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AI Wins AGA’s Shark Tank Competition
CHICAGO — At the 2024 AGA Tech Summit, held April 11-12 at the Chicago headquarters of MATTER, a global healthcare startup incubator, five companies made their pitch to be the winner of the Shark Tank competition that recognizes an outstanding tech start up in the gastroenterology field.
After the companies’ rapid-fire pitches and Q&A sessions, four judges convened to determine a winner and returned to make an announcement.
The winner was Arithmedics, which uses AI technology to automate billing codes. Founder Venthan Elango, PhD, has worked as a software engineer at Google, Urban Engines, and Georgia Tech, and his wife of 17 years is Renumathy Dhanasekaran, MD, PhD, a gastroenterologist and assistant professor of medicine at Stanford (California) University.
Their marriage has brought a unique perspective, according to Dr. Elango. “There isn’t a single day that goes by when she talks to me about the inefficiencies in healthcare, and then I say, ‘this can be easily solved with a software solution,’ ” he said.
When they decided to try a start-up, the two initiated conversations with healthcare providers to identify a key unmet need. “The common recurring theme was that medical billing was a problem, because of [insufficient] institutional knowledge, staff shortage, and inconsistencies with the payers,” said Dr. Elango. During their presentation, the two noted that about 80% of claims include at least one coding error, and this leads to an estimated $125 billion in annual losses.
Generative AI presented a solution. “Automating the medical billing code [determination] from a clinical record became 10 times easier than what it was before. So I thought, I can build a product that actually brings in augmented analytics and generative AI and do something that is tremendously useful to physicians,” he said.
The future goal is to make life easier for healthcare providers, according to Dr. Dhanasekaran. “As physicians, we went into medicine to talk with patients, but a lot of us are just typing away when patients are sitting in the room, because there are all of these requirements for documentation to get the billing so that we can get paid at the end of the day,” she said.
Arithmedics aims to initially target small-group medical practices that are tech savvy. They will analyze a year’s worth of claims for errors and resubmit claims for the past 3 months and split any additional revenue that ensues. They plan to expand to revenue cycle management companies and hospital systems. On the technology side, they will expand to data intelligence and integrate with electronic health records, and ultimately plan to charge 1%-2% of revenue.
The other Shark Tank finalists were:
- Aspero Medical: Balloon overtube that maximizes frictional properties to improve mucosal wall traction and anchoring consistency. (Voted ‘fan favorite’ by AGA Tech Summit attendees)
- Aurora Medical Technologies: Minimally invasive, guided, tissue-anchoring suturing system for complex endoscopic procedures.
- Ergami Endoscopy: Flexible overtube capable of automatic insertion and fixation in the colon, which could potentially eliminate sedation and prevent endoscopic injuries to the physician.
- Lazurite: Wireless surgical camera that eliminates the need for light or video cables, avoiding the associated fire, trip, and contamination hazards.
The judges were swayed by Arithmedics’ practical solution to a widespread problem. “There is for sure a need in terms of inaccurate billing and billing codes that are wrong. There’s lost revenue for physicians around that. So I think we were really focused from a judging standpoint on the fact that their solution was filling truly an unmet need,” said judge Andrea Vossler, a managing director of Varia Ventures, which has partnered with AGA to launch and manage the GI Opportunity Fund, an AGA-member venture fund.
“We were really focused on how to assist physicians in terms of supporting their practices, and really changing what you’re doing. I think AI has the ability to do that, so we liked that about the company,” she added.
The company is an example of how AI is poised to alter healthcare, according to Ms. Vossler. “I think it’s massive. I think we’re at the very beginning of its impact on healthcare,” she said.
Another judge had a similar view. “They won because there is a screaming need to fix billing. So, it’s well known that lots of money is indeed lost in billing practices, which are stressful for office personnel and stressful for physicians. They can fulfill a long-standing need, and we thought that that was the success story,” said Christopher Gostout, MD, emeritus professor of medicine at Mayo Clinic in Rochester, Minnesota.
Dr. Gostout offered advice for gastroenterologists and other physicians interested in starting tech companies. It’s imperative to be a realist, he said. “Is there a real market for it, or [is it just] a niche market? Does your device have legs — can it expand and can evolve into other [spin-off] products? These are things you need to think about because one-offs or single-trick ponies are pretty hard to move along now,” said Dr. Gostout.
He recommended that entrepreneurs apply for Small Business Innovation Research (SBIR) grants. “I think it’s a great opportunity to bring in money and get the ball rolling.”
Finally, he advised entrepreneurs to be thoughtful about their advisory groups. Founders may be tempted to find the highest profile names they can to give the business gravitas, but those big names may not have the best knowledge base to understand the problems that the technology is meant to address. “I’ve seen businesses fail because they went for marquee names that really were not helpful, and they didn’t do their due diligence in seeking out really useful value. You don’t need a lot of advisers, just a couple of really good ones,” said Dr. Gostout.
The summit was sponsored by the AGA Center for GI Innovation and Technology.
Dr. Gostout has founded and advises AdaptivEndo and Lean Medical. He is a consultant to Boston Scientific. Dr. Dhanasekaran has no financial disclosures. Ms. Vossler is an employee of Varia Ventures, which is an investment partner to AGA. Dr. Elango is an employee of Arithmedics.
CHICAGO — At the 2024 AGA Tech Summit, held April 11-12 at the Chicago headquarters of MATTER, a global healthcare startup incubator, five companies made their pitch to be the winner of the Shark Tank competition that recognizes an outstanding tech start up in the gastroenterology field.
After the companies’ rapid-fire pitches and Q&A sessions, four judges convened to determine a winner and returned to make an announcement.
The winner was Arithmedics, which uses AI technology to automate billing codes. Founder Venthan Elango, PhD, has worked as a software engineer at Google, Urban Engines, and Georgia Tech, and his wife of 17 years is Renumathy Dhanasekaran, MD, PhD, a gastroenterologist and assistant professor of medicine at Stanford (California) University.
Their marriage has brought a unique perspective, according to Dr. Elango. “There isn’t a single day that goes by when she talks to me about the inefficiencies in healthcare, and then I say, ‘this can be easily solved with a software solution,’ ” he said.
When they decided to try a start-up, the two initiated conversations with healthcare providers to identify a key unmet need. “The common recurring theme was that medical billing was a problem, because of [insufficient] institutional knowledge, staff shortage, and inconsistencies with the payers,” said Dr. Elango. During their presentation, the two noted that about 80% of claims include at least one coding error, and this leads to an estimated $125 billion in annual losses.
Generative AI presented a solution. “Automating the medical billing code [determination] from a clinical record became 10 times easier than what it was before. So I thought, I can build a product that actually brings in augmented analytics and generative AI and do something that is tremendously useful to physicians,” he said.
The future goal is to make life easier for healthcare providers, according to Dr. Dhanasekaran. “As physicians, we went into medicine to talk with patients, but a lot of us are just typing away when patients are sitting in the room, because there are all of these requirements for documentation to get the billing so that we can get paid at the end of the day,” she said.
Arithmedics aims to initially target small-group medical practices that are tech savvy. They will analyze a year’s worth of claims for errors and resubmit claims for the past 3 months and split any additional revenue that ensues. They plan to expand to revenue cycle management companies and hospital systems. On the technology side, they will expand to data intelligence and integrate with electronic health records, and ultimately plan to charge 1%-2% of revenue.
The other Shark Tank finalists were:
- Aspero Medical: Balloon overtube that maximizes frictional properties to improve mucosal wall traction and anchoring consistency. (Voted ‘fan favorite’ by AGA Tech Summit attendees)
- Aurora Medical Technologies: Minimally invasive, guided, tissue-anchoring suturing system for complex endoscopic procedures.
- Ergami Endoscopy: Flexible overtube capable of automatic insertion and fixation in the colon, which could potentially eliminate sedation and prevent endoscopic injuries to the physician.
- Lazurite: Wireless surgical camera that eliminates the need for light or video cables, avoiding the associated fire, trip, and contamination hazards.
The judges were swayed by Arithmedics’ practical solution to a widespread problem. “There is for sure a need in terms of inaccurate billing and billing codes that are wrong. There’s lost revenue for physicians around that. So I think we were really focused from a judging standpoint on the fact that their solution was filling truly an unmet need,” said judge Andrea Vossler, a managing director of Varia Ventures, which has partnered with AGA to launch and manage the GI Opportunity Fund, an AGA-member venture fund.
“We were really focused on how to assist physicians in terms of supporting their practices, and really changing what you’re doing. I think AI has the ability to do that, so we liked that about the company,” she added.
The company is an example of how AI is poised to alter healthcare, according to Ms. Vossler. “I think it’s massive. I think we’re at the very beginning of its impact on healthcare,” she said.
Another judge had a similar view. “They won because there is a screaming need to fix billing. So, it’s well known that lots of money is indeed lost in billing practices, which are stressful for office personnel and stressful for physicians. They can fulfill a long-standing need, and we thought that that was the success story,” said Christopher Gostout, MD, emeritus professor of medicine at Mayo Clinic in Rochester, Minnesota.
Dr. Gostout offered advice for gastroenterologists and other physicians interested in starting tech companies. It’s imperative to be a realist, he said. “Is there a real market for it, or [is it just] a niche market? Does your device have legs — can it expand and can evolve into other [spin-off] products? These are things you need to think about because one-offs or single-trick ponies are pretty hard to move along now,” said Dr. Gostout.
He recommended that entrepreneurs apply for Small Business Innovation Research (SBIR) grants. “I think it’s a great opportunity to bring in money and get the ball rolling.”
Finally, he advised entrepreneurs to be thoughtful about their advisory groups. Founders may be tempted to find the highest profile names they can to give the business gravitas, but those big names may not have the best knowledge base to understand the problems that the technology is meant to address. “I’ve seen businesses fail because they went for marquee names that really were not helpful, and they didn’t do their due diligence in seeking out really useful value. You don’t need a lot of advisers, just a couple of really good ones,” said Dr. Gostout.
The summit was sponsored by the AGA Center for GI Innovation and Technology.
Dr. Gostout has founded and advises AdaptivEndo and Lean Medical. He is a consultant to Boston Scientific. Dr. Dhanasekaran has no financial disclosures. Ms. Vossler is an employee of Varia Ventures, which is an investment partner to AGA. Dr. Elango is an employee of Arithmedics.
CHICAGO — At the 2024 AGA Tech Summit, held April 11-12 at the Chicago headquarters of MATTER, a global healthcare startup incubator, five companies made their pitch to be the winner of the Shark Tank competition that recognizes an outstanding tech start up in the gastroenterology field.
After the companies’ rapid-fire pitches and Q&A sessions, four judges convened to determine a winner and returned to make an announcement.
The winner was Arithmedics, which uses AI technology to automate billing codes. Founder Venthan Elango, PhD, has worked as a software engineer at Google, Urban Engines, and Georgia Tech, and his wife of 17 years is Renumathy Dhanasekaran, MD, PhD, a gastroenterologist and assistant professor of medicine at Stanford (California) University.
Their marriage has brought a unique perspective, according to Dr. Elango. “There isn’t a single day that goes by when she talks to me about the inefficiencies in healthcare, and then I say, ‘this can be easily solved with a software solution,’ ” he said.
When they decided to try a start-up, the two initiated conversations with healthcare providers to identify a key unmet need. “The common recurring theme was that medical billing was a problem, because of [insufficient] institutional knowledge, staff shortage, and inconsistencies with the payers,” said Dr. Elango. During their presentation, the two noted that about 80% of claims include at least one coding error, and this leads to an estimated $125 billion in annual losses.
Generative AI presented a solution. “Automating the medical billing code [determination] from a clinical record became 10 times easier than what it was before. So I thought, I can build a product that actually brings in augmented analytics and generative AI and do something that is tremendously useful to physicians,” he said.
The future goal is to make life easier for healthcare providers, according to Dr. Dhanasekaran. “As physicians, we went into medicine to talk with patients, but a lot of us are just typing away when patients are sitting in the room, because there are all of these requirements for documentation to get the billing so that we can get paid at the end of the day,” she said.
Arithmedics aims to initially target small-group medical practices that are tech savvy. They will analyze a year’s worth of claims for errors and resubmit claims for the past 3 months and split any additional revenue that ensues. They plan to expand to revenue cycle management companies and hospital systems. On the technology side, they will expand to data intelligence and integrate with electronic health records, and ultimately plan to charge 1%-2% of revenue.
The other Shark Tank finalists were:
- Aspero Medical: Balloon overtube that maximizes frictional properties to improve mucosal wall traction and anchoring consistency. (Voted ‘fan favorite’ by AGA Tech Summit attendees)
- Aurora Medical Technologies: Minimally invasive, guided, tissue-anchoring suturing system for complex endoscopic procedures.
- Ergami Endoscopy: Flexible overtube capable of automatic insertion and fixation in the colon, which could potentially eliminate sedation and prevent endoscopic injuries to the physician.
- Lazurite: Wireless surgical camera that eliminates the need for light or video cables, avoiding the associated fire, trip, and contamination hazards.
The judges were swayed by Arithmedics’ practical solution to a widespread problem. “There is for sure a need in terms of inaccurate billing and billing codes that are wrong. There’s lost revenue for physicians around that. So I think we were really focused from a judging standpoint on the fact that their solution was filling truly an unmet need,” said judge Andrea Vossler, a managing director of Varia Ventures, which has partnered with AGA to launch and manage the GI Opportunity Fund, an AGA-member venture fund.
“We were really focused on how to assist physicians in terms of supporting their practices, and really changing what you’re doing. I think AI has the ability to do that, so we liked that about the company,” she added.
The company is an example of how AI is poised to alter healthcare, according to Ms. Vossler. “I think it’s massive. I think we’re at the very beginning of its impact on healthcare,” she said.
Another judge had a similar view. “They won because there is a screaming need to fix billing. So, it’s well known that lots of money is indeed lost in billing practices, which are stressful for office personnel and stressful for physicians. They can fulfill a long-standing need, and we thought that that was the success story,” said Christopher Gostout, MD, emeritus professor of medicine at Mayo Clinic in Rochester, Minnesota.
Dr. Gostout offered advice for gastroenterologists and other physicians interested in starting tech companies. It’s imperative to be a realist, he said. “Is there a real market for it, or [is it just] a niche market? Does your device have legs — can it expand and can evolve into other [spin-off] products? These are things you need to think about because one-offs or single-trick ponies are pretty hard to move along now,” said Dr. Gostout.
He recommended that entrepreneurs apply for Small Business Innovation Research (SBIR) grants. “I think it’s a great opportunity to bring in money and get the ball rolling.”
Finally, he advised entrepreneurs to be thoughtful about their advisory groups. Founders may be tempted to find the highest profile names they can to give the business gravitas, but those big names may not have the best knowledge base to understand the problems that the technology is meant to address. “I’ve seen businesses fail because they went for marquee names that really were not helpful, and they didn’t do their due diligence in seeking out really useful value. You don’t need a lot of advisers, just a couple of really good ones,” said Dr. Gostout.
The summit was sponsored by the AGA Center for GI Innovation and Technology.
Dr. Gostout has founded and advises AdaptivEndo and Lean Medical. He is a consultant to Boston Scientific. Dr. Dhanasekaran has no financial disclosures. Ms. Vossler is an employee of Varia Ventures, which is an investment partner to AGA. Dr. Elango is an employee of Arithmedics.
FROM THE 2024 AGA TECH SUMMIT
Investing in the Future of GI
Talented young investigators are walking away from gastroenterology and hepatology research frustrated by a lack of support. For the last decades, Congress has slashed research funding and even greater cuts are on the horizon. Investigators in the early stages of their careers are particularly hard hit. Without help from other funding sources, young investigators struggle to continue their research, build their research portfolio, and obtain federal funding.
Decades of research have revolutionized the care of many digestive disease patients. These patients, as well as everyone in the gastroenterology and hepatology fields — clinicians and researchers alike — have benefited from the discoveries of dedicated investigators, past and present.
Right now, creative young researchers are poised to make groundbreaking discoveries that will shape the future of gastroenterology and hepatology. Unfortunately, declining government funding for biomedical research puts this potential in jeopardy. We’re at risk of losing an entire generation of researchers.
To fill this gap, the AGA Research Foundation invites you to support its mission by making a donation. Funds raised through the AGA Research Foundation will support the pipeline of new investigators’ research careers, allowing them to make discoveries that could ultimately improve patient care and even cure diseases.
“I donated to the AGA Research Foundation to ensure the vitality of our specialty, and to fund the research of future generations of gastroenterologists. Funding from organizations like the AGA Research Foundation is crucial for young scientists and gastroenterologists to launch their careers,” states Michael Camilleri, MD, AGAF, AGA Research Foundation Chair.
By joining others in supporting the AGA Research Foundation, you will ensure that young researchers have opportunities to continue their life-saving work. Learn more or make a contribution at www.foundation.gastro.org.
Talented young investigators are walking away from gastroenterology and hepatology research frustrated by a lack of support. For the last decades, Congress has slashed research funding and even greater cuts are on the horizon. Investigators in the early stages of their careers are particularly hard hit. Without help from other funding sources, young investigators struggle to continue their research, build their research portfolio, and obtain federal funding.
Decades of research have revolutionized the care of many digestive disease patients. These patients, as well as everyone in the gastroenterology and hepatology fields — clinicians and researchers alike — have benefited from the discoveries of dedicated investigators, past and present.
Right now, creative young researchers are poised to make groundbreaking discoveries that will shape the future of gastroenterology and hepatology. Unfortunately, declining government funding for biomedical research puts this potential in jeopardy. We’re at risk of losing an entire generation of researchers.
To fill this gap, the AGA Research Foundation invites you to support its mission by making a donation. Funds raised through the AGA Research Foundation will support the pipeline of new investigators’ research careers, allowing them to make discoveries that could ultimately improve patient care and even cure diseases.
“I donated to the AGA Research Foundation to ensure the vitality of our specialty, and to fund the research of future generations of gastroenterologists. Funding from organizations like the AGA Research Foundation is crucial for young scientists and gastroenterologists to launch their careers,” states Michael Camilleri, MD, AGAF, AGA Research Foundation Chair.
By joining others in supporting the AGA Research Foundation, you will ensure that young researchers have opportunities to continue their life-saving work. Learn more or make a contribution at www.foundation.gastro.org.
Talented young investigators are walking away from gastroenterology and hepatology research frustrated by a lack of support. For the last decades, Congress has slashed research funding and even greater cuts are on the horizon. Investigators in the early stages of their careers are particularly hard hit. Without help from other funding sources, young investigators struggle to continue their research, build their research portfolio, and obtain federal funding.
Decades of research have revolutionized the care of many digestive disease patients. These patients, as well as everyone in the gastroenterology and hepatology fields — clinicians and researchers alike — have benefited from the discoveries of dedicated investigators, past and present.
Right now, creative young researchers are poised to make groundbreaking discoveries that will shape the future of gastroenterology and hepatology. Unfortunately, declining government funding for biomedical research puts this potential in jeopardy. We’re at risk of losing an entire generation of researchers.
To fill this gap, the AGA Research Foundation invites you to support its mission by making a donation. Funds raised through the AGA Research Foundation will support the pipeline of new investigators’ research careers, allowing them to make discoveries that could ultimately improve patient care and even cure diseases.
“I donated to the AGA Research Foundation to ensure the vitality of our specialty, and to fund the research of future generations of gastroenterologists. Funding from organizations like the AGA Research Foundation is crucial for young scientists and gastroenterologists to launch their careers,” states Michael Camilleri, MD, AGAF, AGA Research Foundation Chair.
By joining others in supporting the AGA Research Foundation, you will ensure that young researchers have opportunities to continue their life-saving work. Learn more or make a contribution at www.foundation.gastro.org.
Check out our new Crohn’s disease clinician toolkit!
Have you ever wished you could access all of our Crohn’s disease resources in one place? We’ve compiled our Crohn’s disease clinical guidance, continuing education resources, patient education, and FAQs into one convenient toolkit.
Toolkit includes clinical guidance on:
- Role of biomarkers for the management of Crohn’s disease
- Medical management of moderate to severe luminal and perianal fistulizing Crohn’s disease
- Diet and nutritional therapies in patients with IBD
Check it out at www.gastro.org/toolkit.
Have you ever wished you could access all of our Crohn’s disease resources in one place? We’ve compiled our Crohn’s disease clinical guidance, continuing education resources, patient education, and FAQs into one convenient toolkit.
Toolkit includes clinical guidance on:
- Role of biomarkers for the management of Crohn’s disease
- Medical management of moderate to severe luminal and perianal fistulizing Crohn’s disease
- Diet and nutritional therapies in patients with IBD
Check it out at www.gastro.org/toolkit.
Have you ever wished you could access all of our Crohn’s disease resources in one place? We’ve compiled our Crohn’s disease clinical guidance, continuing education resources, patient education, and FAQs into one convenient toolkit.
Toolkit includes clinical guidance on:
- Role of biomarkers for the management of Crohn’s disease
- Medical management of moderate to severe luminal and perianal fistulizing Crohn’s disease
- Diet and nutritional therapies in patients with IBD
Check it out at www.gastro.org/toolkit.
Making invisible problems visible
How Erika Mosesón, MD, educates on the effects of air pollution and encourages community-level advocacy
For Erika Mosesón, MD, a pulmonologist and ICU doctor, advocacy for clean air and climate action started small: signing petitions and writing letters.
Even as she attended conferences and learned about the health impacts of air pollution, her impression was that experts were handling it. “I didn’t really think my voice was worth highlighting,” Dr. Mosesón said.
But her concerns grew with the repeal of the Clean Power Plan in 2019 and rolled-back federal protections around particulate matter and other environmental guidelines.
In response, Dr. Mosesón moved from writing letters to educating people in her home state of Oregon on the lung-related effects of pollution. She spoke at organization meetings and town halls and met with legislators. One way or another, she knew she needed to get the word out.
After all, problem-causing particulates are teeny-tiny; too small to be seen. “It’s literally invisible,” Dr. Mosesón said. But the impact on patients is not.
That’s how the Air Health Our Health podcast was born.
The podcast has a straightforward tagline — ”Clean air saves lives” — and a blunt recommendation: “If you do nothing else, don’t light things on fire and breathe them into your lungs.”
Giving a voice to the voiceless
In early 2017, the Oregon legislature was considering bills aimed at transitioning from diesel-fueled engines to cleaner alternatives. At the time, Dr. Mosesón was on the executive committee for the Oregon Thoracic Society, and, in partnership with the American Lung Association, she was tapped to speak to legislators about clean air and the health impacts of air pollution.
This role made it clear to her that lawmakers don’t hear diverse perspectives. A trucking company may budget for full-time lobbyists, whereas parents of kids with asthma aren’t in the room.
So there’s an asymmetry to who is and is not heard from, Dr. Mosesón said. That’s why in her conversations and presentations, she advocates for those who might not otherwise be represented in the rooms where big decisions are made.
Automating advocacy
Over time, Dr. Mosesón found her schedule was filling up with meetings and presentations.
“I’m a full-time clinician,” Dr. Mosesón noted. She’s also a parent to three kids. When she was asked to attend a hearing, sometimes her schedule required her to decline. And so, early in the pandemic, the Air Health Our Health podcast and the accompanying website were born.
“The podcast and website were honestly a way to automate advocacy,” Dr. Mosesón said.
In many ways, the pandemic was an ideal time to launch the podcast. For one thing, the idea of podcasting from your closet or living room (as opposed to a professional audio studio) became commonplace. Plus, for a pulmonologist, these years were full of relevant topics like how climate change and particulate matter interacted with COVID-19 , Dr. Mosesón noted.
Then, in 2020, the Labor Day fires led to Oregon’s having the worst air quality in the world. That same year, there were George Floyd protests around the country, including in Portland, which led to rampant use of tear gas and prompted Dr. Mosesón to dig into studies about these chemicals.
Given just how much air pollution affects health — and the continued extreme weather events (such as Oregon’s heat dome in summer 2021) — there was no shortage of topics for the podcast.
Next steps to empower physicians
Confronting climate change is daunting, and it is made more challenging by a partisan environment, distrust of experts, and disinformation. On her podcast, Dr. Mosesón aims to make it easier.
In each episode, she shares information and interviews experts. She shares how a patient might be affected by particular issues — radon, wildfires, and so on. The goal is to provide clinicians with a foundation on everyday issues.
“Every single doctor feels like they can talk to a patient about smoking, even if they don’t know all the deep nitty-gritty studies about it,” Dr. Mosesón said. The exact effects of smoking — cancer, heart disease, and lung disease — occur due to air pollution. “When I give talks, I tell people, if you can talk about smoking, you can talk about air pollution.”
Each podcast also features an array of action items.
Some steps are practical, such as creating a plan for heat events or encouraging radon testing. The solution could also be as simple as asking the right questions.
For example, at a doctor’s visit for asthma, common recommendations are to use a HEPA filter or place a sheet protector on the bed, Dr. Mosesón said. It won’t typically come up that a patient’s asthma may be caused or exacerbated by living beside a highway.
Dr. Mosesón also encourages advocacy. “There are all these different levels [of response],” she said. Next steps might involve writing a letter, contacting a councilperson, or advocating for a program (like retiring gas-powered leaf blowers).
For many patients, their doctor is the only person they routinely interact with who has advanced scientific training. Rather than presenting dry data, Dr. Mosesón recommends framing changes and recommendations in ways that are meaningful to neighbors.
“Each physician or clinician is going to know the values of their community,” Dr. Mosesón said. If you’re in a military town, advocating for electric cars may be easier if framed around decreasing dependence on foreign oil. If the region recently experienced back-to-back heat events, advocating for a cooling center might be galvanizing.
What is Dr. Mosesón’s ultimate goal? Inform others so well that she can retire her podcasting equipment.
“I would love,” Dr. Mosesón said, “for every physician in their local community to be a clean air and climate advocate.”
------
Be sure to check out a special episode of the Air Health Our Health podcast, where Dr. Mosesón and CHEST Advocates Editor in Chief, Drew Harris, MD, FCCP, discuss the serious health issues impacting coal miners. They take a deep dive into black lung disease and silica dust, highlighting the science and research, prevention efforts and challenges to implementation, and the importance of advocacy work.
LISTEN NOW »
This article was adapted from the Winter 2024 online issue of CHEST Advocates. For the full article — and to engage with the other content from this issue — visit chestnet.org/chest-advocates.
How Erika Mosesón, MD, educates on the effects of air pollution and encourages community-level advocacy
How Erika Mosesón, MD, educates on the effects of air pollution and encourages community-level advocacy
For Erika Mosesón, MD, a pulmonologist and ICU doctor, advocacy for clean air and climate action started small: signing petitions and writing letters.
Even as she attended conferences and learned about the health impacts of air pollution, her impression was that experts were handling it. “I didn’t really think my voice was worth highlighting,” Dr. Mosesón said.
But her concerns grew with the repeal of the Clean Power Plan in 2019 and rolled-back federal protections around particulate matter and other environmental guidelines.
In response, Dr. Mosesón moved from writing letters to educating people in her home state of Oregon on the lung-related effects of pollution. She spoke at organization meetings and town halls and met with legislators. One way or another, she knew she needed to get the word out.
After all, problem-causing particulates are teeny-tiny; too small to be seen. “It’s literally invisible,” Dr. Mosesón said. But the impact on patients is not.
That’s how the Air Health Our Health podcast was born.
The podcast has a straightforward tagline — ”Clean air saves lives” — and a blunt recommendation: “If you do nothing else, don’t light things on fire and breathe them into your lungs.”
Giving a voice to the voiceless
In early 2017, the Oregon legislature was considering bills aimed at transitioning from diesel-fueled engines to cleaner alternatives. At the time, Dr. Mosesón was on the executive committee for the Oregon Thoracic Society, and, in partnership with the American Lung Association, she was tapped to speak to legislators about clean air and the health impacts of air pollution.
This role made it clear to her that lawmakers don’t hear diverse perspectives. A trucking company may budget for full-time lobbyists, whereas parents of kids with asthma aren’t in the room.
So there’s an asymmetry to who is and is not heard from, Dr. Mosesón said. That’s why in her conversations and presentations, she advocates for those who might not otherwise be represented in the rooms where big decisions are made.
Automating advocacy
Over time, Dr. Mosesón found her schedule was filling up with meetings and presentations.
“I’m a full-time clinician,” Dr. Mosesón noted. She’s also a parent to three kids. When she was asked to attend a hearing, sometimes her schedule required her to decline. And so, early in the pandemic, the Air Health Our Health podcast and the accompanying website were born.
“The podcast and website were honestly a way to automate advocacy,” Dr. Mosesón said.
In many ways, the pandemic was an ideal time to launch the podcast. For one thing, the idea of podcasting from your closet or living room (as opposed to a professional audio studio) became commonplace. Plus, for a pulmonologist, these years were full of relevant topics like how climate change and particulate matter interacted with COVID-19 , Dr. Mosesón noted.
Then, in 2020, the Labor Day fires led to Oregon’s having the worst air quality in the world. That same year, there were George Floyd protests around the country, including in Portland, which led to rampant use of tear gas and prompted Dr. Mosesón to dig into studies about these chemicals.
Given just how much air pollution affects health — and the continued extreme weather events (such as Oregon’s heat dome in summer 2021) — there was no shortage of topics for the podcast.
Next steps to empower physicians
Confronting climate change is daunting, and it is made more challenging by a partisan environment, distrust of experts, and disinformation. On her podcast, Dr. Mosesón aims to make it easier.
In each episode, she shares information and interviews experts. She shares how a patient might be affected by particular issues — radon, wildfires, and so on. The goal is to provide clinicians with a foundation on everyday issues.
“Every single doctor feels like they can talk to a patient about smoking, even if they don’t know all the deep nitty-gritty studies about it,” Dr. Mosesón said. The exact effects of smoking — cancer, heart disease, and lung disease — occur due to air pollution. “When I give talks, I tell people, if you can talk about smoking, you can talk about air pollution.”
Each podcast also features an array of action items.
Some steps are practical, such as creating a plan for heat events or encouraging radon testing. The solution could also be as simple as asking the right questions.
For example, at a doctor’s visit for asthma, common recommendations are to use a HEPA filter or place a sheet protector on the bed, Dr. Mosesón said. It won’t typically come up that a patient’s asthma may be caused or exacerbated by living beside a highway.
Dr. Mosesón also encourages advocacy. “There are all these different levels [of response],” she said. Next steps might involve writing a letter, contacting a councilperson, or advocating for a program (like retiring gas-powered leaf blowers).
For many patients, their doctor is the only person they routinely interact with who has advanced scientific training. Rather than presenting dry data, Dr. Mosesón recommends framing changes and recommendations in ways that are meaningful to neighbors.
“Each physician or clinician is going to know the values of their community,” Dr. Mosesón said. If you’re in a military town, advocating for electric cars may be easier if framed around decreasing dependence on foreign oil. If the region recently experienced back-to-back heat events, advocating for a cooling center might be galvanizing.
What is Dr. Mosesón’s ultimate goal? Inform others so well that she can retire her podcasting equipment.
“I would love,” Dr. Mosesón said, “for every physician in their local community to be a clean air and climate advocate.”
------
Be sure to check out a special episode of the Air Health Our Health podcast, where Dr. Mosesón and CHEST Advocates Editor in Chief, Drew Harris, MD, FCCP, discuss the serious health issues impacting coal miners. They take a deep dive into black lung disease and silica dust, highlighting the science and research, prevention efforts and challenges to implementation, and the importance of advocacy work.
LISTEN NOW »
This article was adapted from the Winter 2024 online issue of CHEST Advocates. For the full article — and to engage with the other content from this issue — visit chestnet.org/chest-advocates.
For Erika Mosesón, MD, a pulmonologist and ICU doctor, advocacy for clean air and climate action started small: signing petitions and writing letters.
Even as she attended conferences and learned about the health impacts of air pollution, her impression was that experts were handling it. “I didn’t really think my voice was worth highlighting,” Dr. Mosesón said.
But her concerns grew with the repeal of the Clean Power Plan in 2019 and rolled-back federal protections around particulate matter and other environmental guidelines.
In response, Dr. Mosesón moved from writing letters to educating people in her home state of Oregon on the lung-related effects of pollution. She spoke at organization meetings and town halls and met with legislators. One way or another, she knew she needed to get the word out.
After all, problem-causing particulates are teeny-tiny; too small to be seen. “It’s literally invisible,” Dr. Mosesón said. But the impact on patients is not.
That’s how the Air Health Our Health podcast was born.
The podcast has a straightforward tagline — ”Clean air saves lives” — and a blunt recommendation: “If you do nothing else, don’t light things on fire and breathe them into your lungs.”
Giving a voice to the voiceless
In early 2017, the Oregon legislature was considering bills aimed at transitioning from diesel-fueled engines to cleaner alternatives. At the time, Dr. Mosesón was on the executive committee for the Oregon Thoracic Society, and, in partnership with the American Lung Association, she was tapped to speak to legislators about clean air and the health impacts of air pollution.
This role made it clear to her that lawmakers don’t hear diverse perspectives. A trucking company may budget for full-time lobbyists, whereas parents of kids with asthma aren’t in the room.
So there’s an asymmetry to who is and is not heard from, Dr. Mosesón said. That’s why in her conversations and presentations, she advocates for those who might not otherwise be represented in the rooms where big decisions are made.
Automating advocacy
Over time, Dr. Mosesón found her schedule was filling up with meetings and presentations.
“I’m a full-time clinician,” Dr. Mosesón noted. She’s also a parent to three kids. When she was asked to attend a hearing, sometimes her schedule required her to decline. And so, early in the pandemic, the Air Health Our Health podcast and the accompanying website were born.
“The podcast and website were honestly a way to automate advocacy,” Dr. Mosesón said.
In many ways, the pandemic was an ideal time to launch the podcast. For one thing, the idea of podcasting from your closet or living room (as opposed to a professional audio studio) became commonplace. Plus, for a pulmonologist, these years were full of relevant topics like how climate change and particulate matter interacted with COVID-19 , Dr. Mosesón noted.
Then, in 2020, the Labor Day fires led to Oregon’s having the worst air quality in the world. That same year, there were George Floyd protests around the country, including in Portland, which led to rampant use of tear gas and prompted Dr. Mosesón to dig into studies about these chemicals.
Given just how much air pollution affects health — and the continued extreme weather events (such as Oregon’s heat dome in summer 2021) — there was no shortage of topics for the podcast.
Next steps to empower physicians
Confronting climate change is daunting, and it is made more challenging by a partisan environment, distrust of experts, and disinformation. On her podcast, Dr. Mosesón aims to make it easier.
In each episode, she shares information and interviews experts. She shares how a patient might be affected by particular issues — radon, wildfires, and so on. The goal is to provide clinicians with a foundation on everyday issues.
“Every single doctor feels like they can talk to a patient about smoking, even if they don’t know all the deep nitty-gritty studies about it,” Dr. Mosesón said. The exact effects of smoking — cancer, heart disease, and lung disease — occur due to air pollution. “When I give talks, I tell people, if you can talk about smoking, you can talk about air pollution.”
Each podcast also features an array of action items.
Some steps are practical, such as creating a plan for heat events or encouraging radon testing. The solution could also be as simple as asking the right questions.
For example, at a doctor’s visit for asthma, common recommendations are to use a HEPA filter or place a sheet protector on the bed, Dr. Mosesón said. It won’t typically come up that a patient’s asthma may be caused or exacerbated by living beside a highway.
Dr. Mosesón also encourages advocacy. “There are all these different levels [of response],” she said. Next steps might involve writing a letter, contacting a councilperson, or advocating for a program (like retiring gas-powered leaf blowers).
For many patients, their doctor is the only person they routinely interact with who has advanced scientific training. Rather than presenting dry data, Dr. Mosesón recommends framing changes and recommendations in ways that are meaningful to neighbors.
“Each physician or clinician is going to know the values of their community,” Dr. Mosesón said. If you’re in a military town, advocating for electric cars may be easier if framed around decreasing dependence on foreign oil. If the region recently experienced back-to-back heat events, advocating for a cooling center might be galvanizing.
What is Dr. Mosesón’s ultimate goal? Inform others so well that she can retire her podcasting equipment.
“I would love,” Dr. Mosesón said, “for every physician in their local community to be a clean air and climate advocate.”
------
Be sure to check out a special episode of the Air Health Our Health podcast, where Dr. Mosesón and CHEST Advocates Editor in Chief, Drew Harris, MD, FCCP, discuss the serious health issues impacting coal miners. They take a deep dive into black lung disease and silica dust, highlighting the science and research, prevention efforts and challenges to implementation, and the importance of advocacy work.
LISTEN NOW »
This article was adapted from the Winter 2024 online issue of CHEST Advocates. For the full article — and to engage with the other content from this issue — visit chestnet.org/chest-advocates.
Fighting for fresh air: RSV’s connection to environmental pollution
Diffuse Lung Disease and Lung Transplant Network
Occupational and Environmental Health Section
Poor air quality has numerous health hazards for patients with chronic lung disease. Now mounting evidence from pediatric studies suggests a concerning link between air pollution and viral infections, specifically respiratory syncytial virus (RSV).
Multiple studies have shown increased incidence and severity of disease in children with exposure to air pollutants such as particulate matter and nitrogen dioxide.1,2,3 Researchers speculate that these pollutants potentiate viral entry to airway epithelium, increase viral load, and dysregulate the immune response.4 Air pollution, increasingly worsened by climate change, is also associated with acute respiratory infections in adults, though adult research remains sparse.5
The adoption of viral testing during the pandemic has revealed a previously under-recognized prevalence of RSV in adults.
RSV accounts for an estimated 60,000 to 160,000 hospitalizations and 6,000 to 10,000 deaths annually among elderly adults. This newfound awareness coincides with the exciting development of a new RSV vaccine that has shown around 85% efficacy at preventing symptomatic RSV infection in the first year, and new data suggest benefits persisting even into the second year after vaccination.6 With an estimated 60 million adults at high risk for RSV in the US, RSV prevention has become an increasingly important aspect of respiratory care.
While more research is needed to definitively quantify the link between air pollution and RSV in adults, the existing data offer valuable insights for all pulmonologists. These findings suggest a benefit in counseling patients with chronic lung conditions on taking steps to mitigate exposure to air pollutants, either through avoidance of outdoor activities or mask-wearing when air quality levels exceed healthy ranges, as well as promoting RSV vaccination for patients who are at risk.7
References
1. Milani GP, Cafora M, Favero C, et al. PM2.5, PM10 and bronchiolitis severity: a cohort study. Pediatr Allergy Immunol. 2022;33(10). https://doi.org/10.1111/pai.13853
2. Wrotek A, Badyda A, Czechowski PO, Owczarek T, Dąbrowiecki P, Jackowska T. Air pollutants’ concentrations are associated with increased number of RSV hospitalizations in Polish children. J Clin Med. 2021;10(15):3224. https://doi.org/10.3390/jcm10153224
3. Horne BD, Joy EA, Hofmann MG, et al. Short-term elevation of fine particulate matter air pollution and acute lower respiratory infection. Am J Respir Crit Care Med. 2018;198(6):759-766. https://doi.org/10.1164/rccm.201709-1883oc
4. Wrotek A, Jackowska T. Molecular mechanisms of RSV and air pollution interaction: a scoping review. Int J Mol Sci. 2022;23(20):12704. https://doi.org/10.3390/ijms232012704
5. Kirwa K, Eckert CM, Vedal S, Hajat A, Kaufman JD. Ambient air pollution and risk of respiratory infection among adults: evidence from the multiethnic study of atherosclerosis (MESA). BMJ Open Respir Res. 2021;8(1). https://doi.org/10.1136/bmjresp-2020-000866
6. Melgar M, Britton A, Roper LE, et al. Use of respiratory syncytial virus vaccines in older adults: recommendations of the Advisory Committee on Immunization Practices — United States, 2023. MMWR Morb Mortal Wkly Rep. 2023;72(29):793-801. http://dx.doi.org/10.15585/mmwr.mm7229a4
7. Kodros JK, O’Dell K, Samet JM, L’Orange C, Pierce JR, Volckens J. Quantifying the health benefits of face masks and respirators to mitigate exposure to severe air pollution. GeoHealth. 2021;5(9). https://doi.org/10.1029/2021gh000482
Diffuse Lung Disease and Lung Transplant Network
Occupational and Environmental Health Section
Poor air quality has numerous health hazards for patients with chronic lung disease. Now mounting evidence from pediatric studies suggests a concerning link between air pollution and viral infections, specifically respiratory syncytial virus (RSV).
Multiple studies have shown increased incidence and severity of disease in children with exposure to air pollutants such as particulate matter and nitrogen dioxide.1,2,3 Researchers speculate that these pollutants potentiate viral entry to airway epithelium, increase viral load, and dysregulate the immune response.4 Air pollution, increasingly worsened by climate change, is also associated with acute respiratory infections in adults, though adult research remains sparse.5
The adoption of viral testing during the pandemic has revealed a previously under-recognized prevalence of RSV in adults.
RSV accounts for an estimated 60,000 to 160,000 hospitalizations and 6,000 to 10,000 deaths annually among elderly adults. This newfound awareness coincides with the exciting development of a new RSV vaccine that has shown around 85% efficacy at preventing symptomatic RSV infection in the first year, and new data suggest benefits persisting even into the second year after vaccination.6 With an estimated 60 million adults at high risk for RSV in the US, RSV prevention has become an increasingly important aspect of respiratory care.
While more research is needed to definitively quantify the link between air pollution and RSV in adults, the existing data offer valuable insights for all pulmonologists. These findings suggest a benefit in counseling patients with chronic lung conditions on taking steps to mitigate exposure to air pollutants, either through avoidance of outdoor activities or mask-wearing when air quality levels exceed healthy ranges, as well as promoting RSV vaccination for patients who are at risk.7
References
1. Milani GP, Cafora M, Favero C, et al. PM2.5, PM10 and bronchiolitis severity: a cohort study. Pediatr Allergy Immunol. 2022;33(10). https://doi.org/10.1111/pai.13853
2. Wrotek A, Badyda A, Czechowski PO, Owczarek T, Dąbrowiecki P, Jackowska T. Air pollutants’ concentrations are associated with increased number of RSV hospitalizations in Polish children. J Clin Med. 2021;10(15):3224. https://doi.org/10.3390/jcm10153224
3. Horne BD, Joy EA, Hofmann MG, et al. Short-term elevation of fine particulate matter air pollution and acute lower respiratory infection. Am J Respir Crit Care Med. 2018;198(6):759-766. https://doi.org/10.1164/rccm.201709-1883oc
4. Wrotek A, Jackowska T. Molecular mechanisms of RSV and air pollution interaction: a scoping review. Int J Mol Sci. 2022;23(20):12704. https://doi.org/10.3390/ijms232012704
5. Kirwa K, Eckert CM, Vedal S, Hajat A, Kaufman JD. Ambient air pollution and risk of respiratory infection among adults: evidence from the multiethnic study of atherosclerosis (MESA). BMJ Open Respir Res. 2021;8(1). https://doi.org/10.1136/bmjresp-2020-000866
6. Melgar M, Britton A, Roper LE, et al. Use of respiratory syncytial virus vaccines in older adults: recommendations of the Advisory Committee on Immunization Practices — United States, 2023. MMWR Morb Mortal Wkly Rep. 2023;72(29):793-801. http://dx.doi.org/10.15585/mmwr.mm7229a4
7. Kodros JK, O’Dell K, Samet JM, L’Orange C, Pierce JR, Volckens J. Quantifying the health benefits of face masks and respirators to mitigate exposure to severe air pollution. GeoHealth. 2021;5(9). https://doi.org/10.1029/2021gh000482
Diffuse Lung Disease and Lung Transplant Network
Occupational and Environmental Health Section
Poor air quality has numerous health hazards for patients with chronic lung disease. Now mounting evidence from pediatric studies suggests a concerning link between air pollution and viral infections, specifically respiratory syncytial virus (RSV).
Multiple studies have shown increased incidence and severity of disease in children with exposure to air pollutants such as particulate matter and nitrogen dioxide.1,2,3 Researchers speculate that these pollutants potentiate viral entry to airway epithelium, increase viral load, and dysregulate the immune response.4 Air pollution, increasingly worsened by climate change, is also associated with acute respiratory infections in adults, though adult research remains sparse.5
The adoption of viral testing during the pandemic has revealed a previously under-recognized prevalence of RSV in adults.
RSV accounts for an estimated 60,000 to 160,000 hospitalizations and 6,000 to 10,000 deaths annually among elderly adults. This newfound awareness coincides with the exciting development of a new RSV vaccine that has shown around 85% efficacy at preventing symptomatic RSV infection in the first year, and new data suggest benefits persisting even into the second year after vaccination.6 With an estimated 60 million adults at high risk for RSV in the US, RSV prevention has become an increasingly important aspect of respiratory care.
While more research is needed to definitively quantify the link between air pollution and RSV in adults, the existing data offer valuable insights for all pulmonologists. These findings suggest a benefit in counseling patients with chronic lung conditions on taking steps to mitigate exposure to air pollutants, either through avoidance of outdoor activities or mask-wearing when air quality levels exceed healthy ranges, as well as promoting RSV vaccination for patients who are at risk.7
References
1. Milani GP, Cafora M, Favero C, et al. PM2.5, PM10 and bronchiolitis severity: a cohort study. Pediatr Allergy Immunol. 2022;33(10). https://doi.org/10.1111/pai.13853
2. Wrotek A, Badyda A, Czechowski PO, Owczarek T, Dąbrowiecki P, Jackowska T. Air pollutants’ concentrations are associated with increased number of RSV hospitalizations in Polish children. J Clin Med. 2021;10(15):3224. https://doi.org/10.3390/jcm10153224
3. Horne BD, Joy EA, Hofmann MG, et al. Short-term elevation of fine particulate matter air pollution and acute lower respiratory infection. Am J Respir Crit Care Med. 2018;198(6):759-766. https://doi.org/10.1164/rccm.201709-1883oc
4. Wrotek A, Jackowska T. Molecular mechanisms of RSV and air pollution interaction: a scoping review. Int J Mol Sci. 2022;23(20):12704. https://doi.org/10.3390/ijms232012704
5. Kirwa K, Eckert CM, Vedal S, Hajat A, Kaufman JD. Ambient air pollution and risk of respiratory infection among adults: evidence from the multiethnic study of atherosclerosis (MESA). BMJ Open Respir Res. 2021;8(1). https://doi.org/10.1136/bmjresp-2020-000866
6. Melgar M, Britton A, Roper LE, et al. Use of respiratory syncytial virus vaccines in older adults: recommendations of the Advisory Committee on Immunization Practices — United States, 2023. MMWR Morb Mortal Wkly Rep. 2023;72(29):793-801. http://dx.doi.org/10.15585/mmwr.mm7229a4
7. Kodros JK, O’Dell K, Samet JM, L’Orange C, Pierce JR, Volckens J. Quantifying the health benefits of face masks and respirators to mitigate exposure to severe air pollution. GeoHealth. 2021;5(9). https://doi.org/10.1029/2021gh000482
A word of caution on e-cigarettes: Retracted paper
Editor’s note: On March 29, 2024, the authors of the study, “Efficacy of Electronic Cigarettes vs Varenicline and Nicotine Chewing Gum as an Aid to Stop Smoking: A Randomized Clinical Trial,” published in JAMA Internal Medicine, issued a formal retraction of their article. The CHEST Physician® Editorial Board apologizes for any confusion this may have caused.
An article in the April issue of the CHEST Physician publication headlined, “E-cigarettes beat nicotine gum for smoking cessation,” was based on an article in JAMA Internal Medicine by Liu Z and colleagues which was subsequently retracted by the author due to coding errors and discrepancies in calculations that cast doubt on the accuracy and reliability of the reported findings.
One should be cautious in evaluating claims of the benefits of electronic cigarettes (e-cigarettes). e-Cigarettes are a highly addictive and largely unregulated product. The fine print in previous clinical trials of e-cigarettes shows greater rates of stopping nicotine products—including e-cigarettes—in the groups assigned to recommendation for nicotine replacement therapy. e-Cigarettes have substantial acute and chronic harms.
Although much of the research to date is from animal models, there is a growing body of evidence in humans that validates the findings from the animal models. In laboratory animal models, e-cigarettes impair airway defenses, contribute to epithelial dysfunction, lead to apoptosis of airway cells, cause emphysematous changes, and lead to increased cancer rates.
Adverse effects on cardiovascular health have also been demonstrated. There is evidence of genotoxicity from e-cigarette exposure, with increased rates of DNA damage and decreased rates of DNA repair. Carcinogenic substances are present in e-cigarettes, and we may not see the carcinogenic effects in humans for several years or even decades. Commonly used flavoring chemicals have substantial pulmonary toxicity. There is evidence that the dual use of e-cigarettes and combustible tobacco can be more harmful than the use of combustible tobacco alone, as the person who smokes is now exposed to additional toxins unique to the e-cigarette.
E-cigarettes can cause severe acute lung disease; 14% of the severe e-cigarette or vaping product use-associated lung injury (EVALI) cases reported use of only nicotine-containing e-cigarette products. There are reports of people who used e-cigarettes who required lung transplant due to complications of their e-cigarette use.
The tobacco industry has a long history of “harm reduction” products that were anything but—from filter cigarettes (the “advanced” Kent Micronite filter contained asbestos) to the so-called low tar and nicotine cigarettes (which were no less harmful). There is a long history of physicians endorsing these products as “must be better.” The growing evidence that e-cigarettes carry distinct health risks of their own should prompt us to consider a broader picture beyond just comparing them with traditional cigarettes to assess their impact on health.
Physicians treating tobacco dependence should recommend US Food and Drug Administration-approved medications for pharmacotherapy. These have a robust evidence base documenting that they help people who smoke to break free of nicotine addiction. The goal of tobacco dependence treatment should be stopping ALL harmful tobacco/nicotine products—including e-cigarettes—not simply changing from one harmful product to another.
References
Liu Z. Notice of retraction: Lin HX et al. Efficacy of electronic cigarettes vs varenicline and nicotine chewing gum as an aid to stop smoking: a randomized clinical trial. JAMA Intern Med. 2024;184(3):291-299. JAMA Intern Med. Preprint. Posted online March 29, 2024. PMID: 38551593. doi: 10.1001/jamainternmed.2024.1125
Farber HJ, Conrado Pacheco Gallego M, Galiatsatos P, Folan P, Lamphere T, Pakhale S. Harms of electronic cigarettes: what the healthcare provider needs to know. Ann Am Thorac Soc. 2021;18(4):567-572. PMID: 33284731. doi: 10.1513/AnnalsATS.202009-1113CME
Proctor RN. Golden Holocaust: Origins of the Cigarette Catastrophe and the Case for Abolition. University of California Press; 2011.
Auer R, Schoeni A, Humair JP, et al. Electronic nicotine-delivery systems for smoking cessation. N Engl J Med. 2024;390(7):601-610. PMID: 38354139. doi: 10.1056/NEJMoa2308815
Hajek P, Phillips-Waller A, Przulj D, et al. A randomized trial of e-cigarettes versus nicotine-replacement therapy. N Engl J Med. 2019;380(7):629-637. Preprint. Posted online January 30, 2019. PMID: 30699054. doi: 10.1056/NEJMoa1808779
Editor’s note: On March 29, 2024, the authors of the study, “Efficacy of Electronic Cigarettes vs Varenicline and Nicotine Chewing Gum as an Aid to Stop Smoking: A Randomized Clinical Trial,” published in JAMA Internal Medicine, issued a formal retraction of their article. The CHEST Physician® Editorial Board apologizes for any confusion this may have caused.
An article in the April issue of the CHEST Physician publication headlined, “E-cigarettes beat nicotine gum for smoking cessation,” was based on an article in JAMA Internal Medicine by Liu Z and colleagues which was subsequently retracted by the author due to coding errors and discrepancies in calculations that cast doubt on the accuracy and reliability of the reported findings.
One should be cautious in evaluating claims of the benefits of electronic cigarettes (e-cigarettes). e-Cigarettes are a highly addictive and largely unregulated product. The fine print in previous clinical trials of e-cigarettes shows greater rates of stopping nicotine products—including e-cigarettes—in the groups assigned to recommendation for nicotine replacement therapy. e-Cigarettes have substantial acute and chronic harms.
Although much of the research to date is from animal models, there is a growing body of evidence in humans that validates the findings from the animal models. In laboratory animal models, e-cigarettes impair airway defenses, contribute to epithelial dysfunction, lead to apoptosis of airway cells, cause emphysematous changes, and lead to increased cancer rates.
Adverse effects on cardiovascular health have also been demonstrated. There is evidence of genotoxicity from e-cigarette exposure, with increased rates of DNA damage and decreased rates of DNA repair. Carcinogenic substances are present in e-cigarettes, and we may not see the carcinogenic effects in humans for several years or even decades. Commonly used flavoring chemicals have substantial pulmonary toxicity. There is evidence that the dual use of e-cigarettes and combustible tobacco can be more harmful than the use of combustible tobacco alone, as the person who smokes is now exposed to additional toxins unique to the e-cigarette.
E-cigarettes can cause severe acute lung disease; 14% of the severe e-cigarette or vaping product use-associated lung injury (EVALI) cases reported use of only nicotine-containing e-cigarette products. There are reports of people who used e-cigarettes who required lung transplant due to complications of their e-cigarette use.
The tobacco industry has a long history of “harm reduction” products that were anything but—from filter cigarettes (the “advanced” Kent Micronite filter contained asbestos) to the so-called low tar and nicotine cigarettes (which were no less harmful). There is a long history of physicians endorsing these products as “must be better.” The growing evidence that e-cigarettes carry distinct health risks of their own should prompt us to consider a broader picture beyond just comparing them with traditional cigarettes to assess their impact on health.
Physicians treating tobacco dependence should recommend US Food and Drug Administration-approved medications for pharmacotherapy. These have a robust evidence base documenting that they help people who smoke to break free of nicotine addiction. The goal of tobacco dependence treatment should be stopping ALL harmful tobacco/nicotine products—including e-cigarettes—not simply changing from one harmful product to another.
References
Liu Z. Notice of retraction: Lin HX et al. Efficacy of electronic cigarettes vs varenicline and nicotine chewing gum as an aid to stop smoking: a randomized clinical trial. JAMA Intern Med. 2024;184(3):291-299. JAMA Intern Med. Preprint. Posted online March 29, 2024. PMID: 38551593. doi: 10.1001/jamainternmed.2024.1125
Farber HJ, Conrado Pacheco Gallego M, Galiatsatos P, Folan P, Lamphere T, Pakhale S. Harms of electronic cigarettes: what the healthcare provider needs to know. Ann Am Thorac Soc. 2021;18(4):567-572. PMID: 33284731. doi: 10.1513/AnnalsATS.202009-1113CME
Proctor RN. Golden Holocaust: Origins of the Cigarette Catastrophe and the Case for Abolition. University of California Press; 2011.
Auer R, Schoeni A, Humair JP, et al. Electronic nicotine-delivery systems for smoking cessation. N Engl J Med. 2024;390(7):601-610. PMID: 38354139. doi: 10.1056/NEJMoa2308815
Hajek P, Phillips-Waller A, Przulj D, et al. A randomized trial of e-cigarettes versus nicotine-replacement therapy. N Engl J Med. 2019;380(7):629-637. Preprint. Posted online January 30, 2019. PMID: 30699054. doi: 10.1056/NEJMoa1808779
Editor’s note: On March 29, 2024, the authors of the study, “Efficacy of Electronic Cigarettes vs Varenicline and Nicotine Chewing Gum as an Aid to Stop Smoking: A Randomized Clinical Trial,” published in JAMA Internal Medicine, issued a formal retraction of their article. The CHEST Physician® Editorial Board apologizes for any confusion this may have caused.
An article in the April issue of the CHEST Physician publication headlined, “E-cigarettes beat nicotine gum for smoking cessation,” was based on an article in JAMA Internal Medicine by Liu Z and colleagues which was subsequently retracted by the author due to coding errors and discrepancies in calculations that cast doubt on the accuracy and reliability of the reported findings.
One should be cautious in evaluating claims of the benefits of electronic cigarettes (e-cigarettes). e-Cigarettes are a highly addictive and largely unregulated product. The fine print in previous clinical trials of e-cigarettes shows greater rates of stopping nicotine products—including e-cigarettes—in the groups assigned to recommendation for nicotine replacement therapy. e-Cigarettes have substantial acute and chronic harms.
Although much of the research to date is from animal models, there is a growing body of evidence in humans that validates the findings from the animal models. In laboratory animal models, e-cigarettes impair airway defenses, contribute to epithelial dysfunction, lead to apoptosis of airway cells, cause emphysematous changes, and lead to increased cancer rates.
Adverse effects on cardiovascular health have also been demonstrated. There is evidence of genotoxicity from e-cigarette exposure, with increased rates of DNA damage and decreased rates of DNA repair. Carcinogenic substances are present in e-cigarettes, and we may not see the carcinogenic effects in humans for several years or even decades. Commonly used flavoring chemicals have substantial pulmonary toxicity. There is evidence that the dual use of e-cigarettes and combustible tobacco can be more harmful than the use of combustible tobacco alone, as the person who smokes is now exposed to additional toxins unique to the e-cigarette.
E-cigarettes can cause severe acute lung disease; 14% of the severe e-cigarette or vaping product use-associated lung injury (EVALI) cases reported use of only nicotine-containing e-cigarette products. There are reports of people who used e-cigarettes who required lung transplant due to complications of their e-cigarette use.
The tobacco industry has a long history of “harm reduction” products that were anything but—from filter cigarettes (the “advanced” Kent Micronite filter contained asbestos) to the so-called low tar and nicotine cigarettes (which were no less harmful). There is a long history of physicians endorsing these products as “must be better.” The growing evidence that e-cigarettes carry distinct health risks of their own should prompt us to consider a broader picture beyond just comparing them with traditional cigarettes to assess their impact on health.
Physicians treating tobacco dependence should recommend US Food and Drug Administration-approved medications for pharmacotherapy. These have a robust evidence base documenting that they help people who smoke to break free of nicotine addiction. The goal of tobacco dependence treatment should be stopping ALL harmful tobacco/nicotine products—including e-cigarettes—not simply changing from one harmful product to another.
References
Liu Z. Notice of retraction: Lin HX et al. Efficacy of electronic cigarettes vs varenicline and nicotine chewing gum as an aid to stop smoking: a randomized clinical trial. JAMA Intern Med. 2024;184(3):291-299. JAMA Intern Med. Preprint. Posted online March 29, 2024. PMID: 38551593. doi: 10.1001/jamainternmed.2024.1125
Farber HJ, Conrado Pacheco Gallego M, Galiatsatos P, Folan P, Lamphere T, Pakhale S. Harms of electronic cigarettes: what the healthcare provider needs to know. Ann Am Thorac Soc. 2021;18(4):567-572. PMID: 33284731. doi: 10.1513/AnnalsATS.202009-1113CME
Proctor RN. Golden Holocaust: Origins of the Cigarette Catastrophe and the Case for Abolition. University of California Press; 2011.
Auer R, Schoeni A, Humair JP, et al. Electronic nicotine-delivery systems for smoking cessation. N Engl J Med. 2024;390(7):601-610. PMID: 38354139. doi: 10.1056/NEJMoa2308815
Hajek P, Phillips-Waller A, Przulj D, et al. A randomized trial of e-cigarettes versus nicotine-replacement therapy. N Engl J Med. 2019;380(7):629-637. Preprint. Posted online January 30, 2019. PMID: 30699054. doi: 10.1056/NEJMoa1808779
Fellow to use diversity scholar mentorship to strengthen care in pediatric-to-adult transitions
During residency training at the Rush University Medical Center in Internal Medicine and Pediatrics, Esha Kapania, MD, quickly became interested in the pulmonary pathologies that span the life of a patient, beginning in childhood and lasting into adulthood.
Now in her first year of fellowship at the University of Louisville and as the recipient of the 2024 Medical Educator Scholar Diversity Fellowship from CHEST and the Association of Pulmonary and Critical Care Medicine Program Directors (APCCMPD), Dr. Kapania will utilize the support of the program to explore this space.
“Recent advancements in pediatric pulmonary medicine have prolonged the expected lifespan of many previously fatal diagnoses, and I have realized that, despite these innovations, there remains very little communication between the adult and pediatric subspecialists,” Dr. Kapania said. “There is minimal education on congenital pulmonary pathology in adult medicine and, perhaps equally as important, negligible instruction on the cultural and social changes that patients experience when they transition from pediatric to adult providers.”
In residency, Dr. Kapania witnessed the success of cystic fibrosis (CF) clinics and hopes to leverage that experience to advance transitional care across disease states. Using the guidelines set to transition patients with CF from pediatric to adult care as a model, Dr. Kapania will focus her time on creating a streamlined process for patients living with severe asthma and patients with neuromuscular diseases who are chronically vented.
“Patients who are chronically vented tend not to have a lot of resources dedicated to them and are a resource- and time-heavy population,” Dr. Kapania said. “Because there is no defined process to transition these patients, we tend to see pediatric providers hold on to these patients for a lot longer than they do with [patients with CF]. A set of evidence-based practices would go a long way in this space.”
Through the APCCMPD and CHEST Medical Educator Scholar Diversity Fellowship, Dr. Kapania will work closely with the program’s selected mentor, Başak Çoruh, MD, FCCP, who is an Associate Professor of Pulmonary, Critical Care, and Sleep Medicine and Director of the Pulmonary and Critical Care Medicine fellowship program at the University of Washington.
“I’m looking forward to working with Dr. Çoruh for career guidance and for support of my area of interest within [pulmonary and critical care medicine],” Dr. Kapania said. “She is an established physician who has a lot of insight to share, and this is a great opportunity to make the best of my fellowship.”
This is the first year for the APCCMPD and CHEST Medical Educator Scholar Diversity Fellowship. To learn more about the scholarship, visit the CHEST website.
During residency training at the Rush University Medical Center in Internal Medicine and Pediatrics, Esha Kapania, MD, quickly became interested in the pulmonary pathologies that span the life of a patient, beginning in childhood and lasting into adulthood.
Now in her first year of fellowship at the University of Louisville and as the recipient of the 2024 Medical Educator Scholar Diversity Fellowship from CHEST and the Association of Pulmonary and Critical Care Medicine Program Directors (APCCMPD), Dr. Kapania will utilize the support of the program to explore this space.
“Recent advancements in pediatric pulmonary medicine have prolonged the expected lifespan of many previously fatal diagnoses, and I have realized that, despite these innovations, there remains very little communication between the adult and pediatric subspecialists,” Dr. Kapania said. “There is minimal education on congenital pulmonary pathology in adult medicine and, perhaps equally as important, negligible instruction on the cultural and social changes that patients experience when they transition from pediatric to adult providers.”
In residency, Dr. Kapania witnessed the success of cystic fibrosis (CF) clinics and hopes to leverage that experience to advance transitional care across disease states. Using the guidelines set to transition patients with CF from pediatric to adult care as a model, Dr. Kapania will focus her time on creating a streamlined process for patients living with severe asthma and patients with neuromuscular diseases who are chronically vented.
“Patients who are chronically vented tend not to have a lot of resources dedicated to them and are a resource- and time-heavy population,” Dr. Kapania said. “Because there is no defined process to transition these patients, we tend to see pediatric providers hold on to these patients for a lot longer than they do with [patients with CF]. A set of evidence-based practices would go a long way in this space.”
Through the APCCMPD and CHEST Medical Educator Scholar Diversity Fellowship, Dr. Kapania will work closely with the program’s selected mentor, Başak Çoruh, MD, FCCP, who is an Associate Professor of Pulmonary, Critical Care, and Sleep Medicine and Director of the Pulmonary and Critical Care Medicine fellowship program at the University of Washington.
“I’m looking forward to working with Dr. Çoruh for career guidance and for support of my area of interest within [pulmonary and critical care medicine],” Dr. Kapania said. “She is an established physician who has a lot of insight to share, and this is a great opportunity to make the best of my fellowship.”
This is the first year for the APCCMPD and CHEST Medical Educator Scholar Diversity Fellowship. To learn more about the scholarship, visit the CHEST website.
During residency training at the Rush University Medical Center in Internal Medicine and Pediatrics, Esha Kapania, MD, quickly became interested in the pulmonary pathologies that span the life of a patient, beginning in childhood and lasting into adulthood.
Now in her first year of fellowship at the University of Louisville and as the recipient of the 2024 Medical Educator Scholar Diversity Fellowship from CHEST and the Association of Pulmonary and Critical Care Medicine Program Directors (APCCMPD), Dr. Kapania will utilize the support of the program to explore this space.
“Recent advancements in pediatric pulmonary medicine have prolonged the expected lifespan of many previously fatal diagnoses, and I have realized that, despite these innovations, there remains very little communication between the adult and pediatric subspecialists,” Dr. Kapania said. “There is minimal education on congenital pulmonary pathology in adult medicine and, perhaps equally as important, negligible instruction on the cultural and social changes that patients experience when they transition from pediatric to adult providers.”
In residency, Dr. Kapania witnessed the success of cystic fibrosis (CF) clinics and hopes to leverage that experience to advance transitional care across disease states. Using the guidelines set to transition patients with CF from pediatric to adult care as a model, Dr. Kapania will focus her time on creating a streamlined process for patients living with severe asthma and patients with neuromuscular diseases who are chronically vented.
“Patients who are chronically vented tend not to have a lot of resources dedicated to them and are a resource- and time-heavy population,” Dr. Kapania said. “Because there is no defined process to transition these patients, we tend to see pediatric providers hold on to these patients for a lot longer than they do with [patients with CF]. A set of evidence-based practices would go a long way in this space.”
Through the APCCMPD and CHEST Medical Educator Scholar Diversity Fellowship, Dr. Kapania will work closely with the program’s selected mentor, Başak Çoruh, MD, FCCP, who is an Associate Professor of Pulmonary, Critical Care, and Sleep Medicine and Director of the Pulmonary and Critical Care Medicine fellowship program at the University of Washington.
“I’m looking forward to working with Dr. Çoruh for career guidance and for support of my area of interest within [pulmonary and critical care medicine],” Dr. Kapania said. “She is an established physician who has a lot of insight to share, and this is a great opportunity to make the best of my fellowship.”
This is the first year for the APCCMPD and CHEST Medical Educator Scholar Diversity Fellowship. To learn more about the scholarship, visit the CHEST website.
Transesophageal ultrasound: The future of ultrasound in the ICU
Thoracic Oncology and Chest Procedures Network
Ultrasound and Chest Imaging Section
Historically, transesophageal ultrasound (TEE) has been regarded as a diagnostic and management tool for structural heart disease in relatively stable patients. However, TEE is more commonly being utilized by intensivists as a first-line tool in the diagnostics and management of patients in the ICU.
TEE, with its unobstructed superior cardiac views, facilitates rapid diagnosis in undifferentiated shock and guides appropriate resuscitation efforts. Studies have shown that TEE alters management strategies in 40% of cases, following transthoracic echocardiography with an extremely low complication rate of 2% to 3% (primarily in the form of self-limited gastrointestinal bleeding).1,2,3,4
TEE also provides ultrasonographic evaluation of the lungs through transesophageal lung ultrasound (TELUS). TELUS allows for visualization of all six traditional lung zones utilized in traditional lung ultrasound.5 Patients with severe acute respiratory distress syndrome may greatly benefit from TEE utilization. TEE enables early detection of right ventricular dysfunction, aids in fluid management, and assesses the severity of lung consolidation, thereby facilitating prompt utilization of prone positioning or adjustments in positive end-expiratory pressure.
Cardiac arrest is another unique opportunity for TEE utilization by providing real-time cardiac visualization during active cardiopulmonary resuscitation. This facilitates optimal chest compression positioning, early recognition of arrhythmia, timely identification of reversible cause, and procedural guidance for ECMO-assisted CPR.6 TEE is an invaluable tool for the modern-day intensivist, providing rapid and accurate assessments, and therefore holds the potential to become standard of care in the ICU.
References
1. Prager R, Bowdridge J, Pratte M, Cheng J, McInnes MD, Arntfield R. Indications, clinical impact, and complications of critical care transesophageal echocardiography: a scoping review. J Intensive Care Med. 2023;38(3):245-272. Preprint. Posted online July 19, 2022. PMID: 35854414; PMCID: PMC9806486. doi: 10.1177/08850666221115348
2. Hüttemann E, Schelenz C, Kara F, Chatzinikolaou K, Reinhart K. The use and safety of transoesophageal echocardiography in the general ICU – a minireview. Acta Anaesthesiol Scand. 2004;48(7):827-36. PMID: 15242426. doi: 10.1111/j.0001-5172.2004.00423.x
3. Mayo PH, Narasimhan M, Koenig S. Critical care transesophageal echocardiography. Chest. 2015;148(5):1323-1332. PMID: 26204465. doi: 10.1378/chest.15-0260
4. Prager R, Ainsworth C, Arntfield R. Critical care transesophageal echocardiography for the resuscitation of shock: an important diagnostic skill for the modern intensivist. Chest. 2023;163(2):268-269. PMID: 36759112. doi: 10.1016/j.chest.2022.09.001
5. Cavayas YA, Girard M, Desjardins G, Denault AY. Transesophageal lung ultrasonography: a novel technique for investigating hypoxemia. Can J Anaesth. 2016;63(11):1266-76. Preprint. Posted online July 29, 2016. PMID: 27473720. doi: 10.1007/s12630-016-0702-2
6. Teran F, Prats MI, Nelson BP, et al. Focused transesophageal echocardiography during cardiac arrest resuscitation: JACC review wopic of the Week. J Am Coll Cardiol. 2020;76(6):745-754. PMID: 32762909. doi: 10.1016/j.jacc.2020.05.074
Thoracic Oncology and Chest Procedures Network
Ultrasound and Chest Imaging Section
Historically, transesophageal ultrasound (TEE) has been regarded as a diagnostic and management tool for structural heart disease in relatively stable patients. However, TEE is more commonly being utilized by intensivists as a first-line tool in the diagnostics and management of patients in the ICU.
TEE, with its unobstructed superior cardiac views, facilitates rapid diagnosis in undifferentiated shock and guides appropriate resuscitation efforts. Studies have shown that TEE alters management strategies in 40% of cases, following transthoracic echocardiography with an extremely low complication rate of 2% to 3% (primarily in the form of self-limited gastrointestinal bleeding).1,2,3,4
TEE also provides ultrasonographic evaluation of the lungs through transesophageal lung ultrasound (TELUS). TELUS allows for visualization of all six traditional lung zones utilized in traditional lung ultrasound.5 Patients with severe acute respiratory distress syndrome may greatly benefit from TEE utilization. TEE enables early detection of right ventricular dysfunction, aids in fluid management, and assesses the severity of lung consolidation, thereby facilitating prompt utilization of prone positioning or adjustments in positive end-expiratory pressure.
Cardiac arrest is another unique opportunity for TEE utilization by providing real-time cardiac visualization during active cardiopulmonary resuscitation. This facilitates optimal chest compression positioning, early recognition of arrhythmia, timely identification of reversible cause, and procedural guidance for ECMO-assisted CPR.6 TEE is an invaluable tool for the modern-day intensivist, providing rapid and accurate assessments, and therefore holds the potential to become standard of care in the ICU.
References
1. Prager R, Bowdridge J, Pratte M, Cheng J, McInnes MD, Arntfield R. Indications, clinical impact, and complications of critical care transesophageal echocardiography: a scoping review. J Intensive Care Med. 2023;38(3):245-272. Preprint. Posted online July 19, 2022. PMID: 35854414; PMCID: PMC9806486. doi: 10.1177/08850666221115348
2. Hüttemann E, Schelenz C, Kara F, Chatzinikolaou K, Reinhart K. The use and safety of transoesophageal echocardiography in the general ICU – a minireview. Acta Anaesthesiol Scand. 2004;48(7):827-36. PMID: 15242426. doi: 10.1111/j.0001-5172.2004.00423.x
3. Mayo PH, Narasimhan M, Koenig S. Critical care transesophageal echocardiography. Chest. 2015;148(5):1323-1332. PMID: 26204465. doi: 10.1378/chest.15-0260
4. Prager R, Ainsworth C, Arntfield R. Critical care transesophageal echocardiography for the resuscitation of shock: an important diagnostic skill for the modern intensivist. Chest. 2023;163(2):268-269. PMID: 36759112. doi: 10.1016/j.chest.2022.09.001
5. Cavayas YA, Girard M, Desjardins G, Denault AY. Transesophageal lung ultrasonography: a novel technique for investigating hypoxemia. Can J Anaesth. 2016;63(11):1266-76. Preprint. Posted online July 29, 2016. PMID: 27473720. doi: 10.1007/s12630-016-0702-2
6. Teran F, Prats MI, Nelson BP, et al. Focused transesophageal echocardiography during cardiac arrest resuscitation: JACC review wopic of the Week. J Am Coll Cardiol. 2020;76(6):745-754. PMID: 32762909. doi: 10.1016/j.jacc.2020.05.074
Thoracic Oncology and Chest Procedures Network
Ultrasound and Chest Imaging Section
Historically, transesophageal ultrasound (TEE) has been regarded as a diagnostic and management tool for structural heart disease in relatively stable patients. However, TEE is more commonly being utilized by intensivists as a first-line tool in the diagnostics and management of patients in the ICU.
TEE, with its unobstructed superior cardiac views, facilitates rapid diagnosis in undifferentiated shock and guides appropriate resuscitation efforts. Studies have shown that TEE alters management strategies in 40% of cases, following transthoracic echocardiography with an extremely low complication rate of 2% to 3% (primarily in the form of self-limited gastrointestinal bleeding).1,2,3,4
TEE also provides ultrasonographic evaluation of the lungs through transesophageal lung ultrasound (TELUS). TELUS allows for visualization of all six traditional lung zones utilized in traditional lung ultrasound.5 Patients with severe acute respiratory distress syndrome may greatly benefit from TEE utilization. TEE enables early detection of right ventricular dysfunction, aids in fluid management, and assesses the severity of lung consolidation, thereby facilitating prompt utilization of prone positioning or adjustments in positive end-expiratory pressure.
Cardiac arrest is another unique opportunity for TEE utilization by providing real-time cardiac visualization during active cardiopulmonary resuscitation. This facilitates optimal chest compression positioning, early recognition of arrhythmia, timely identification of reversible cause, and procedural guidance for ECMO-assisted CPR.6 TEE is an invaluable tool for the modern-day intensivist, providing rapid and accurate assessments, and therefore holds the potential to become standard of care in the ICU.
References
1. Prager R, Bowdridge J, Pratte M, Cheng J, McInnes MD, Arntfield R. Indications, clinical impact, and complications of critical care transesophageal echocardiography: a scoping review. J Intensive Care Med. 2023;38(3):245-272. Preprint. Posted online July 19, 2022. PMID: 35854414; PMCID: PMC9806486. doi: 10.1177/08850666221115348
2. Hüttemann E, Schelenz C, Kara F, Chatzinikolaou K, Reinhart K. The use and safety of transoesophageal echocardiography in the general ICU – a minireview. Acta Anaesthesiol Scand. 2004;48(7):827-36. PMID: 15242426. doi: 10.1111/j.0001-5172.2004.00423.x
3. Mayo PH, Narasimhan M, Koenig S. Critical care transesophageal echocardiography. Chest. 2015;148(5):1323-1332. PMID: 26204465. doi: 10.1378/chest.15-0260
4. Prager R, Ainsworth C, Arntfield R. Critical care transesophageal echocardiography for the resuscitation of shock: an important diagnostic skill for the modern intensivist. Chest. 2023;163(2):268-269. PMID: 36759112. doi: 10.1016/j.chest.2022.09.001
5. Cavayas YA, Girard M, Desjardins G, Denault AY. Transesophageal lung ultrasonography: a novel technique for investigating hypoxemia. Can J Anaesth. 2016;63(11):1266-76. Preprint. Posted online July 29, 2016. PMID: 27473720. doi: 10.1007/s12630-016-0702-2
6. Teran F, Prats MI, Nelson BP, et al. Focused transesophageal echocardiography during cardiac arrest resuscitation: JACC review wopic of the Week. J Am Coll Cardiol. 2020;76(6):745-754. PMID: 32762909. doi: 10.1016/j.jacc.2020.05.074
The pendulum swings in favor of corticosteroids
Critical Care Network
Sepsis/Shock Section
The pendulum swings in favor of corticosteroids and endorses the colloquialism among intensivists that no patient shall die without steroids, especially as it relates to sepsis and septic shock.
In 2018, we saw divergence among randomized controlled trials in the use of glucocorticoids for adults with septic shock such that hydrocortisone without the use of fludrocortisone showed no 90-day mortality benefit; however, hydrocortisone with fludrocortisone showed a 90-day mortality benefit.1,2 The Surviving Sepsis Guidelines in 2021 favored using low-dose corticosteroids in those with persistent vasopressor requirements in whom other core interventions had been instituted.
In 2023, a patient-level meta-analysis of low-dose hydrocortisone in adults with septic shock included seven trials and failed to demonstrate a mortality benefit by relative risk in those who received hydrocortisone compared with placebo. Separately, a network meta-analysis with hydrocortisone plus enteral fludrocortisone was associated with a 90-day all-cause mortality. Of the secondary outcomes, these results offered a possible association of hydrocortisone with a decreased risk of ICU mortality and with increased vasopressor-free days.3
The 2024 Society of Critical Care Medicine recently shared an update of focused guidelines on the use of corticosteroids in sepsis, acute respiratory distress syndrome, and community-acquired pneumonia. These included a conditional recommendation to administer corticosteroids for patients with septic shock but recommended against high-dose/short-duration administration of corticosteroids in these patients. These guidelines were supported by data from 46 randomized controlled trials, which showed that corticosteroid use may reduce hospital/long-term mortality and ICU/short-term mortality, as well as result in higher rates of shock reversal and reduced organ dysfunction.
With the results of these meta-analyses and randomized controlled trials, clinicians should consider low-dose corticosteroids paired with fludrocortisone as a tool in treating patients with septic shock given that the short- and long-term benefits may exceed any risks.
References
1. Venkatesh B, et al. Adjunctive glucocorticoid therapy in patients with septic shock. N Engl J Med. 2018;378:797-808.
2. Annane D, et al. Hydrocortisone plus fludrocortisone for adults with septic shock. N Engl J Med. 2018;378:809-818.
3. Pirracchio R, et al. Patient-level meta-analysis of low-dose hydrocortisone in adults with septic shock. NEJM Evid. 2023;2(6).
Critical Care Network
Sepsis/Shock Section
The pendulum swings in favor of corticosteroids and endorses the colloquialism among intensivists that no patient shall die without steroids, especially as it relates to sepsis and septic shock.
In 2018, we saw divergence among randomized controlled trials in the use of glucocorticoids for adults with septic shock such that hydrocortisone without the use of fludrocortisone showed no 90-day mortality benefit; however, hydrocortisone with fludrocortisone showed a 90-day mortality benefit.1,2 The Surviving Sepsis Guidelines in 2021 favored using low-dose corticosteroids in those with persistent vasopressor requirements in whom other core interventions had been instituted.
In 2023, a patient-level meta-analysis of low-dose hydrocortisone in adults with septic shock included seven trials and failed to demonstrate a mortality benefit by relative risk in those who received hydrocortisone compared with placebo. Separately, a network meta-analysis with hydrocortisone plus enteral fludrocortisone was associated with a 90-day all-cause mortality. Of the secondary outcomes, these results offered a possible association of hydrocortisone with a decreased risk of ICU mortality and with increased vasopressor-free days.3
The 2024 Society of Critical Care Medicine recently shared an update of focused guidelines on the use of corticosteroids in sepsis, acute respiratory distress syndrome, and community-acquired pneumonia. These included a conditional recommendation to administer corticosteroids for patients with septic shock but recommended against high-dose/short-duration administration of corticosteroids in these patients. These guidelines were supported by data from 46 randomized controlled trials, which showed that corticosteroid use may reduce hospital/long-term mortality and ICU/short-term mortality, as well as result in higher rates of shock reversal and reduced organ dysfunction.
With the results of these meta-analyses and randomized controlled trials, clinicians should consider low-dose corticosteroids paired with fludrocortisone as a tool in treating patients with septic shock given that the short- and long-term benefits may exceed any risks.
References
1. Venkatesh B, et al. Adjunctive glucocorticoid therapy in patients with septic shock. N Engl J Med. 2018;378:797-808.
2. Annane D, et al. Hydrocortisone plus fludrocortisone for adults with septic shock. N Engl J Med. 2018;378:809-818.
3. Pirracchio R, et al. Patient-level meta-analysis of low-dose hydrocortisone in adults with septic shock. NEJM Evid. 2023;2(6).
Critical Care Network
Sepsis/Shock Section
The pendulum swings in favor of corticosteroids and endorses the colloquialism among intensivists that no patient shall die without steroids, especially as it relates to sepsis and septic shock.
In 2018, we saw divergence among randomized controlled trials in the use of glucocorticoids for adults with septic shock such that hydrocortisone without the use of fludrocortisone showed no 90-day mortality benefit; however, hydrocortisone with fludrocortisone showed a 90-day mortality benefit.1,2 The Surviving Sepsis Guidelines in 2021 favored using low-dose corticosteroids in those with persistent vasopressor requirements in whom other core interventions had been instituted.
In 2023, a patient-level meta-analysis of low-dose hydrocortisone in adults with septic shock included seven trials and failed to demonstrate a mortality benefit by relative risk in those who received hydrocortisone compared with placebo. Separately, a network meta-analysis with hydrocortisone plus enteral fludrocortisone was associated with a 90-day all-cause mortality. Of the secondary outcomes, these results offered a possible association of hydrocortisone with a decreased risk of ICU mortality and with increased vasopressor-free days.3
The 2024 Society of Critical Care Medicine recently shared an update of focused guidelines on the use of corticosteroids in sepsis, acute respiratory distress syndrome, and community-acquired pneumonia. These included a conditional recommendation to administer corticosteroids for patients with septic shock but recommended against high-dose/short-duration administration of corticosteroids in these patients. These guidelines were supported by data from 46 randomized controlled trials, which showed that corticosteroid use may reduce hospital/long-term mortality and ICU/short-term mortality, as well as result in higher rates of shock reversal and reduced organ dysfunction.
With the results of these meta-analyses and randomized controlled trials, clinicians should consider low-dose corticosteroids paired with fludrocortisone as a tool in treating patients with septic shock given that the short- and long-term benefits may exceed any risks.
References
1. Venkatesh B, et al. Adjunctive glucocorticoid therapy in patients with septic shock. N Engl J Med. 2018;378:797-808.
2. Annane D, et al. Hydrocortisone plus fludrocortisone for adults with septic shock. N Engl J Med. 2018;378:809-818.
3. Pirracchio R, et al. Patient-level meta-analysis of low-dose hydrocortisone in adults with septic shock. NEJM Evid. 2023;2(6).
Is it time to embrace a multinight sleep study?
Sleep Medicine Network
Respiratory-Related Sleep Disorders Section
Since the 1960s, sleep researchers have been intrigued by the first-night effect (FNE) in polysomnography (PSG) studies. A meta-analysis by Ding and colleagues revealed FNE’s impact on sleep metrics, like total sleep time and REM sleep, without affecting the apnea-hypopnea index, highlighting PSG’s limitations in simulating natural sleep patterns.1
Lechat and colleagues conducted a study using a home-based sleep analyzer on more than 67,000 individuals, averaging 170 nights each.2 This study found that single-night studies could lead to a 20% misdiagnosis rate in OSA, attributed to overlooking real sleep factors such as body posture, environmental effects, alcohol, and medication. Despite this, the wider use of multinight studies for accurate diagnosis is limited by insurance coverage issues.3
The last decade has seen substantial advances in health technology, particularly in consumer wearables capable of detecting various medical conditions. Devices employing techniques like actigraphy and accelerometry have reached a level of performance comparable with US Food and Drug Administration-approved clinical tools. However, these technologies are still in development for the diagnosis and classification of sleep-disordered breathing.
Tech companies are actively innovating sleep sensing technologies, smartwatches, bed sensors, wireless EEG, radiofrequency, and ultrasound sensors. With significant investments in this sector, these technologies could be ready for widespread use in the next 5 to 10 years. Health care professionals should consider data from sleep-tracking wearables when there are inconsistencies between a patient’s sleep study results and symptoms. The insights from these devices could provide crucial diagnostic information, enhancing the accuracy of sleep disorder diagnoses.
References
1. Ding L, Chen B, Dai Y, Li Y. A meta-analysis of the first-night effect in healthy individuals for the full age spectrum. Sleep Med. 2022;89:159-165. Preprint. Posted online December 17, 2021. PMID: 34998093. doi: 10.1016/j.sleep.2021.12.007
2. Lechat B, Naik G, Reynolds A, et al. Multinight prevalence, variability, and diagnostic misclassification of obstructive sleep apnea. Am J Respir Crit Care Med. 2022;205(5):563-569. PMID: 34904935; PMCID: PMC8906484. doi: 10.1164/rccm.202107-1761OC
3. Abreu A, Punjabi NM. How many nights are really needed to diagnose obstructive sleep apnea? Am J Respir Crit Care Med. 2022;206(1):125-126. PMID: 35476613; PMCID: PMC9954337. doi: 10.1164/rccm.202112-2837LE
Sleep Medicine Network
Respiratory-Related Sleep Disorders Section
Since the 1960s, sleep researchers have been intrigued by the first-night effect (FNE) in polysomnography (PSG) studies. A meta-analysis by Ding and colleagues revealed FNE’s impact on sleep metrics, like total sleep time and REM sleep, without affecting the apnea-hypopnea index, highlighting PSG’s limitations in simulating natural sleep patterns.1
Lechat and colleagues conducted a study using a home-based sleep analyzer on more than 67,000 individuals, averaging 170 nights each.2 This study found that single-night studies could lead to a 20% misdiagnosis rate in OSA, attributed to overlooking real sleep factors such as body posture, environmental effects, alcohol, and medication. Despite this, the wider use of multinight studies for accurate diagnosis is limited by insurance coverage issues.3
The last decade has seen substantial advances in health technology, particularly in consumer wearables capable of detecting various medical conditions. Devices employing techniques like actigraphy and accelerometry have reached a level of performance comparable with US Food and Drug Administration-approved clinical tools. However, these technologies are still in development for the diagnosis and classification of sleep-disordered breathing.
Tech companies are actively innovating sleep sensing technologies, smartwatches, bed sensors, wireless EEG, radiofrequency, and ultrasound sensors. With significant investments in this sector, these technologies could be ready for widespread use in the next 5 to 10 years. Health care professionals should consider data from sleep-tracking wearables when there are inconsistencies between a patient’s sleep study results and symptoms. The insights from these devices could provide crucial diagnostic information, enhancing the accuracy of sleep disorder diagnoses.
References
1. Ding L, Chen B, Dai Y, Li Y. A meta-analysis of the first-night effect in healthy individuals for the full age spectrum. Sleep Med. 2022;89:159-165. Preprint. Posted online December 17, 2021. PMID: 34998093. doi: 10.1016/j.sleep.2021.12.007
2. Lechat B, Naik G, Reynolds A, et al. Multinight prevalence, variability, and diagnostic misclassification of obstructive sleep apnea. Am J Respir Crit Care Med. 2022;205(5):563-569. PMID: 34904935; PMCID: PMC8906484. doi: 10.1164/rccm.202107-1761OC
3. Abreu A, Punjabi NM. How many nights are really needed to diagnose obstructive sleep apnea? Am J Respir Crit Care Med. 2022;206(1):125-126. PMID: 35476613; PMCID: PMC9954337. doi: 10.1164/rccm.202112-2837LE
Sleep Medicine Network
Respiratory-Related Sleep Disorders Section
Since the 1960s, sleep researchers have been intrigued by the first-night effect (FNE) in polysomnography (PSG) studies. A meta-analysis by Ding and colleagues revealed FNE’s impact on sleep metrics, like total sleep time and REM sleep, without affecting the apnea-hypopnea index, highlighting PSG’s limitations in simulating natural sleep patterns.1
Lechat and colleagues conducted a study using a home-based sleep analyzer on more than 67,000 individuals, averaging 170 nights each.2 This study found that single-night studies could lead to a 20% misdiagnosis rate in OSA, attributed to overlooking real sleep factors such as body posture, environmental effects, alcohol, and medication. Despite this, the wider use of multinight studies for accurate diagnosis is limited by insurance coverage issues.3
The last decade has seen substantial advances in health technology, particularly in consumer wearables capable of detecting various medical conditions. Devices employing techniques like actigraphy and accelerometry have reached a level of performance comparable with US Food and Drug Administration-approved clinical tools. However, these technologies are still in development for the diagnosis and classification of sleep-disordered breathing.
Tech companies are actively innovating sleep sensing technologies, smartwatches, bed sensors, wireless EEG, radiofrequency, and ultrasound sensors. With significant investments in this sector, these technologies could be ready for widespread use in the next 5 to 10 years. Health care professionals should consider data from sleep-tracking wearables when there are inconsistencies between a patient’s sleep study results and symptoms. The insights from these devices could provide crucial diagnostic information, enhancing the accuracy of sleep disorder diagnoses.
References
1. Ding L, Chen B, Dai Y, Li Y. A meta-analysis of the first-night effect in healthy individuals for the full age spectrum. Sleep Med. 2022;89:159-165. Preprint. Posted online December 17, 2021. PMID: 34998093. doi: 10.1016/j.sleep.2021.12.007
2. Lechat B, Naik G, Reynolds A, et al. Multinight prevalence, variability, and diagnostic misclassification of obstructive sleep apnea. Am J Respir Crit Care Med. 2022;205(5):563-569. PMID: 34904935; PMCID: PMC8906484. doi: 10.1164/rccm.202107-1761OC
3. Abreu A, Punjabi NM. How many nights are really needed to diagnose obstructive sleep apnea? Am J Respir Crit Care Med. 2022;206(1):125-126. PMID: 35476613; PMCID: PMC9954337. doi: 10.1164/rccm.202112-2837LE