to questions about impairment. That was a line that I wouldn’t cross – if you’re impaired, you shouldn’t be practicing.”
 

Does the focus on current impairment protect the public?

New York, Texas, California, Montana, Illinois, and North Carolina are among the 21 states that either ask no health-related questions or ask only a single question to address physical and mental health, said Mr. Feist.

Most of these changes align with the 2018 Federation of State Medical Boards recommendations, said Joe Knickrehm, FSMB vice president of communications. “Application questions must focus only on current impairment and not on illness, diagnosis, or previous treatment in order to be compliant with the Americans With Disabilities Act,” states the FSMB.

Mental health questions were often added to licensing and credentialing applications out of a “misplaced desire to protect patients and families from clinicians who might not be fit to give care. Yet there is no evidence they serve that function,” said Mr. Feist.

Marian Hollingsworth, a patient safety advocate in California, says medical boards have a responsibility to ensure that doctors pose no risk or a negligible risk to the public. She questioned whether the medical boards can adequately protect the public if they only ask about medical conditions rather than mental illness or substance abuse.

“There’s a fine line between privacy and right to know for public protection. I would want to see the approving medical board have assurance from a treating professional that this physician is stable and is doing well with continued treatment,” said Ms. Hollingsworth.
 

Legislation requires that mental health questions be removed

In March, Virginia became the first state to enact a law that requires all health care profession regulatory boards, including medical boards, to remove or replace mental health questions on licensing, certification, and registration applications.

The law requires that boards use the following wording if they replace mental health questions: “Do you have any reason to believe you would pose a risk to the safety or well-being of patients?” “Are you able to perform the essential functions of your job with or without reasonable accommodations?”

The Illinois General Assembly passed a more limited bill in May that requires medical boards to remove or replace mental health questions on its licensing applications. Gov. J. B. Pritzker (D) is expected to sign the bill.

The Virginia Healthcare and Hospital Association, which represents more than 100 hospitals and health systems in the state, partnered with the Medical Society of Virginia and the Virginia Nurses Association to advocate for the new legislation.

“The reason that the Virginia coalition pushed for the law was because the state’s medical boards weren’t acting quickly enough. Although state laws vary about what medical boards can do, legislation isn’t necessary in most states to change licensing questions,” said Mr. Feist.

Virginia hospitals began working last year with the foundation to change their mental health questions on credentialing applications. About 20% of Virginia’s hospitals have completed the process, including four large health systems: Inova, UVA Health, Centerra, and Children’s Hospitals of King’s Daughters, said Mr. Feist.

The foundation also challenged Lisa MacLean, MD, a psychiatrist and chief clinical wellness officer at the Henry Ford Medical Group in Detroit, to review their credentialing application for any stigmatizing mental health questions.

Dr. MacLean told the American Medical Association that she had found one question that needed to be changed but that it took time to get through the hospital›s approval process. Ultimately, the wording was changed from “a diagnosis or treatment of a physical, mental, chemical dependency or emotional condition” to “a diagnosis or treatment of any condition which could impair your ability to practice medicine.”
 

National medical organizations back changes

The Joint Commission, which accredits hospitals, has emphasized since 2020 that it doesn’t require hospitals to ask about an applicant’s mental health history.

“We strongly encourage organizations to not ask about past history of mental health conditions or treatment,” the Commission said in a statement. “It is critical that we ensure health care workers can feel free to access mental health resources.”

The Joint Commission said it supports the FSMB recommendations and the AMA’s recommendation that questions about clinicians’ mental health be limited to “conditions that currently impair the clinicians’ ability to perform their job.”

More than 40 professional medical organizations, including the American Academy of Family Physicians and the American Psychiatric Association, signed a joint statement in 2020 calling for changes in disclosure rules about mental health.

“The backing of major organizations is helpful because it’s changing the conversation that occurs within and outside the house of medicine,” said Mr. Feist.
 

Should doctors answer mental health questions?

Many states continue to ask questions about hospitalization and mental health diagnoses or treatment on their licensing and credentialing applications.

Yellowlees advises doctors to “be honest and not lie or deny past mental health problems, as medical boards tend to take a very serious view of physicians who do not tell the truth.”

However, the questions asked by medical boards can vary by state. “If it’s possible, physicians can give accurate but minimal information while trying to focus mainly on their current work capacity,” said Dr. Yellowlees.

He also suggested that physicians who are uncertain about how to respond to mental health questions consider obtaining advice from lawyers accustomed to working with the relevant medical boards.

Physicians who want to get involved in removing licensing and credentialing barriers to mental health care can find resources here and here.

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

Since May, physicians in 21 states are no longer being asked broad mental health or substance abuse questions when they apply for a medical license. That’s a major shift that could ease doctors’ concerns about seeking treatment, according to the Dr. Lorna Breen Heroes› Foundation, a physician burnout prevention group that tracks such changes.

The foundation was named in honor of Lorna Breen, MD, an emergency medicine physician in New York City who died by suicide in April 2020 as the pandemic unfolded. The rate of suicide among physicians is twice that of the general population.

“The issue is not whether a physician may have had a serious or a mild mental illness ... but whether they have any disabilities that may affect their current work,” said Peter Yellowlees, MD, distinguished professor of psychiatry at the University of California, Davis. “Asking about any past mental illness episodes, which may have occurred years previously ... is simply discriminatory and is an example of the stigma associated with mental disorders.”

The Breen Foundation has been working with state medical boards and hospitals to remove stigmatizing mental health and substance abuse questions from licensing and credentialing applications.

Dr. Breen had told her sister and brother-in-law shortly before her suicide that she was afraid she could lose her license and the career she loved if the medical board found out that she had received inpatient mental health treatment, said J. Corey Feist, JD, MBA, her brother-in-law and cofounder and president of the foundation.

She wasn’t aware that New York was a state that didn’t ask physicians questions about their mental health, said Mr. Feist.

“That’s why we want to make it very clear to physicians which states continue to ask these questions and which ones don’t,” Mr. Feist said.

Many physicians share Dr. Breen’s concern about professional consequences.

Four in 10 physicians said that they did not seek help for burnout or depression because they worried that their employer or state medical board would find out, according to the Medscape ‘I Cry but No One Cares’: Physician Burnout & Depression Report 2023.

One Oregon emergency department physician said that informing her state medical board about an episode of mania resulted in public disclosures, a 4-month long investigation, lost income, and poorer work evaluations. Looking back on her decision to be transparent with the board, Susan Haney, MD, said that she was naive. “The board is not your friend.”

Fearing for her career, now-retired ob.gyn. Robyn Alley-Hay, MD, never disclosed on licensing applications that in the 1990s, she had been hospitalized and treated for depression. She stopped practicing medicine in 2014 and now works as a life coach.

“I hated those questions because I felt I could never tell the whole truth,” Dr. Alley-Hay said. “But I could always truthfully answer ‘no’ to questions about impairment. That was a line that I wouldn’t cross – if you’re impaired, you shouldn’t be practicing.”
 

Does the focus on current impairment protect the public?

New York, Texas, California, Montana, Illinois, and North Carolina are among the 21 states that either ask no health-related questions or ask only a single question to address physical and mental health, said Mr. Feist.

Most of these changes align with the 2018 Federation of State Medical Boards recommendations, said Joe Knickrehm, FSMB vice president of communications. “Application questions must focus only on current impairment and not on illness, diagnosis, or previous treatment in order to be compliant with the Americans With Disabilities Act,” states the FSMB.

Mental health questions were often added to licensing and credentialing applications out of a “misplaced desire to protect patients and families from clinicians who might not be fit to give care. Yet there is no evidence they serve that function,” said Mr. Feist.

Marian Hollingsworth, a patient safety advocate in California, says medical boards have a responsibility to ensure that doctors pose no risk or a negligible risk to the public. She questioned whether the medical boards can adequately protect the public if they only ask about medical conditions rather than mental illness or substance abuse.

“There’s a fine line between privacy and right to know for public protection. I would want to see the approving medical board have assurance from a treating professional that this physician is stable and is doing well with continued treatment,” said Ms. Hollingsworth.
 

Legislation requires that mental health questions be removed

In March, Virginia became the first state to enact a law that requires all health care profession regulatory boards, including medical boards, to remove or replace mental health questions on licensing, certification, and registration applications.

The law requires that boards use the following wording if they replace mental health questions: “Do you have any reason to believe you would pose a risk to the safety or well-being of patients?” “Are you able to perform the essential functions of your job with or without reasonable accommodations?”

The Illinois General Assembly passed a more limited bill in May that requires medical boards to remove or replace mental health questions on its licensing applications. Gov. J. B. Pritzker (D) is expected to sign the bill.

The Virginia Healthcare and Hospital Association, which represents more than 100 hospitals and health systems in the state, partnered with the Medical Society of Virginia and the Virginia Nurses Association to advocate for the new legislation.

“The reason that the Virginia coalition pushed for the law was because the state’s medical boards weren’t acting quickly enough. Although state laws vary about what medical boards can do, legislation isn’t necessary in most states to change licensing questions,” said Mr. Feist.

Virginia hospitals began working last year with the foundation to change their mental health questions on credentialing applications. About 20% of Virginia’s hospitals have completed the process, including four large health systems: Inova, UVA Health, Centerra, and Children’s Hospitals of King’s Daughters, said Mr. Feist.

The foundation also challenged Lisa MacLean, MD, a psychiatrist and chief clinical wellness officer at the Henry Ford Medical Group in Detroit, to review their credentialing application for any stigmatizing mental health questions.

Dr. MacLean told the American Medical Association that she had found one question that needed to be changed but that it took time to get through the hospital›s approval process. Ultimately, the wording was changed from “a diagnosis or treatment of a physical, mental, chemical dependency or emotional condition” to “a diagnosis or treatment of any condition which could impair your ability to practice medicine.”
 

National medical organizations back changes

The Joint Commission, which accredits hospitals, has emphasized since 2020 that it doesn’t require hospitals to ask about an applicant’s mental health history.

“We strongly encourage organizations to not ask about past history of mental health conditions or treatment,” the Commission said in a statement. “It is critical that we ensure health care workers can feel free to access mental health resources.”

The Joint Commission said it supports the FSMB recommendations and the AMA’s recommendation that questions about clinicians’ mental health be limited to “conditions that currently impair the clinicians’ ability to perform their job.”

More than 40 professional medical organizations, including the American Academy of Family Physicians and the American Psychiatric Association, signed a joint statement in 2020 calling for changes in disclosure rules about mental health.

“The backing of major organizations is helpful because it’s changing the conversation that occurs within and outside the house of medicine,” said Mr. Feist.
 

Should doctors answer mental health questions?

Many states continue to ask questions about hospitalization and mental health diagnoses or treatment on their licensing and credentialing applications.

Yellowlees advises doctors to “be honest and not lie or deny past mental health problems, as medical boards tend to take a very serious view of physicians who do not tell the truth.”

However, the questions asked by medical boards can vary by state. “If it’s possible, physicians can give accurate but minimal information while trying to focus mainly on their current work capacity,” said Dr. Yellowlees.

He also suggested that physicians who are uncertain about how to respond to mental health questions consider obtaining advice from lawyers accustomed to working with the relevant medical boards.

Physicians who want to get involved in removing licensing and credentialing barriers to mental health care can find resources here and here.

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

Since May, physicians in 21 states are no longer being asked broad mental health or substance abuse questions when they apply for a medical license. That’s a major shift that could ease doctors’ concerns about seeking treatment, according to the Dr. Lorna Breen Heroes› Foundation, a physician burnout prevention group that tracks such changes.

The foundation was named in honor of Lorna Breen, MD, an emergency medicine physician in New York City who died by suicide in April 2020 as the pandemic unfolded. The rate of suicide among physicians is twice that of the general population.

“The issue is not whether a physician may have had a serious or a mild mental illness ... but whether they have any disabilities that may affect their current work,” said Peter Yellowlees, MD, distinguished professor of psychiatry at the University of California, Davis. “Asking about any past mental illness episodes, which may have occurred years previously ... is simply discriminatory and is an example of the stigma associated with mental disorders.”

The Breen Foundation has been working with state medical boards and hospitals to remove stigmatizing mental health and substance abuse questions from licensing and credentialing applications.

Dr. Breen had told her sister and brother-in-law shortly before her suicide that she was afraid she could lose her license and the career she loved if the medical board found out that she had received inpatient mental health treatment, said J. Corey Feist, JD, MBA, her brother-in-law and cofounder and president of the foundation.

She wasn’t aware that New York was a state that didn’t ask physicians questions about their mental health, said Mr. Feist.

“That’s why we want to make it very clear to physicians which states continue to ask these questions and which ones don’t,” Mr. Feist said.

Many physicians share Dr. Breen’s concern about professional consequences.

Four in 10 physicians said that they did not seek help for burnout or depression because they worried that their employer or state medical board would find out, according to the Medscape ‘I Cry but No One Cares’: Physician Burnout & Depression Report 2023.

One Oregon emergency department physician said that informing her state medical board about an episode of mania resulted in public disclosures, a 4-month long investigation, lost income, and poorer work evaluations. Looking back on her decision to be transparent with the board, Susan Haney, MD, said that she was naive. “The board is not your friend.”

Fearing for her career, now-retired ob.gyn. Robyn Alley-Hay, MD, never disclosed on licensing applications that in the 1990s, she had been hospitalized and treated for depression. She stopped practicing medicine in 2014 and now works as a life coach.

“I hated those questions because I felt I could never tell the whole truth,” Dr. Alley-Hay said. “But I could always truthfully answer ‘no’ to questions about impairment. That was a line that I wouldn’t cross – if you’re impaired, you shouldn’t be practicing.”
 

Does the focus on current impairment protect the public?

New York, Texas, California, Montana, Illinois, and North Carolina are among the 21 states that either ask no health-related questions or ask only a single question to address physical and mental health, said Mr. Feist.

Most of these changes align with the 2018 Federation of State Medical Boards recommendations, said Joe Knickrehm, FSMB vice president of communications. “Application questions must focus only on current impairment and not on illness, diagnosis, or previous treatment in order to be compliant with the Americans With Disabilities Act,” states the FSMB.

Mental health questions were often added to licensing and credentialing applications out of a “misplaced desire to protect patients and families from clinicians who might not be fit to give care. Yet there is no evidence they serve that function,” said Mr. Feist.

Marian Hollingsworth, a patient safety advocate in California, says medical boards have a responsibility to ensure that doctors pose no risk or a negligible risk to the public. She questioned whether the medical boards can adequately protect the public if they only ask about medical conditions rather than mental illness or substance abuse.

“There’s a fine line between privacy and right to know for public protection. I would want to see the approving medical board have assurance from a treating professional that this physician is stable and is doing well with continued treatment,” said Ms. Hollingsworth.
 

Legislation requires that mental health questions be removed

In March, Virginia became the first state to enact a law that requires all health care profession regulatory boards, including medical boards, to remove or replace mental health questions on licensing, certification, and registration applications.

The law requires that boards use the following wording if they replace mental health questions: “Do you have any reason to believe you would pose a risk to the safety or well-being of patients?” “Are you able to perform the essential functions of your job with or without reasonable accommodations?”

The Illinois General Assembly passed a more limited bill in May that requires medical boards to remove or replace mental health questions on its licensing applications. Gov. J. B. Pritzker (D) is expected to sign the bill.

The Virginia Healthcare and Hospital Association, which represents more than 100 hospitals and health systems in the state, partnered with the Medical Society of Virginia and the Virginia Nurses Association to advocate for the new legislation.

“The reason that the Virginia coalition pushed for the law was because the state’s medical boards weren’t acting quickly enough. Although state laws vary about what medical boards can do, legislation isn’t necessary in most states to change licensing questions,” said Mr. Feist.

Virginia hospitals began working last year with the foundation to change their mental health questions on credentialing applications. About 20% of Virginia’s hospitals have completed the process, including four large health systems: Inova, UVA Health, Centerra, and Children’s Hospitals of King’s Daughters, said Mr. Feist.

The foundation also challenged Lisa MacLean, MD, a psychiatrist and chief clinical wellness officer at the Henry Ford Medical Group in Detroit, to review their credentialing application for any stigmatizing mental health questions.

Dr. MacLean told the American Medical Association that she had found one question that needed to be changed but that it took time to get through the hospital›s approval process. Ultimately, the wording was changed from “a diagnosis or treatment of a physical, mental, chemical dependency or emotional condition” to “a diagnosis or treatment of any condition which could impair your ability to practice medicine.”
 

National medical organizations back changes

The Joint Commission, which accredits hospitals, has emphasized since 2020 that it doesn’t require hospitals to ask about an applicant’s mental health history.

“We strongly encourage organizations to not ask about past history of mental health conditions or treatment,” the Commission said in a statement. “It is critical that we ensure health care workers can feel free to access mental health resources.”

The Joint Commission said it supports the FSMB recommendations and the AMA’s recommendation that questions about clinicians’ mental health be limited to “conditions that currently impair the clinicians’ ability to perform their job.”

More than 40 professional medical organizations, including the American Academy of Family Physicians and the American Psychiatric Association, signed a joint statement in 2020 calling for changes in disclosure rules about mental health.

“The backing of major organizations is helpful because it’s changing the conversation that occurs within and outside the house of medicine,” said Mr. Feist.
 

Should doctors answer mental health questions?

Many states continue to ask questions about hospitalization and mental health diagnoses or treatment on their licensing and credentialing applications.

Yellowlees advises doctors to “be honest and not lie or deny past mental health problems, as medical boards tend to take a very serious view of physicians who do not tell the truth.”

However, the questions asked by medical boards can vary by state. “If it’s possible, physicians can give accurate but minimal information while trying to focus mainly on their current work capacity,” said Dr. Yellowlees.

He also suggested that physicians who are uncertain about how to respond to mental health questions consider obtaining advice from lawyers accustomed to working with the relevant medical boards.

Physicians who want to get involved in removing licensing and credentialing barriers to mental health care can find resources here and here.

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

If you’re a regular reader of the journal CHEST^®, you may have noticed an exciting new initiative for clinicians looking to enhance their understanding of the latest advances in research, improve their clinical knowledge, and earn credits toward certification: the opportunity to earn continuing medical education (CME) credits from monthly journal issues. Launched in late 2022, this new initiative was inspired by the desire to complement the excellent clinical work already being done by readers of the journal.

“Essentially, the idea was that CHEST journal readers are doing the work to keep themselves current and stay excellent doctors, and they should get credit for that work,” said Amy Morris, MD, FCCP, Chair of the CHEST Journal CME Editorial Board. “We all have to do CME, so why not get some credit for the reading that we do on a regular basis to stay current, and add some additional value for journal readers?”

But the initiative isn’t just an opportunity to offer free credits. The goal of the CME Editorial Board is to create greater awareness of important research and offer readers regular opportunities to improve their knowledge in a wide variety of specialties and clinical areas.

“We try to rotate topics month to month, but more than that, we look for articles that either have a broad impact on current clinical practice for a lot of providers, or convey some particular new interest – a way for our readers to learn about something new and interesting,” she said. “We avoid trivia, essentially “gotcha” questions that simply ensure you read the article, but rather focus on questions that reinforce key points in the article.”

To ensure the content covers a wide breadth of topics, the CME Editorial Board – comprising leaders from pulmonary, critical care, and sleep medicine to ensure the process meets a high clinical standard – reviews articles that are slated for publication monthly and selects one or more manuscripts with impactful findings. Once the articles are selected, they are sent to a cohort of experienced question writers sourced from the Network specialty areas within CHEST to draft clinically relevant questions. The final questions and answers then are returned to the Board for a careful review of their accuracy, quality, and relevancy.

Readers can visit chestnet.org/journalcme every month to see a new selection of CME-eligible articles and access questions from past issues – an offering that will only grow more robust as the initiative progresses.

“We have a regularly accumulating collection of questions such that folks who read the journal every month will always have questions to answer, and those who prefer to do some reading and CME acquisition in bulk can find a rich database of useful, interesting articles that maybe they didn’t have a chance to read when they first came out,” said Dr. Morris.

As the initiative evolves, so too will the content selected and the questions offered – a process readers will have an integral role in guiding. After answering the questions, readers will have the opportunity to provide feedback on whether the activity achieved its learning objectives, future topics to cover, and more.

Although the initiative will evolve with this feedback, said Dr. Morris, one thing remains constant: the commitment of the team developing these resources to their fellow clinicians. “We couldn’t do this without a dedicated team and a lot of volunteer time from individuals who really care about education and clinical practice, and making the literature relevant to clinical practice. It takes a lot of time and effort, and I so appreciate the work those individuals are doing.”

To access the latest CME-eligible research, and review past questions, visit chestnet.org/journalcme.

If you’re a regular reader of the journal CHEST^®, you may have noticed an exciting new initiative for clinicians looking to enhance their understanding of the latest advances in research, improve their clinical knowledge, and earn credits toward certification: the opportunity to earn continuing medical education (CME) credits from monthly journal issues. Launched in late 2022, this new initiative was inspired by the desire to complement the excellent clinical work already being done by readers of the journal.

“Essentially, the idea was that CHEST journal readers are doing the work to keep themselves current and stay excellent doctors, and they should get credit for that work,” said Amy Morris, MD, FCCP, Chair of the CHEST Journal CME Editorial Board. “We all have to do CME, so why not get some credit for the reading that we do on a regular basis to stay current, and add some additional value for journal readers?”

But the initiative isn’t just an opportunity to offer free credits. The goal of the CME Editorial Board is to create greater awareness of important research and offer readers regular opportunities to improve their knowledge in a wide variety of specialties and clinical areas.

“We try to rotate topics month to month, but more than that, we look for articles that either have a broad impact on current clinical practice for a lot of providers, or convey some particular new interest – a way for our readers to learn about something new and interesting,” she said. “We avoid trivia, essentially “gotcha” questions that simply ensure you read the article, but rather focus on questions that reinforce key points in the article.”

To ensure the content covers a wide breadth of topics, the CME Editorial Board – comprising leaders from pulmonary, critical care, and sleep medicine to ensure the process meets a high clinical standard – reviews articles that are slated for publication monthly and selects one or more manuscripts with impactful findings. Once the articles are selected, they are sent to a cohort of experienced question writers sourced from the Network specialty areas within CHEST to draft clinically relevant questions. The final questions and answers then are returned to the Board for a careful review of their accuracy, quality, and relevancy.

Readers can visit chestnet.org/journalcme every month to see a new selection of CME-eligible articles and access questions from past issues – an offering that will only grow more robust as the initiative progresses.

“We have a regularly accumulating collection of questions such that folks who read the journal every month will always have questions to answer, and those who prefer to do some reading and CME acquisition in bulk can find a rich database of useful, interesting articles that maybe they didn’t have a chance to read when they first came out,” said Dr. Morris.

As the initiative evolves, so too will the content selected and the questions offered – a process readers will have an integral role in guiding. After answering the questions, readers will have the opportunity to provide feedback on whether the activity achieved its learning objectives, future topics to cover, and more.

Although the initiative will evolve with this feedback, said Dr. Morris, one thing remains constant: the commitment of the team developing these resources to their fellow clinicians. “We couldn’t do this without a dedicated team and a lot of volunteer time from individuals who really care about education and clinical practice, and making the literature relevant to clinical practice. It takes a lot of time and effort, and I so appreciate the work those individuals are doing.”

To access the latest CME-eligible research, and review past questions, visit chestnet.org/journalcme.

If you’re a regular reader of the journal CHEST^®, you may have noticed an exciting new initiative for clinicians looking to enhance their understanding of the latest advances in research, improve their clinical knowledge, and earn credits toward certification: the opportunity to earn continuing medical education (CME) credits from monthly journal issues. Launched in late 2022, this new initiative was inspired by the desire to complement the excellent clinical work already being done by readers of the journal.

“Essentially, the idea was that CHEST journal readers are doing the work to keep themselves current and stay excellent doctors, and they should get credit for that work,” said Amy Morris, MD, FCCP, Chair of the CHEST Journal CME Editorial Board. “We all have to do CME, so why not get some credit for the reading that we do on a regular basis to stay current, and add some additional value for journal readers?”

But the initiative isn’t just an opportunity to offer free credits. The goal of the CME Editorial Board is to create greater awareness of important research and offer readers regular opportunities to improve their knowledge in a wide variety of specialties and clinical areas.

“We try to rotate topics month to month, but more than that, we look for articles that either have a broad impact on current clinical practice for a lot of providers, or convey some particular new interest – a way for our readers to learn about something new and interesting,” she said. “We avoid trivia, essentially “gotcha” questions that simply ensure you read the article, but rather focus on questions that reinforce key points in the article.”

To ensure the content covers a wide breadth of topics, the CME Editorial Board – comprising leaders from pulmonary, critical care, and sleep medicine to ensure the process meets a high clinical standard – reviews articles that are slated for publication monthly and selects one or more manuscripts with impactful findings. Once the articles are selected, they are sent to a cohort of experienced question writers sourced from the Network specialty areas within CHEST to draft clinically relevant questions. The final questions and answers then are returned to the Board for a careful review of their accuracy, quality, and relevancy.

Readers can visit chestnet.org/journalcme every month to see a new selection of CME-eligible articles and access questions from past issues – an offering that will only grow more robust as the initiative progresses.

“We have a regularly accumulating collection of questions such that folks who read the journal every month will always have questions to answer, and those who prefer to do some reading and CME acquisition in bulk can find a rich database of useful, interesting articles that maybe they didn’t have a chance to read when they first came out,” said Dr. Morris.

As the initiative evolves, so too will the content selected and the questions offered – a process readers will have an integral role in guiding. After answering the questions, readers will have the opportunity to provide feedback on whether the activity achieved its learning objectives, future topics to cover, and more.

Although the initiative will evolve with this feedback, said Dr. Morris, one thing remains constant: the commitment of the team developing these resources to their fellow clinicians. “We couldn’t do this without a dedicated team and a lot of volunteer time from individuals who really care about education and clinical practice, and making the literature relevant to clinical practice. It takes a lot of time and effort, and I so appreciate the work those individuals are doing.”

To access the latest CME-eligible research, and review past questions, visit chestnet.org/journalcme.

Maximize your learning experiences at CHEST 2023 (October 8-11 in Hawai’i) by attending a Master Class. Taking place before and after the annual meeting, these advanced-level courses on October 7, 12, and 13 will give you a deep dive into specific clinical areas with the guidance of distinguished faculty.

Replacing the “postgraduate courses” offered in previous years, the new Master Classes are open to both CHEST 2023 registrants and nonregistrants. Faculty will explore complex topics, and you will have the opportunity to participate in intensive case-based discussions with master clinicians.

“At CHEST, we’re always looking for ways to tailor the learning experience for the folks who come to the annual meeting. These Master Classes will be particularly useful for seasoned providers who are looking for a challenging education experience,” said Education Committee Chair, Amy E. Morris, MD, FCCP.

These classes will have some didactic elements, but a lot of time will be spent reviewing challenging cases that aren’t easily addressed by guidelines or a quick read of the literature and will go beyond what’s easily found online.

“Master Classes will focus on deeper-dive learning, in-depth pathophysiology and research, and conversational, interactive discussions,” Dr. Morris said.

She encourages everyone to seize the opportunity to attend these classes taught by “true masters of clinical medicine” in Hawai’i after years of strictly virtual learning that didn’t allow for as much interactivity.

“That’s why we’re in medicine – to learn from each other. This is an opportunity not just to learn facts or new ways of doing things, but a chance to interact on a personal level with providers from around the globe and master clinicians who are not always available to us in person,” she said. “In an increasingly digital world, an opportunity like this is harder to come by these days.”

Make the most of your trip to Hawai’i with advanced learning taught by highly regarded speakers. Take a look at the Master Classes available to you this year, and add a course to your meeting registration. For more information on CHEST 2023 educational offerings, browse the preliminary program at chestmeeting.chestnet.org.
 

October 7 (held in Honolulu on O’ahu)

How I Do It – Challenging Cases in Sleep Medicine

Faculty: Babak Mokhlesi, MD, FCCP; Timothy Morgenthaler, MD, FCCP; Lauren A. Tobias, MD, FCCP; and Lisa F. Wolfe, MD.

Interstitial Lung Disease

Faculty: Ayodeji Adegunsoye, MD, FCCP; Jonathan H. Chung, MD; Tejaswini Kulkarni, MD, MBBS, FCCP; Ganesh Raghu, MD; and Mary Beth Scholand, MD, FCCP.

Advances in Lung Cancer – Rocketing Forward With the Cancer Moonshot

Faculty: A. Christine Argento, MD, FCCP; Frank C. Detterbeck, MD, FCCP; Gerard A. Silvestri, MD, Master FCCP; and Lynn T. Tanoue, MD, FCCP.

Pulmonary Hypertension – Expert Didactics and Discussion

Faculty: Jean M. Elwing, MD, FCCP; Peter Leary, MD, PhD; and Namita Sood, MBBCh, FCCP.

October 12-13 (held in Wailea on Maui)

2023 Pulmonary Literature Review and Complex Case Presentations – An Interactive Course With the Masters in Pulmonology

Faculty: Doreen Addrizzo-Harris, MD, FCCP; Kevin M. Chan, MD, FCCP; Stephanie M. Levine, MD, FCCP; Diego J. Maselli, MD, FCCP; Marcos I. Restrepo, MD, PhD, FCCP; Linda Rogers, MD, FCCP; Gerard A. Silvestri, MD, Master FCCP; and David J. Steiger, MBChB, FCCP.

Avoiding Catastrophic Crisis in the ICU and Mastering Critical Care

Faculty: Kristin Burkart, MD, MS, FCCP; David Janz, MD; Patricia A. Kritek, MD; Matthew E. Prekker, MD; Nida Qadir, MD; Todd W. Rice, MD, FCCP; and Jonathan Sevransky, MD, FCCP.

CHEST 2023 hands-on and inter­active learning opportunities

By experiencing the latest developments for yourself through several different kinds of interactive sessions, you’ll take home actionable information that you can apply directly to your patient care. Explore the many ticketed sessions available to add on to your CHEST 2023 registration.

Simulation sessions

Choose from 25 different sessions offering hands-on experience with procedures relevant to your clinical practice.

Problem-based learning sessions

Supplement your schedule with these unique sessions, where you’ll solve real-world clinical problems in small groups and refine your expertise on clinical topics.

Meet the Professor sessions

Connect with leading chest medicine experts during these limited-capacity discussions capped at 24 registrants per session.

Maximize your learning experiences at CHEST 2023 (October 8-11 in Hawai’i) by attending a Master Class. Taking place before and after the annual meeting, these advanced-level courses on October 7, 12, and 13 will give you a deep dive into specific clinical areas with the guidance of distinguished faculty.

Replacing the “postgraduate courses” offered in previous years, the new Master Classes are open to both CHEST 2023 registrants and nonregistrants. Faculty will explore complex topics, and you will have the opportunity to participate in intensive case-based discussions with master clinicians.

“At CHEST, we’re always looking for ways to tailor the learning experience for the folks who come to the annual meeting. These Master Classes will be particularly useful for seasoned providers who are looking for a challenging education experience,” said Education Committee Chair, Amy E. Morris, MD, FCCP.

These classes will have some didactic elements, but a lot of time will be spent reviewing challenging cases that aren’t easily addressed by guidelines or a quick read of the literature and will go beyond what’s easily found online.

“Master Classes will focus on deeper-dive learning, in-depth pathophysiology and research, and conversational, interactive discussions,” Dr. Morris said.

She encourages everyone to seize the opportunity to attend these classes taught by “true masters of clinical medicine” in Hawai’i after years of strictly virtual learning that didn’t allow for as much interactivity.

“That’s why we’re in medicine – to learn from each other. This is an opportunity not just to learn facts or new ways of doing things, but a chance to interact on a personal level with providers from around the globe and master clinicians who are not always available to us in person,” she said. “In an increasingly digital world, an opportunity like this is harder to come by these days.”

Make the most of your trip to Hawai’i with advanced learning taught by highly regarded speakers. Take a look at the Master Classes available to you this year, and add a course to your meeting registration. For more information on CHEST 2023 educational offerings, browse the preliminary program at chestmeeting.chestnet.org.
 

October 7 (held in Honolulu on O’ahu)

How I Do It – Challenging Cases in Sleep Medicine

Faculty: Babak Mokhlesi, MD, FCCP; Timothy Morgenthaler, MD, FCCP; Lauren A. Tobias, MD, FCCP; and Lisa F. Wolfe, MD.

Interstitial Lung Disease

Faculty: Ayodeji Adegunsoye, MD, FCCP; Jonathan H. Chung, MD; Tejaswini Kulkarni, MD, MBBS, FCCP; Ganesh Raghu, MD; and Mary Beth Scholand, MD, FCCP.

Advances in Lung Cancer – Rocketing Forward With the Cancer Moonshot

Faculty: A. Christine Argento, MD, FCCP; Frank C. Detterbeck, MD, FCCP; Gerard A. Silvestri, MD, Master FCCP; and Lynn T. Tanoue, MD, FCCP.

Pulmonary Hypertension – Expert Didactics and Discussion

Faculty: Jean M. Elwing, MD, FCCP; Peter Leary, MD, PhD; and Namita Sood, MBBCh, FCCP.

October 12-13 (held in Wailea on Maui)

2023 Pulmonary Literature Review and Complex Case Presentations – An Interactive Course With the Masters in Pulmonology

Faculty: Doreen Addrizzo-Harris, MD, FCCP; Kevin M. Chan, MD, FCCP; Stephanie M. Levine, MD, FCCP; Diego J. Maselli, MD, FCCP; Marcos I. Restrepo, MD, PhD, FCCP; Linda Rogers, MD, FCCP; Gerard A. Silvestri, MD, Master FCCP; and David J. Steiger, MBChB, FCCP.

Avoiding Catastrophic Crisis in the ICU and Mastering Critical Care

Faculty: Kristin Burkart, MD, MS, FCCP; David Janz, MD; Patricia A. Kritek, MD; Matthew E. Prekker, MD; Nida Qadir, MD; Todd W. Rice, MD, FCCP; and Jonathan Sevransky, MD, FCCP.

CHEST 2023 hands-on and inter­active learning opportunities

By experiencing the latest developments for yourself through several different kinds of interactive sessions, you’ll take home actionable information that you can apply directly to your patient care. Explore the many ticketed sessions available to add on to your CHEST 2023 registration.

Simulation sessions

Choose from 25 different sessions offering hands-on experience with procedures relevant to your clinical practice.

Problem-based learning sessions

Supplement your schedule with these unique sessions, where you’ll solve real-world clinical problems in small groups and refine your expertise on clinical topics.

Meet the Professor sessions

Connect with leading chest medicine experts during these limited-capacity discussions capped at 24 registrants per session.

Maximize your learning experiences at CHEST 2023 (October 8-11 in Hawai’i) by attending a Master Class. Taking place before and after the annual meeting, these advanced-level courses on October 7, 12, and 13 will give you a deep dive into specific clinical areas with the guidance of distinguished faculty.

Replacing the “postgraduate courses” offered in previous years, the new Master Classes are open to both CHEST 2023 registrants and nonregistrants. Faculty will explore complex topics, and you will have the opportunity to participate in intensive case-based discussions with master clinicians.

“At CHEST, we’re always looking for ways to tailor the learning experience for the folks who come to the annual meeting. These Master Classes will be particularly useful for seasoned providers who are looking for a challenging education experience,” said Education Committee Chair, Amy E. Morris, MD, FCCP.

These classes will have some didactic elements, but a lot of time will be spent reviewing challenging cases that aren’t easily addressed by guidelines or a quick read of the literature and will go beyond what’s easily found online.

“Master Classes will focus on deeper-dive learning, in-depth pathophysiology and research, and conversational, interactive discussions,” Dr. Morris said.

She encourages everyone to seize the opportunity to attend these classes taught by “true masters of clinical medicine” in Hawai’i after years of strictly virtual learning that didn’t allow for as much interactivity.

“That’s why we’re in medicine – to learn from each other. This is an opportunity not just to learn facts or new ways of doing things, but a chance to interact on a personal level with providers from around the globe and master clinicians who are not always available to us in person,” she said. “In an increasingly digital world, an opportunity like this is harder to come by these days.”

Make the most of your trip to Hawai’i with advanced learning taught by highly regarded speakers. Take a look at the Master Classes available to you this year, and add a course to your meeting registration. For more information on CHEST 2023 educational offerings, browse the preliminary program at chestmeeting.chestnet.org.
 

October 7 (held in Honolulu on O’ahu)

How I Do It – Challenging Cases in Sleep Medicine

Faculty: Babak Mokhlesi, MD, FCCP; Timothy Morgenthaler, MD, FCCP; Lauren A. Tobias, MD, FCCP; and Lisa F. Wolfe, MD.

Interstitial Lung Disease

Faculty: Ayodeji Adegunsoye, MD, FCCP; Jonathan H. Chung, MD; Tejaswini Kulkarni, MD, MBBS, FCCP; Ganesh Raghu, MD; and Mary Beth Scholand, MD, FCCP.

Advances in Lung Cancer – Rocketing Forward With the Cancer Moonshot

Faculty: A. Christine Argento, MD, FCCP; Frank C. Detterbeck, MD, FCCP; Gerard A. Silvestri, MD, Master FCCP; and Lynn T. Tanoue, MD, FCCP.

Pulmonary Hypertension – Expert Didactics and Discussion

Faculty: Jean M. Elwing, MD, FCCP; Peter Leary, MD, PhD; and Namita Sood, MBBCh, FCCP.

October 12-13 (held in Wailea on Maui)

2023 Pulmonary Literature Review and Complex Case Presentations – An Interactive Course With the Masters in Pulmonology

Faculty: Doreen Addrizzo-Harris, MD, FCCP; Kevin M. Chan, MD, FCCP; Stephanie M. Levine, MD, FCCP; Diego J. Maselli, MD, FCCP; Marcos I. Restrepo, MD, PhD, FCCP; Linda Rogers, MD, FCCP; Gerard A. Silvestri, MD, Master FCCP; and David J. Steiger, MBChB, FCCP.

Avoiding Catastrophic Crisis in the ICU and Mastering Critical Care

Faculty: Kristin Burkart, MD, MS, FCCP; David Janz, MD; Patricia A. Kritek, MD; Matthew E. Prekker, MD; Nida Qadir, MD; Todd W. Rice, MD, FCCP; and Jonathan Sevransky, MD, FCCP.

CHEST 2023 hands-on and inter­active learning opportunities

By experiencing the latest developments for yourself through several different kinds of interactive sessions, you’ll take home actionable information that you can apply directly to your patient care. Explore the many ticketed sessions available to add on to your CHEST 2023 registration.

Simulation sessions

Choose from 25 different sessions offering hands-on experience with procedures relevant to your clinical practice.

Problem-based learning sessions

Supplement your schedule with these unique sessions, where you’ll solve real-world clinical problems in small groups and refine your expertise on clinical topics.

Meet the Professor sessions

Connect with leading chest medicine experts during these limited-capacity discussions capped at 24 registrants per session.

When we celebrated Women’s History Month in March, Drs. Carolyn D’Ambrosio, Aneesa Das, and I discussed our experiences as women in chest medicine and why connecting is so important. We touched on the critical role of mentors. This conversation prompted me to dedicate this President’s column to the value of mentorship. The conversation is available on the CHEST YouTube for viewing.

Pursuing a career in medicine is not something you do on your own, and I have been fortunate to have had a strong support system. I think many of us who have been successful and fulfilled in our careers can say we were blessed by having great mentors along the way.

I have been blessed in having mentors who were both within my institution and outside, but one of the most important places that I found mentors was through my involvement with CHEST. It is critically important to find a mentor or mentors who can guide you through the initial phases of your career. It is also very important to allow yourself time to be a mentor to those who need you.

To the junior faculty or trainees who have yet to connect with someone to provide guidance, I cannot stress enough the importance of getting involved in an organization like CHEST.

The best way to begin is to attend the annual meeting. Know that you are invited to approach any member of CHEST leadership, introduce yourself, and tell us that you want to get involved. (Conveniently, registration for CHEST 2023 in Hawaii just opened.)

I genuinely believe our community would say yes to anyone looking for guidance.

To my colleagues who are established in their careers, I am issuing a personal request (and a bit of a challenge). Before the upcoming annual meeting, consider who among your newer colleagues could benefit from having a mentor.

Take the time to tell them that you are there to support their development. Making that connection could mean re-establishing a relationship that got off track and that you want to re-engage.

Show how the commitment to mentorship matters by sharing a post (with a picture, if possible) on social media. Tag your post using the hashtags #CHESTMentee and #CHEST2023 to introduce them to your network. This type of exposure and support can have a lasting impact.

While attending CHEST 2023 – ideally with your mentee – be sure to add the mentoring ribbons to your badge. We will be heavily socializing these ribbons, sharing that anyone wearing the “I’m a mentor” ribbon is either open to accepting new mentees or will help facilitate a conversation that may lead to mentorship.

Beyond its incredible education opportunities, the CHEST Annual Meeting is well-known for being a welcoming environment. It’s up to us to take the extra steps to help earlier-career clinicians succeed by providing the best possible education and guidance for years to come.



Until next time,

Doreen J. Addrizzo- Harris, MD, FCCP

When we celebrated Women’s History Month in March, Drs. Carolyn D’Ambrosio, Aneesa Das, and I discussed our experiences as women in chest medicine and why connecting is so important. We touched on the critical role of mentors. This conversation prompted me to dedicate this President’s column to the value of mentorship. The conversation is available on the CHEST YouTube for viewing.

Pursuing a career in medicine is not something you do on your own, and I have been fortunate to have had a strong support system. I think many of us who have been successful and fulfilled in our careers can say we were blessed by having great mentors along the way.

I have been blessed in having mentors who were both within my institution and outside, but one of the most important places that I found mentors was through my involvement with CHEST. It is critically important to find a mentor or mentors who can guide you through the initial phases of your career. It is also very important to allow yourself time to be a mentor to those who need you.

To the junior faculty or trainees who have yet to connect with someone to provide guidance, I cannot stress enough the importance of getting involved in an organization like CHEST.

The best way to begin is to attend the annual meeting. Know that you are invited to approach any member of CHEST leadership, introduce yourself, and tell us that you want to get involved. (Conveniently, registration for CHEST 2023 in Hawaii just opened.)

I genuinely believe our community would say yes to anyone looking for guidance.

To my colleagues who are established in their careers, I am issuing a personal request (and a bit of a challenge). Before the upcoming annual meeting, consider who among your newer colleagues could benefit from having a mentor.

Take the time to tell them that you are there to support their development. Making that connection could mean re-establishing a relationship that got off track and that you want to re-engage.

Show how the commitment to mentorship matters by sharing a post (with a picture, if possible) on social media. Tag your post using the hashtags #CHESTMentee and #CHEST2023 to introduce them to your network. This type of exposure and support can have a lasting impact.

While attending CHEST 2023 – ideally with your mentee – be sure to add the mentoring ribbons to your badge. We will be heavily socializing these ribbons, sharing that anyone wearing the “I’m a mentor” ribbon is either open to accepting new mentees or will help facilitate a conversation that may lead to mentorship.

Beyond its incredible education opportunities, the CHEST Annual Meeting is well-known for being a welcoming environment. It’s up to us to take the extra steps to help earlier-career clinicians succeed by providing the best possible education and guidance for years to come.



Until next time,

Doreen J. Addrizzo- Harris, MD, FCCP

When we celebrated Women’s History Month in March, Drs. Carolyn D’Ambrosio, Aneesa Das, and I discussed our experiences as women in chest medicine and why connecting is so important. We touched on the critical role of mentors. This conversation prompted me to dedicate this President’s column to the value of mentorship. The conversation is available on the CHEST YouTube for viewing.

Pursuing a career in medicine is not something you do on your own, and I have been fortunate to have had a strong support system. I think many of us who have been successful and fulfilled in our careers can say we were blessed by having great mentors along the way.

I have been blessed in having mentors who were both within my institution and outside, but one of the most important places that I found mentors was through my involvement with CHEST. It is critically important to find a mentor or mentors who can guide you through the initial phases of your career. It is also very important to allow yourself time to be a mentor to those who need you.

To the junior faculty or trainees who have yet to connect with someone to provide guidance, I cannot stress enough the importance of getting involved in an organization like CHEST.

The best way to begin is to attend the annual meeting. Know that you are invited to approach any member of CHEST leadership, introduce yourself, and tell us that you want to get involved. (Conveniently, registration for CHEST 2023 in Hawaii just opened.)

I genuinely believe our community would say yes to anyone looking for guidance.

To my colleagues who are established in their careers, I am issuing a personal request (and a bit of a challenge). Before the upcoming annual meeting, consider who among your newer colleagues could benefit from having a mentor.

Take the time to tell them that you are there to support their development. Making that connection could mean re-establishing a relationship that got off track and that you want to re-engage.

Show how the commitment to mentorship matters by sharing a post (with a picture, if possible) on social media. Tag your post using the hashtags #CHESTMentee and #CHEST2023 to introduce them to your network. This type of exposure and support can have a lasting impact.

While attending CHEST 2023 – ideally with your mentee – be sure to add the mentoring ribbons to your badge. We will be heavily socializing these ribbons, sharing that anyone wearing the “I’m a mentor” ribbon is either open to accepting new mentees or will help facilitate a conversation that may lead to mentorship.

Beyond its incredible education opportunities, the CHEST Annual Meeting is well-known for being a welcoming environment. It’s up to us to take the extra steps to help earlier-career clinicians succeed by providing the best possible education and guidance for years to come.



Until next time,

Doreen J. Addrizzo- Harris, MD, FCCP

Obstructive sleep apnea (OSA) affects roughly 1 billion people worldwide, according to a report by the American Academy of Sleep Medicine. Severe OSA has been associated with an elevated risk of all-cause and cardiovascular-specific mortality. Studies support an association between OSA and a host of comorbidities, including hypertension, stroke, atrial fibrillation, mood disorders, and neurocognitive outcomes. Undiagnosed and untreated OSA also has major economic and societal costs, reducing workplace productivity and increasing one’s risk of accidents both on the job and while driving.

Positive airway pressure (PAP) is widely considered the most effective treatment for OSA. The majority of patients tolerate CPAP: real-world estimates using international big data show good adherence in over 70% of patients. Robust evidence shows that PAP reduces snoring, decreases daytime sleepiness, and improves quality of life in a dose-dependent manner. Economic analyses have also found CPAP to be cost-effective (Streatfeild, et al. Sleep. 2019;42[12]:zsz181).

But what do we know about the impact of PAP on health outcomes? Perhaps the best studied outcome is cardiovascular disease. Results of observational trials have suggested that CPAP adherence was associated with survival (Pepin JL et al. Chest. 2022;161[6]:1657). However, it has been speculated that these findings may have been driven, at least in part, by the “healthy user effect.” This phenomenon refers to the tendency for people who engage in one health-promoting behavior (eg, CPAP adherence) to engage in another as well (eg, eating well, exercising, taking prescribed medications). When we observe that patients who use CPAP live longer, we must ask ourselves whether perhaps their better outcomes resulted from healthy habits in general, as opposed to their CPAP usage per se.

Randomization eliminates the potential for the healthy user effect, by assigning patients to a certain intervention as opposed to simply observing whether they choose to use it. And herein lies one of the great disappointments for our field over the past decade: multiple large-scale randomized controlled trials have failed to demonstrate that CPAP reduces cardiovascular mortality, even in patients with pre-existing CAD. The first two of these were the SAVE (Sleep Apnea Cardiovascular Endpoints) (McEvoy R, et al.  N Engl J Med. 2016;375[10]:919) and RICCADSA (Randomized Intervention with Continuous Positive Airway Pressure in CAD and OSA) (Peker Y, et al. Am J Respir Crit Care Med. 2016;194[5]:613) trials evaluating the effects of PAP on a composite endpoint that included cardiovascular death and nonfatal cardiovascular events. Both trials found no difference between PAP and control groups, leading to a conclusion that PAP did not prevent cardiovascular events in patients with moderate-to-severe OSA and established cardiovascular disease. The ISAAC study (Impact of Sleep Apnea syndrome in the evolution of Acute Coronary syndrome) also failed to show a benefit of CPAP for secondary prevention of cardiovascular events in patients with moderate to severe OSA.

These negative findings were echoed in a recent report by the Agency for Healthcare Research and Quality evaluating a variety of long-term health outcomes in obstructive sleep apnea. The authors stated that “RCTs do not provide evidence that CPAP prescription affects long-term, clinically important outcomes. Specifically, with low strength of evidence, RCTs do not demonstrate that CPAP affects all-cause mortality, various CV outcomes, clinically important changes in psychosocial measures, or other clinical events” (AHRQ, Project ID: SLPT0919, 12/1/2022).

What plausible explanations have been offered for these negative results? Perhaps trials were underpowered. Perhaps patients did not use PAP for a sufficient duration to achieve benefit (usage was under 3 hours in most studies). Perhaps the patients selected for these trials were at such low-risk of adverse outcomes in the first place that treating their OSA didn’t have much impact. Many trials have excluded sleepy patients due to ethical concerns about withholding treatment from this population. But this may have effectively excluded the patients most likely to benefit; in other studies, sleepy patients seem to experience the greatest cardiovascular risk reduction with CPAP. For example, a meta-analysis showed that CPAP is most strongly associated with blood pressure reduction in patients who are sleepy, compared with those with minimally symptomatic OSA (Bratton D, et al. Thorax. 2014;69[12]:1128). And, recent work suggests that even among non-sleepy patients, it might be possible to identify a subset who could benefit from CPAP. A recent analysis suggested that non-sleepy patients who exhibit a higher change in heart rate following a respiratory event may derive greater cardiovascular benefit from CPAP therapy (Azarbarzin, et al. Am J Respir Crit Care Med. 2022;206[6]:767).

We are moving toward a more personalized approach to characterizing OSA, which eventually may allow for more nuanced, individualized counseling rather than a “one-size -called-CPAP-fits-all” approach. Until we are there, a patient-centered approach that elicits the presence of sleep-related symptoms and daytime impairment, as opposed to isolated comorbidities, provides the most compelling justification for CPAP.

Obstructive sleep apnea (OSA) affects roughly 1 billion people worldwide, according to a report by the American Academy of Sleep Medicine. Severe OSA has been associated with an elevated risk of all-cause and cardiovascular-specific mortality. Studies support an association between OSA and a host of comorbidities, including hypertension, stroke, atrial fibrillation, mood disorders, and neurocognitive outcomes. Undiagnosed and untreated OSA also has major economic and societal costs, reducing workplace productivity and increasing one’s risk of accidents both on the job and while driving.

Positive airway pressure (PAP) is widely considered the most effective treatment for OSA. The majority of patients tolerate CPAP: real-world estimates using international big data show good adherence in over 70% of patients. Robust evidence shows that PAP reduces snoring, decreases daytime sleepiness, and improves quality of life in a dose-dependent manner. Economic analyses have also found CPAP to be cost-effective (Streatfeild, et al. Sleep. 2019;42[12]:zsz181).

But what do we know about the impact of PAP on health outcomes? Perhaps the best studied outcome is cardiovascular disease. Results of observational trials have suggested that CPAP adherence was associated with survival (Pepin JL et al. Chest. 2022;161[6]:1657). However, it has been speculated that these findings may have been driven, at least in part, by the “healthy user effect.” This phenomenon refers to the tendency for people who engage in one health-promoting behavior (eg, CPAP adherence) to engage in another as well (eg, eating well, exercising, taking prescribed medications). When we observe that patients who use CPAP live longer, we must ask ourselves whether perhaps their better outcomes resulted from healthy habits in general, as opposed to their CPAP usage per se.

Randomization eliminates the potential for the healthy user effect, by assigning patients to a certain intervention as opposed to simply observing whether they choose to use it. And herein lies one of the great disappointments for our field over the past decade: multiple large-scale randomized controlled trials have failed to demonstrate that CPAP reduces cardiovascular mortality, even in patients with pre-existing CAD. The first two of these were the SAVE (Sleep Apnea Cardiovascular Endpoints) (McEvoy R, et al.  N Engl J Med. 2016;375[10]:919) and RICCADSA (Randomized Intervention with Continuous Positive Airway Pressure in CAD and OSA) (Peker Y, et al. Am J Respir Crit Care Med. 2016;194[5]:613) trials evaluating the effects of PAP on a composite endpoint that included cardiovascular death and nonfatal cardiovascular events. Both trials found no difference between PAP and control groups, leading to a conclusion that PAP did not prevent cardiovascular events in patients with moderate-to-severe OSA and established cardiovascular disease. The ISAAC study (Impact of Sleep Apnea syndrome in the evolution of Acute Coronary syndrome) also failed to show a benefit of CPAP for secondary prevention of cardiovascular events in patients with moderate to severe OSA.

These negative findings were echoed in a recent report by the Agency for Healthcare Research and Quality evaluating a variety of long-term health outcomes in obstructive sleep apnea. The authors stated that “RCTs do not provide evidence that CPAP prescription affects long-term, clinically important outcomes. Specifically, with low strength of evidence, RCTs do not demonstrate that CPAP affects all-cause mortality, various CV outcomes, clinically important changes in psychosocial measures, or other clinical events” (AHRQ, Project ID: SLPT0919, 12/1/2022).

What plausible explanations have been offered for these negative results? Perhaps trials were underpowered. Perhaps patients did not use PAP for a sufficient duration to achieve benefit (usage was under 3 hours in most studies). Perhaps the patients selected for these trials were at such low-risk of adverse outcomes in the first place that treating their OSA didn’t have much impact. Many trials have excluded sleepy patients due to ethical concerns about withholding treatment from this population. But this may have effectively excluded the patients most likely to benefit; in other studies, sleepy patients seem to experience the greatest cardiovascular risk reduction with CPAP. For example, a meta-analysis showed that CPAP is most strongly associated with blood pressure reduction in patients who are sleepy, compared with those with minimally symptomatic OSA (Bratton D, et al. Thorax. 2014;69[12]:1128). And, recent work suggests that even among non-sleepy patients, it might be possible to identify a subset who could benefit from CPAP. A recent analysis suggested that non-sleepy patients who exhibit a higher change in heart rate following a respiratory event may derive greater cardiovascular benefit from CPAP therapy (Azarbarzin, et al. Am J Respir Crit Care Med. 2022;206[6]:767).

We are moving toward a more personalized approach to characterizing OSA, which eventually may allow for more nuanced, individualized counseling rather than a “one-size -called-CPAP-fits-all” approach. Until we are there, a patient-centered approach that elicits the presence of sleep-related symptoms and daytime impairment, as opposed to isolated comorbidities, provides the most compelling justification for CPAP.

Obstructive sleep apnea (OSA) affects roughly 1 billion people worldwide, according to a report by the American Academy of Sleep Medicine. Severe OSA has been associated with an elevated risk of all-cause and cardiovascular-specific mortality. Studies support an association between OSA and a host of comorbidities, including hypertension, stroke, atrial fibrillation, mood disorders, and neurocognitive outcomes. Undiagnosed and untreated OSA also has major economic and societal costs, reducing workplace productivity and increasing one’s risk of accidents both on the job and while driving.

Positive airway pressure (PAP) is widely considered the most effective treatment for OSA. The majority of patients tolerate CPAP: real-world estimates using international big data show good adherence in over 70% of patients. Robust evidence shows that PAP reduces snoring, decreases daytime sleepiness, and improves quality of life in a dose-dependent manner. Economic analyses have also found CPAP to be cost-effective (Streatfeild, et al. Sleep. 2019;42[12]:zsz181).

But what do we know about the impact of PAP on health outcomes? Perhaps the best studied outcome is cardiovascular disease. Results of observational trials have suggested that CPAP adherence was associated with survival (Pepin JL et al. Chest. 2022;161[6]:1657). However, it has been speculated that these findings may have been driven, at least in part, by the “healthy user effect.” This phenomenon refers to the tendency for people who engage in one health-promoting behavior (eg, CPAP adherence) to engage in another as well (eg, eating well, exercising, taking prescribed medications). When we observe that patients who use CPAP live longer, we must ask ourselves whether perhaps their better outcomes resulted from healthy habits in general, as opposed to their CPAP usage per se.

Randomization eliminates the potential for the healthy user effect, by assigning patients to a certain intervention as opposed to simply observing whether they choose to use it. And herein lies one of the great disappointments for our field over the past decade: multiple large-scale randomized controlled trials have failed to demonstrate that CPAP reduces cardiovascular mortality, even in patients with pre-existing CAD. The first two of these were the SAVE (Sleep Apnea Cardiovascular Endpoints) (McEvoy R, et al.  N Engl J Med. 2016;375[10]:919) and RICCADSA (Randomized Intervention with Continuous Positive Airway Pressure in CAD and OSA) (Peker Y, et al. Am J Respir Crit Care Med. 2016;194[5]:613) trials evaluating the effects of PAP on a composite endpoint that included cardiovascular death and nonfatal cardiovascular events. Both trials found no difference between PAP and control groups, leading to a conclusion that PAP did not prevent cardiovascular events in patients with moderate-to-severe OSA and established cardiovascular disease. The ISAAC study (Impact of Sleep Apnea syndrome in the evolution of Acute Coronary syndrome) also failed to show a benefit of CPAP for secondary prevention of cardiovascular events in patients with moderate to severe OSA.

These negative findings were echoed in a recent report by the Agency for Healthcare Research and Quality evaluating a variety of long-term health outcomes in obstructive sleep apnea. The authors stated that “RCTs do not provide evidence that CPAP prescription affects long-term, clinically important outcomes. Specifically, with low strength of evidence, RCTs do not demonstrate that CPAP affects all-cause mortality, various CV outcomes, clinically important changes in psychosocial measures, or other clinical events” (AHRQ, Project ID: SLPT0919, 12/1/2022).

What plausible explanations have been offered for these negative results? Perhaps trials were underpowered. Perhaps patients did not use PAP for a sufficient duration to achieve benefit (usage was under 3 hours in most studies). Perhaps the patients selected for these trials were at such low-risk of adverse outcomes in the first place that treating their OSA didn’t have much impact. Many trials have excluded sleepy patients due to ethical concerns about withholding treatment from this population. But this may have effectively excluded the patients most likely to benefit; in other studies, sleepy patients seem to experience the greatest cardiovascular risk reduction with CPAP. For example, a meta-analysis showed that CPAP is most strongly associated with blood pressure reduction in patients who are sleepy, compared with those with minimally symptomatic OSA (Bratton D, et al. Thorax. 2014;69[12]:1128). And, recent work suggests that even among non-sleepy patients, it might be possible to identify a subset who could benefit from CPAP. A recent analysis suggested that non-sleepy patients who exhibit a higher change in heart rate following a respiratory event may derive greater cardiovascular benefit from CPAP therapy (Azarbarzin, et al. Am J Respir Crit Care Med. 2022;206[6]:767).

We are moving toward a more personalized approach to characterizing OSA, which eventually may allow for more nuanced, individualized counseling rather than a “one-size -called-CPAP-fits-all” approach. Until we are there, a patient-centered approach that elicits the presence of sleep-related symptoms and daytime impairment, as opposed to isolated comorbidities, provides the most compelling justification for CPAP.