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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The study was published online in JAMA Psychiatry.
 

Questions remain

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

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

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

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

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

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

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

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

‘Important research’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The study was published online in JAMA Psychiatry.
 

Questions remain

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

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

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

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

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

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

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

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

‘Important research’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The study was published online in JAMA Psychiatry.
 

Questions remain

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

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

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

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

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

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

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

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

‘Important research’

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

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

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

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

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

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

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

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

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

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

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

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

“They Paused Puberty but Is There a Cost?”

“Bone Health: Puberty Blockers Not Fully Reversible.”

UT Southwestern Medical Center

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

GnRH agonists and puberty

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

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

Concerns over bone health

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

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

Lingering questions

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

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

References

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

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

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

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

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

“They Paused Puberty but Is There a Cost?”

“Bone Health: Puberty Blockers Not Fully Reversible.”

UT Southwestern Medical Center

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

GnRH agonists and puberty

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

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

Concerns over bone health

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

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

Lingering questions

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

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

References

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

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

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

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

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

“They Paused Puberty but Is There a Cost?”

“Bone Health: Puberty Blockers Not Fully Reversible.”

UT Southwestern Medical Center

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

GnRH agonists and puberty

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

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

Concerns over bone health

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

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

Lingering questions

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

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

References

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

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

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

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

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

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

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

Where you stand depends a lot on where you sit.

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

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

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

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

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

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

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

A jobs program

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

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

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

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

The MBAization of medicine

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

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

My goodness! Well done.

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

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

Take it all over?

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

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

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

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

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

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

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

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

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

Where you stand depends a lot on where you sit.

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

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

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

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

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

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

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

A jobs program

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

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

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

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

The MBAization of medicine

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

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

My goodness! Well done.

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

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

Take it all over?

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

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

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

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

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

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

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

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

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

Where you stand depends a lot on where you sit.

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

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

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

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

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

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

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

A jobs program

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

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

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

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

The MBAization of medicine

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

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

My goodness! Well done.

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

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

Take it all over?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CHEST

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

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

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


David

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

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

CHEST

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

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

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


David

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

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

CHEST

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

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

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


David

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

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

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

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

 

Breadth of coverage

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

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

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

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

The CHEST atmosphere

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

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

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

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

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

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

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

 

Breadth of coverage

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

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

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

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

The CHEST atmosphere

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

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

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

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

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

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

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

 

Breadth of coverage

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

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

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

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

The CHEST atmosphere

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

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

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

The abnormal upward curve to the fingernails was consistent with a diagnosis of koilonychia—otherwise known as spoon nails.

Koilonychia is an abnormal nail growth pattern where the distal nail matrix is depressed below its normal level, resulting in the spoon shape. The reverse, where the distal nail matrix is elevated in contrast to the proximal nail matrix, results in clubbing.¹

There are multiple factors and diseases that result in koilonychia, including lichen planus, psoriasis, nutritional deficiencies (including iron deficiency anemia), and endocrinopathies.¹ Lichen planus, which can cause koilonychia, often affects multiple nails and can also cause an associated central ridge pattern. Psoriasis may display a range of nail abnormalities; these include koilonychia, pitting onycholysis, and oil staining.

This patient did not have any signs or symptoms of psoriasis or lichen planus of her nails or skin. A review of her laboratory tests on file made no mention of anemia. Her chemistry profile—including liver tests, renal function tests, and protein levels—were all normal except for glucose levels, which was consistent with her prediabetes. Her thyroid function was also normal. No additional testing was performed since she had no symptoms, physical exam findings, or laboratory clues that pointed to other diseases or systemic processes.

The patient was advised to pick up over-the-counter nail strengtheners and to keep her fingernails trimmed short to minimize the likelihood of painful distal splitting that often occurs with brittle nails. Her physician advised her to follow up with the primary care team if she developed any new signs or symptoms.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Professor and Chair, Department of Family and Community Medicine, Western Michigan University Homer Stryker, MD School of Medicine, Kalamazoo.

The abnormal upward curve to the fingernails was consistent with a diagnosis of koilonychia—otherwise known as spoon nails.

Koilonychia is an abnormal nail growth pattern where the distal nail matrix is depressed below its normal level, resulting in the spoon shape. The reverse, where the distal nail matrix is elevated in contrast to the proximal nail matrix, results in clubbing.¹

There are multiple factors and diseases that result in koilonychia, including lichen planus, psoriasis, nutritional deficiencies (including iron deficiency anemia), and endocrinopathies.¹ Lichen planus, which can cause koilonychia, often affects multiple nails and can also cause an associated central ridge pattern. Psoriasis may display a range of nail abnormalities; these include koilonychia, pitting onycholysis, and oil staining.

This patient did not have any signs or symptoms of psoriasis or lichen planus of her nails or skin. A review of her laboratory tests on file made no mention of anemia. Her chemistry profile—including liver tests, renal function tests, and protein levels—were all normal except for glucose levels, which was consistent with her prediabetes. Her thyroid function was also normal. No additional testing was performed since she had no symptoms, physical exam findings, or laboratory clues that pointed to other diseases or systemic processes.

The patient was advised to pick up over-the-counter nail strengtheners and to keep her fingernails trimmed short to minimize the likelihood of painful distal splitting that often occurs with brittle nails. Her physician advised her to follow up with the primary care team if she developed any new signs or symptoms.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Professor and Chair, Department of Family and Community Medicine, Western Michigan University Homer Stryker, MD School of Medicine, Kalamazoo.

The abnormal upward curve to the fingernails was consistent with a diagnosis of koilonychia—otherwise known as spoon nails.

Koilonychia is an abnormal nail growth pattern where the distal nail matrix is depressed below its normal level, resulting in the spoon shape. The reverse, where the distal nail matrix is elevated in contrast to the proximal nail matrix, results in clubbing.¹

There are multiple factors and diseases that result in koilonychia, including lichen planus, psoriasis, nutritional deficiencies (including iron deficiency anemia), and endocrinopathies.¹ Lichen planus, which can cause koilonychia, often affects multiple nails and can also cause an associated central ridge pattern. Psoriasis may display a range of nail abnormalities; these include koilonychia, pitting onycholysis, and oil staining.

This patient did not have any signs or symptoms of psoriasis or lichen planus of her nails or skin. A review of her laboratory tests on file made no mention of anemia. Her chemistry profile—including liver tests, renal function tests, and protein levels—were all normal except for glucose levels, which was consistent with her prediabetes. Her thyroid function was also normal. No additional testing was performed since she had no symptoms, physical exam findings, or laboratory clues that pointed to other diseases or systemic processes.

The patient was advised to pick up over-the-counter nail strengtheners and to keep her fingernails trimmed short to minimize the likelihood of painful distal splitting that often occurs with brittle nails. Her physician advised her to follow up with the primary care team if she developed any new signs or symptoms.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Professor and Chair, Department of Family and Community Medicine, Western Michigan University Homer Stryker, MD School of Medicine, Kalamazoo.

Although an elevated and pigmented lesion should be considered for possible melanoma, this one had prominent telangiectasias and was proven to be a basal cell carcinoma (BCC) on biopsy.

While the literature often focuses on light-colored skin types and the high risk of skin cancers, individuals with darker skin can also get melanoma and nonmelanoma skin cancer. Half of the BCCs in African American people are pigmented BCCs, compared to less than 10% for Caucasian individuals. Individuals who are Hispanic have twice the likelihood of pigmented BCCs as those who are Caucasian.¹ Pigmented BCCs manifest as darker lesions, as occurred in this individual. Nonpigmented BCCs tend to be pink or pale in color.

Typically, superficial and very small, nodular BCCs can be successfully treated with 2 cycles of electrodesiccation and curettage. EDC should, however, be avoided in low-risk BCCs when these lesions occur in areas of secondary hair growth, such as the beard or scalp. This is because the epidermis follows the hair follicle, and in sites with deep hair follicles, EDC would have to get down to the subcutis to effectively clear the tumor.

For larger, nodular BCCs, full-thickness excision with adequate margins is warranted. For high-risk types, and those in high-risk areas near the nose, eyes, mouth, and ears, Mohs micrographic surgery is recommended to maximize the likelihood of complete excision while minimizing the loss of normal tissue.

Since the physician suspected this was a pigmented BCC, he performed a superficial shave biopsy on a small representative area of the lesion for diagnosis. This patient’s biopsy confirmed a nodular-type pigmented BCC. The lesion was removed in the office with 5-mm margins oriented along the resting skin tension lines with good closure and cosmetic results.

The patient was advised to have routine skin evaluations every 6 months due to the high risk of additional cancers. He was also advised to take oral niacinamide 500 mg twice daily, which can reduce the risk of actinic keratoses and nonmelanoma skin cancers by 15% and 23%, respectively, in those who have had lesions.²

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Professor and Chair, Department of Family and Community Medicine, Western Michigan University Homer Stryker, MD School of Medicine, Kalamazoo.

Although an elevated and pigmented lesion should be considered for possible melanoma, this one had prominent telangiectasias and was proven to be a basal cell carcinoma (BCC) on biopsy.

While the literature often focuses on light-colored skin types and the high risk of skin cancers, individuals with darker skin can also get melanoma and nonmelanoma skin cancer. Half of the BCCs in African American people are pigmented BCCs, compared to less than 10% for Caucasian individuals. Individuals who are Hispanic have twice the likelihood of pigmented BCCs as those who are Caucasian.¹ Pigmented BCCs manifest as darker lesions, as occurred in this individual. Nonpigmented BCCs tend to be pink or pale in color.

Typically, superficial and very small, nodular BCCs can be successfully treated with 2 cycles of electrodesiccation and curettage. EDC should, however, be avoided in low-risk BCCs when these lesions occur in areas of secondary hair growth, such as the beard or scalp. This is because the epidermis follows the hair follicle, and in sites with deep hair follicles, EDC would have to get down to the subcutis to effectively clear the tumor.

For larger, nodular BCCs, full-thickness excision with adequate margins is warranted. For high-risk types, and those in high-risk areas near the nose, eyes, mouth, and ears, Mohs micrographic surgery is recommended to maximize the likelihood of complete excision while minimizing the loss of normal tissue.

Since the physician suspected this was a pigmented BCC, he performed a superficial shave biopsy on a small representative area of the lesion for diagnosis. This patient’s biopsy confirmed a nodular-type pigmented BCC. The lesion was removed in the office with 5-mm margins oriented along the resting skin tension lines with good closure and cosmetic results.

The patient was advised to have routine skin evaluations every 6 months due to the high risk of additional cancers. He was also advised to take oral niacinamide 500 mg twice daily, which can reduce the risk of actinic keratoses and nonmelanoma skin cancers by 15% and 23%, respectively, in those who have had lesions.²

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Professor and Chair, Department of Family and Community Medicine, Western Michigan University Homer Stryker, MD School of Medicine, Kalamazoo.

Although an elevated and pigmented lesion should be considered for possible melanoma, this one had prominent telangiectasias and was proven to be a basal cell carcinoma (BCC) on biopsy.

While the literature often focuses on light-colored skin types and the high risk of skin cancers, individuals with darker skin can also get melanoma and nonmelanoma skin cancer. Half of the BCCs in African American people are pigmented BCCs, compared to less than 10% for Caucasian individuals. Individuals who are Hispanic have twice the likelihood of pigmented BCCs as those who are Caucasian.¹ Pigmented BCCs manifest as darker lesions, as occurred in this individual. Nonpigmented BCCs tend to be pink or pale in color.

Typically, superficial and very small, nodular BCCs can be successfully treated with 2 cycles of electrodesiccation and curettage. EDC should, however, be avoided in low-risk BCCs when these lesions occur in areas of secondary hair growth, such as the beard or scalp. This is because the epidermis follows the hair follicle, and in sites with deep hair follicles, EDC would have to get down to the subcutis to effectively clear the tumor.

For larger, nodular BCCs, full-thickness excision with adequate margins is warranted. For high-risk types, and those in high-risk areas near the nose, eyes, mouth, and ears, Mohs micrographic surgery is recommended to maximize the likelihood of complete excision while minimizing the loss of normal tissue.

Since the physician suspected this was a pigmented BCC, he performed a superficial shave biopsy on a small representative area of the lesion for diagnosis. This patient’s biopsy confirmed a nodular-type pigmented BCC. The lesion was removed in the office with 5-mm margins oriented along the resting skin tension lines with good closure and cosmetic results.

The patient was advised to have routine skin evaluations every 6 months due to the high risk of additional cancers. He was also advised to take oral niacinamide 500 mg twice daily, which can reduce the risk of actinic keratoses and nonmelanoma skin cancers by 15% and 23%, respectively, in those who have had lesions.²

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Professor and Chair, Department of Family and Community Medicine, Western Michigan University Homer Stryker, MD School of Medicine, Kalamazoo.

Filmmaker Gez Medinger and immunologist Danny Altmann have been dubbed by British media as “COVID’s odd couple,” and they don’t mind at all. Discussing their recent book, The Long COVID Handbook, the authors lean into their animated roles: Medinger is a passionate patient-researcher and “guinea pig” (his words) in search of his own healing, and Altmann is a no-nonsense, data-driven scientist and “Professor Boring” (as he puts it).

And the message they have about the impact of long COVID is stunning.

“The clinical burden [of long COVID] is somewhere on par with the whole of heart disease all over again, or the whole of oncology all over again, which are our biggest clinical bills concurrently,” Altmann said.

The pair met early in the pandemic, after Medinger became infected during the first wave and interviewed Altmann for his YouTube channel, which has more than 5 million views. 

“Danny was one of the first people from the medical establishment to sort of stand up on the parapet and wave a flag and say, ‘Hey, guys, there’s a problem here.’ And that was incredibly validating for 2 million people in the U.K. alone who were suffering with long COVID,” Medinger said. 

Their relationship works, not just for publishing one of the first definitive guides to long COVID, but also as a model for how patients with lived experiences can lead the way in medicine – from giving the condition its name to driving the medical establishment for recognition, clinical research, and therapeutic answers. 

With Altmann currently leading a major research project at Imperial College London on long COVID and Medinger’s social media platform and communication skills, they’re both advancing the world’s understanding of the disease in their own way.

“We’re now more than 3 years into this completely mysterious, uncharted disease process with a whole globe full of really desperate people,” said Altmann. “It’s a living, organic thing, and yet that also demands some kind of order and collation and pulling together into some kind of sense. So I was very pleased when Gez approached me to help him with the book.”

In it, they translate everything they’ve learned about the condition that’s “scattered in 100,000 places around the globe” into a digestible format. It tells two sides of the same story: the anecdotal experiences Medinger has undergone or observed in the long COVID community through more than a dozen of his own patient-led studies, as well the hard science and research that’s amassing in the medical world. 

In an interview, Medinger and Altmann discussed how their book can help both patients and clinicians, and the next steps needed to combat long COVID.
 

What are the book’s key takeaways for you?

Medinger: “I would say we put together an incredibly comprehensive couple of chapters on the hypotheses, big picture, what’s causing long COVID. And then the nitty-gritty research for everything that we’ve found out that is going on. ... And the other part of the book that I think is particularly important, beyond the tips for managing symptoms, is the content on mental health and the impact on your emotional state and your capacity and just how huge that is. ... That has been the most powerful thing for patients when they’ve read it. And they’ve said that they’ve just been crying all the way through those chapters because suddenly they feel heard and seen.”

Altmann: “Obviously, you’d expect me to say that the parts of the book that I love most are the kind of hard-nosed, medical, mechanistic bits. ... We’ve got 150 million-plus desperate people deciding or not deciding to go and see their general practitioner, getting a fair hearing or not getting a fair hearing. And the poor doctor has never learned this in medical school, has never read a textbook on it, and hasn’t a clue what’s coming through the door. 

How are they expected to know what to do? So I think the least we can do in some of those chapters is feed into their knowledge of general medicine and give them some clues. ... I think if we can explain to people what might be going on in them, and to their doctors, what on earth they might do about it, what kind of tests they might order, that helps a bit.”
 

How did you balance the more controversial parts of the book, including the chapter about so-called “treatments”? For instance, the book recounts Gez’s harrowing experience with ivermectin as a frightening warning. But Danny, you were nervous about even mentioning unproven and potentially dangerous treatments as things people have tried and have looked into. 

Medinger: “We had to try and work out how to handle the topic, how to handle those points of view, whilst at the same time still being informative. I think the book is stronger for that chapter, too. The other thing would certainly have been to just not address the subject, but it’s one of the things that people want to know the most about. And there’s also a lot of bad information floating around out there about certain treatments. Ivermectin, for example, and this is what happened to me when I tried it. ‘Don’t do it. It’s not recommended. Please don’t.’ 

I think it was also very important to include because that cautionary tale really applies to every single one of those treatments that people might be hearing about that hasn’t been backed up by efficacy and safety studies.”

Altmann: “I think Gez has been quite diplomatic. That chapter was, I think, a testament to the power of the book. And the biggest test of our marriage as ‘the odd couple.’ Because when I first read the first draft of what Gez had written, I said, ‘my name can’t even be on this book. Otherwise, I’ll be sacked.’ 

And we had to find marriage counseling after that, and a way back to write a version of that chapter that expressed both halves of those concerns in a way that did justice to those different viewpoints. And I think that makes it quite a strong chapter.”
 

What do you think are the most urgent next steps in the search for solving long COVID?

Medinger: “I would personally like to try and get some sort of answer on viral persistence. ... If there’s one thing that feels like it would be treatable in theory, and would make sense why we’re still getting all of these symptoms this whole time later, it’s that, so I would like to try and establish or eliminate viral persistence. So if you gave me Elon Musk’s wealth, that’s what I would throw a bunch of the money at, trying to either eliminate or establish that. 

And then, you know, the other important thing is a diagnostic test. Danny always talks about how important it is. Once you have that, it helps you suddenly open the doors to all these other things that you can do. And treatment trials. Let’s throw some meds at this so that we have an educated guess at what might work and put them into high-powered, randomized, controlled trials and see if anything comes out because from the patient perspective, I don’t think any of us wants to wait for 5 years for that stuff to start happening.”

Altmann: “I completely agree. If you go to a website, like clinicaltrials.gov, you’ll find an immense number of clinical trials on COVID. There isn’t really a shortage of them, some of them better-powered to get an answer than others.”

How do you think public policy needs to adapt for long COVID, including social safety nets such as workers’ compensation and disability benefits?

Medinger: “In terms of public policy, what I would like would be some public acknowledgment that it’s real from government sources. Just the acknowledgment that it’s real and it remains a risk even now.”

Altmann: “Nobody in politics asks my opinion. I think they’d hate to hear it. Because if I went to see them and said, well, actually, if you thought the COVID pandemic was bad, wait till you see what’s on the table now. We’ve created a disabled population in our country of 2 million, at least a portion if not more of people who are not fully contributory to the workforce anymore ... [with] legal wrangles about retirement and health insurance and pensions, and a human right to adequate health care. Which means, ideally, a purpose-built clinic where they can have their respiratory opinion and their rheumatology opinion and their endocrine opinion and their neurology opinion, all under one roof.”

You’ve both shown so much optimism. Why is that?

Altmann: “I’ve been an immunologist for a long time now, and written all my decades of grant applications, where as a community we made what, at the time, were kind of wild promises and wildly optimistic projections of how our knowledge of tumor immunity would revolutionize cancer care, and how knowledge of autoimmunity would revolutionize care of all the autoimmune diseases. 

And weirdly almost every word we wrote over those 25 or 30 years came true. Cancer immunotherapy was revolutionized, and biologics for diabetes, multiple sclerosis, and arthritis were revolutionized. So if I have faith that those things came true, I have complete faith in this as well.”

Medinger: “From the patient perspective, what I would say is that we are seeing people who’ve been ill for more than 2 years recover. People are suddenly turning the corner when they might not have expected to. 

And while we don’t quite know exactly why yet, and it’s not everyone, every single time I hear the story of someone saying, ‘I’m pretty much back to where I was, I feel like I’ve recovered,’ I feel great. Even if I haven’t. Because I know that every single time I hear someone say that, that just increases the probability that I will, too.”
 

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

Filmmaker Gez Medinger and immunologist Danny Altmann have been dubbed by British media as “COVID’s odd couple,” and they don’t mind at all. Discussing their recent book, The Long COVID Handbook, the authors lean into their animated roles: Medinger is a passionate patient-researcher and “guinea pig” (his words) in search of his own healing, and Altmann is a no-nonsense, data-driven scientist and “Professor Boring” (as he puts it).

And the message they have about the impact of long COVID is stunning.

“The clinical burden [of long COVID] is somewhere on par with the whole of heart disease all over again, or the whole of oncology all over again, which are our biggest clinical bills concurrently,” Altmann said.

The pair met early in the pandemic, after Medinger became infected during the first wave and interviewed Altmann for his YouTube channel, which has more than 5 million views. 

“Danny was one of the first people from the medical establishment to sort of stand up on the parapet and wave a flag and say, ‘Hey, guys, there’s a problem here.’ And that was incredibly validating for 2 million people in the U.K. alone who were suffering with long COVID,” Medinger said. 

Their relationship works, not just for publishing one of the first definitive guides to long COVID, but also as a model for how patients with lived experiences can lead the way in medicine – from giving the condition its name to driving the medical establishment for recognition, clinical research, and therapeutic answers. 

With Altmann currently leading a major research project at Imperial College London on long COVID and Medinger’s social media platform and communication skills, they’re both advancing the world’s understanding of the disease in their own way.

“We’re now more than 3 years into this completely mysterious, uncharted disease process with a whole globe full of really desperate people,” said Altmann. “It’s a living, organic thing, and yet that also demands some kind of order and collation and pulling together into some kind of sense. So I was very pleased when Gez approached me to help him with the book.”

In it, they translate everything they’ve learned about the condition that’s “scattered in 100,000 places around the globe” into a digestible format. It tells two sides of the same story: the anecdotal experiences Medinger has undergone or observed in the long COVID community through more than a dozen of his own patient-led studies, as well the hard science and research that’s amassing in the medical world. 

In an interview, Medinger and Altmann discussed how their book can help both patients and clinicians, and the next steps needed to combat long COVID.
 

What are the book’s key takeaways for you?

Medinger: “I would say we put together an incredibly comprehensive couple of chapters on the hypotheses, big picture, what’s causing long COVID. And then the nitty-gritty research for everything that we’ve found out that is going on. ... And the other part of the book that I think is particularly important, beyond the tips for managing symptoms, is the content on mental health and the impact on your emotional state and your capacity and just how huge that is. ... That has been the most powerful thing for patients when they’ve read it. And they’ve said that they’ve just been crying all the way through those chapters because suddenly they feel heard and seen.”

Altmann: “Obviously, you’d expect me to say that the parts of the book that I love most are the kind of hard-nosed, medical, mechanistic bits. ... We’ve got 150 million-plus desperate people deciding or not deciding to go and see their general practitioner, getting a fair hearing or not getting a fair hearing. And the poor doctor has never learned this in medical school, has never read a textbook on it, and hasn’t a clue what’s coming through the door. 

How are they expected to know what to do? So I think the least we can do in some of those chapters is feed into their knowledge of general medicine and give them some clues. ... I think if we can explain to people what might be going on in them, and to their doctors, what on earth they might do about it, what kind of tests they might order, that helps a bit.”
 

How did you balance the more controversial parts of the book, including the chapter about so-called “treatments”? For instance, the book recounts Gez’s harrowing experience with ivermectin as a frightening warning. But Danny, you were nervous about even mentioning unproven and potentially dangerous treatments as things people have tried and have looked into. 

Medinger: “We had to try and work out how to handle the topic, how to handle those points of view, whilst at the same time still being informative. I think the book is stronger for that chapter, too. The other thing would certainly have been to just not address the subject, but it’s one of the things that people want to know the most about. And there’s also a lot of bad information floating around out there about certain treatments. Ivermectin, for example, and this is what happened to me when I tried it. ‘Don’t do it. It’s not recommended. Please don’t.’ 

I think it was also very important to include because that cautionary tale really applies to every single one of those treatments that people might be hearing about that hasn’t been backed up by efficacy and safety studies.”

Altmann: “I think Gez has been quite diplomatic. That chapter was, I think, a testament to the power of the book. And the biggest test of our marriage as ‘the odd couple.’ Because when I first read the first draft of what Gez had written, I said, ‘my name can’t even be on this book. Otherwise, I’ll be sacked.’ 

And we had to find marriage counseling after that, and a way back to write a version of that chapter that expressed both halves of those concerns in a way that did justice to those different viewpoints. And I think that makes it quite a strong chapter.”
 

What do you think are the most urgent next steps in the search for solving long COVID?

Medinger: “I would personally like to try and get some sort of answer on viral persistence. ... If there’s one thing that feels like it would be treatable in theory, and would make sense why we’re still getting all of these symptoms this whole time later, it’s that, so I would like to try and establish or eliminate viral persistence. So if you gave me Elon Musk’s wealth, that’s what I would throw a bunch of the money at, trying to either eliminate or establish that. 

And then, you know, the other important thing is a diagnostic test. Danny always talks about how important it is. Once you have that, it helps you suddenly open the doors to all these other things that you can do. And treatment trials. Let’s throw some meds at this so that we have an educated guess at what might work and put them into high-powered, randomized, controlled trials and see if anything comes out because from the patient perspective, I don’t think any of us wants to wait for 5 years for that stuff to start happening.”

Altmann: “I completely agree. If you go to a website, like clinicaltrials.gov, you’ll find an immense number of clinical trials on COVID. There isn’t really a shortage of them, some of them better-powered to get an answer than others.”

How do you think public policy needs to adapt for long COVID, including social safety nets such as workers’ compensation and disability benefits?

Medinger: “In terms of public policy, what I would like would be some public acknowledgment that it’s real from government sources. Just the acknowledgment that it’s real and it remains a risk even now.”

Altmann: “Nobody in politics asks my opinion. I think they’d hate to hear it. Because if I went to see them and said, well, actually, if you thought the COVID pandemic was bad, wait till you see what’s on the table now. We’ve created a disabled population in our country of 2 million, at least a portion if not more of people who are not fully contributory to the workforce anymore ... [with] legal wrangles about retirement and health insurance and pensions, and a human right to adequate health care. Which means, ideally, a purpose-built clinic where they can have their respiratory opinion and their rheumatology opinion and their endocrine opinion and their neurology opinion, all under one roof.”

You’ve both shown so much optimism. Why is that?

Altmann: “I’ve been an immunologist for a long time now, and written all my decades of grant applications, where as a community we made what, at the time, were kind of wild promises and wildly optimistic projections of how our knowledge of tumor immunity would revolutionize cancer care, and how knowledge of autoimmunity would revolutionize care of all the autoimmune diseases. 

And weirdly almost every word we wrote over those 25 or 30 years came true. Cancer immunotherapy was revolutionized, and biologics for diabetes, multiple sclerosis, and arthritis were revolutionized. So if I have faith that those things came true, I have complete faith in this as well.”

Medinger: “From the patient perspective, what I would say is that we are seeing people who’ve been ill for more than 2 years recover. People are suddenly turning the corner when they might not have expected to. 

And while we don’t quite know exactly why yet, and it’s not everyone, every single time I hear the story of someone saying, ‘I’m pretty much back to where I was, I feel like I’ve recovered,’ I feel great. Even if I haven’t. Because I know that every single time I hear someone say that, that just increases the probability that I will, too.”
 

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

Filmmaker Gez Medinger and immunologist Danny Altmann have been dubbed by British media as “COVID’s odd couple,” and they don’t mind at all. Discussing their recent book, The Long COVID Handbook, the authors lean into their animated roles: Medinger is a passionate patient-researcher and “guinea pig” (his words) in search of his own healing, and Altmann is a no-nonsense, data-driven scientist and “Professor Boring” (as he puts it).

And the message they have about the impact of long COVID is stunning.

“The clinical burden [of long COVID] is somewhere on par with the whole of heart disease all over again, or the whole of oncology all over again, which are our biggest clinical bills concurrently,” Altmann said.

The pair met early in the pandemic, after Medinger became infected during the first wave and interviewed Altmann for his YouTube channel, which has more than 5 million views. 

“Danny was one of the first people from the medical establishment to sort of stand up on the parapet and wave a flag and say, ‘Hey, guys, there’s a problem here.’ And that was incredibly validating for 2 million people in the U.K. alone who were suffering with long COVID,” Medinger said. 

Their relationship works, not just for publishing one of the first definitive guides to long COVID, but also as a model for how patients with lived experiences can lead the way in medicine – from giving the condition its name to driving the medical establishment for recognition, clinical research, and therapeutic answers. 

With Altmann currently leading a major research project at Imperial College London on long COVID and Medinger’s social media platform and communication skills, they’re both advancing the world’s understanding of the disease in their own way.

“We’re now more than 3 years into this completely mysterious, uncharted disease process with a whole globe full of really desperate people,” said Altmann. “It’s a living, organic thing, and yet that also demands some kind of order and collation and pulling together into some kind of sense. So I was very pleased when Gez approached me to help him with the book.”

In it, they translate everything they’ve learned about the condition that’s “scattered in 100,000 places around the globe” into a digestible format. It tells two sides of the same story: the anecdotal experiences Medinger has undergone or observed in the long COVID community through more than a dozen of his own patient-led studies, as well the hard science and research that’s amassing in the medical world. 

In an interview, Medinger and Altmann discussed how their book can help both patients and clinicians, and the next steps needed to combat long COVID.
 

What are the book’s key takeaways for you?

Medinger: “I would say we put together an incredibly comprehensive couple of chapters on the hypotheses, big picture, what’s causing long COVID. And then the nitty-gritty research for everything that we’ve found out that is going on. ... And the other part of the book that I think is particularly important, beyond the tips for managing symptoms, is the content on mental health and the impact on your emotional state and your capacity and just how huge that is. ... That has been the most powerful thing for patients when they’ve read it. And they’ve said that they’ve just been crying all the way through those chapters because suddenly they feel heard and seen.”

Altmann: “Obviously, you’d expect me to say that the parts of the book that I love most are the kind of hard-nosed, medical, mechanistic bits. ... We’ve got 150 million-plus desperate people deciding or not deciding to go and see their general practitioner, getting a fair hearing or not getting a fair hearing. And the poor doctor has never learned this in medical school, has never read a textbook on it, and hasn’t a clue what’s coming through the door. 

How are they expected to know what to do? So I think the least we can do in some of those chapters is feed into their knowledge of general medicine and give them some clues. ... I think if we can explain to people what might be going on in them, and to their doctors, what on earth they might do about it, what kind of tests they might order, that helps a bit.”
 

How did you balance the more controversial parts of the book, including the chapter about so-called “treatments”? For instance, the book recounts Gez’s harrowing experience with ivermectin as a frightening warning. But Danny, you were nervous about even mentioning unproven and potentially dangerous treatments as things people have tried and have looked into. 

Medinger: “We had to try and work out how to handle the topic, how to handle those points of view, whilst at the same time still being informative. I think the book is stronger for that chapter, too. The other thing would certainly have been to just not address the subject, but it’s one of the things that people want to know the most about. And there’s also a lot of bad information floating around out there about certain treatments. Ivermectin, for example, and this is what happened to me when I tried it. ‘Don’t do it. It’s not recommended. Please don’t.’ 

I think it was also very important to include because that cautionary tale really applies to every single one of those treatments that people might be hearing about that hasn’t been backed up by efficacy and safety studies.”

Altmann: “I think Gez has been quite diplomatic. That chapter was, I think, a testament to the power of the book. And the biggest test of our marriage as ‘the odd couple.’ Because when I first read the first draft of what Gez had written, I said, ‘my name can’t even be on this book. Otherwise, I’ll be sacked.’ 

And we had to find marriage counseling after that, and a way back to write a version of that chapter that expressed both halves of those concerns in a way that did justice to those different viewpoints. And I think that makes it quite a strong chapter.”
 

What do you think are the most urgent next steps in the search for solving long COVID?

Medinger: “I would personally like to try and get some sort of answer on viral persistence. ... If there’s one thing that feels like it would be treatable in theory, and would make sense why we’re still getting all of these symptoms this whole time later, it’s that, so I would like to try and establish or eliminate viral persistence. So if you gave me Elon Musk’s wealth, that’s what I would throw a bunch of the money at, trying to either eliminate or establish that. 

And then, you know, the other important thing is a diagnostic test. Danny always talks about how important it is. Once you have that, it helps you suddenly open the doors to all these other things that you can do. And treatment trials. Let’s throw some meds at this so that we have an educated guess at what might work and put them into high-powered, randomized, controlled trials and see if anything comes out because from the patient perspective, I don’t think any of us wants to wait for 5 years for that stuff to start happening.”

Altmann: “I completely agree. If you go to a website, like clinicaltrials.gov, you’ll find an immense number of clinical trials on COVID. There isn’t really a shortage of them, some of them better-powered to get an answer than others.”

How do you think public policy needs to adapt for long COVID, including social safety nets such as workers’ compensation and disability benefits?

Medinger: “In terms of public policy, what I would like would be some public acknowledgment that it’s real from government sources. Just the acknowledgment that it’s real and it remains a risk even now.”

Altmann: “Nobody in politics asks my opinion. I think they’d hate to hear it. Because if I went to see them and said, well, actually, if you thought the COVID pandemic was bad, wait till you see what’s on the table now. We’ve created a disabled population in our country of 2 million, at least a portion if not more of people who are not fully contributory to the workforce anymore ... [with] legal wrangles about retirement and health insurance and pensions, and a human right to adequate health care. Which means, ideally, a purpose-built clinic where they can have their respiratory opinion and their rheumatology opinion and their endocrine opinion and their neurology opinion, all under one roof.”

You’ve both shown so much optimism. Why is that?

Altmann: “I’ve been an immunologist for a long time now, and written all my decades of grant applications, where as a community we made what, at the time, were kind of wild promises and wildly optimistic projections of how our knowledge of tumor immunity would revolutionize cancer care, and how knowledge of autoimmunity would revolutionize care of all the autoimmune diseases. 

And weirdly almost every word we wrote over those 25 or 30 years came true. Cancer immunotherapy was revolutionized, and biologics for diabetes, multiple sclerosis, and arthritis were revolutionized. So if I have faith that those things came true, I have complete faith in this as well.”

Medinger: “From the patient perspective, what I would say is that we are seeing people who’ve been ill for more than 2 years recover. People are suddenly turning the corner when they might not have expected to. 

And while we don’t quite know exactly why yet, and it’s not everyone, every single time I hear the story of someone saying, ‘I’m pretty much back to where I was, I feel like I’ve recovered,’ I feel great. Even if I haven’t. Because I know that every single time I hear someone say that, that just increases the probability that I will, too.”
 

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