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A Few Rural Towns Are Bucking the Trend and Building New Hospitals
There’s a new morning ritual in Pinedale, Wyoming, a town of about 2000, nestled against the Wind River Mountains.
Friends and neighbors in the oil- and gas-rich community “take their morning coffee and pull up” to watch workers building the county’s first hospital, said Kari DeWitt, the project’s public relations director.
“I think it’s just gratitude,” Ms. DeWitt said.
Sublette County is the only one in Wyoming — where counties span thousands of square miles — without a hospital. The 10-bed, 40,000-square-foot hospital, with a similarly sized attached long-term care facility, is slated to open by the summer of 2025.
Ms. DeWitt, who also is executive director of the Sublette County Health Foundation, has an office at the town’s health clinic with a window view of the construction.
Pinedale’s residents have good reason to be excited. New full-service hospitals with inpatient beds are rare in rural America, where declining population has spurred decades of downsizing and closures. Yet, a few communities in Wyoming and others in Kansas and Georgia are defying the trend.
“To be honest with you, it even seems strange to me,” said Wyoming Hospital Association President Eric Boley. Small rural “hospitals are really struggling all across the country,” he said.
There is no official tally of new hospitals being built in rural America, but industry experts such as Mr. Boley said they’re rare. Typically, health-related construction projects in rural areas are for smaller urgent care centers or stand-alone emergency facilities or are replacements for old hospitals.
About half of rural hospitals lost money in the prior year, according to Chartis, a health analytics and consulting firm. And nearly 150 rural hospitals have closed or converted to smaller operations since 2010, according to data collected by the University of North Carolina’s Cecil G. Sheps Center for Health Services Research.
To stem the tide of closures, Congress created a new rural emergency hospital designation that allowed struggling hospitals to close their inpatient units and provide only outpatient and emergency services. Since January 2023, when the program took effect, 32 of the more than 1700 eligible rural hospitals — from Georgia to New Mexico — have joined the program, according to data from the Centers for Medicare & Medicaid Services.
Tony Breitlow is healthcare studio director for EUA, which has extensive experience working for rural health care systems. Mr. Breitlow said his national architecture and engineering firm’s work expands, replaces, or revamps older buildings, many of which were constructed during the middle of the last century.
The work, Mr. Breitlow said, is part of health care “systems figuring out how to remain robust and viable.”
Freeman Health System, based in Joplin, Missouri, announced plans last year to build a new 50-bed hospital across the state line in Kansas. Paula Baker, Freeman’s president and chief executive, said the system is building for patients in the southeastern corner of the state who travel 45 minutes or more to its bigger Joplin facilities for care.
Freeman’s new hospital, with construction on the building expected to begin in the spring, will be less than 10 miles away from an older, 64-bed hospital that has existed for decades. Kansas is one of more than a dozen states with no “certificate of need” law that would require health providers to obtain approval from the state before offering new services or building or expanding facilities.
Ms. Baker also said Freeman plans to operate emergency services and a small 10-bed outpost in Fort Scott, Kansas, opening early next year in a corner of a hospital that closed in late 2018. Residents there “cried, they cheered, they hugged me,” Ms. Baker said, adding that the “level of appreciation and gratitude that they felt and they displayed was overwhelming to me.”
Michael Topchik, executive director of the Chartis Center for Rural Health, said regional healthcare systems in the Upper Midwest have been particularly active in competing for patients by, among other things, building new hospitals.
And while private corporate money can drive construction, many rural hospital projects tap government programs, especially those supported by the US Department of Agriculture, Mr. Topchik said. That, he said, “surprises a lot of people.”
Since 2021, the USDA’s rural Community Facilities Programs have awarded $2.24 billion in loans and grants to 68 rural hospitals for work that was not related to an emergency or disaster, according to data analyzed by KFF Health News and confirmed by the agency. The federal program is funded through what is often known as the farm bill, which faces a September congressional renewal deadline.
Nearly all the projects are replacements or expansions and updates of older facilities.
The USDA confirmed that three new or planned Wyoming hospitals received federal funding. Hospital projects in Riverton and Saratoga received loans of $37.2 million and $18.3 million, respectively. Pinedale’s hospital received a $29.2 million loan from the agency.
Wyoming’s new construction is rare in a state where more than 80% of rural hospitals reported losses in the third quarter of 2023, according to Chartis. The state association’s Mr. Boley said he worries about several hospitals that have less than 10 days’ cash on hand “day and night.”
Pinedale’s project loan was approved after the community submitted a feasibility study to the USDA that included local clinics and a long-term care facility. “It’s pretty remote and right up in the mountains,” Mr. Boley said.
Pinedale’s Ms. DeWitt said the community was missing key services, such as blood transfusions, which are often necessary when there is a trauma like a car crash or if a pregnant woman faces severe complications. Local ambulances drove 94,000 miles last year, she said.
Ms. DeWitt began working to raise support for the new hospital after her own pregnancy-related trauma in 2014. She was bleeding heavily and arrived at the local health clinic believing it operated like a hospital.
“It was shocking to hear, ‘No, we’re not a hospital. We can’t do blood transfusions. We’re just going to have to pray you live for the next 45 minutes,’ ” Ms. DeWitt said.
Ms. DeWitt had to be airlifted to Idaho, where she delivered a few minutes after landing. When the hospital financing went on the ballot in 2020, Ms. DeWitt — fully recovered, with healthy grade-schoolers at home — began making five calls a night to rally support for a county tax increase to help fund the hospital.
“By improving health care, I think we improve everybody’s chances of survival. You know, it’s pretty basic,” Ms. DeWitt said.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
There’s a new morning ritual in Pinedale, Wyoming, a town of about 2000, nestled against the Wind River Mountains.
Friends and neighbors in the oil- and gas-rich community “take their morning coffee and pull up” to watch workers building the county’s first hospital, said Kari DeWitt, the project’s public relations director.
“I think it’s just gratitude,” Ms. DeWitt said.
Sublette County is the only one in Wyoming — where counties span thousands of square miles — without a hospital. The 10-bed, 40,000-square-foot hospital, with a similarly sized attached long-term care facility, is slated to open by the summer of 2025.
Ms. DeWitt, who also is executive director of the Sublette County Health Foundation, has an office at the town’s health clinic with a window view of the construction.
Pinedale’s residents have good reason to be excited. New full-service hospitals with inpatient beds are rare in rural America, where declining population has spurred decades of downsizing and closures. Yet, a few communities in Wyoming and others in Kansas and Georgia are defying the trend.
“To be honest with you, it even seems strange to me,” said Wyoming Hospital Association President Eric Boley. Small rural “hospitals are really struggling all across the country,” he said.
There is no official tally of new hospitals being built in rural America, but industry experts such as Mr. Boley said they’re rare. Typically, health-related construction projects in rural areas are for smaller urgent care centers or stand-alone emergency facilities or are replacements for old hospitals.
About half of rural hospitals lost money in the prior year, according to Chartis, a health analytics and consulting firm. And nearly 150 rural hospitals have closed or converted to smaller operations since 2010, according to data collected by the University of North Carolina’s Cecil G. Sheps Center for Health Services Research.
To stem the tide of closures, Congress created a new rural emergency hospital designation that allowed struggling hospitals to close their inpatient units and provide only outpatient and emergency services. Since January 2023, when the program took effect, 32 of the more than 1700 eligible rural hospitals — from Georgia to New Mexico — have joined the program, according to data from the Centers for Medicare & Medicaid Services.
Tony Breitlow is healthcare studio director for EUA, which has extensive experience working for rural health care systems. Mr. Breitlow said his national architecture and engineering firm’s work expands, replaces, or revamps older buildings, many of which were constructed during the middle of the last century.
The work, Mr. Breitlow said, is part of health care “systems figuring out how to remain robust and viable.”
Freeman Health System, based in Joplin, Missouri, announced plans last year to build a new 50-bed hospital across the state line in Kansas. Paula Baker, Freeman’s president and chief executive, said the system is building for patients in the southeastern corner of the state who travel 45 minutes or more to its bigger Joplin facilities for care.
Freeman’s new hospital, with construction on the building expected to begin in the spring, will be less than 10 miles away from an older, 64-bed hospital that has existed for decades. Kansas is one of more than a dozen states with no “certificate of need” law that would require health providers to obtain approval from the state before offering new services or building or expanding facilities.
Ms. Baker also said Freeman plans to operate emergency services and a small 10-bed outpost in Fort Scott, Kansas, opening early next year in a corner of a hospital that closed in late 2018. Residents there “cried, they cheered, they hugged me,” Ms. Baker said, adding that the “level of appreciation and gratitude that they felt and they displayed was overwhelming to me.”
Michael Topchik, executive director of the Chartis Center for Rural Health, said regional healthcare systems in the Upper Midwest have been particularly active in competing for patients by, among other things, building new hospitals.
And while private corporate money can drive construction, many rural hospital projects tap government programs, especially those supported by the US Department of Agriculture, Mr. Topchik said. That, he said, “surprises a lot of people.”
Since 2021, the USDA’s rural Community Facilities Programs have awarded $2.24 billion in loans and grants to 68 rural hospitals for work that was not related to an emergency or disaster, according to data analyzed by KFF Health News and confirmed by the agency. The federal program is funded through what is often known as the farm bill, which faces a September congressional renewal deadline.
Nearly all the projects are replacements or expansions and updates of older facilities.
The USDA confirmed that three new or planned Wyoming hospitals received federal funding. Hospital projects in Riverton and Saratoga received loans of $37.2 million and $18.3 million, respectively. Pinedale’s hospital received a $29.2 million loan from the agency.
Wyoming’s new construction is rare in a state where more than 80% of rural hospitals reported losses in the third quarter of 2023, according to Chartis. The state association’s Mr. Boley said he worries about several hospitals that have less than 10 days’ cash on hand “day and night.”
Pinedale’s project loan was approved after the community submitted a feasibility study to the USDA that included local clinics and a long-term care facility. “It’s pretty remote and right up in the mountains,” Mr. Boley said.
Pinedale’s Ms. DeWitt said the community was missing key services, such as blood transfusions, which are often necessary when there is a trauma like a car crash or if a pregnant woman faces severe complications. Local ambulances drove 94,000 miles last year, she said.
Ms. DeWitt began working to raise support for the new hospital after her own pregnancy-related trauma in 2014. She was bleeding heavily and arrived at the local health clinic believing it operated like a hospital.
“It was shocking to hear, ‘No, we’re not a hospital. We can’t do blood transfusions. We’re just going to have to pray you live for the next 45 minutes,’ ” Ms. DeWitt said.
Ms. DeWitt had to be airlifted to Idaho, where she delivered a few minutes after landing. When the hospital financing went on the ballot in 2020, Ms. DeWitt — fully recovered, with healthy grade-schoolers at home — began making five calls a night to rally support for a county tax increase to help fund the hospital.
“By improving health care, I think we improve everybody’s chances of survival. You know, it’s pretty basic,” Ms. DeWitt said.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
There’s a new morning ritual in Pinedale, Wyoming, a town of about 2000, nestled against the Wind River Mountains.
Friends and neighbors in the oil- and gas-rich community “take their morning coffee and pull up” to watch workers building the county’s first hospital, said Kari DeWitt, the project’s public relations director.
“I think it’s just gratitude,” Ms. DeWitt said.
Sublette County is the only one in Wyoming — where counties span thousands of square miles — without a hospital. The 10-bed, 40,000-square-foot hospital, with a similarly sized attached long-term care facility, is slated to open by the summer of 2025.
Ms. DeWitt, who also is executive director of the Sublette County Health Foundation, has an office at the town’s health clinic with a window view of the construction.
Pinedale’s residents have good reason to be excited. New full-service hospitals with inpatient beds are rare in rural America, where declining population has spurred decades of downsizing and closures. Yet, a few communities in Wyoming and others in Kansas and Georgia are defying the trend.
“To be honest with you, it even seems strange to me,” said Wyoming Hospital Association President Eric Boley. Small rural “hospitals are really struggling all across the country,” he said.
There is no official tally of new hospitals being built in rural America, but industry experts such as Mr. Boley said they’re rare. Typically, health-related construction projects in rural areas are for smaller urgent care centers or stand-alone emergency facilities or are replacements for old hospitals.
About half of rural hospitals lost money in the prior year, according to Chartis, a health analytics and consulting firm. And nearly 150 rural hospitals have closed or converted to smaller operations since 2010, according to data collected by the University of North Carolina’s Cecil G. Sheps Center for Health Services Research.
To stem the tide of closures, Congress created a new rural emergency hospital designation that allowed struggling hospitals to close their inpatient units and provide only outpatient and emergency services. Since January 2023, when the program took effect, 32 of the more than 1700 eligible rural hospitals — from Georgia to New Mexico — have joined the program, according to data from the Centers for Medicare & Medicaid Services.
Tony Breitlow is healthcare studio director for EUA, which has extensive experience working for rural health care systems. Mr. Breitlow said his national architecture and engineering firm’s work expands, replaces, or revamps older buildings, many of which were constructed during the middle of the last century.
The work, Mr. Breitlow said, is part of health care “systems figuring out how to remain robust and viable.”
Freeman Health System, based in Joplin, Missouri, announced plans last year to build a new 50-bed hospital across the state line in Kansas. Paula Baker, Freeman’s president and chief executive, said the system is building for patients in the southeastern corner of the state who travel 45 minutes or more to its bigger Joplin facilities for care.
Freeman’s new hospital, with construction on the building expected to begin in the spring, will be less than 10 miles away from an older, 64-bed hospital that has existed for decades. Kansas is one of more than a dozen states with no “certificate of need” law that would require health providers to obtain approval from the state before offering new services or building or expanding facilities.
Ms. Baker also said Freeman plans to operate emergency services and a small 10-bed outpost in Fort Scott, Kansas, opening early next year in a corner of a hospital that closed in late 2018. Residents there “cried, they cheered, they hugged me,” Ms. Baker said, adding that the “level of appreciation and gratitude that they felt and they displayed was overwhelming to me.”
Michael Topchik, executive director of the Chartis Center for Rural Health, said regional healthcare systems in the Upper Midwest have been particularly active in competing for patients by, among other things, building new hospitals.
And while private corporate money can drive construction, many rural hospital projects tap government programs, especially those supported by the US Department of Agriculture, Mr. Topchik said. That, he said, “surprises a lot of people.”
Since 2021, the USDA’s rural Community Facilities Programs have awarded $2.24 billion in loans and grants to 68 rural hospitals for work that was not related to an emergency or disaster, according to data analyzed by KFF Health News and confirmed by the agency. The federal program is funded through what is often known as the farm bill, which faces a September congressional renewal deadline.
Nearly all the projects are replacements or expansions and updates of older facilities.
The USDA confirmed that three new or planned Wyoming hospitals received federal funding. Hospital projects in Riverton and Saratoga received loans of $37.2 million and $18.3 million, respectively. Pinedale’s hospital received a $29.2 million loan from the agency.
Wyoming’s new construction is rare in a state where more than 80% of rural hospitals reported losses in the third quarter of 2023, according to Chartis. The state association’s Mr. Boley said he worries about several hospitals that have less than 10 days’ cash on hand “day and night.”
Pinedale’s project loan was approved after the community submitted a feasibility study to the USDA that included local clinics and a long-term care facility. “It’s pretty remote and right up in the mountains,” Mr. Boley said.
Pinedale’s Ms. DeWitt said the community was missing key services, such as blood transfusions, which are often necessary when there is a trauma like a car crash or if a pregnant woman faces severe complications. Local ambulances drove 94,000 miles last year, she said.
Ms. DeWitt began working to raise support for the new hospital after her own pregnancy-related trauma in 2014. She was bleeding heavily and arrived at the local health clinic believing it operated like a hospital.
“It was shocking to hear, ‘No, we’re not a hospital. We can’t do blood transfusions. We’re just going to have to pray you live for the next 45 minutes,’ ” Ms. DeWitt said.
Ms. DeWitt had to be airlifted to Idaho, where she delivered a few minutes after landing. When the hospital financing went on the ballot in 2020, Ms. DeWitt — fully recovered, with healthy grade-schoolers at home — began making five calls a night to rally support for a county tax increase to help fund the hospital.
“By improving health care, I think we improve everybody’s chances of survival. You know, it’s pretty basic,” Ms. DeWitt said.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
Top reads from the CHEST journal portfolio
Explore articles on PAP adherence, plasma biomarkers in ARDS, and airways disorders hospitalizations during wildfire season
Journal CHEST®
Association Between Healthy Behaviors and Health Care Resource Use With Subsequent Positive Airway Pressure Therapy Adherence in OSA
By Launois, MD, PhD, and colleagues
One of the pitfalls in the interpretation of the effect of treatment adherence on health outcomes is the healthy-adherer effect (HAE) bias. Healthy-adherer bias occurs when patients who are treatment-adherent tend to actively seek out preventative care and engage in other healthy behaviors. Incomplete adjustment for such behaviors can lead to spurious inferences regarding study outcomes because healthy behaviors are associated with a reduced risk of many poor health outcomes.
This study demonstrates that HAE proxies (adherence to CV active drugs, no history of smoking, or sleepiness-related car accidents) were associated with subsequent PAP adherence after adjustment for confounders. PAP-adherent patients used less health care resources before PAP initiation. Unfortunately, the study did not measure other healthy behaviors (nutrition, physical activity, psychosocial support) that could also potentially explain HAE. Until the HAE associated with PAP adherence is better understood, clinicians should use caution when interpreting the association of PAP adherence with CV health outcomes and health care resource use.
– Commentary by Sai Venkateshiah, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
Circulating Biomarkers of Endothelial Dysfunction Associated With Ventilatory Ratio and Mortality in ARDS Resulting From SARS-CoV-2 Infection Treated With Anti-inflammatory Therapies
By Alladina, MD, and colleagues
Practitioners in the intensive care unit have become increasingly aware that the population of patients with ARDS is highly heterogenous not only in terms of the inciting factors of their condition but also in terms of their respiratory physiology. Calfee and co-workers opened new horizons for us with their 2014 descriptions of two phenotypes of ARDS based upon biological markers that had different clinical outcome profiles. The work by Alladina et al adds to this body of knowledge by studying biomarkers from patients with COVID-ARDS who were receiving anti-inflammatory therapies. These researchers demonstrated that in such patients, endothelial biomarkers, particularly NEDD9, were associated with 60-day mortality. Increased understanding of biologic phenotypes in ARDS patients may facilitate the application of precision medicine to patients with this condition, improving outcome prediction and allowing practitioners to target specific treatments to selected patients.
– Commentary by Daniel R. Ouellette, MD, FCCP, Critical Care Commentary Editor of CHEST Physician
CHEST® Pulmonary
Association of Short-Term Increases in Ambient Fine Particulate Matter With Hospitalization for Asthma or COPD During Wildfire Season and Other Time Periods
By Horne, PhD, MStat, MPH, and colleagues
Trigger avoidance is one the most important interventions in the control of symptoms and prevention of exacerbations in chronic airways diseases. Nevertheless, trigger avoidance is at times not possible. This is the case with wildfire smoke and other environmental irritants—an increasing global health problem. Using data from 11 hospitals along the Utah’s Wasatch Front, the study by Horne and colleagues shows a clear association between a short-term increase in ambient fine particulate matter exposure resulting from wildfires and a surge in asthma exacerbations. This effect was also seen in patients with COPD but to a lesser degree. The study is limited by its observational design and because measurements of pollution levels were performed regionally and not at individual patient level. Yet this study offers valuable insights on the effects of environmental exposures in patients with chronic airways diseases and the consequences to our health care systems. Futures studies are still needed to assess the long-term consequences of sustained exposures to these irritants in patients with respiratory conditions.
– Commentary by Diego J. Maselli, MD, FCCP, Member of the CHEST Physician Editorial Board
Explore articles on PAP adherence, plasma biomarkers in ARDS, and airways disorders hospitalizations during wildfire season
Explore articles on PAP adherence, plasma biomarkers in ARDS, and airways disorders hospitalizations during wildfire season
Journal CHEST®
Association Between Healthy Behaviors and Health Care Resource Use With Subsequent Positive Airway Pressure Therapy Adherence in OSA
By Launois, MD, PhD, and colleagues
One of the pitfalls in the interpretation of the effect of treatment adherence on health outcomes is the healthy-adherer effect (HAE) bias. Healthy-adherer bias occurs when patients who are treatment-adherent tend to actively seek out preventative care and engage in other healthy behaviors. Incomplete adjustment for such behaviors can lead to spurious inferences regarding study outcomes because healthy behaviors are associated with a reduced risk of many poor health outcomes.
This study demonstrates that HAE proxies (adherence to CV active drugs, no history of smoking, or sleepiness-related car accidents) were associated with subsequent PAP adherence after adjustment for confounders. PAP-adherent patients used less health care resources before PAP initiation. Unfortunately, the study did not measure other healthy behaviors (nutrition, physical activity, psychosocial support) that could also potentially explain HAE. Until the HAE associated with PAP adherence is better understood, clinicians should use caution when interpreting the association of PAP adherence with CV health outcomes and health care resource use.
– Commentary by Sai Venkateshiah, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
Circulating Biomarkers of Endothelial Dysfunction Associated With Ventilatory Ratio and Mortality in ARDS Resulting From SARS-CoV-2 Infection Treated With Anti-inflammatory Therapies
By Alladina, MD, and colleagues
Practitioners in the intensive care unit have become increasingly aware that the population of patients with ARDS is highly heterogenous not only in terms of the inciting factors of their condition but also in terms of their respiratory physiology. Calfee and co-workers opened new horizons for us with their 2014 descriptions of two phenotypes of ARDS based upon biological markers that had different clinical outcome profiles. The work by Alladina et al adds to this body of knowledge by studying biomarkers from patients with COVID-ARDS who were receiving anti-inflammatory therapies. These researchers demonstrated that in such patients, endothelial biomarkers, particularly NEDD9, were associated with 60-day mortality. Increased understanding of biologic phenotypes in ARDS patients may facilitate the application of precision medicine to patients with this condition, improving outcome prediction and allowing practitioners to target specific treatments to selected patients.
– Commentary by Daniel R. Ouellette, MD, FCCP, Critical Care Commentary Editor of CHEST Physician
CHEST® Pulmonary
Association of Short-Term Increases in Ambient Fine Particulate Matter With Hospitalization for Asthma or COPD During Wildfire Season and Other Time Periods
By Horne, PhD, MStat, MPH, and colleagues
Trigger avoidance is one the most important interventions in the control of symptoms and prevention of exacerbations in chronic airways diseases. Nevertheless, trigger avoidance is at times not possible. This is the case with wildfire smoke and other environmental irritants—an increasing global health problem. Using data from 11 hospitals along the Utah’s Wasatch Front, the study by Horne and colleagues shows a clear association between a short-term increase in ambient fine particulate matter exposure resulting from wildfires and a surge in asthma exacerbations. This effect was also seen in patients with COPD but to a lesser degree. The study is limited by its observational design and because measurements of pollution levels were performed regionally and not at individual patient level. Yet this study offers valuable insights on the effects of environmental exposures in patients with chronic airways diseases and the consequences to our health care systems. Futures studies are still needed to assess the long-term consequences of sustained exposures to these irritants in patients with respiratory conditions.
– Commentary by Diego J. Maselli, MD, FCCP, Member of the CHEST Physician Editorial Board
Journal CHEST®
Association Between Healthy Behaviors and Health Care Resource Use With Subsequent Positive Airway Pressure Therapy Adherence in OSA
By Launois, MD, PhD, and colleagues
One of the pitfalls in the interpretation of the effect of treatment adherence on health outcomes is the healthy-adherer effect (HAE) bias. Healthy-adherer bias occurs when patients who are treatment-adherent tend to actively seek out preventative care and engage in other healthy behaviors. Incomplete adjustment for such behaviors can lead to spurious inferences regarding study outcomes because healthy behaviors are associated with a reduced risk of many poor health outcomes.
This study demonstrates that HAE proxies (adherence to CV active drugs, no history of smoking, or sleepiness-related car accidents) were associated with subsequent PAP adherence after adjustment for confounders. PAP-adherent patients used less health care resources before PAP initiation. Unfortunately, the study did not measure other healthy behaviors (nutrition, physical activity, psychosocial support) that could also potentially explain HAE. Until the HAE associated with PAP adherence is better understood, clinicians should use caution when interpreting the association of PAP adherence with CV health outcomes and health care resource use.
– Commentary by Sai Venkateshiah, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
Circulating Biomarkers of Endothelial Dysfunction Associated With Ventilatory Ratio and Mortality in ARDS Resulting From SARS-CoV-2 Infection Treated With Anti-inflammatory Therapies
By Alladina, MD, and colleagues
Practitioners in the intensive care unit have become increasingly aware that the population of patients with ARDS is highly heterogenous not only in terms of the inciting factors of their condition but also in terms of their respiratory physiology. Calfee and co-workers opened new horizons for us with their 2014 descriptions of two phenotypes of ARDS based upon biological markers that had different clinical outcome profiles. The work by Alladina et al adds to this body of knowledge by studying biomarkers from patients with COVID-ARDS who were receiving anti-inflammatory therapies. These researchers demonstrated that in such patients, endothelial biomarkers, particularly NEDD9, were associated with 60-day mortality. Increased understanding of biologic phenotypes in ARDS patients may facilitate the application of precision medicine to patients with this condition, improving outcome prediction and allowing practitioners to target specific treatments to selected patients.
– Commentary by Daniel R. Ouellette, MD, FCCP, Critical Care Commentary Editor of CHEST Physician
CHEST® Pulmonary
Association of Short-Term Increases in Ambient Fine Particulate Matter With Hospitalization for Asthma or COPD During Wildfire Season and Other Time Periods
By Horne, PhD, MStat, MPH, and colleagues
Trigger avoidance is one the most important interventions in the control of symptoms and prevention of exacerbations in chronic airways diseases. Nevertheless, trigger avoidance is at times not possible. This is the case with wildfire smoke and other environmental irritants—an increasing global health problem. Using data from 11 hospitals along the Utah’s Wasatch Front, the study by Horne and colleagues shows a clear association between a short-term increase in ambient fine particulate matter exposure resulting from wildfires and a surge in asthma exacerbations. This effect was also seen in patients with COPD but to a lesser degree. The study is limited by its observational design and because measurements of pollution levels were performed regionally and not at individual patient level. Yet this study offers valuable insights on the effects of environmental exposures in patients with chronic airways diseases and the consequences to our health care systems. Futures studies are still needed to assess the long-term consequences of sustained exposures to these irritants in patients with respiratory conditions.
– Commentary by Diego J. Maselli, MD, FCCP, Member of the CHEST Physician Editorial Board
Advocating for diversity in medical education
Earlier this year,
If enacted, the EDUCATE Act would cut off federal funding to medical schools that force students or faculty to adopt specific beliefs; discriminate based on race or ethnicity; or have diversity, equity, and inclusion (DEI) offices or any functional equivalent. The bill would also require accreditation agencies to check that their standards do not push these practices, while still allowing instruction about health issues tied to race or collecting data for research.
In response to the introduction of this act, CHEST published a statement in support of DEI practices and their necessary role within the practice of health care and medical training programs.
It is our belief that health care requires a solid patient-provider therapeutic alliance to achieve successful outcomes, and decades of scientific research have shown that a lack of clinician diversity worsens health disparities. For patients from historically underserved communities, having clinicians who share similar lived experiences almost always leads to significant improvements in patient outcomes. If identity concordance is not feasible, clinicians with considerable exposure to diverse patient populations, equitable approaches to care, and inclusive perspectives on health gained through continuing, comprehensive medical education and professional training can also positively impact outcomes.
Research indicates that a diverse medical workforce improves cultural competence and can help clinicians better meet the needs of patients from diverse backgrounds and ethnicities and that the benefits of diverse learning environments enhance the educational experience of all participants. Racial and ethnic health inequities illuminate the greatest gaps and worst patient outcomes, especially when compounded by disparities related to gender identity, ability, language, immigration status, sexual orientation, age, socioeconomics, and other social drivers of health. Research also shows that nearly one-fifth of Latine Americans avoid medical care due to concern about experiencing discrimination, Black Americans have significantly lower life expectancies, and Asian Americans are the only racial group to experience cancer as a leading cause of death. It is also well documented that communities experiencing disproportionately high rates of COVID-19 infection, hospitalization, and mortality when compared with White Americans include Black, Latine, Asian, Native Hawaiian, and Native Americans.
“In 2023, the CHEST organization shared its organizational values: community, inclusivity, innovation, advocacy, and integrity,” said CHEST President, Jack D. Buckley, MD, MPH, FCCP. “In strong accordance with these values and with our mission to champion the prevention, diagnosis, and treatment of chest diseases and advance the best patient outcomes, CHEST is firmly committed to the necessity of diversity, equity, and inclusion in health care research, education, and delivery.”
Guided by our core values, CHEST is relentlessly committed to improving the professional’s experience and patient outcomes equally. This commitment compels us to work toward eliminating disparities in the medical field. According to the most recent US Census projections, by 2045, White Americans will no longer be considered a racial majority, with Black, Latine, and Asian Americans continuing to rise. It is incumbent upon us to ensure that our clinician workforce reflects the diversity of its local and national communities.
The underrepresentation of physicians from racially diverse backgrounds is factually clear. Black physicians comprise 5% of the current physician workforce despite Black Americans representing 13% of the population.1 Similarly, while Native Americans comprise 3% of the United States population, Native American physicians account for less than 1% of the physician workforce, with less than 10% of medical schools reporting total enrollment of more than four Native American students.2 Where gender is concerned, women make up about 36% of the physician workforce, a professional disparity that is further exacerbated given the intersections of race and gender, resulting in a significant impact on the current workforce.3 Allowing disinformation to influence the future of medical education and patient care directly contradicts our mission as clinicians dedicated to improving the health of all people.
If physician representation and patient outcomes are linked, as research shows, the lack of diverse medical school representation has dire consequences for matriculation, job recruitment, retention, and promotion. Without supportive policies, programs, and equity-focused curriculums in medical education, we will never close the gap on professional disparities, which means we will similarly never close the gap on health disparities.
Our commitment to our members, all health care professionals, and the field of medicine means that we will stand firm in our defense of DEI today and every day until we have achieved optimal, equitable health for all people in all places. CHEST is committed to an intersectional approach to equitable health care education and delivery. We strive to design solutions that center the most impacted and radiate support outward, ensuring our interventions benefit all others experiencing discrimination.
Read more about CHEST’s commitment to diversity and other advocacy work on the CHEST website.
References
1. AAMC. Figure 18. Percentage of all active physicians by race/ethnicity, 2018. AAMC; 2019. https://www.aamc.org/data-reports/workforce/data/figure-18-percentage-all-active-physicians-race/ethnicity-2018#:~:text=Diversity%20in%20Medicine%3A%20Facts%20and%20Figures%202019,-Diversity%20in%20Medicine&text=Among%20active%20physicians%2C%2056.2%25%20identified,as%20Black%20or%20African%20American
2. Murphy B. New effort to help Native American pre-meds pursue physician dreams. AMA. January 13, 2022. https://www.ama-assn.org/education/medical-school-diversity/new-effort-help-native-american-pre-meds-pursue-physician-dreams
3. AAMC. U.S. Physician Workforce Data Dashboard. AAMC; 2023. https://www.aamc.org/data-reports/report/us-physician-workforce-data-dashboard
Earlier this year,
If enacted, the EDUCATE Act would cut off federal funding to medical schools that force students or faculty to adopt specific beliefs; discriminate based on race or ethnicity; or have diversity, equity, and inclusion (DEI) offices or any functional equivalent. The bill would also require accreditation agencies to check that their standards do not push these practices, while still allowing instruction about health issues tied to race or collecting data for research.
In response to the introduction of this act, CHEST published a statement in support of DEI practices and their necessary role within the practice of health care and medical training programs.
It is our belief that health care requires a solid patient-provider therapeutic alliance to achieve successful outcomes, and decades of scientific research have shown that a lack of clinician diversity worsens health disparities. For patients from historically underserved communities, having clinicians who share similar lived experiences almost always leads to significant improvements in patient outcomes. If identity concordance is not feasible, clinicians with considerable exposure to diverse patient populations, equitable approaches to care, and inclusive perspectives on health gained through continuing, comprehensive medical education and professional training can also positively impact outcomes.
Research indicates that a diverse medical workforce improves cultural competence and can help clinicians better meet the needs of patients from diverse backgrounds and ethnicities and that the benefits of diverse learning environments enhance the educational experience of all participants. Racial and ethnic health inequities illuminate the greatest gaps and worst patient outcomes, especially when compounded by disparities related to gender identity, ability, language, immigration status, sexual orientation, age, socioeconomics, and other social drivers of health. Research also shows that nearly one-fifth of Latine Americans avoid medical care due to concern about experiencing discrimination, Black Americans have significantly lower life expectancies, and Asian Americans are the only racial group to experience cancer as a leading cause of death. It is also well documented that communities experiencing disproportionately high rates of COVID-19 infection, hospitalization, and mortality when compared with White Americans include Black, Latine, Asian, Native Hawaiian, and Native Americans.
“In 2023, the CHEST organization shared its organizational values: community, inclusivity, innovation, advocacy, and integrity,” said CHEST President, Jack D. Buckley, MD, MPH, FCCP. “In strong accordance with these values and with our mission to champion the prevention, diagnosis, and treatment of chest diseases and advance the best patient outcomes, CHEST is firmly committed to the necessity of diversity, equity, and inclusion in health care research, education, and delivery.”
Guided by our core values, CHEST is relentlessly committed to improving the professional’s experience and patient outcomes equally. This commitment compels us to work toward eliminating disparities in the medical field. According to the most recent US Census projections, by 2045, White Americans will no longer be considered a racial majority, with Black, Latine, and Asian Americans continuing to rise. It is incumbent upon us to ensure that our clinician workforce reflects the diversity of its local and national communities.
The underrepresentation of physicians from racially diverse backgrounds is factually clear. Black physicians comprise 5% of the current physician workforce despite Black Americans representing 13% of the population.1 Similarly, while Native Americans comprise 3% of the United States population, Native American physicians account for less than 1% of the physician workforce, with less than 10% of medical schools reporting total enrollment of more than four Native American students.2 Where gender is concerned, women make up about 36% of the physician workforce, a professional disparity that is further exacerbated given the intersections of race and gender, resulting in a significant impact on the current workforce.3 Allowing disinformation to influence the future of medical education and patient care directly contradicts our mission as clinicians dedicated to improving the health of all people.
If physician representation and patient outcomes are linked, as research shows, the lack of diverse medical school representation has dire consequences for matriculation, job recruitment, retention, and promotion. Without supportive policies, programs, and equity-focused curriculums in medical education, we will never close the gap on professional disparities, which means we will similarly never close the gap on health disparities.
Our commitment to our members, all health care professionals, and the field of medicine means that we will stand firm in our defense of DEI today and every day until we have achieved optimal, equitable health for all people in all places. CHEST is committed to an intersectional approach to equitable health care education and delivery. We strive to design solutions that center the most impacted and radiate support outward, ensuring our interventions benefit all others experiencing discrimination.
Read more about CHEST’s commitment to diversity and other advocacy work on the CHEST website.
References
1. AAMC. Figure 18. Percentage of all active physicians by race/ethnicity, 2018. AAMC; 2019. https://www.aamc.org/data-reports/workforce/data/figure-18-percentage-all-active-physicians-race/ethnicity-2018#:~:text=Diversity%20in%20Medicine%3A%20Facts%20and%20Figures%202019,-Diversity%20in%20Medicine&text=Among%20active%20physicians%2C%2056.2%25%20identified,as%20Black%20or%20African%20American
2. Murphy B. New effort to help Native American pre-meds pursue physician dreams. AMA. January 13, 2022. https://www.ama-assn.org/education/medical-school-diversity/new-effort-help-native-american-pre-meds-pursue-physician-dreams
3. AAMC. U.S. Physician Workforce Data Dashboard. AAMC; 2023. https://www.aamc.org/data-reports/report/us-physician-workforce-data-dashboard
Earlier this year,
If enacted, the EDUCATE Act would cut off federal funding to medical schools that force students or faculty to adopt specific beliefs; discriminate based on race or ethnicity; or have diversity, equity, and inclusion (DEI) offices or any functional equivalent. The bill would also require accreditation agencies to check that their standards do not push these practices, while still allowing instruction about health issues tied to race or collecting data for research.
In response to the introduction of this act, CHEST published a statement in support of DEI practices and their necessary role within the practice of health care and medical training programs.
It is our belief that health care requires a solid patient-provider therapeutic alliance to achieve successful outcomes, and decades of scientific research have shown that a lack of clinician diversity worsens health disparities. For patients from historically underserved communities, having clinicians who share similar lived experiences almost always leads to significant improvements in patient outcomes. If identity concordance is not feasible, clinicians with considerable exposure to diverse patient populations, equitable approaches to care, and inclusive perspectives on health gained through continuing, comprehensive medical education and professional training can also positively impact outcomes.
Research indicates that a diverse medical workforce improves cultural competence and can help clinicians better meet the needs of patients from diverse backgrounds and ethnicities and that the benefits of diverse learning environments enhance the educational experience of all participants. Racial and ethnic health inequities illuminate the greatest gaps and worst patient outcomes, especially when compounded by disparities related to gender identity, ability, language, immigration status, sexual orientation, age, socioeconomics, and other social drivers of health. Research also shows that nearly one-fifth of Latine Americans avoid medical care due to concern about experiencing discrimination, Black Americans have significantly lower life expectancies, and Asian Americans are the only racial group to experience cancer as a leading cause of death. It is also well documented that communities experiencing disproportionately high rates of COVID-19 infection, hospitalization, and mortality when compared with White Americans include Black, Latine, Asian, Native Hawaiian, and Native Americans.
“In 2023, the CHEST organization shared its organizational values: community, inclusivity, innovation, advocacy, and integrity,” said CHEST President, Jack D. Buckley, MD, MPH, FCCP. “In strong accordance with these values and with our mission to champion the prevention, diagnosis, and treatment of chest diseases and advance the best patient outcomes, CHEST is firmly committed to the necessity of diversity, equity, and inclusion in health care research, education, and delivery.”
Guided by our core values, CHEST is relentlessly committed to improving the professional’s experience and patient outcomes equally. This commitment compels us to work toward eliminating disparities in the medical field. According to the most recent US Census projections, by 2045, White Americans will no longer be considered a racial majority, with Black, Latine, and Asian Americans continuing to rise. It is incumbent upon us to ensure that our clinician workforce reflects the diversity of its local and national communities.
The underrepresentation of physicians from racially diverse backgrounds is factually clear. Black physicians comprise 5% of the current physician workforce despite Black Americans representing 13% of the population.1 Similarly, while Native Americans comprise 3% of the United States population, Native American physicians account for less than 1% of the physician workforce, with less than 10% of medical schools reporting total enrollment of more than four Native American students.2 Where gender is concerned, women make up about 36% of the physician workforce, a professional disparity that is further exacerbated given the intersections of race and gender, resulting in a significant impact on the current workforce.3 Allowing disinformation to influence the future of medical education and patient care directly contradicts our mission as clinicians dedicated to improving the health of all people.
If physician representation and patient outcomes are linked, as research shows, the lack of diverse medical school representation has dire consequences for matriculation, job recruitment, retention, and promotion. Without supportive policies, programs, and equity-focused curriculums in medical education, we will never close the gap on professional disparities, which means we will similarly never close the gap on health disparities.
Our commitment to our members, all health care professionals, and the field of medicine means that we will stand firm in our defense of DEI today and every day until we have achieved optimal, equitable health for all people in all places. CHEST is committed to an intersectional approach to equitable health care education and delivery. We strive to design solutions that center the most impacted and radiate support outward, ensuring our interventions benefit all others experiencing discrimination.
Read more about CHEST’s commitment to diversity and other advocacy work on the CHEST website.
References
1. AAMC. Figure 18. Percentage of all active physicians by race/ethnicity, 2018. AAMC; 2019. https://www.aamc.org/data-reports/workforce/data/figure-18-percentage-all-active-physicians-race/ethnicity-2018#:~:text=Diversity%20in%20Medicine%3A%20Facts%20and%20Figures%202019,-Diversity%20in%20Medicine&text=Among%20active%20physicians%2C%2056.2%25%20identified,as%20Black%20or%20African%20American
2. Murphy B. New effort to help Native American pre-meds pursue physician dreams. AMA. January 13, 2022. https://www.ama-assn.org/education/medical-school-diversity/new-effort-help-native-american-pre-meds-pursue-physician-dreams
3. AAMC. U.S. Physician Workforce Data Dashboard. AAMC; 2023. https://www.aamc.org/data-reports/report/us-physician-workforce-data-dashboard
Pseudomonas infection in patients with noncystic fibrosis bronchiectasis
Pseudomonas aeruginosa is a clinically important organism that infects patients with noncystic fibrosis bronchiectasis (NCFB). In the United States, the estimated prevalence of NCFB is 213 per 100,000 across all age groups and 813 per 100,000 in the over 65 age group.1 A retrospective cohort study suggests the incidence of NCFB as ascertained from International Classification of Diseases codes may significantly underestimate its true prevalence.2
As the incidence of patients with NCFB continues to increase, the impact of the Pseudomonas infection is expected to grow. A recent retrospective cohort study of commercial claims from IQVIA’s PharMetrics Plus database for the period 2006 to 2020 showed that patients with NCFB and Pseudomonas infection had on average 2.58 hospital admissions per year, with a mean length of stay of 9.94 (± 11.06) days, compared with 1.18 admissions per year, with a mean length of stay of 6.5 (± 8.42) days, in patients with Pseudomonas-negative NCFB. The same trend applied to 30-day readmissions and ICU admissions, 1.32 (± 2.51 days) vs 0.47 (± 1.30 days) and 0.95 (± 1.62 days) vs 0.33 (± 0.76 days), respectively. The differential cost of care per patient per year between patients with NCFB with and without Pseudomonas infection ranged from $55,225 to $315,901.3
Recent data from the United States Bronchiectasis Registry showed the probability of acquiring Pseudomonas aeruginosa was 3% annually.4 The prevalence of Pseudomonas infection in a large, geographically diverse cohort in the United States was quoted at 15%.5 A retrospective analysis of the European Bronchiectasis Registry database showed Pseudomonas infection was the most commonly isolated pathogen (21.8%).6
Given the high incidence and prevalence of NCFB, the high prevalence of Pseudomonas infection in patients with NCFB, and the associated costs and morbidity from infection, identifying effective treatments has become a priority. The British, Spanish (SEPAR), South African, and European bronchiectasis guidelines outline several antibiotic regimens meant to achieve eradication. Generally, there is induction with a (1) quinolone, (2) β-lactam + aminoglycoside, or (3) quinolone with an inhaled antibiotic followed by three months of maintenance inhaled antibiotics.7-10 SEPAR allows for retreatment for recurrence at any time during the first year with any regimen.
For chronic Pseudomonas infection, SEPAR recommends treatment with inhaled antibiotics for patients with more than two exacerbations or one hospitalization, while the threshold in the British and European guidelines is more than three exacerbations. Azithromycin may be used for those who are intolerant or allergic to the nebulized antibiotics. It is worth noting that in the United States, the antibiotics colistin, ciprofloxacin, aztreonam, gentamicin, and tobramycin are administered off label for this indication. A systematic review found a 10% rate of bronchospasm in the treated group compared with 2.3% in the control group, and premedication with albuterol is often needed.11
Unfortunately, the data supporting the listed eradication and suppressive regimens are weak. A systematic review and meta-analysis of six observational studies including 289 patients showed a 12-month eradication rate of only 40% (95% CI, 34-45; P < 0.00001; I2 = 0).12 These results are disappointing and identify a need for further research into the manner in which Pseudomonas infection interacts with the host lung.
We currently know Pseudomonas infection evades antibiotics and host defenses by accumulating mutations and deletions. These include loss-of-function mutations in mucA (mucoidy), lasR (quorum-sensing), mexS (regulates the antibiotic efflux pump), and other genes related to the production of the polysaccharides Psl and Pel (which contribute to biofilm formation).13 There may also be differences in low and high bacteria microbial networks that interact differently with host cytokines to create an unstable environment that predisposes to exacerbation.14
In an attempt to improve our eradication and suppression rates, investigators have begun to target specific aspects of Pseudomonas infection behavior. The GREAT-2 trial compares gremubamab (a bivalent, bispecific, monoclonal antibody targeting Psl exopolysaccharide and the type 3 secretion system component of PcrV) with placebo in patients with chronic Pseudomonas infection. A phase II trial with the phosphodiesterase inhibitor esifentrine, a phase III trial with a reversible DPP1 inhibitor called brensocatib (ASPEN), and a phase II trial with the CatC inhibitor BI 1291583 (Airleaf) are also being conducted. Each of these agents targets mediators of neutrophil inflammation.
In summary, NCFB with Pseudomonas infection is common and leads to an increase in costs, respiratory exacerbations, and hospitalizations. While eradication and suppression are recommended, they are difficult to achieve and require sustained durations of expensive medications that can be difficult to tolerate. Antibiotic therapies will continue to be studied (the ERASE randomized controlled trial to investigate the efficacy and safety of tobramycin to eradicate Pseudomonas infection is currently underway), but targeted therapies represent a promising new approach to combating this stubbornly resistant bacteria. The NCFB community will be watching closely to see whether medicines targeting molecular behavior and host interaction can achieve what antibiotic regimens thus far have not: consistent and sustainable eradication.
Dr. Green is Assistant Professor in Medicine, Medical Director, Bronchiectasis Program, UMass Chan/Baystate Health, Chest Infections Section, Member-at-Large
References
1. Weycker D, Hansen GL, Seifer FD. Prevalence and incidence of noncystic fibrosis bronchiectasis among US adults in 2013. Chron Respir Dis. 2017;14(4):377-384. doi: 10.1177/1479972317709649
2. Green O, Liautaud S, Knee A, Modahl L. Measuring accuracy of International Classification of Diseases codes in identification of patients with non-cystic fibrosis bronchiectasis. ERJ Open Res. 2024;10(2):00715-2023. doi: 10.1183/23120541.00715-2023
3. Franklin M, Minshall ME, Pontenani F, Devarajan S. Impact of Pseudomonas aeruginosa on resource utilization and costs in patients with exacerbated non-cystic fibrosis bronchiectasis. J Med Econ. 2024;27(1):671-677. doi: 10.1080/13696998.2024.2340382
4. Aksamit TR, Locantore N, Addrizzo-Harris D, et al. Five-year outcomes among U.S. bronchiectasis and NTM research registry patients. Am J Respir Crit Care Med. Accepted manuscript. Published online April 26, 2024.
5. Dean SG, Blakney RA, Ricotta EE, et al. Bronchiectasis-associated infections and outcomes in a large, geographically diverse electronic health record cohort in the United States. BMC Pulm Med. 2024;24(1):172. doi: 10.1186/s12890-024-02973-3
6. Chalmers JD, Polverino E, Crichton ML, et al. Bronchiectasis in Europe: data on disease characteristics from the European Bronchiectasis registry (EMBARC). Lancet Respir Med. 2023;11(7):637-649. doi: 10.1016/S2213-2600(23)00093-0
7. Polverino E, Goeminne PC, McDonnell MJ, et al. European Respiratory Society guidelines for the management of adult bronchiectasis. Eur Respir J. 2017;50(3):1700629. doi: 10.1183/13993003.00629-2017
8. Martínez-García MÁ, Máiz L, Olveira C, et al. Spanish guidelines on treatment of bronchiectasis in adults. Arch Bronconeumol. 2018;54(2):88-98. doi: 10.1016/j.arbres.2017.07.016
9. Hill AT, Sullivan AL, Chalmers JD, et al. British Thoracic Society guideline for bronchiectasis in adults. Thorax. 2019;74(Suppl 1):1-69. doi: 10.1136/thoraxjnl-2018-212463
10. Goolam Mahomed A, Maasdorp SD, Barnes R, et al. South African Thoracic Society position statement on the management of non-cystic fibrosis bronchiectasis in adults: 2023. Afr J Thorac Crit Care Med. 2023;29(2):10.7196/AJTCCM. 2023.v29i2.647. doi: 10.7196/AJTCCM.2023.v29i2.647
11. Brodt AM, Stovold E, Zhang L. Inhaled antibiotics for stable non-cystic fibrosis bronchiectasis: a systematic review. Eur Respir J. 2014;44(2):382-393. doi: 10.1183/09031936.00018414
12. Conceição M, Shteinberg M, Goeminne P, Altenburg J, Chalmers JD. Eradication treatment for Pseudomonas aeruginosa infection in adults with bronchiectasis: a systematic review and meta-analysis. Eur Respir Rev. 2024;33(171):230178. doi: 10.1183/16000617.0178-2023
13. Hilliam Y, Moore MP, Lamont IL, et al. Pseudomonas aeruginosa adaptation and diversification in the non-cystic fibrosis bronchiectasis lung. Eur Respir J. 2017;49(4):1602108. doi: 10.1183/13993003.02108-2016
14. Gramegna A, Kumar Narayana J, Amati F, et al. Microbial inflammatory networks in bronchiectasis exacerbators with Pseudomonas aeruginosa. Chest. 2023;164(1):65-68. doi: 10.1016/j.chest.2023.02.014
Pseudomonas aeruginosa is a clinically important organism that infects patients with noncystic fibrosis bronchiectasis (NCFB). In the United States, the estimated prevalence of NCFB is 213 per 100,000 across all age groups and 813 per 100,000 in the over 65 age group.1 A retrospective cohort study suggests the incidence of NCFB as ascertained from International Classification of Diseases codes may significantly underestimate its true prevalence.2
As the incidence of patients with NCFB continues to increase, the impact of the Pseudomonas infection is expected to grow. A recent retrospective cohort study of commercial claims from IQVIA’s PharMetrics Plus database for the period 2006 to 2020 showed that patients with NCFB and Pseudomonas infection had on average 2.58 hospital admissions per year, with a mean length of stay of 9.94 (± 11.06) days, compared with 1.18 admissions per year, with a mean length of stay of 6.5 (± 8.42) days, in patients with Pseudomonas-negative NCFB. The same trend applied to 30-day readmissions and ICU admissions, 1.32 (± 2.51 days) vs 0.47 (± 1.30 days) and 0.95 (± 1.62 days) vs 0.33 (± 0.76 days), respectively. The differential cost of care per patient per year between patients with NCFB with and without Pseudomonas infection ranged from $55,225 to $315,901.3
Recent data from the United States Bronchiectasis Registry showed the probability of acquiring Pseudomonas aeruginosa was 3% annually.4 The prevalence of Pseudomonas infection in a large, geographically diverse cohort in the United States was quoted at 15%.5 A retrospective analysis of the European Bronchiectasis Registry database showed Pseudomonas infection was the most commonly isolated pathogen (21.8%).6
Given the high incidence and prevalence of NCFB, the high prevalence of Pseudomonas infection in patients with NCFB, and the associated costs and morbidity from infection, identifying effective treatments has become a priority. The British, Spanish (SEPAR), South African, and European bronchiectasis guidelines outline several antibiotic regimens meant to achieve eradication. Generally, there is induction with a (1) quinolone, (2) β-lactam + aminoglycoside, or (3) quinolone with an inhaled antibiotic followed by three months of maintenance inhaled antibiotics.7-10 SEPAR allows for retreatment for recurrence at any time during the first year with any regimen.
For chronic Pseudomonas infection, SEPAR recommends treatment with inhaled antibiotics for patients with more than two exacerbations or one hospitalization, while the threshold in the British and European guidelines is more than three exacerbations. Azithromycin may be used for those who are intolerant or allergic to the nebulized antibiotics. It is worth noting that in the United States, the antibiotics colistin, ciprofloxacin, aztreonam, gentamicin, and tobramycin are administered off label for this indication. A systematic review found a 10% rate of bronchospasm in the treated group compared with 2.3% in the control group, and premedication with albuterol is often needed.11
Unfortunately, the data supporting the listed eradication and suppressive regimens are weak. A systematic review and meta-analysis of six observational studies including 289 patients showed a 12-month eradication rate of only 40% (95% CI, 34-45; P < 0.00001; I2 = 0).12 These results are disappointing and identify a need for further research into the manner in which Pseudomonas infection interacts with the host lung.
We currently know Pseudomonas infection evades antibiotics and host defenses by accumulating mutations and deletions. These include loss-of-function mutations in mucA (mucoidy), lasR (quorum-sensing), mexS (regulates the antibiotic efflux pump), and other genes related to the production of the polysaccharides Psl and Pel (which contribute to biofilm formation).13 There may also be differences in low and high bacteria microbial networks that interact differently with host cytokines to create an unstable environment that predisposes to exacerbation.14
In an attempt to improve our eradication and suppression rates, investigators have begun to target specific aspects of Pseudomonas infection behavior. The GREAT-2 trial compares gremubamab (a bivalent, bispecific, monoclonal antibody targeting Psl exopolysaccharide and the type 3 secretion system component of PcrV) with placebo in patients with chronic Pseudomonas infection. A phase II trial with the phosphodiesterase inhibitor esifentrine, a phase III trial with a reversible DPP1 inhibitor called brensocatib (ASPEN), and a phase II trial with the CatC inhibitor BI 1291583 (Airleaf) are also being conducted. Each of these agents targets mediators of neutrophil inflammation.
In summary, NCFB with Pseudomonas infection is common and leads to an increase in costs, respiratory exacerbations, and hospitalizations. While eradication and suppression are recommended, they are difficult to achieve and require sustained durations of expensive medications that can be difficult to tolerate. Antibiotic therapies will continue to be studied (the ERASE randomized controlled trial to investigate the efficacy and safety of tobramycin to eradicate Pseudomonas infection is currently underway), but targeted therapies represent a promising new approach to combating this stubbornly resistant bacteria. The NCFB community will be watching closely to see whether medicines targeting molecular behavior and host interaction can achieve what antibiotic regimens thus far have not: consistent and sustainable eradication.
Dr. Green is Assistant Professor in Medicine, Medical Director, Bronchiectasis Program, UMass Chan/Baystate Health, Chest Infections Section, Member-at-Large
References
1. Weycker D, Hansen GL, Seifer FD. Prevalence and incidence of noncystic fibrosis bronchiectasis among US adults in 2013. Chron Respir Dis. 2017;14(4):377-384. doi: 10.1177/1479972317709649
2. Green O, Liautaud S, Knee A, Modahl L. Measuring accuracy of International Classification of Diseases codes in identification of patients with non-cystic fibrosis bronchiectasis. ERJ Open Res. 2024;10(2):00715-2023. doi: 10.1183/23120541.00715-2023
3. Franklin M, Minshall ME, Pontenani F, Devarajan S. Impact of Pseudomonas aeruginosa on resource utilization and costs in patients with exacerbated non-cystic fibrosis bronchiectasis. J Med Econ. 2024;27(1):671-677. doi: 10.1080/13696998.2024.2340382
4. Aksamit TR, Locantore N, Addrizzo-Harris D, et al. Five-year outcomes among U.S. bronchiectasis and NTM research registry patients. Am J Respir Crit Care Med. Accepted manuscript. Published online April 26, 2024.
5. Dean SG, Blakney RA, Ricotta EE, et al. Bronchiectasis-associated infections and outcomes in a large, geographically diverse electronic health record cohort in the United States. BMC Pulm Med. 2024;24(1):172. doi: 10.1186/s12890-024-02973-3
6. Chalmers JD, Polverino E, Crichton ML, et al. Bronchiectasis in Europe: data on disease characteristics from the European Bronchiectasis registry (EMBARC). Lancet Respir Med. 2023;11(7):637-649. doi: 10.1016/S2213-2600(23)00093-0
7. Polverino E, Goeminne PC, McDonnell MJ, et al. European Respiratory Society guidelines for the management of adult bronchiectasis. Eur Respir J. 2017;50(3):1700629. doi: 10.1183/13993003.00629-2017
8. Martínez-García MÁ, Máiz L, Olveira C, et al. Spanish guidelines on treatment of bronchiectasis in adults. Arch Bronconeumol. 2018;54(2):88-98. doi: 10.1016/j.arbres.2017.07.016
9. Hill AT, Sullivan AL, Chalmers JD, et al. British Thoracic Society guideline for bronchiectasis in adults. Thorax. 2019;74(Suppl 1):1-69. doi: 10.1136/thoraxjnl-2018-212463
10. Goolam Mahomed A, Maasdorp SD, Barnes R, et al. South African Thoracic Society position statement on the management of non-cystic fibrosis bronchiectasis in adults: 2023. Afr J Thorac Crit Care Med. 2023;29(2):10.7196/AJTCCM. 2023.v29i2.647. doi: 10.7196/AJTCCM.2023.v29i2.647
11. Brodt AM, Stovold E, Zhang L. Inhaled antibiotics for stable non-cystic fibrosis bronchiectasis: a systematic review. Eur Respir J. 2014;44(2):382-393. doi: 10.1183/09031936.00018414
12. Conceição M, Shteinberg M, Goeminne P, Altenburg J, Chalmers JD. Eradication treatment for Pseudomonas aeruginosa infection in adults with bronchiectasis: a systematic review and meta-analysis. Eur Respir Rev. 2024;33(171):230178. doi: 10.1183/16000617.0178-2023
13. Hilliam Y, Moore MP, Lamont IL, et al. Pseudomonas aeruginosa adaptation and diversification in the non-cystic fibrosis bronchiectasis lung. Eur Respir J. 2017;49(4):1602108. doi: 10.1183/13993003.02108-2016
14. Gramegna A, Kumar Narayana J, Amati F, et al. Microbial inflammatory networks in bronchiectasis exacerbators with Pseudomonas aeruginosa. Chest. 2023;164(1):65-68. doi: 10.1016/j.chest.2023.02.014
Pseudomonas aeruginosa is a clinically important organism that infects patients with noncystic fibrosis bronchiectasis (NCFB). In the United States, the estimated prevalence of NCFB is 213 per 100,000 across all age groups and 813 per 100,000 in the over 65 age group.1 A retrospective cohort study suggests the incidence of NCFB as ascertained from International Classification of Diseases codes may significantly underestimate its true prevalence.2
As the incidence of patients with NCFB continues to increase, the impact of the Pseudomonas infection is expected to grow. A recent retrospective cohort study of commercial claims from IQVIA’s PharMetrics Plus database for the period 2006 to 2020 showed that patients with NCFB and Pseudomonas infection had on average 2.58 hospital admissions per year, with a mean length of stay of 9.94 (± 11.06) days, compared with 1.18 admissions per year, with a mean length of stay of 6.5 (± 8.42) days, in patients with Pseudomonas-negative NCFB. The same trend applied to 30-day readmissions and ICU admissions, 1.32 (± 2.51 days) vs 0.47 (± 1.30 days) and 0.95 (± 1.62 days) vs 0.33 (± 0.76 days), respectively. The differential cost of care per patient per year between patients with NCFB with and without Pseudomonas infection ranged from $55,225 to $315,901.3
Recent data from the United States Bronchiectasis Registry showed the probability of acquiring Pseudomonas aeruginosa was 3% annually.4 The prevalence of Pseudomonas infection in a large, geographically diverse cohort in the United States was quoted at 15%.5 A retrospective analysis of the European Bronchiectasis Registry database showed Pseudomonas infection was the most commonly isolated pathogen (21.8%).6
Given the high incidence and prevalence of NCFB, the high prevalence of Pseudomonas infection in patients with NCFB, and the associated costs and morbidity from infection, identifying effective treatments has become a priority. The British, Spanish (SEPAR), South African, and European bronchiectasis guidelines outline several antibiotic regimens meant to achieve eradication. Generally, there is induction with a (1) quinolone, (2) β-lactam + aminoglycoside, or (3) quinolone with an inhaled antibiotic followed by three months of maintenance inhaled antibiotics.7-10 SEPAR allows for retreatment for recurrence at any time during the first year with any regimen.
For chronic Pseudomonas infection, SEPAR recommends treatment with inhaled antibiotics for patients with more than two exacerbations or one hospitalization, while the threshold in the British and European guidelines is more than three exacerbations. Azithromycin may be used for those who are intolerant or allergic to the nebulized antibiotics. It is worth noting that in the United States, the antibiotics colistin, ciprofloxacin, aztreonam, gentamicin, and tobramycin are administered off label for this indication. A systematic review found a 10% rate of bronchospasm in the treated group compared with 2.3% in the control group, and premedication with albuterol is often needed.11
Unfortunately, the data supporting the listed eradication and suppressive regimens are weak. A systematic review and meta-analysis of six observational studies including 289 patients showed a 12-month eradication rate of only 40% (95% CI, 34-45; P < 0.00001; I2 = 0).12 These results are disappointing and identify a need for further research into the manner in which Pseudomonas infection interacts with the host lung.
We currently know Pseudomonas infection evades antibiotics and host defenses by accumulating mutations and deletions. These include loss-of-function mutations in mucA (mucoidy), lasR (quorum-sensing), mexS (regulates the antibiotic efflux pump), and other genes related to the production of the polysaccharides Psl and Pel (which contribute to biofilm formation).13 There may also be differences in low and high bacteria microbial networks that interact differently with host cytokines to create an unstable environment that predisposes to exacerbation.14
In an attempt to improve our eradication and suppression rates, investigators have begun to target specific aspects of Pseudomonas infection behavior. The GREAT-2 trial compares gremubamab (a bivalent, bispecific, monoclonal antibody targeting Psl exopolysaccharide and the type 3 secretion system component of PcrV) with placebo in patients with chronic Pseudomonas infection. A phase II trial with the phosphodiesterase inhibitor esifentrine, a phase III trial with a reversible DPP1 inhibitor called brensocatib (ASPEN), and a phase II trial with the CatC inhibitor BI 1291583 (Airleaf) are also being conducted. Each of these agents targets mediators of neutrophil inflammation.
In summary, NCFB with Pseudomonas infection is common and leads to an increase in costs, respiratory exacerbations, and hospitalizations. While eradication and suppression are recommended, they are difficult to achieve and require sustained durations of expensive medications that can be difficult to tolerate. Antibiotic therapies will continue to be studied (the ERASE randomized controlled trial to investigate the efficacy and safety of tobramycin to eradicate Pseudomonas infection is currently underway), but targeted therapies represent a promising new approach to combating this stubbornly resistant bacteria. The NCFB community will be watching closely to see whether medicines targeting molecular behavior and host interaction can achieve what antibiotic regimens thus far have not: consistent and sustainable eradication.
Dr. Green is Assistant Professor in Medicine, Medical Director, Bronchiectasis Program, UMass Chan/Baystate Health, Chest Infections Section, Member-at-Large
References
1. Weycker D, Hansen GL, Seifer FD. Prevalence and incidence of noncystic fibrosis bronchiectasis among US adults in 2013. Chron Respir Dis. 2017;14(4):377-384. doi: 10.1177/1479972317709649
2. Green O, Liautaud S, Knee A, Modahl L. Measuring accuracy of International Classification of Diseases codes in identification of patients with non-cystic fibrosis bronchiectasis. ERJ Open Res. 2024;10(2):00715-2023. doi: 10.1183/23120541.00715-2023
3. Franklin M, Minshall ME, Pontenani F, Devarajan S. Impact of Pseudomonas aeruginosa on resource utilization and costs in patients with exacerbated non-cystic fibrosis bronchiectasis. J Med Econ. 2024;27(1):671-677. doi: 10.1080/13696998.2024.2340382
4. Aksamit TR, Locantore N, Addrizzo-Harris D, et al. Five-year outcomes among U.S. bronchiectasis and NTM research registry patients. Am J Respir Crit Care Med. Accepted manuscript. Published online April 26, 2024.
5. Dean SG, Blakney RA, Ricotta EE, et al. Bronchiectasis-associated infections and outcomes in a large, geographically diverse electronic health record cohort in the United States. BMC Pulm Med. 2024;24(1):172. doi: 10.1186/s12890-024-02973-3
6. Chalmers JD, Polverino E, Crichton ML, et al. Bronchiectasis in Europe: data on disease characteristics from the European Bronchiectasis registry (EMBARC). Lancet Respir Med. 2023;11(7):637-649. doi: 10.1016/S2213-2600(23)00093-0
7. Polverino E, Goeminne PC, McDonnell MJ, et al. European Respiratory Society guidelines for the management of adult bronchiectasis. Eur Respir J. 2017;50(3):1700629. doi: 10.1183/13993003.00629-2017
8. Martínez-García MÁ, Máiz L, Olveira C, et al. Spanish guidelines on treatment of bronchiectasis in adults. Arch Bronconeumol. 2018;54(2):88-98. doi: 10.1016/j.arbres.2017.07.016
9. Hill AT, Sullivan AL, Chalmers JD, et al. British Thoracic Society guideline for bronchiectasis in adults. Thorax. 2019;74(Suppl 1):1-69. doi: 10.1136/thoraxjnl-2018-212463
10. Goolam Mahomed A, Maasdorp SD, Barnes R, et al. South African Thoracic Society position statement on the management of non-cystic fibrosis bronchiectasis in adults: 2023. Afr J Thorac Crit Care Med. 2023;29(2):10.7196/AJTCCM. 2023.v29i2.647. doi: 10.7196/AJTCCM.2023.v29i2.647
11. Brodt AM, Stovold E, Zhang L. Inhaled antibiotics for stable non-cystic fibrosis bronchiectasis: a systematic review. Eur Respir J. 2014;44(2):382-393. doi: 10.1183/09031936.00018414
12. Conceição M, Shteinberg M, Goeminne P, Altenburg J, Chalmers JD. Eradication treatment for Pseudomonas aeruginosa infection in adults with bronchiectasis: a systematic review and meta-analysis. Eur Respir Rev. 2024;33(171):230178. doi: 10.1183/16000617.0178-2023
13. Hilliam Y, Moore MP, Lamont IL, et al. Pseudomonas aeruginosa adaptation and diversification in the non-cystic fibrosis bronchiectasis lung. Eur Respir J. 2017;49(4):1602108. doi: 10.1183/13993003.02108-2016
14. Gramegna A, Kumar Narayana J, Amati F, et al. Microbial inflammatory networks in bronchiectasis exacerbators with Pseudomonas aeruginosa. Chest. 2023;164(1):65-68. doi: 10.1016/j.chest.2023.02.014
Sleep and athletic performance
Sleep Medicine Network
Respiratory-Related Sleep Disorders Section
Considering the recent Olympics, it is timely to review the importance of sleep for optimal athletic performance. When surveyed, 20% to 50% of athletes report poor or insufficient sleep, with consequences across four categories.1,2
Athletic performance: Objective measures of athletic performance, such as oxygen-carrying capacity during cardiopulmonary exercise and even sport-specific accuracy measures, like shooting percentage in basketball, have been shown to worsen with decreased sleep.
Decision-making: Insufficient sleep can impact split-second decisions in competition. In a study of male soccer players, sleep restriction negatively impacted perceptual abilities and reaction time. Traveling across time zones also appears to degrade performance; NBA players’ free-throw shooting worsens when they are jet-lagged.
Recovery and injury prevention: Getting less than eight hours of sleep may increase one’s chances of injury during performance. Sleepiness and insomnia are both independent risk factors for developing a concussion in college athletes and outperform more intuitive risk factors such as a history of prior concussion or participating in a high-risk sport. Impaired sleep directly alters secretion of growth hormone, cortisol, and proinflammatory cytokines—all of which can hinder recovery.
Mental health: Over a third of elite athletes are estimated to experience a mental health problem. A clear bidirectional relationship exists between mental health and sleep health, with important implications not only for optimal competitive mindset but also longevity and success over one’s career.
Although much of clinical sleep medicine focuses on pathology, we can also help our patients reach their athletic goals by strategizing ways to prioritize and improve sleep.
References
1. Cook JD, Charest J. Sleep and performance in professional athletes. Curr Sleep Med Rep. 2023;9(1):56-81.
2. Charest J, Grandner MA. Sleep and athletic performance: impacts on physical performance, mental performance, injury risk and recovery, and mental health. Sleep Med Clin. 2020;15(1):41-57.
Sleep Medicine Network
Respiratory-Related Sleep Disorders Section
Considering the recent Olympics, it is timely to review the importance of sleep for optimal athletic performance. When surveyed, 20% to 50% of athletes report poor or insufficient sleep, with consequences across four categories.1,2
Athletic performance: Objective measures of athletic performance, such as oxygen-carrying capacity during cardiopulmonary exercise and even sport-specific accuracy measures, like shooting percentage in basketball, have been shown to worsen with decreased sleep.
Decision-making: Insufficient sleep can impact split-second decisions in competition. In a study of male soccer players, sleep restriction negatively impacted perceptual abilities and reaction time. Traveling across time zones also appears to degrade performance; NBA players’ free-throw shooting worsens when they are jet-lagged.
Recovery and injury prevention: Getting less than eight hours of sleep may increase one’s chances of injury during performance. Sleepiness and insomnia are both independent risk factors for developing a concussion in college athletes and outperform more intuitive risk factors such as a history of prior concussion or participating in a high-risk sport. Impaired sleep directly alters secretion of growth hormone, cortisol, and proinflammatory cytokines—all of which can hinder recovery.
Mental health: Over a third of elite athletes are estimated to experience a mental health problem. A clear bidirectional relationship exists between mental health and sleep health, with important implications not only for optimal competitive mindset but also longevity and success over one’s career.
Although much of clinical sleep medicine focuses on pathology, we can also help our patients reach their athletic goals by strategizing ways to prioritize and improve sleep.
References
1. Cook JD, Charest J. Sleep and performance in professional athletes. Curr Sleep Med Rep. 2023;9(1):56-81.
2. Charest J, Grandner MA. Sleep and athletic performance: impacts on physical performance, mental performance, injury risk and recovery, and mental health. Sleep Med Clin. 2020;15(1):41-57.
Sleep Medicine Network
Respiratory-Related Sleep Disorders Section
Considering the recent Olympics, it is timely to review the importance of sleep for optimal athletic performance. When surveyed, 20% to 50% of athletes report poor or insufficient sleep, with consequences across four categories.1,2
Athletic performance: Objective measures of athletic performance, such as oxygen-carrying capacity during cardiopulmonary exercise and even sport-specific accuracy measures, like shooting percentage in basketball, have been shown to worsen with decreased sleep.
Decision-making: Insufficient sleep can impact split-second decisions in competition. In a study of male soccer players, sleep restriction negatively impacted perceptual abilities and reaction time. Traveling across time zones also appears to degrade performance; NBA players’ free-throw shooting worsens when they are jet-lagged.
Recovery and injury prevention: Getting less than eight hours of sleep may increase one’s chances of injury during performance. Sleepiness and insomnia are both independent risk factors for developing a concussion in college athletes and outperform more intuitive risk factors such as a history of prior concussion or participating in a high-risk sport. Impaired sleep directly alters secretion of growth hormone, cortisol, and proinflammatory cytokines—all of which can hinder recovery.
Mental health: Over a third of elite athletes are estimated to experience a mental health problem. A clear bidirectional relationship exists between mental health and sleep health, with important implications not only for optimal competitive mindset but also longevity and success over one’s career.
Although much of clinical sleep medicine focuses on pathology, we can also help our patients reach their athletic goals by strategizing ways to prioritize and improve sleep.
References
1. Cook JD, Charest J. Sleep and performance in professional athletes. Curr Sleep Med Rep. 2023;9(1):56-81.
2. Charest J, Grandner MA. Sleep and athletic performance: impacts on physical performance, mental performance, injury risk and recovery, and mental health. Sleep Med Clin. 2020;15(1):41-57.
Undertreatment of Women With MS Unjustified
COPENHAGEN — , even after accounting for treatment discontinuations during pregnancy and the postpartum period, new research suggested.
“We believe that pregnancy-related considerations probably still explain the major part of this gap,” said Antoine Gavoille, MD, University of Lyon, France, who presented the study at the 2024 ECTRIMS annual meeting.
This is likely due to “factors such as anticipation of pregnancy long before it occurs and fear of exposing women of childbearing age to certain treatments even in the absence of planned pregnancy,” he added.
Caution is warranted when medications are first marketed because there are no data on safety in pregnancy. However, in 2024, “this lesser treatment in women is unacceptable,” said Dr. Gavoille. “We now have several highly effective treatment options which are compatible with pregnancy,” he noted.
The researchers analyzed the French MS registry of 22,657 patients with relapsing MS (74.2% women) between 1997 and 2022 for treatment differences between women and their male counterparts. The results were adjusted for multiple factors including educational level, disease activity, disability levels, and discontinuation of drugs during pregnancy.
They found that over a median follow-up of 11.6 years, women had a significantly lower probability of receiving any disease-modifying treatment (odds ratio [OR], 0.92; 95% CI, 0.87-0.97).
In addition, women were even less likely to receive high-efficacy treatments such as natalizumab, anti-CD20 antibodies, or S1P modulators such as fingolimod (OR, 0.80; 95% CI, 0.74-0.86).
The difference in disease-modifying treatment usage varied across different treatments and over time. Teriflunomide, fingolimod, and anti-CD20 therapies were significantly underused throughout their entire availability (OR, 0.87, 0.78, and 0.80, respectively).
Interferon and natalizumab were initially used less frequently in women, but the use of these medications equalized over time.
In contrast, glatiramer acetate and dimethyl fumarate were initially used equally between genders but eventually became more commonly prescribed to women (OR, 1.27 and 1.17, respectively).
The disparity in treatment emerged after 2 years of disease duration for disease-modifying treatments in general and as early as 1 year for highly effective treatments.
The gender-based treatment gap did not significantly vary with patient age, indicating that therapeutic inertia may persist regardless of a woman’s age.
“Women may not be receiving the most effective therapies at the optimal time, often due to concerns about pregnancy risks that may never materialize,” said the study’s lead investigator Sandra Vukusic, MD, Lyon University Hospital, France.
“The main impact of this therapeutic inertia in women is the less effective control of disease activity, leading to the accumulation of lesions and an increased risk of long-term disability. This represents a real loss of opportunity for women, especially in an era where disease-modifying treatments so effective when used early,” she added.
Dr. Gavoille said that recommendations in France allow the use of moderately active drugs, including interferon and glatiramer acetate, during pregnancy or in women planning a pregnancy. More recently there has been enough data to allow the use of natalizumab up until the second trimester.
In addition, although not in the guidelines, it is thought that the anti-CD20 monoclonal antibodies, such as rituximab or ocrelizumab, may be safe as they are very long acting. Women can be dosed before pregnancy and be covered for the whole pregnancy period without exposing the fetus to the drug, he explained.
“The message is that now we have both moderately and highly effective treatments that are compatible with a pregnancy plan,” Dr. Gavoille said.
First, clinicians have to select a level of treatment based on disease activity and then choose the best option, depending on the woman’s plans with respect to pregnancy.
Drugs that are contraindicated in pregnancy include teriflunomide and S1P modulators such as fingolimod, which have been shown to be harmful to the fetus.
“But they could still be used in women of childbearing years as long as they are not planning a pregnancy and understand the need for contraception,” Dr. Gavoille noted.
He believes both neurologists and patients are afraid of using drugs in pregnancy. “It is, of course, important to be cautious on this issue, but we should not let fear stop these women receiving the best treatments available.”
However, he added, clinical practice is changing, and confidence is gradually building around using highly effective treatments in women of childbearing age.
Dr. Gavoille also called for more research to collate data in pregnant women with MS who are exposed to various treatments, starting with case reports and then academic registries, which he described as “difficult but important work.”
Commenting on the study, Robert Hoepner, MD, University Hospital of Bern, Switzerland, agreed that this treatment disparity between men and women is “unacceptable.”
Dr. Hoepner noted that a recent study showed that women have different relapse symptoms than men, which may also affect treatment choice.
Dr. Gavoille responded that other research has shown that women are less likely to have treatment escalation post-relapse. “This could be because of a difference in symptoms. But this is something we haven’t looked at yet.”
Also commenting on the research, Frauke Zipp, MD, University Medical Center Mainz in Germany, said it would be interesting to follow this cohort over the long term to see if the women do less well several years down the line.
The study authors and commentators reported no relevant disclosures.
A version of this article first appeared on Medscape.com.
COPENHAGEN — , even after accounting for treatment discontinuations during pregnancy and the postpartum period, new research suggested.
“We believe that pregnancy-related considerations probably still explain the major part of this gap,” said Antoine Gavoille, MD, University of Lyon, France, who presented the study at the 2024 ECTRIMS annual meeting.
This is likely due to “factors such as anticipation of pregnancy long before it occurs and fear of exposing women of childbearing age to certain treatments even in the absence of planned pregnancy,” he added.
Caution is warranted when medications are first marketed because there are no data on safety in pregnancy. However, in 2024, “this lesser treatment in women is unacceptable,” said Dr. Gavoille. “We now have several highly effective treatment options which are compatible with pregnancy,” he noted.
The researchers analyzed the French MS registry of 22,657 patients with relapsing MS (74.2% women) between 1997 and 2022 for treatment differences between women and their male counterparts. The results were adjusted for multiple factors including educational level, disease activity, disability levels, and discontinuation of drugs during pregnancy.
They found that over a median follow-up of 11.6 years, women had a significantly lower probability of receiving any disease-modifying treatment (odds ratio [OR], 0.92; 95% CI, 0.87-0.97).
In addition, women were even less likely to receive high-efficacy treatments such as natalizumab, anti-CD20 antibodies, or S1P modulators such as fingolimod (OR, 0.80; 95% CI, 0.74-0.86).
The difference in disease-modifying treatment usage varied across different treatments and over time. Teriflunomide, fingolimod, and anti-CD20 therapies were significantly underused throughout their entire availability (OR, 0.87, 0.78, and 0.80, respectively).
Interferon and natalizumab were initially used less frequently in women, but the use of these medications equalized over time.
In contrast, glatiramer acetate and dimethyl fumarate were initially used equally between genders but eventually became more commonly prescribed to women (OR, 1.27 and 1.17, respectively).
The disparity in treatment emerged after 2 years of disease duration for disease-modifying treatments in general and as early as 1 year for highly effective treatments.
The gender-based treatment gap did not significantly vary with patient age, indicating that therapeutic inertia may persist regardless of a woman’s age.
“Women may not be receiving the most effective therapies at the optimal time, often due to concerns about pregnancy risks that may never materialize,” said the study’s lead investigator Sandra Vukusic, MD, Lyon University Hospital, France.
“The main impact of this therapeutic inertia in women is the less effective control of disease activity, leading to the accumulation of lesions and an increased risk of long-term disability. This represents a real loss of opportunity for women, especially in an era where disease-modifying treatments so effective when used early,” she added.
Dr. Gavoille said that recommendations in France allow the use of moderately active drugs, including interferon and glatiramer acetate, during pregnancy or in women planning a pregnancy. More recently there has been enough data to allow the use of natalizumab up until the second trimester.
In addition, although not in the guidelines, it is thought that the anti-CD20 monoclonal antibodies, such as rituximab or ocrelizumab, may be safe as they are very long acting. Women can be dosed before pregnancy and be covered for the whole pregnancy period without exposing the fetus to the drug, he explained.
“The message is that now we have both moderately and highly effective treatments that are compatible with a pregnancy plan,” Dr. Gavoille said.
First, clinicians have to select a level of treatment based on disease activity and then choose the best option, depending on the woman’s plans with respect to pregnancy.
Drugs that are contraindicated in pregnancy include teriflunomide and S1P modulators such as fingolimod, which have been shown to be harmful to the fetus.
“But they could still be used in women of childbearing years as long as they are not planning a pregnancy and understand the need for contraception,” Dr. Gavoille noted.
He believes both neurologists and patients are afraid of using drugs in pregnancy. “It is, of course, important to be cautious on this issue, but we should not let fear stop these women receiving the best treatments available.”
However, he added, clinical practice is changing, and confidence is gradually building around using highly effective treatments in women of childbearing age.
Dr. Gavoille also called for more research to collate data in pregnant women with MS who are exposed to various treatments, starting with case reports and then academic registries, which he described as “difficult but important work.”
Commenting on the study, Robert Hoepner, MD, University Hospital of Bern, Switzerland, agreed that this treatment disparity between men and women is “unacceptable.”
Dr. Hoepner noted that a recent study showed that women have different relapse symptoms than men, which may also affect treatment choice.
Dr. Gavoille responded that other research has shown that women are less likely to have treatment escalation post-relapse. “This could be because of a difference in symptoms. But this is something we haven’t looked at yet.”
Also commenting on the research, Frauke Zipp, MD, University Medical Center Mainz in Germany, said it would be interesting to follow this cohort over the long term to see if the women do less well several years down the line.
The study authors and commentators reported no relevant disclosures.
A version of this article first appeared on Medscape.com.
COPENHAGEN — , even after accounting for treatment discontinuations during pregnancy and the postpartum period, new research suggested.
“We believe that pregnancy-related considerations probably still explain the major part of this gap,” said Antoine Gavoille, MD, University of Lyon, France, who presented the study at the 2024 ECTRIMS annual meeting.
This is likely due to “factors such as anticipation of pregnancy long before it occurs and fear of exposing women of childbearing age to certain treatments even in the absence of planned pregnancy,” he added.
Caution is warranted when medications are first marketed because there are no data on safety in pregnancy. However, in 2024, “this lesser treatment in women is unacceptable,” said Dr. Gavoille. “We now have several highly effective treatment options which are compatible with pregnancy,” he noted.
The researchers analyzed the French MS registry of 22,657 patients with relapsing MS (74.2% women) between 1997 and 2022 for treatment differences between women and their male counterparts. The results were adjusted for multiple factors including educational level, disease activity, disability levels, and discontinuation of drugs during pregnancy.
They found that over a median follow-up of 11.6 years, women had a significantly lower probability of receiving any disease-modifying treatment (odds ratio [OR], 0.92; 95% CI, 0.87-0.97).
In addition, women were even less likely to receive high-efficacy treatments such as natalizumab, anti-CD20 antibodies, or S1P modulators such as fingolimod (OR, 0.80; 95% CI, 0.74-0.86).
The difference in disease-modifying treatment usage varied across different treatments and over time. Teriflunomide, fingolimod, and anti-CD20 therapies were significantly underused throughout their entire availability (OR, 0.87, 0.78, and 0.80, respectively).
Interferon and natalizumab were initially used less frequently in women, but the use of these medications equalized over time.
In contrast, glatiramer acetate and dimethyl fumarate were initially used equally between genders but eventually became more commonly prescribed to women (OR, 1.27 and 1.17, respectively).
The disparity in treatment emerged after 2 years of disease duration for disease-modifying treatments in general and as early as 1 year for highly effective treatments.
The gender-based treatment gap did not significantly vary with patient age, indicating that therapeutic inertia may persist regardless of a woman’s age.
“Women may not be receiving the most effective therapies at the optimal time, often due to concerns about pregnancy risks that may never materialize,” said the study’s lead investigator Sandra Vukusic, MD, Lyon University Hospital, France.
“The main impact of this therapeutic inertia in women is the less effective control of disease activity, leading to the accumulation of lesions and an increased risk of long-term disability. This represents a real loss of opportunity for women, especially in an era where disease-modifying treatments so effective when used early,” she added.
Dr. Gavoille said that recommendations in France allow the use of moderately active drugs, including interferon and glatiramer acetate, during pregnancy or in women planning a pregnancy. More recently there has been enough data to allow the use of natalizumab up until the second trimester.
In addition, although not in the guidelines, it is thought that the anti-CD20 monoclonal antibodies, such as rituximab or ocrelizumab, may be safe as they are very long acting. Women can be dosed before pregnancy and be covered for the whole pregnancy period without exposing the fetus to the drug, he explained.
“The message is that now we have both moderately and highly effective treatments that are compatible with a pregnancy plan,” Dr. Gavoille said.
First, clinicians have to select a level of treatment based on disease activity and then choose the best option, depending on the woman’s plans with respect to pregnancy.
Drugs that are contraindicated in pregnancy include teriflunomide and S1P modulators such as fingolimod, which have been shown to be harmful to the fetus.
“But they could still be used in women of childbearing years as long as they are not planning a pregnancy and understand the need for contraception,” Dr. Gavoille noted.
He believes both neurologists and patients are afraid of using drugs in pregnancy. “It is, of course, important to be cautious on this issue, but we should not let fear stop these women receiving the best treatments available.”
However, he added, clinical practice is changing, and confidence is gradually building around using highly effective treatments in women of childbearing age.
Dr. Gavoille also called for more research to collate data in pregnant women with MS who are exposed to various treatments, starting with case reports and then academic registries, which he described as “difficult but important work.”
Commenting on the study, Robert Hoepner, MD, University Hospital of Bern, Switzerland, agreed that this treatment disparity between men and women is “unacceptable.”
Dr. Hoepner noted that a recent study showed that women have different relapse symptoms than men, which may also affect treatment choice.
Dr. Gavoille responded that other research has shown that women are less likely to have treatment escalation post-relapse. “This could be because of a difference in symptoms. But this is something we haven’t looked at yet.”
Also commenting on the research, Frauke Zipp, MD, University Medical Center Mainz in Germany, said it would be interesting to follow this cohort over the long term to see if the women do less well several years down the line.
The study authors and commentators reported no relevant disclosures.
A version of this article first appeared on Medscape.com.
FROM ECTRIMS 2024
The gas stove: Friend or foe?
Diffuse Lung Disease and Lung Transplant Network
Occupational and Environmental Health Section
The kitchen is considered the heart of the home, but recent discoveries have raised concerns about whether this beloved space might also pose hidden health risks. Gas stoves, present in 38% of U.S. homes, generate multiple pollutants including nitrogen dioxide (NO₂), a known respiratory irritant.1 Studies have identified a correlation between NO₂ levels and respiratory conditions, with children being particularly vulnerable.2 The association between domestic NO₂ exposure from gas stoves and conditions such as asthma has led to increased scrutiny of indoor air quality.
Studies have demonstrated that households using gas stoves have higher indoor NO₂ levels, with levels that far exceed the EPA national ambient air quality standards.3 While the predominance of studies have looked at a correlation with pediatric pulmonary processes, there is also evidence of increased lung function loss in patients who smoke and have COPD.4
Switching from gas to electric stoves is one proposed solution to mitigate exposure to NO₂. Evidence suggests that electric stoves significantly reduce indoor NO₂ levels, lowering the risk of respiratory illnesses.
Another proposed solution has been to utilize hoods; however, capture efficiency is variable and some recycle the air and return it indoors.5 While existing data indicates a connection between gas stove use and respiratory health risks, conclusive evidence examining the magnitude and mechanisms linking these factors to chronic lung diseases is still needed. Comprehensive studies will help determine whether the kitchen staple—a gas stove—is indeed a friend or a foe to our respiratory health.
References
1. U.S. Energy Information Administration, Appliances in U.S. homes, by household income, 2020. https://www.eia.gov/consumption/residential/data/2020/hc/pdf/HC%203.5.pdf. Accessed September 10, 2024.
2. Belanger K, Holford TR, Gent JF, Hill ME, Kezik JM, Leaderer BP. Household levels of nitrogen dioxide and pediatric asthma severity. Epidemiology. 2013;24(2):320-330.
3. Singer BC, Pass RZ, Delp WW, Lorenzetti DM, Maddalena RL. Pollutant concentrations and emission rates from natural gas cooking burners without and with range hood exhaust in nine California homes. Building and Environment. 2017;122:215-229.
4. Hansel NN, Woo H, Koehler K, et al. Indoor pollution and lung function decline in current and former smokers: SPIROMICS AIR. Am J Respir Crit Care Med. 2023;208(10):1042-1051.
5. Nassikas NJ, McCormack MC, Ewart G, et al. Indoor air sources of outdoor air pollution: health consequences, policy, and recommendations: an Official American Thoracic Society Workshop report. Ann Am Thorac Soc. 2024;21(3), 365-376.
Diffuse Lung Disease and Lung Transplant Network
Occupational and Environmental Health Section
The kitchen is considered the heart of the home, but recent discoveries have raised concerns about whether this beloved space might also pose hidden health risks. Gas stoves, present in 38% of U.S. homes, generate multiple pollutants including nitrogen dioxide (NO₂), a known respiratory irritant.1 Studies have identified a correlation between NO₂ levels and respiratory conditions, with children being particularly vulnerable.2 The association between domestic NO₂ exposure from gas stoves and conditions such as asthma has led to increased scrutiny of indoor air quality.
Studies have demonstrated that households using gas stoves have higher indoor NO₂ levels, with levels that far exceed the EPA national ambient air quality standards.3 While the predominance of studies have looked at a correlation with pediatric pulmonary processes, there is also evidence of increased lung function loss in patients who smoke and have COPD.4
Switching from gas to electric stoves is one proposed solution to mitigate exposure to NO₂. Evidence suggests that electric stoves significantly reduce indoor NO₂ levels, lowering the risk of respiratory illnesses.
Another proposed solution has been to utilize hoods; however, capture efficiency is variable and some recycle the air and return it indoors.5 While existing data indicates a connection between gas stove use and respiratory health risks, conclusive evidence examining the magnitude and mechanisms linking these factors to chronic lung diseases is still needed. Comprehensive studies will help determine whether the kitchen staple—a gas stove—is indeed a friend or a foe to our respiratory health.
References
1. U.S. Energy Information Administration, Appliances in U.S. homes, by household income, 2020. https://www.eia.gov/consumption/residential/data/2020/hc/pdf/HC%203.5.pdf. Accessed September 10, 2024.
2. Belanger K, Holford TR, Gent JF, Hill ME, Kezik JM, Leaderer BP. Household levels of nitrogen dioxide and pediatric asthma severity. Epidemiology. 2013;24(2):320-330.
3. Singer BC, Pass RZ, Delp WW, Lorenzetti DM, Maddalena RL. Pollutant concentrations and emission rates from natural gas cooking burners without and with range hood exhaust in nine California homes. Building and Environment. 2017;122:215-229.
4. Hansel NN, Woo H, Koehler K, et al. Indoor pollution and lung function decline in current and former smokers: SPIROMICS AIR. Am J Respir Crit Care Med. 2023;208(10):1042-1051.
5. Nassikas NJ, McCormack MC, Ewart G, et al. Indoor air sources of outdoor air pollution: health consequences, policy, and recommendations: an Official American Thoracic Society Workshop report. Ann Am Thorac Soc. 2024;21(3), 365-376.
Diffuse Lung Disease and Lung Transplant Network
Occupational and Environmental Health Section
The kitchen is considered the heart of the home, but recent discoveries have raised concerns about whether this beloved space might also pose hidden health risks. Gas stoves, present in 38% of U.S. homes, generate multiple pollutants including nitrogen dioxide (NO₂), a known respiratory irritant.1 Studies have identified a correlation between NO₂ levels and respiratory conditions, with children being particularly vulnerable.2 The association between domestic NO₂ exposure from gas stoves and conditions such as asthma has led to increased scrutiny of indoor air quality.
Studies have demonstrated that households using gas stoves have higher indoor NO₂ levels, with levels that far exceed the EPA national ambient air quality standards.3 While the predominance of studies have looked at a correlation with pediatric pulmonary processes, there is also evidence of increased lung function loss in patients who smoke and have COPD.4
Switching from gas to electric stoves is one proposed solution to mitigate exposure to NO₂. Evidence suggests that electric stoves significantly reduce indoor NO₂ levels, lowering the risk of respiratory illnesses.
Another proposed solution has been to utilize hoods; however, capture efficiency is variable and some recycle the air and return it indoors.5 While existing data indicates a connection between gas stove use and respiratory health risks, conclusive evidence examining the magnitude and mechanisms linking these factors to chronic lung diseases is still needed. Comprehensive studies will help determine whether the kitchen staple—a gas stove—is indeed a friend or a foe to our respiratory health.
References
1. U.S. Energy Information Administration, Appliances in U.S. homes, by household income, 2020. https://www.eia.gov/consumption/residential/data/2020/hc/pdf/HC%203.5.pdf. Accessed September 10, 2024.
2. Belanger K, Holford TR, Gent JF, Hill ME, Kezik JM, Leaderer BP. Household levels of nitrogen dioxide and pediatric asthma severity. Epidemiology. 2013;24(2):320-330.
3. Singer BC, Pass RZ, Delp WW, Lorenzetti DM, Maddalena RL. Pollutant concentrations and emission rates from natural gas cooking burners without and with range hood exhaust in nine California homes. Building and Environment. 2017;122:215-229.
4. Hansel NN, Woo H, Koehler K, et al. Indoor pollution and lung function decline in current and former smokers: SPIROMICS AIR. Am J Respir Crit Care Med. 2023;208(10):1042-1051.
5. Nassikas NJ, McCormack MC, Ewart G, et al. Indoor air sources of outdoor air pollution: health consequences, policy, and recommendations: an Official American Thoracic Society Workshop report. Ann Am Thorac Soc. 2024;21(3), 365-376.
Prediction models in sepsis
Critical Care Network
Sepsis/Shock Section
Early recognition is the linchpin of sepsis management, as mortality from sepsis increases by 4% to 9% for every hour that diagnosis and treatment are delayed.1,2 Artificial intelligence (AI) and machine learning (ML) are increasingly featured in discussions and publications about sepsis care. Already ML models are embedded in electronic medical records (EMR), driving best-practice advisories that are presented to users.3 Epic, the EMR that serves over half of patients in the US, offers its own proprietary cognitive computing model for early detection.
As ML permeates the critical care space, it is increasingly important that clinicians understand the limitations of these models. Recently Kamran et al (NEJM AI) evaluated the Epic sepsis model with disappointing results after excluding cases already recognized by clinicians. The model achieved a positive predictive value of 5%, and 80% of high-risk sepsis cases were missed.3
An application study by Lilly et al (CHEST) showed that an ML model for clinically actionable events was more accurate with less alarm burden when compared to biomedical monitor alarms or telemedicine systems.4 The clinical utility of this model, however, remains questionable; presumably by the time a patient monitor has alarmed, the term “early recognition” can no longer be applied. In this study a significantly elevated false-positive rate required clinicians to review all cases prior to action.
ML models seem to offer incredible potential to clinicians. How they fit into current practice, however, deserves careful consideration. It may be that we just are not there yet.
References
1. Sepsis Alliance. (2024, June 19). Septic shock. 2024. https://www.sepsis.org/sepsisand/septic-shock/. Accessed September 10, 2024.
2. Djikic M, Milenkovic M, Stojadinovic M, et al. The six scoring systems’ prognostic value in predicting 24-hour mortality in septic patients. Eur Rev Med Pharmacol Sci. 2024;28(12):3849-3859.
3. Kamran F, Tjandra D, Heiler A, et al. Evaluation of sepsis prediction models before onset of treatment. NEJM AI. 2024.
4. Lilly CM, Kirk D, Pessach IM, et al. Application of machine learning models to biomedical and information system signals from critically ill adults. CHEST. 2024;165(5):1139-1148.
Critical Care Network
Sepsis/Shock Section
Early recognition is the linchpin of sepsis management, as mortality from sepsis increases by 4% to 9% for every hour that diagnosis and treatment are delayed.1,2 Artificial intelligence (AI) and machine learning (ML) are increasingly featured in discussions and publications about sepsis care. Already ML models are embedded in electronic medical records (EMR), driving best-practice advisories that are presented to users.3 Epic, the EMR that serves over half of patients in the US, offers its own proprietary cognitive computing model for early detection.
As ML permeates the critical care space, it is increasingly important that clinicians understand the limitations of these models. Recently Kamran et al (NEJM AI) evaluated the Epic sepsis model with disappointing results after excluding cases already recognized by clinicians. The model achieved a positive predictive value of 5%, and 80% of high-risk sepsis cases were missed.3
An application study by Lilly et al (CHEST) showed that an ML model for clinically actionable events was more accurate with less alarm burden when compared to biomedical monitor alarms or telemedicine systems.4 The clinical utility of this model, however, remains questionable; presumably by the time a patient monitor has alarmed, the term “early recognition” can no longer be applied. In this study a significantly elevated false-positive rate required clinicians to review all cases prior to action.
ML models seem to offer incredible potential to clinicians. How they fit into current practice, however, deserves careful consideration. It may be that we just are not there yet.
References
1. Sepsis Alliance. (2024, June 19). Septic shock. 2024. https://www.sepsis.org/sepsisand/septic-shock/. Accessed September 10, 2024.
2. Djikic M, Milenkovic M, Stojadinovic M, et al. The six scoring systems’ prognostic value in predicting 24-hour mortality in septic patients. Eur Rev Med Pharmacol Sci. 2024;28(12):3849-3859.
3. Kamran F, Tjandra D, Heiler A, et al. Evaluation of sepsis prediction models before onset of treatment. NEJM AI. 2024.
4. Lilly CM, Kirk D, Pessach IM, et al. Application of machine learning models to biomedical and information system signals from critically ill adults. CHEST. 2024;165(5):1139-1148.
Critical Care Network
Sepsis/Shock Section
Early recognition is the linchpin of sepsis management, as mortality from sepsis increases by 4% to 9% for every hour that diagnosis and treatment are delayed.1,2 Artificial intelligence (AI) and machine learning (ML) are increasingly featured in discussions and publications about sepsis care. Already ML models are embedded in electronic medical records (EMR), driving best-practice advisories that are presented to users.3 Epic, the EMR that serves over half of patients in the US, offers its own proprietary cognitive computing model for early detection.
As ML permeates the critical care space, it is increasingly important that clinicians understand the limitations of these models. Recently Kamran et al (NEJM AI) evaluated the Epic sepsis model with disappointing results after excluding cases already recognized by clinicians. The model achieved a positive predictive value of 5%, and 80% of high-risk sepsis cases were missed.3
An application study by Lilly et al (CHEST) showed that an ML model for clinically actionable events was more accurate with less alarm burden when compared to biomedical monitor alarms or telemedicine systems.4 The clinical utility of this model, however, remains questionable; presumably by the time a patient monitor has alarmed, the term “early recognition” can no longer be applied. In this study a significantly elevated false-positive rate required clinicians to review all cases prior to action.
ML models seem to offer incredible potential to clinicians. How they fit into current practice, however, deserves careful consideration. It may be that we just are not there yet.
References
1. Sepsis Alliance. (2024, June 19). Septic shock. 2024. https://www.sepsis.org/sepsisand/septic-shock/. Accessed September 10, 2024.
2. Djikic M, Milenkovic M, Stojadinovic M, et al. The six scoring systems’ prognostic value in predicting 24-hour mortality in septic patients. Eur Rev Med Pharmacol Sci. 2024;28(12):3849-3859.
3. Kamran F, Tjandra D, Heiler A, et al. Evaluation of sepsis prediction models before onset of treatment. NEJM AI. 2024.
4. Lilly CM, Kirk D, Pessach IM, et al. Application of machine learning models to biomedical and information system signals from critically ill adults. CHEST. 2024;165(5):1139-1148.
Lung ultrasound: An indispensable yet underutilized tool
Thoracic Oncology and Chest Procedures Network
Ultrasound and Chest Imaging Section
An assessment using bedside thoracic ultrasound (TUS) improves diagnostic evaluation and therapeutic management in critically ill patients without undue risk. With changes in diagnosis occurring in 23% of cases and alterations in management in 39% of critically ill patients, TUS can improve length of stay, reduce complications, minimize delays in therapy, and lower hospitalization costs.1 Compared with its cardiac counterpart, attaining proficiency in lung ultrasound (LUS) is easier.2 Intensivists are at risk of forgoing mastering LUS in favor of developing more difficult skills. Proficiency in LUS is essential, as more than half of TUS evaluations are for respiratory complaints and most findings are pulmonary.1
A quick bedside assessment outperforms chest radiographs and available clinical scores in distinguishing pneumonia from atelectasis. The presence of dynamic air bronchograms within the consolidation is 45% sensitive and 99% specific for pneumonia over atelectasis.3 When air bronchograms are static, the presence of flow on color Doppler is 98% sensitive and 68% specific for pneumonia over atelectasis. Similarly, a closer look at the pleural lining shows more than the presence or absence of lung sliding. The presence of fragmentation, irregularity, or thickening of pleural lines provides 100% specificity in discriminating a noncardiogenic interstitial pathology from cardiogenic pulmonary edema.4
LUS is the workhorse and unsung hero of point-of-care ultrasound. In the last year, LUS has shown utility beyond evaluation for pneumothorax, pulmonary edema, and pleural effusion. Its potential impact on diagnosis and management is still growing. We just need to take a closer look.
References
1. Heldeweg M, Lopez Matta JE, Pisani L, Slot S. The impact of thoracic ultrasound on clinical management of critically ill patients (UltraMan): an international prospective observational study. Crit Care Med. 2023;51:357-364.
2. Kraaijenbrink BVC, Mousa A, Bos LD, et al. Defining basic (lung) ultrasound skills: not so basic after all? Intensive Care Med. 2022;48:628–629.
3. Haaksma M, Smit J, Heldeweg M, Nooitgedacht J, de Grooth H. Extended lung ultrasound to differentiate between pneumonia and atelectasis in critically ill patients: a diagnostic accuracy study. Crit Care Med. 2022;50:750-759.
4. Heldeweg M, Smit M, Kramer-Elliott S, et al. Lung ultrasound signs to diagnose and discriminate interstitial syndromes in ICU patients: a diagnostic accuracy study in two cohorts. Crit Care Med. 2022;50(11):1607-1617.
Thoracic Oncology and Chest Procedures Network
Ultrasound and Chest Imaging Section
An assessment using bedside thoracic ultrasound (TUS) improves diagnostic evaluation and therapeutic management in critically ill patients without undue risk. With changes in diagnosis occurring in 23% of cases and alterations in management in 39% of critically ill patients, TUS can improve length of stay, reduce complications, minimize delays in therapy, and lower hospitalization costs.1 Compared with its cardiac counterpart, attaining proficiency in lung ultrasound (LUS) is easier.2 Intensivists are at risk of forgoing mastering LUS in favor of developing more difficult skills. Proficiency in LUS is essential, as more than half of TUS evaluations are for respiratory complaints and most findings are pulmonary.1
A quick bedside assessment outperforms chest radiographs and available clinical scores in distinguishing pneumonia from atelectasis. The presence of dynamic air bronchograms within the consolidation is 45% sensitive and 99% specific for pneumonia over atelectasis.3 When air bronchograms are static, the presence of flow on color Doppler is 98% sensitive and 68% specific for pneumonia over atelectasis. Similarly, a closer look at the pleural lining shows more than the presence or absence of lung sliding. The presence of fragmentation, irregularity, or thickening of pleural lines provides 100% specificity in discriminating a noncardiogenic interstitial pathology from cardiogenic pulmonary edema.4
LUS is the workhorse and unsung hero of point-of-care ultrasound. In the last year, LUS has shown utility beyond evaluation for pneumothorax, pulmonary edema, and pleural effusion. Its potential impact on diagnosis and management is still growing. We just need to take a closer look.
References
1. Heldeweg M, Lopez Matta JE, Pisani L, Slot S. The impact of thoracic ultrasound on clinical management of critically ill patients (UltraMan): an international prospective observational study. Crit Care Med. 2023;51:357-364.
2. Kraaijenbrink BVC, Mousa A, Bos LD, et al. Defining basic (lung) ultrasound skills: not so basic after all? Intensive Care Med. 2022;48:628–629.
3. Haaksma M, Smit J, Heldeweg M, Nooitgedacht J, de Grooth H. Extended lung ultrasound to differentiate between pneumonia and atelectasis in critically ill patients: a diagnostic accuracy study. Crit Care Med. 2022;50:750-759.
4. Heldeweg M, Smit M, Kramer-Elliott S, et al. Lung ultrasound signs to diagnose and discriminate interstitial syndromes in ICU patients: a diagnostic accuracy study in two cohorts. Crit Care Med. 2022;50(11):1607-1617.
Thoracic Oncology and Chest Procedures Network
Ultrasound and Chest Imaging Section
An assessment using bedside thoracic ultrasound (TUS) improves diagnostic evaluation and therapeutic management in critically ill patients without undue risk. With changes in diagnosis occurring in 23% of cases and alterations in management in 39% of critically ill patients, TUS can improve length of stay, reduce complications, minimize delays in therapy, and lower hospitalization costs.1 Compared with its cardiac counterpart, attaining proficiency in lung ultrasound (LUS) is easier.2 Intensivists are at risk of forgoing mastering LUS in favor of developing more difficult skills. Proficiency in LUS is essential, as more than half of TUS evaluations are for respiratory complaints and most findings are pulmonary.1
A quick bedside assessment outperforms chest radiographs and available clinical scores in distinguishing pneumonia from atelectasis. The presence of dynamic air bronchograms within the consolidation is 45% sensitive and 99% specific for pneumonia over atelectasis.3 When air bronchograms are static, the presence of flow on color Doppler is 98% sensitive and 68% specific for pneumonia over atelectasis. Similarly, a closer look at the pleural lining shows more than the presence or absence of lung sliding. The presence of fragmentation, irregularity, or thickening of pleural lines provides 100% specificity in discriminating a noncardiogenic interstitial pathology from cardiogenic pulmonary edema.4
LUS is the workhorse and unsung hero of point-of-care ultrasound. In the last year, LUS has shown utility beyond evaluation for pneumothorax, pulmonary edema, and pleural effusion. Its potential impact on diagnosis and management is still growing. We just need to take a closer look.
References
1. Heldeweg M, Lopez Matta JE, Pisani L, Slot S. The impact of thoracic ultrasound on clinical management of critically ill patients (UltraMan): an international prospective observational study. Crit Care Med. 2023;51:357-364.
2. Kraaijenbrink BVC, Mousa A, Bos LD, et al. Defining basic (lung) ultrasound skills: not so basic after all? Intensive Care Med. 2022;48:628–629.
3. Haaksma M, Smit J, Heldeweg M, Nooitgedacht J, de Grooth H. Extended lung ultrasound to differentiate between pneumonia and atelectasis in critically ill patients: a diagnostic accuracy study. Crit Care Med. 2022;50:750-759.
4. Heldeweg M, Smit M, Kramer-Elliott S, et al. Lung ultrasound signs to diagnose and discriminate interstitial syndromes in ICU patients: a diagnostic accuracy study in two cohorts. Crit Care Med. 2022;50(11):1607-1617.
Doctors Seek Additional Obesity Training in Wake of Obesity Patient Boom
Gitanjali Srivastava, MD, professor of medicine, pediatrics, and surgery, and medical director of obesity medicine at Vanderbilt University School of Medicine in Nashville, Tennessee, was nearly 10 years into practicing pediatric medicine when she graduated from the obesity medicine fellowship at Massachusetts General Hospital in Boston in 2013. “We were the very first sort of fellows to speak of then; there were no standards or curriculum,” she said.
Obesity was already epidemic, but stigma and bias were still pervasive in the medical community and within the public. After graduating, Dr. Srivastava spent months vying for a position with hospital CEOs. She traveled across the country explaining the specialty and its value, going into detail about the budget, business model, space requirement, and revenue potential of obesity medicine.
Today marks a very different era.
Obesity medicine is exploding. Patients are spilling into doctors’ offices looking for obesity treatment. Healthcare systems are seeking out obesity specialists and building metabolic health centers. Next month, another 2115 doctors from primary care, surgery, orthopedics, pediatrics, fertility, endocrinology, and beyond will sit for the 2024 exam. The once niche specialty is quickly becoming intertwined with most of modern medicine.
The Need to Treat
It’s no mystery that the rapid expansion of obesity medicine coincides with the US Food and Drug Administration’s approval of GLP-1 injections. The drugs’ radical weight loss properties have captured headlines and driven up patient demand. Meanwhile, doctors are finally able to offer effective treatment for a disease that affects 40% of US adults.
“We are finally treating it as a chronic disease, not as a lifestyle,” said Marcio Griebeler, MD, director of the obesity medicine fellowship at the Cleveland Clinic. And “I think it’s fulfilling for physicians,” he said.
For so long, the advice for obesity was about lifestyle. Move more, eat less, and harness willpower, “which really is a fallacy,” said Kimberly Gudzune, MD, MPH, an obesity medicine specialist and chief medical officer for the American Board of Obesity Medicine (ABOM) Foundation. For people with obesity, “your brain is operating differently,” she said. “Your body really is set up to work against you.”
Brianna Johnson-Rabbett, MD, medical director of the ABOM, told this news organization that with the advent of GLP-1s, “there’s a clearer recognition that obesity is a disease that needs to be treated like other diseases.” Some of that is thanks to clinical trial data showing that just as with other diseases such as high blood pressure or diabetes, obesity can be treated with medication and it resurges when the medication is stopped, she said.
Doctors don’t have to go looking for patients with obesity, dr. Griebeler added. Now that treatment options exist, they’re showing up in droves at the doctor’s office — all the doctors’ offices. In primary care, endocrinology, surgery, pediatrics — a wide variety of doctors are being asked about obesity drugs, Dr. Griebeler noted.
And while doctors are often just as excited as patients about the potential for treatment, many find themselves under-equipped when it comes to obesity. “More physicians are ... recognizing the value in treating this, and some are realizing, “Oh gosh, I never learned how to do this,” said Dr. Gudzune.
Information Patients Have Been Waiting For
Medical training has traditionally devoted minimal, if any, curriculum to obesity and metabolism. “To be honest, we didn’t really cover this at all in my training,” said Nina Paddu, MD, obesity medicine specialist at Maimonides Medical Center in New York City who finished her training only 2 years ago. “The guidance even in residency was ‘let’s send them to nutrition’ and ‘recommend exercising.’ ”
In addition to the medical education gap, until recently there was a “paucity of robust evidence,” Dr. Srivastava said. Leaders in the field wanted to establish standards and guidelines, but there wasn’t enough strong evidence on obesity and its treatments to build them, she said.
Only in the last 5 years or so has the evidence-based understanding of obesity’s pathophysiology truly accelerated: The brain’s driving roles, its interplay with hormones, and its interactions with other diseases. “We are just at the cusp of understanding all the different factors,” Dr. Gudzune said.
But already endocrinologists, surgeons, fertility specialists, gynecologists, and oncologists, to name a few, see the critical overlap with their own field. “Conditions were once suspected of being intertwined [with obesity], and now we have data to connect them,” Dr. Srivastava said. For example, there’s now data connecting semaglutide to a 20% reduction in cardiovascular events for people with obesity. That’s a game changer for multiple specialties, she told this news organization.
Getting Trained in Obesity Management
The recent uptick in obesity insights and increased patient need has doctors from every career stage seeking additional training.
The ABOM offers two board certification pathways: 60 hours of CME credits or a 12-month fellowship. Both paths require doctors to pass the board’s exam.
Many doctors incorporate the training into their existing practice. The CME credit pathway, especially, is designed to help get doctors up to speed without requiring them to upend their lives for a fellowship.
Dr. Srivastava said that the fellowship is more consuming and immersive. While it’s often younger doctors just out of training who apply to fellowship, every year, “I’m astonished at the number of talented physicians with clinical and research experience who want to immerse themselves in a fellowship experience.”
Some doctors return to their previous specialties after fellowship. But many will go on to take obesity medicine–specific roles or set aside clinic hours for obesity medicine. Their credentials are “really attractive to institutions, especially those looking to open up obesity medicine or weight management programs,” said Dr. Srivastava.
Dr. Paddu, who finished her obesity medicine fellowship this year, said there are a variety of obesity medicine jobs to choose from — far different from Dr. Srivastava’s job search 15 years ago. Dr. Paddu’s new role combines 2 days of primary care with 2 days devoted to obesity medicine and 1 day each week set aside for administrative work so she can build up the hospital’s new metabolic health clinic.
Still Not Enough Obesity Specialists
As with all things, rapid growth requires careful oversight. “Part of the responsibility of the board is to think critically of how the field is growing” and conduct ongoing monitoring, Dr. Gudzune said.
This is also why the board’s credentials are time-limited and must be recertified, Dr. Johnson-Rabbett added.
But even with the rise in certified doctors and obesity medicine positions, the 8263 doctors certified by ABOM are only a tiny fraction of US physicians. As a result, there’s genuine likelihood that many patients seeking GLP-1s or other obesity treatment don’t yet have access to the holistic care they need. Plus, doctors may still not have obesity expertise within their networks.
“The field has grown rapidly, but it’s still such a small field relative to the patient need,” said Dr. Gudzune.
A version of this article appeared on Medscape.com.
Gitanjali Srivastava, MD, professor of medicine, pediatrics, and surgery, and medical director of obesity medicine at Vanderbilt University School of Medicine in Nashville, Tennessee, was nearly 10 years into practicing pediatric medicine when she graduated from the obesity medicine fellowship at Massachusetts General Hospital in Boston in 2013. “We were the very first sort of fellows to speak of then; there were no standards or curriculum,” she said.
Obesity was already epidemic, but stigma and bias were still pervasive in the medical community and within the public. After graduating, Dr. Srivastava spent months vying for a position with hospital CEOs. She traveled across the country explaining the specialty and its value, going into detail about the budget, business model, space requirement, and revenue potential of obesity medicine.
Today marks a very different era.
Obesity medicine is exploding. Patients are spilling into doctors’ offices looking for obesity treatment. Healthcare systems are seeking out obesity specialists and building metabolic health centers. Next month, another 2115 doctors from primary care, surgery, orthopedics, pediatrics, fertility, endocrinology, and beyond will sit for the 2024 exam. The once niche specialty is quickly becoming intertwined with most of modern medicine.
The Need to Treat
It’s no mystery that the rapid expansion of obesity medicine coincides with the US Food and Drug Administration’s approval of GLP-1 injections. The drugs’ radical weight loss properties have captured headlines and driven up patient demand. Meanwhile, doctors are finally able to offer effective treatment for a disease that affects 40% of US adults.
“We are finally treating it as a chronic disease, not as a lifestyle,” said Marcio Griebeler, MD, director of the obesity medicine fellowship at the Cleveland Clinic. And “I think it’s fulfilling for physicians,” he said.
For so long, the advice for obesity was about lifestyle. Move more, eat less, and harness willpower, “which really is a fallacy,” said Kimberly Gudzune, MD, MPH, an obesity medicine specialist and chief medical officer for the American Board of Obesity Medicine (ABOM) Foundation. For people with obesity, “your brain is operating differently,” she said. “Your body really is set up to work against you.”
Brianna Johnson-Rabbett, MD, medical director of the ABOM, told this news organization that with the advent of GLP-1s, “there’s a clearer recognition that obesity is a disease that needs to be treated like other diseases.” Some of that is thanks to clinical trial data showing that just as with other diseases such as high blood pressure or diabetes, obesity can be treated with medication and it resurges when the medication is stopped, she said.
Doctors don’t have to go looking for patients with obesity, dr. Griebeler added. Now that treatment options exist, they’re showing up in droves at the doctor’s office — all the doctors’ offices. In primary care, endocrinology, surgery, pediatrics — a wide variety of doctors are being asked about obesity drugs, Dr. Griebeler noted.
And while doctors are often just as excited as patients about the potential for treatment, many find themselves under-equipped when it comes to obesity. “More physicians are ... recognizing the value in treating this, and some are realizing, “Oh gosh, I never learned how to do this,” said Dr. Gudzune.
Information Patients Have Been Waiting For
Medical training has traditionally devoted minimal, if any, curriculum to obesity and metabolism. “To be honest, we didn’t really cover this at all in my training,” said Nina Paddu, MD, obesity medicine specialist at Maimonides Medical Center in New York City who finished her training only 2 years ago. “The guidance even in residency was ‘let’s send them to nutrition’ and ‘recommend exercising.’ ”
In addition to the medical education gap, until recently there was a “paucity of robust evidence,” Dr. Srivastava said. Leaders in the field wanted to establish standards and guidelines, but there wasn’t enough strong evidence on obesity and its treatments to build them, she said.
Only in the last 5 years or so has the evidence-based understanding of obesity’s pathophysiology truly accelerated: The brain’s driving roles, its interplay with hormones, and its interactions with other diseases. “We are just at the cusp of understanding all the different factors,” Dr. Gudzune said.
But already endocrinologists, surgeons, fertility specialists, gynecologists, and oncologists, to name a few, see the critical overlap with their own field. “Conditions were once suspected of being intertwined [with obesity], and now we have data to connect them,” Dr. Srivastava said. For example, there’s now data connecting semaglutide to a 20% reduction in cardiovascular events for people with obesity. That’s a game changer for multiple specialties, she told this news organization.
Getting Trained in Obesity Management
The recent uptick in obesity insights and increased patient need has doctors from every career stage seeking additional training.
The ABOM offers two board certification pathways: 60 hours of CME credits or a 12-month fellowship. Both paths require doctors to pass the board’s exam.
Many doctors incorporate the training into their existing practice. The CME credit pathway, especially, is designed to help get doctors up to speed without requiring them to upend their lives for a fellowship.
Dr. Srivastava said that the fellowship is more consuming and immersive. While it’s often younger doctors just out of training who apply to fellowship, every year, “I’m astonished at the number of talented physicians with clinical and research experience who want to immerse themselves in a fellowship experience.”
Some doctors return to their previous specialties after fellowship. But many will go on to take obesity medicine–specific roles or set aside clinic hours for obesity medicine. Their credentials are “really attractive to institutions, especially those looking to open up obesity medicine or weight management programs,” said Dr. Srivastava.
Dr. Paddu, who finished her obesity medicine fellowship this year, said there are a variety of obesity medicine jobs to choose from — far different from Dr. Srivastava’s job search 15 years ago. Dr. Paddu’s new role combines 2 days of primary care with 2 days devoted to obesity medicine and 1 day each week set aside for administrative work so she can build up the hospital’s new metabolic health clinic.
Still Not Enough Obesity Specialists
As with all things, rapid growth requires careful oversight. “Part of the responsibility of the board is to think critically of how the field is growing” and conduct ongoing monitoring, Dr. Gudzune said.
This is also why the board’s credentials are time-limited and must be recertified, Dr. Johnson-Rabbett added.
But even with the rise in certified doctors and obesity medicine positions, the 8263 doctors certified by ABOM are only a tiny fraction of US physicians. As a result, there’s genuine likelihood that many patients seeking GLP-1s or other obesity treatment don’t yet have access to the holistic care they need. Plus, doctors may still not have obesity expertise within their networks.
“The field has grown rapidly, but it’s still such a small field relative to the patient need,” said Dr. Gudzune.
A version of this article appeared on Medscape.com.
Gitanjali Srivastava, MD, professor of medicine, pediatrics, and surgery, and medical director of obesity medicine at Vanderbilt University School of Medicine in Nashville, Tennessee, was nearly 10 years into practicing pediatric medicine when she graduated from the obesity medicine fellowship at Massachusetts General Hospital in Boston in 2013. “We were the very first sort of fellows to speak of then; there were no standards or curriculum,” she said.
Obesity was already epidemic, but stigma and bias were still pervasive in the medical community and within the public. After graduating, Dr. Srivastava spent months vying for a position with hospital CEOs. She traveled across the country explaining the specialty and its value, going into detail about the budget, business model, space requirement, and revenue potential of obesity medicine.
Today marks a very different era.
Obesity medicine is exploding. Patients are spilling into doctors’ offices looking for obesity treatment. Healthcare systems are seeking out obesity specialists and building metabolic health centers. Next month, another 2115 doctors from primary care, surgery, orthopedics, pediatrics, fertility, endocrinology, and beyond will sit for the 2024 exam. The once niche specialty is quickly becoming intertwined with most of modern medicine.
The Need to Treat
It’s no mystery that the rapid expansion of obesity medicine coincides with the US Food and Drug Administration’s approval of GLP-1 injections. The drugs’ radical weight loss properties have captured headlines and driven up patient demand. Meanwhile, doctors are finally able to offer effective treatment for a disease that affects 40% of US adults.
“We are finally treating it as a chronic disease, not as a lifestyle,” said Marcio Griebeler, MD, director of the obesity medicine fellowship at the Cleveland Clinic. And “I think it’s fulfilling for physicians,” he said.
For so long, the advice for obesity was about lifestyle. Move more, eat less, and harness willpower, “which really is a fallacy,” said Kimberly Gudzune, MD, MPH, an obesity medicine specialist and chief medical officer for the American Board of Obesity Medicine (ABOM) Foundation. For people with obesity, “your brain is operating differently,” she said. “Your body really is set up to work against you.”
Brianna Johnson-Rabbett, MD, medical director of the ABOM, told this news organization that with the advent of GLP-1s, “there’s a clearer recognition that obesity is a disease that needs to be treated like other diseases.” Some of that is thanks to clinical trial data showing that just as with other diseases such as high blood pressure or diabetes, obesity can be treated with medication and it resurges when the medication is stopped, she said.
Doctors don’t have to go looking for patients with obesity, dr. Griebeler added. Now that treatment options exist, they’re showing up in droves at the doctor’s office — all the doctors’ offices. In primary care, endocrinology, surgery, pediatrics — a wide variety of doctors are being asked about obesity drugs, Dr. Griebeler noted.
And while doctors are often just as excited as patients about the potential for treatment, many find themselves under-equipped when it comes to obesity. “More physicians are ... recognizing the value in treating this, and some are realizing, “Oh gosh, I never learned how to do this,” said Dr. Gudzune.
Information Patients Have Been Waiting For
Medical training has traditionally devoted minimal, if any, curriculum to obesity and metabolism. “To be honest, we didn’t really cover this at all in my training,” said Nina Paddu, MD, obesity medicine specialist at Maimonides Medical Center in New York City who finished her training only 2 years ago. “The guidance even in residency was ‘let’s send them to nutrition’ and ‘recommend exercising.’ ”
In addition to the medical education gap, until recently there was a “paucity of robust evidence,” Dr. Srivastava said. Leaders in the field wanted to establish standards and guidelines, but there wasn’t enough strong evidence on obesity and its treatments to build them, she said.
Only in the last 5 years or so has the evidence-based understanding of obesity’s pathophysiology truly accelerated: The brain’s driving roles, its interplay with hormones, and its interactions with other diseases. “We are just at the cusp of understanding all the different factors,” Dr. Gudzune said.
But already endocrinologists, surgeons, fertility specialists, gynecologists, and oncologists, to name a few, see the critical overlap with their own field. “Conditions were once suspected of being intertwined [with obesity], and now we have data to connect them,” Dr. Srivastava said. For example, there’s now data connecting semaglutide to a 20% reduction in cardiovascular events for people with obesity. That’s a game changer for multiple specialties, she told this news organization.
Getting Trained in Obesity Management
The recent uptick in obesity insights and increased patient need has doctors from every career stage seeking additional training.
The ABOM offers two board certification pathways: 60 hours of CME credits or a 12-month fellowship. Both paths require doctors to pass the board’s exam.
Many doctors incorporate the training into their existing practice. The CME credit pathway, especially, is designed to help get doctors up to speed without requiring them to upend their lives for a fellowship.
Dr. Srivastava said that the fellowship is more consuming and immersive. While it’s often younger doctors just out of training who apply to fellowship, every year, “I’m astonished at the number of talented physicians with clinical and research experience who want to immerse themselves in a fellowship experience.”
Some doctors return to their previous specialties after fellowship. But many will go on to take obesity medicine–specific roles or set aside clinic hours for obesity medicine. Their credentials are “really attractive to institutions, especially those looking to open up obesity medicine or weight management programs,” said Dr. Srivastava.
Dr. Paddu, who finished her obesity medicine fellowship this year, said there are a variety of obesity medicine jobs to choose from — far different from Dr. Srivastava’s job search 15 years ago. Dr. Paddu’s new role combines 2 days of primary care with 2 days devoted to obesity medicine and 1 day each week set aside for administrative work so she can build up the hospital’s new metabolic health clinic.
Still Not Enough Obesity Specialists
As with all things, rapid growth requires careful oversight. “Part of the responsibility of the board is to think critically of how the field is growing” and conduct ongoing monitoring, Dr. Gudzune said.
This is also why the board’s credentials are time-limited and must be recertified, Dr. Johnson-Rabbett added.
But even with the rise in certified doctors and obesity medicine positions, the 8263 doctors certified by ABOM are only a tiny fraction of US physicians. As a result, there’s genuine likelihood that many patients seeking GLP-1s or other obesity treatment don’t yet have access to the holistic care they need. Plus, doctors may still not have obesity expertise within their networks.
“The field has grown rapidly, but it’s still such a small field relative to the patient need,” said Dr. Gudzune.
A version of this article appeared on Medscape.com.