When a patient with cancer hears there isn’t much left that doctors can do, it always stays fresh in the mind.

Doug Olson was first diagnosed with chronic lymphocytic leukemia (CLL) over 20 years ago, in 1996. For several years, his doctors used the watch-and-wait approach. But then his cancer progressed and needed treatment. By 2010, it had mutated so much that it no longer responded to standard therapy.

He was rapidly running out of options. Back then, the only treatment left was a bone marrow transplant. Without one, his doctors said, he would have 1 or 2 years left to live.

“I was really trying to avoid a bone marrow transplant. You’re playing your last card if that doesn’t work. It’s a pretty rough procedure,” Olson told Medscape Medical News.

Looking back, Olson counts himself as lucky – for being in the right place, at the right time, with the right doctor. His oncologist was David Porter, MD, the principal investigator on a trial at the University of Pennsylvania that was investigating a brand new approach to treating cancer: chimeric antigen receptor (CAR) T-cell therapy.

CAR T-cell therapy uses a patient’s own T cells engineered to express a receptor that targets proteins on cancer cells. CAR T cells are considered “living drugs” because they expand inside the body and stick around for years – maybe for a lifetime – to fight the cancer if it tries to come back.

“I was certainly intrigued by the approach. It had worked in mice, and it was the sort of thing that looked like it would work,” Olson recalled.

Science is not a foreign language to Olson. He holds a PhD in medicinal chemistry, spent most of his career in the in vitro diagnostics industry, and currently acts as chief executive officer of Buhlmann Diagnostics Corp.

So he read the clinical protocol for the first in-human trial of CAR T cells and agreed to become patient number two.

Olson’s T cells were harvested, engineered to attack the CD19 antigen found on malignant and normal B lymphocytes, and then were expanded into millions in the lab. After undergoing preconditioning with chemotherapy to minimize rejection and boost the CAR T cells’ expansion inside the body, he received several infusions of the new therapy over the course of 3 days.

Nothing really happened for 2 weeks. Then he developed severe flu-like symptoms – so bad that he was hospitalized.

Ironically, getting sick was a sign that the CAR T cells were working. Olson was experiencing one of the main short-term effects of CAR T-cell therapy: cytokine release syndrome. Symptoms include extremely high fevers and dangerous drops in blood pressure that can potentially cause end-organ damage.

In the early trials of these products, some patients experienced such a severe reaction that they needed intensive care, and some died. With increasing clinical experience, doctors have learned to control the reaction with the use of steroids and interleukein-6 inhibitors such as tocilizumab (Actemra).

Fortunately for Olson, the reaction passed, and he was eventually discharged.

Then the “aha moment” happened. Four weeks after receiving the CAR T cells, Olson found out that he was cancer free.

“It still gives me shivers,” he said. “Dr Porter said, ‘Your bone marrow’s completely free. We just can’t find a cancer cell anywhere.’ “

The remission has lasted, and it is now 10 years later.
 

Balancing long-term risks vs benefits

Long-term data have been accumulating for these novel therapies since Olson’s treatment in 2010. This is particularly important for CAR T-cell therapy, because of its longevity. Because these are living cells and are expected to persist in the body for years, there is great interest in longer-term data, especially the risks for toxicity.

The FDA requires clinical follow-up for at least 15 years for patients treated with CAR T-cell therapy or any other genetically modified cells.

So far, most of the experience with CAR T cells comes from anti-CD19-directed therapy, which has shown “remarkable” remission rates in the 50% to 85% range, said Nirali Shah, MD, head of the hematologic malignancies section of the Pediatric Oncology Branch at the National Cancer Institute (NCI).

The most recent results presented at this year’s annual meeting of the American Society of Clinical Oncology support earlier efficacy data, she noted. In the longest follow-up to date, researchers reported remissions lasting over 9 years in patients with relapsed/refractory B-cell lymphoma or CLL treated with Kite›s axicaptagene cilleucel (Yescarta), one of two anti-CD19-directed CAR T-cell therapies approved by the FDA in 2017 (the other is Novartis’ tisagenlecleucel [Kymriah]).

This study included 43 patients and showed an overall remission rate of 76%. Complete remission was achieved in 54% of patients, and 22% had partial remission.

The other focus is long-term safety. Although some of the long-term adverse effects are known and are manageable, others fall into the theoretical realm. In early May 2020, the NCI held a multidisciplinary virtual conference on CAR T-cell therapy «to encourage collaborative research about the subacute and potentially long-term toxicity profile of these treatments.»

“We know just a little at this point about late- and long-term effects of CAR-T therapy, because we are relatively early in the era of CAR T cells,” said Merav Bar, MD, from the Fred Hutchinson Cancer Research Center in Seattle, Washington.
 

B-cell aplasia and risk for new infections

What is known is that B-cell aplasia represents the most common long-term adverse effect of CAR T-cell therapy. B-cell aplasia results when anti-CD19 CAR-T therapy wipes out healthy B cells as well as the malignant ones responsible for leukemia/lymphoma.

As major players in the immune system, B cells are a key defense against viruses. So B-cell aplasia represents a very specific type of immunosuppression. It is generally less severe than immunosuppression that occurs after organ transplant, which hits the immune system pretty much across the board and carries a much higher risk for infection.

The main concern is what happens when someone with B-cell aplasia encounters a new pathogen, such as SARS-CoV-2.

After infection, B cells generate memory cells, which are not killed off by anti-CD19 therapy and that stick around for life. So a patient such as Olson would still make antibodies that fight infections they experienced before receiving CAR-T therapy, such as childhood chickenpox. But now they are unable to make new memory cells, so these patients receive monthly immunoglobulin infusions to protect against pathogens they have not previously encountered.

Olson takes this in stride and says he isn’t overly worried about COVID-19. He follows the recommended precautions for a man his age. He wears a mask, washes his hands frequently, and tries to maintain social distancing. But he doesn’t stay locked up in his New Hampshire home.

“I took the attitude when I was diagnosed with cancer that I’m going to live my life,” he said. “Quality of life to me is more important than quantity.”
 

Neuropsychiatric toxicity

Another problem is the possibility of neuropsychiatric toxicity. Past studies have reported a wide range of such toxicities associated with CAR T-cell therapy, including seizures and hallucinations. Most have occurred early in the course of treatment and appear to be short-lived and reversible. However, there remain questions about long-term neuropsychiatric problems.

In a long-term study of 40 patients with relapsed/refractory CLL, non-Hodgkin lymphoma, and ALL, nearly half of patients (47.5%, 19/40) self-reported at least one clinically meaningful negative neuropsychiatric outcome (anxiety, depression, or cognitive difficulty) 1 to 5 years after anti-CD19 CAR T-cell therapy. In addition, 37.5% (15/40) self-reported cognitive difficulties.

“Patients with more severe neurotoxicity showed a trend for more cognitive difficulties afterwards,» said Bar, senior author of the study.

However, teasing out the role that CAR T-cell therapy plays in these problems poses a challenge. All of these patients had been heavily pretreated with previous cancer therapy, which has also been associated with neuropsychiatric problems.

“So far, we don’t know what caused it,” Bar said. “Nevertheless, people need to pay attention to neuropsychiatric symptoms in CAR T-cell therapy. It is important to continue to monitor these patients for these issues.”
 

Graft-vs-host disease

Another potential problem is graft-vs-host disease (GVHD). This is not uncommon after hematopoietic stem cell transplants. It develops when the donor T cells view antigens on healthy recipient cells as foreign and attack them.

For patients who are treated with CAR T cells, GVHD is mostly a concern among individuals who have previously had a transplant and who are already at increased risk for it.

In a study of late effects among 86 adults treated with anti-CD19 CAR T cells for relapsed/refractory non-Hodgkin lymphoma, Bar and colleagues found that GVHD occurred only among patients who had received a previous donor stem cell transplant. Of these, 20% (3/15) developed GVHD about 28 months after CAR-T therapy.

“The data for CAR T cells causing GVHD really hasn’t shown that it’s a huge problem, although we have seen it and are continuing to monitor for it,” the NCI’s Shah commented to Medscape Medical News.

Other Long-term Adverse Effects

A range of other long-term adverse effects have been reported with CAR-T therapy, including prolonged cytopenias (reduced mature blood cells), myelodysplasia (bone marrow failure), and second malignancies.

In the study with the longest follow-up to date, 16% (7/43) of patients developed second malignancies, which is comparable to data from Bar’s study in Seattle (15%, 13/86). The researchers in this study consider this rate to be no higher than expected: these patients had already received extensive chemotherapy, which increases the risk for other cancers, they point out.

However, this brings up theoretical concerns about the long-term effects of gene modification. CAR T cells are engineered using retroviruses (mainly lentiviruses), which randomly insert the CAR genes into the host genome. Doing so may cause mutations that could promote cancer. These lentiviruses also carry the theoretical risk of becoming capable of viral replication once inside the body.

To address these concerns, viruses used to engineer CAR T cells go through comprehensive safety testing. After therapy, patients are checked every few months during the first year and annually after that.

So far, there have been no reports of cancers associated with CAR T-cell therapy.

“Any type of cancer is a very theoretical risk,” Bar told Medscape Medical News. «Most likely the malignancies in our study were related to prior treatment that the patients received. None of them had any evidence of replication-competent lentivirus, or any other evidence that the malignancies were related to the CAR T cells.»

Another theoretical concern is the possibility of new-onset autoimmune disease, although, once again, no cases have been reported so far.

“We think of it as a theoretic possibility. Whenever you jack up the immune system, autoimmune disease is a potential risk,” said Carl June, MD, director of the Center for Cellular Immunotherapies at the University of Pennsylvania.

June was the co–principal investigator of the trial in which Olson participated. He is also the inventor on patents for CAR T cells licensed by the University of Pennsylvania to Novartis and Tmunity and is a scientific founder with equity in Tmunity.

Still, autoimmunity could occur, and scientists are looking out for it.

“We are continuing to be vigilant in our monitoring for autoimmune disease,” Shah added. “We’ve been doing CAR T-cell therapy since 2012, and I think we have yet to see true autoimmunity beyond GVHD.”
 

Future directions

In the 10 years since Olson received CAR T-cell therapy, an entire industry has sprung up. Over 100 companies worldwide are now developing CAR T-cell therapies targeting various antigens. These therapies are directed at about 60 different tumor types, including solid tumors. Nearly 200 clinical trials are underway, though most are still in early stages: as of September 2019, only 5% had reached phase 3.

Clinical data show promising results for CAR T-cell therapy directed against CD22 (overexpressed on ALL cells), and BCMA (found on almost all multiple myeloma cells). Yet questions remain as to whether CAR T cells will be as effective if they target antigens other than CD19 or cells other than B lymphocytes. One of the biggest research questions is whether they will be effective against solid tumors.

One research avenue being watched with great interest is the development of universal CAR T cells. So far, such products are at very early stages of development (phase 1 trials), but they are attractive because of the potential advantages they offer over bespoke CAR T cells. Automating the process holds the promise of immediate availability, standardizing production, expanding access, and lowering costs. And because the T cells for this universal product come from healthy donors, they may function better than T cells that have been battered and bruised by past cancer treatments, or even the cancer itself.

However, precisely because they are developed from healthy donor T cells, universal CAR T cells may pose increased risk for GVHD. Scientists are trying to get around this problem by engineering universal CAR T cells that lack the T-cell receptor involved in GVHD.

There are also other concerns. Nature has a penchant for mutation. Engineering CAR T cells without T-cell receptors means the body may no longer detect or reject a universal CAR T cell if it goes rogue. Also, gene insertion in universal CAR-T therapy is targeted rather than random (as in bespoke CAR T cells), which could create off-target effects. Both issues create a theoretical risk of such products inducing an untreatable CAR T-cell therapy–associated cancer.

“The theoretic risk with universal cells is that their safety profile may not be as good for long term,” June commented.
 

Hope for the future

From that first trial in which June and Porter used CAR T cells, two of three patients they treated are still alive 10 years later.

Olson is one of these two, and he still undergoes monitoring every 3 months to check for relapse. So far, none of his tests have shown signs of his cancer returning.

After going into remission, Doug spent the next 6 to 9 months regaining his health and strength.

“I figured if I had this amazing treatment that saved my life, I had an obligation to stay alive,” he said. “I’d better not die of something like a heart attack!”

He took up long distance running and has completed six half marathons. He became involved in the Leukemia and Lymphoma Society, participating in fund-raising and helping newly diagnosed patients. Over the years, he has also given talks for researchers, people with cancer, and healthcare providers.

Doug is now 73. Today, he marvels at how rapidly the CAR-T field has progressed.

“Twenty years ago, if you had cancer, your prospects weren’t nearly as good as these days. In 2010, people still didn’t believe in CAR T-cell therapy,” he said. “My goal always in telling my story is a message of hope.”

This article first appeared on Medscape.com.

When a patient with cancer hears there isn’t much left that doctors can do, it always stays fresh in the mind.

Doug Olson was first diagnosed with chronic lymphocytic leukemia (CLL) over 20 years ago, in 1996. For several years, his doctors used the watch-and-wait approach. But then his cancer progressed and needed treatment. By 2010, it had mutated so much that it no longer responded to standard therapy.

He was rapidly running out of options. Back then, the only treatment left was a bone marrow transplant. Without one, his doctors said, he would have 1 or 2 years left to live.

“I was really trying to avoid a bone marrow transplant. You’re playing your last card if that doesn’t work. It’s a pretty rough procedure,” Olson told Medscape Medical News.

Looking back, Olson counts himself as lucky – for being in the right place, at the right time, with the right doctor. His oncologist was David Porter, MD, the principal investigator on a trial at the University of Pennsylvania that was investigating a brand new approach to treating cancer: chimeric antigen receptor (CAR) T-cell therapy.

CAR T-cell therapy uses a patient’s own T cells engineered to express a receptor that targets proteins on cancer cells. CAR T cells are considered “living drugs” because they expand inside the body and stick around for years – maybe for a lifetime – to fight the cancer if it tries to come back.

“I was certainly intrigued by the approach. It had worked in mice, and it was the sort of thing that looked like it would work,” Olson recalled.

Science is not a foreign language to Olson. He holds a PhD in medicinal chemistry, spent most of his career in the in vitro diagnostics industry, and currently acts as chief executive officer of Buhlmann Diagnostics Corp.

So he read the clinical protocol for the first in-human trial of CAR T cells and agreed to become patient number two.

Olson’s T cells were harvested, engineered to attack the CD19 antigen found on malignant and normal B lymphocytes, and then were expanded into millions in the lab. After undergoing preconditioning with chemotherapy to minimize rejection and boost the CAR T cells’ expansion inside the body, he received several infusions of the new therapy over the course of 3 days.

Nothing really happened for 2 weeks. Then he developed severe flu-like symptoms – so bad that he was hospitalized.

Ironically, getting sick was a sign that the CAR T cells were working. Olson was experiencing one of the main short-term effects of CAR T-cell therapy: cytokine release syndrome. Symptoms include extremely high fevers and dangerous drops in blood pressure that can potentially cause end-organ damage.

In the early trials of these products, some patients experienced such a severe reaction that they needed intensive care, and some died. With increasing clinical experience, doctors have learned to control the reaction with the use of steroids and interleukein-6 inhibitors such as tocilizumab (Actemra).

Fortunately for Olson, the reaction passed, and he was eventually discharged.

Then the “aha moment” happened. Four weeks after receiving the CAR T cells, Olson found out that he was cancer free.

“It still gives me shivers,” he said. “Dr Porter said, ‘Your bone marrow’s completely free. We just can’t find a cancer cell anywhere.’ “

The remission has lasted, and it is now 10 years later.
 

Balancing long-term risks vs benefits

Long-term data have been accumulating for these novel therapies since Olson’s treatment in 2010. This is particularly important for CAR T-cell therapy, because of its longevity. Because these are living cells and are expected to persist in the body for years, there is great interest in longer-term data, especially the risks for toxicity.

The FDA requires clinical follow-up for at least 15 years for patients treated with CAR T-cell therapy or any other genetically modified cells.

So far, most of the experience with CAR T cells comes from anti-CD19-directed therapy, which has shown “remarkable” remission rates in the 50% to 85% range, said Nirali Shah, MD, head of the hematologic malignancies section of the Pediatric Oncology Branch at the National Cancer Institute (NCI).

The most recent results presented at this year’s annual meeting of the American Society of Clinical Oncology support earlier efficacy data, she noted. In the longest follow-up to date, researchers reported remissions lasting over 9 years in patients with relapsed/refractory B-cell lymphoma or CLL treated with Kite›s axicaptagene cilleucel (Yescarta), one of two anti-CD19-directed CAR T-cell therapies approved by the FDA in 2017 (the other is Novartis’ tisagenlecleucel [Kymriah]).

This study included 43 patients and showed an overall remission rate of 76%. Complete remission was achieved in 54% of patients, and 22% had partial remission.

The other focus is long-term safety. Although some of the long-term adverse effects are known and are manageable, others fall into the theoretical realm. In early May 2020, the NCI held a multidisciplinary virtual conference on CAR T-cell therapy «to encourage collaborative research about the subacute and potentially long-term toxicity profile of these treatments.»

“We know just a little at this point about late- and long-term effects of CAR-T therapy, because we are relatively early in the era of CAR T cells,” said Merav Bar, MD, from the Fred Hutchinson Cancer Research Center in Seattle, Washington.
 

B-cell aplasia and risk for new infections

What is known is that B-cell aplasia represents the most common long-term adverse effect of CAR T-cell therapy. B-cell aplasia results when anti-CD19 CAR-T therapy wipes out healthy B cells as well as the malignant ones responsible for leukemia/lymphoma.

As major players in the immune system, B cells are a key defense against viruses. So B-cell aplasia represents a very specific type of immunosuppression. It is generally less severe than immunosuppression that occurs after organ transplant, which hits the immune system pretty much across the board and carries a much higher risk for infection.

The main concern is what happens when someone with B-cell aplasia encounters a new pathogen, such as SARS-CoV-2.

After infection, B cells generate memory cells, which are not killed off by anti-CD19 therapy and that stick around for life. So a patient such as Olson would still make antibodies that fight infections they experienced before receiving CAR-T therapy, such as childhood chickenpox. But now they are unable to make new memory cells, so these patients receive monthly immunoglobulin infusions to protect against pathogens they have not previously encountered.

Olson takes this in stride and says he isn’t overly worried about COVID-19. He follows the recommended precautions for a man his age. He wears a mask, washes his hands frequently, and tries to maintain social distancing. But he doesn’t stay locked up in his New Hampshire home.

“I took the attitude when I was diagnosed with cancer that I’m going to live my life,” he said. “Quality of life to me is more important than quantity.”
 

Neuropsychiatric toxicity

Another problem is the possibility of neuropsychiatric toxicity. Past studies have reported a wide range of such toxicities associated with CAR T-cell therapy, including seizures and hallucinations. Most have occurred early in the course of treatment and appear to be short-lived and reversible. However, there remain questions about long-term neuropsychiatric problems.

In a long-term study of 40 patients with relapsed/refractory CLL, non-Hodgkin lymphoma, and ALL, nearly half of patients (47.5%, 19/40) self-reported at least one clinically meaningful negative neuropsychiatric outcome (anxiety, depression, or cognitive difficulty) 1 to 5 years after anti-CD19 CAR T-cell therapy. In addition, 37.5% (15/40) self-reported cognitive difficulties.

“Patients with more severe neurotoxicity showed a trend for more cognitive difficulties afterwards,» said Bar, senior author of the study.

However, teasing out the role that CAR T-cell therapy plays in these problems poses a challenge. All of these patients had been heavily pretreated with previous cancer therapy, which has also been associated with neuropsychiatric problems.

“So far, we don’t know what caused it,” Bar said. “Nevertheless, people need to pay attention to neuropsychiatric symptoms in CAR T-cell therapy. It is important to continue to monitor these patients for these issues.”
 

Graft-vs-host disease

Another potential problem is graft-vs-host disease (GVHD). This is not uncommon after hematopoietic stem cell transplants. It develops when the donor T cells view antigens on healthy recipient cells as foreign and attack them.

For patients who are treated with CAR T cells, GVHD is mostly a concern among individuals who have previously had a transplant and who are already at increased risk for it.

In a study of late effects among 86 adults treated with anti-CD19 CAR T cells for relapsed/refractory non-Hodgkin lymphoma, Bar and colleagues found that GVHD occurred only among patients who had received a previous donor stem cell transplant. Of these, 20% (3/15) developed GVHD about 28 months after CAR-T therapy.

“The data for CAR T cells causing GVHD really hasn’t shown that it’s a huge problem, although we have seen it and are continuing to monitor for it,” the NCI’s Shah commented to Medscape Medical News.

Other Long-term Adverse Effects

A range of other long-term adverse effects have been reported with CAR-T therapy, including prolonged cytopenias (reduced mature blood cells), myelodysplasia (bone marrow failure), and second malignancies.

In the study with the longest follow-up to date, 16% (7/43) of patients developed second malignancies, which is comparable to data from Bar’s study in Seattle (15%, 13/86). The researchers in this study consider this rate to be no higher than expected: these patients had already received extensive chemotherapy, which increases the risk for other cancers, they point out.

However, this brings up theoretical concerns about the long-term effects of gene modification. CAR T cells are engineered using retroviruses (mainly lentiviruses), which randomly insert the CAR genes into the host genome. Doing so may cause mutations that could promote cancer. These lentiviruses also carry the theoretical risk of becoming capable of viral replication once inside the body.

To address these concerns, viruses used to engineer CAR T cells go through comprehensive safety testing. After therapy, patients are checked every few months during the first year and annually after that.

So far, there have been no reports of cancers associated with CAR T-cell therapy.

“Any type of cancer is a very theoretical risk,” Bar told Medscape Medical News. «Most likely the malignancies in our study were related to prior treatment that the patients received. None of them had any evidence of replication-competent lentivirus, or any other evidence that the malignancies were related to the CAR T cells.»

Another theoretical concern is the possibility of new-onset autoimmune disease, although, once again, no cases have been reported so far.

“We think of it as a theoretic possibility. Whenever you jack up the immune system, autoimmune disease is a potential risk,” said Carl June, MD, director of the Center for Cellular Immunotherapies at the University of Pennsylvania.

June was the co–principal investigator of the trial in which Olson participated. He is also the inventor on patents for CAR T cells licensed by the University of Pennsylvania to Novartis and Tmunity and is a scientific founder with equity in Tmunity.

Still, autoimmunity could occur, and scientists are looking out for it.

“We are continuing to be vigilant in our monitoring for autoimmune disease,” Shah added. “We’ve been doing CAR T-cell therapy since 2012, and I think we have yet to see true autoimmunity beyond GVHD.”
 

Future directions

In the 10 years since Olson received CAR T-cell therapy, an entire industry has sprung up. Over 100 companies worldwide are now developing CAR T-cell therapies targeting various antigens. These therapies are directed at about 60 different tumor types, including solid tumors. Nearly 200 clinical trials are underway, though most are still in early stages: as of September 2019, only 5% had reached phase 3.

Clinical data show promising results for CAR T-cell therapy directed against CD22 (overexpressed on ALL cells), and BCMA (found on almost all multiple myeloma cells). Yet questions remain as to whether CAR T cells will be as effective if they target antigens other than CD19 or cells other than B lymphocytes. One of the biggest research questions is whether they will be effective against solid tumors.

One research avenue being watched with great interest is the development of universal CAR T cells. So far, such products are at very early stages of development (phase 1 trials), but they are attractive because of the potential advantages they offer over bespoke CAR T cells. Automating the process holds the promise of immediate availability, standardizing production, expanding access, and lowering costs. And because the T cells for this universal product come from healthy donors, they may function better than T cells that have been battered and bruised by past cancer treatments, or even the cancer itself.

However, precisely because they are developed from healthy donor T cells, universal CAR T cells may pose increased risk for GVHD. Scientists are trying to get around this problem by engineering universal CAR T cells that lack the T-cell receptor involved in GVHD.

There are also other concerns. Nature has a penchant for mutation. Engineering CAR T cells without T-cell receptors means the body may no longer detect or reject a universal CAR T cell if it goes rogue. Also, gene insertion in universal CAR-T therapy is targeted rather than random (as in bespoke CAR T cells), which could create off-target effects. Both issues create a theoretical risk of such products inducing an untreatable CAR T-cell therapy–associated cancer.

“The theoretic risk with universal cells is that their safety profile may not be as good for long term,” June commented.
 

Hope for the future

From that first trial in which June and Porter used CAR T cells, two of three patients they treated are still alive 10 years later.

Olson is one of these two, and he still undergoes monitoring every 3 months to check for relapse. So far, none of his tests have shown signs of his cancer returning.

After going into remission, Doug spent the next 6 to 9 months regaining his health and strength.

“I figured if I had this amazing treatment that saved my life, I had an obligation to stay alive,” he said. “I’d better not die of something like a heart attack!”

He took up long distance running and has completed six half marathons. He became involved in the Leukemia and Lymphoma Society, participating in fund-raising and helping newly diagnosed patients. Over the years, he has also given talks for researchers, people with cancer, and healthcare providers.

Doug is now 73. Today, he marvels at how rapidly the CAR-T field has progressed.

“Twenty years ago, if you had cancer, your prospects weren’t nearly as good as these days. In 2010, people still didn’t believe in CAR T-cell therapy,” he said. “My goal always in telling my story is a message of hope.”

This article first appeared on Medscape.com.

When a patient with cancer hears there isn’t much left that doctors can do, it always stays fresh in the mind.

Doug Olson was first diagnosed with chronic lymphocytic leukemia (CLL) over 20 years ago, in 1996. For several years, his doctors used the watch-and-wait approach. But then his cancer progressed and needed treatment. By 2010, it had mutated so much that it no longer responded to standard therapy.

He was rapidly running out of options. Back then, the only treatment left was a bone marrow transplant. Without one, his doctors said, he would have 1 or 2 years left to live.

“I was really trying to avoid a bone marrow transplant. You’re playing your last card if that doesn’t work. It’s a pretty rough procedure,” Olson told Medscape Medical News.

Looking back, Olson counts himself as lucky – for being in the right place, at the right time, with the right doctor. His oncologist was David Porter, MD, the principal investigator on a trial at the University of Pennsylvania that was investigating a brand new approach to treating cancer: chimeric antigen receptor (CAR) T-cell therapy.

CAR T-cell therapy uses a patient’s own T cells engineered to express a receptor that targets proteins on cancer cells. CAR T cells are considered “living drugs” because they expand inside the body and stick around for years – maybe for a lifetime – to fight the cancer if it tries to come back.

“I was certainly intrigued by the approach. It had worked in mice, and it was the sort of thing that looked like it would work,” Olson recalled.

Science is not a foreign language to Olson. He holds a PhD in medicinal chemistry, spent most of his career in the in vitro diagnostics industry, and currently acts as chief executive officer of Buhlmann Diagnostics Corp.

So he read the clinical protocol for the first in-human trial of CAR T cells and agreed to become patient number two.

Olson’s T cells were harvested, engineered to attack the CD19 antigen found on malignant and normal B lymphocytes, and then were expanded into millions in the lab. After undergoing preconditioning with chemotherapy to minimize rejection and boost the CAR T cells’ expansion inside the body, he received several infusions of the new therapy over the course of 3 days.

Nothing really happened for 2 weeks. Then he developed severe flu-like symptoms – so bad that he was hospitalized.

Ironically, getting sick was a sign that the CAR T cells were working. Olson was experiencing one of the main short-term effects of CAR T-cell therapy: cytokine release syndrome. Symptoms include extremely high fevers and dangerous drops in blood pressure that can potentially cause end-organ damage.

In the early trials of these products, some patients experienced such a severe reaction that they needed intensive care, and some died. With increasing clinical experience, doctors have learned to control the reaction with the use of steroids and interleukein-6 inhibitors such as tocilizumab (Actemra).

Fortunately for Olson, the reaction passed, and he was eventually discharged.

Then the “aha moment” happened. Four weeks after receiving the CAR T cells, Olson found out that he was cancer free.

“It still gives me shivers,” he said. “Dr Porter said, ‘Your bone marrow’s completely free. We just can’t find a cancer cell anywhere.’ “

The remission has lasted, and it is now 10 years later.
 

Balancing long-term risks vs benefits

Long-term data have been accumulating for these novel therapies since Olson’s treatment in 2010. This is particularly important for CAR T-cell therapy, because of its longevity. Because these are living cells and are expected to persist in the body for years, there is great interest in longer-term data, especially the risks for toxicity.

The FDA requires clinical follow-up for at least 15 years for patients treated with CAR T-cell therapy or any other genetically modified cells.

So far, most of the experience with CAR T cells comes from anti-CD19-directed therapy, which has shown “remarkable” remission rates in the 50% to 85% range, said Nirali Shah, MD, head of the hematologic malignancies section of the Pediatric Oncology Branch at the National Cancer Institute (NCI).

The most recent results presented at this year’s annual meeting of the American Society of Clinical Oncology support earlier efficacy data, she noted. In the longest follow-up to date, researchers reported remissions lasting over 9 years in patients with relapsed/refractory B-cell lymphoma or CLL treated with Kite›s axicaptagene cilleucel (Yescarta), one of two anti-CD19-directed CAR T-cell therapies approved by the FDA in 2017 (the other is Novartis’ tisagenlecleucel [Kymriah]).

This study included 43 patients and showed an overall remission rate of 76%. Complete remission was achieved in 54% of patients, and 22% had partial remission.

The other focus is long-term safety. Although some of the long-term adverse effects are known and are manageable, others fall into the theoretical realm. In early May 2020, the NCI held a multidisciplinary virtual conference on CAR T-cell therapy «to encourage collaborative research about the subacute and potentially long-term toxicity profile of these treatments.»

“We know just a little at this point about late- and long-term effects of CAR-T therapy, because we are relatively early in the era of CAR T cells,” said Merav Bar, MD, from the Fred Hutchinson Cancer Research Center in Seattle, Washington.
 

B-cell aplasia and risk for new infections

What is known is that B-cell aplasia represents the most common long-term adverse effect of CAR T-cell therapy. B-cell aplasia results when anti-CD19 CAR-T therapy wipes out healthy B cells as well as the malignant ones responsible for leukemia/lymphoma.

As major players in the immune system, B cells are a key defense against viruses. So B-cell aplasia represents a very specific type of immunosuppression. It is generally less severe than immunosuppression that occurs after organ transplant, which hits the immune system pretty much across the board and carries a much higher risk for infection.

The main concern is what happens when someone with B-cell aplasia encounters a new pathogen, such as SARS-CoV-2.

After infection, B cells generate memory cells, which are not killed off by anti-CD19 therapy and that stick around for life. So a patient such as Olson would still make antibodies that fight infections they experienced before receiving CAR-T therapy, such as childhood chickenpox. But now they are unable to make new memory cells, so these patients receive monthly immunoglobulin infusions to protect against pathogens they have not previously encountered.

Olson takes this in stride and says he isn’t overly worried about COVID-19. He follows the recommended precautions for a man his age. He wears a mask, washes his hands frequently, and tries to maintain social distancing. But he doesn’t stay locked up in his New Hampshire home.

“I took the attitude when I was diagnosed with cancer that I’m going to live my life,” he said. “Quality of life to me is more important than quantity.”
 

Neuropsychiatric toxicity

Another problem is the possibility of neuropsychiatric toxicity. Past studies have reported a wide range of such toxicities associated with CAR T-cell therapy, including seizures and hallucinations. Most have occurred early in the course of treatment and appear to be short-lived and reversible. However, there remain questions about long-term neuropsychiatric problems.

In a long-term study of 40 patients with relapsed/refractory CLL, non-Hodgkin lymphoma, and ALL, nearly half of patients (47.5%, 19/40) self-reported at least one clinically meaningful negative neuropsychiatric outcome (anxiety, depression, or cognitive difficulty) 1 to 5 years after anti-CD19 CAR T-cell therapy. In addition, 37.5% (15/40) self-reported cognitive difficulties.

“Patients with more severe neurotoxicity showed a trend for more cognitive difficulties afterwards,» said Bar, senior author of the study.

However, teasing out the role that CAR T-cell therapy plays in these problems poses a challenge. All of these patients had been heavily pretreated with previous cancer therapy, which has also been associated with neuropsychiatric problems.

“So far, we don’t know what caused it,” Bar said. “Nevertheless, people need to pay attention to neuropsychiatric symptoms in CAR T-cell therapy. It is important to continue to monitor these patients for these issues.”
 

Graft-vs-host disease

Another potential problem is graft-vs-host disease (GVHD). This is not uncommon after hematopoietic stem cell transplants. It develops when the donor T cells view antigens on healthy recipient cells as foreign and attack them.

For patients who are treated with CAR T cells, GVHD is mostly a concern among individuals who have previously had a transplant and who are already at increased risk for it.

In a study of late effects among 86 adults treated with anti-CD19 CAR T cells for relapsed/refractory non-Hodgkin lymphoma, Bar and colleagues found that GVHD occurred only among patients who had received a previous donor stem cell transplant. Of these, 20% (3/15) developed GVHD about 28 months after CAR-T therapy.

“The data for CAR T cells causing GVHD really hasn’t shown that it’s a huge problem, although we have seen it and are continuing to monitor for it,” the NCI’s Shah commented to Medscape Medical News.

Other Long-term Adverse Effects

A range of other long-term adverse effects have been reported with CAR-T therapy, including prolonged cytopenias (reduced mature blood cells), myelodysplasia (bone marrow failure), and second malignancies.

In the study with the longest follow-up to date, 16% (7/43) of patients developed second malignancies, which is comparable to data from Bar’s study in Seattle (15%, 13/86). The researchers in this study consider this rate to be no higher than expected: these patients had already received extensive chemotherapy, which increases the risk for other cancers, they point out.

However, this brings up theoretical concerns about the long-term effects of gene modification. CAR T cells are engineered using retroviruses (mainly lentiviruses), which randomly insert the CAR genes into the host genome. Doing so may cause mutations that could promote cancer. These lentiviruses also carry the theoretical risk of becoming capable of viral replication once inside the body.

To address these concerns, viruses used to engineer CAR T cells go through comprehensive safety testing. After therapy, patients are checked every few months during the first year and annually after that.

So far, there have been no reports of cancers associated with CAR T-cell therapy.

“Any type of cancer is a very theoretical risk,” Bar told Medscape Medical News. «Most likely the malignancies in our study were related to prior treatment that the patients received. None of them had any evidence of replication-competent lentivirus, or any other evidence that the malignancies were related to the CAR T cells.»

Another theoretical concern is the possibility of new-onset autoimmune disease, although, once again, no cases have been reported so far.

“We think of it as a theoretic possibility. Whenever you jack up the immune system, autoimmune disease is a potential risk,” said Carl June, MD, director of the Center for Cellular Immunotherapies at the University of Pennsylvania.

June was the co–principal investigator of the trial in which Olson participated. He is also the inventor on patents for CAR T cells licensed by the University of Pennsylvania to Novartis and Tmunity and is a scientific founder with equity in Tmunity.

Still, autoimmunity could occur, and scientists are looking out for it.

“We are continuing to be vigilant in our monitoring for autoimmune disease,” Shah added. “We’ve been doing CAR T-cell therapy since 2012, and I think we have yet to see true autoimmunity beyond GVHD.”
 

Future directions

In the 10 years since Olson received CAR T-cell therapy, an entire industry has sprung up. Over 100 companies worldwide are now developing CAR T-cell therapies targeting various antigens. These therapies are directed at about 60 different tumor types, including solid tumors. Nearly 200 clinical trials are underway, though most are still in early stages: as of September 2019, only 5% had reached phase 3.

Clinical data show promising results for CAR T-cell therapy directed against CD22 (overexpressed on ALL cells), and BCMA (found on almost all multiple myeloma cells). Yet questions remain as to whether CAR T cells will be as effective if they target antigens other than CD19 or cells other than B lymphocytes. One of the biggest research questions is whether they will be effective against solid tumors.

One research avenue being watched with great interest is the development of universal CAR T cells. So far, such products are at very early stages of development (phase 1 trials), but they are attractive because of the potential advantages they offer over bespoke CAR T cells. Automating the process holds the promise of immediate availability, standardizing production, expanding access, and lowering costs. And because the T cells for this universal product come from healthy donors, they may function better than T cells that have been battered and bruised by past cancer treatments, or even the cancer itself.

However, precisely because they are developed from healthy donor T cells, universal CAR T cells may pose increased risk for GVHD. Scientists are trying to get around this problem by engineering universal CAR T cells that lack the T-cell receptor involved in GVHD.

There are also other concerns. Nature has a penchant for mutation. Engineering CAR T cells without T-cell receptors means the body may no longer detect or reject a universal CAR T cell if it goes rogue. Also, gene insertion in universal CAR-T therapy is targeted rather than random (as in bespoke CAR T cells), which could create off-target effects. Both issues create a theoretical risk of such products inducing an untreatable CAR T-cell therapy–associated cancer.

“The theoretic risk with universal cells is that their safety profile may not be as good for long term,” June commented.
 

Hope for the future

From that first trial in which June and Porter used CAR T cells, two of three patients they treated are still alive 10 years later.

Olson is one of these two, and he still undergoes monitoring every 3 months to check for relapse. So far, none of his tests have shown signs of his cancer returning.

After going into remission, Doug spent the next 6 to 9 months regaining his health and strength.

“I figured if I had this amazing treatment that saved my life, I had an obligation to stay alive,” he said. “I’d better not die of something like a heart attack!”

He took up long distance running and has completed six half marathons. He became involved in the Leukemia and Lymphoma Society, participating in fund-raising and helping newly diagnosed patients. Over the years, he has also given talks for researchers, people with cancer, and healthcare providers.

Doug is now 73. Today, he marvels at how rapidly the CAR-T field has progressed.

“Twenty years ago, if you had cancer, your prospects weren’t nearly as good as these days. In 2010, people still didn’t believe in CAR T-cell therapy,” he said. “My goal always in telling my story is a message of hope.”

This article first appeared on Medscape.com.

As SARS-CoV-2 cases surged in New York this past spring, one hospital system met the growing demand for palliative care in COVID-19 patients in acute care and emergency settings by training and redeploying psychiatry trainees, producing 100 consultations during a crisis period. Developers of this program wrote about their experience in the Journal of Pain and Symptom Management.

Research shows that psychiatrists can play an important, complementary role in palliative care, but not many models have explored this in practice. Over a 45-day period in March and April, New York Presbyterian/Columbia University Irving Medical Center saw an influx of 7,600 COVID-19 patients. Many were critically ill, and palliative care needs skyrocketed. Initial efforts to install a palliative care team at the emergency department and a proactive consultation model in the step-down units failed to meet demand for consults.

COVID-19 patients present unique challenges. Their clinical trajectory is less clear than those with cancer or other illnesses, Daniel Shalev, MD, a fellow in hospice and palliative medicine at Columbia University/New York State Psychiatric Institute, New York, and the study’s first author, said in an interview. “Ethical and systems issues around distribution of scarce resources may inflect patients’ and physicians’ responses,” Dr. Shalev said. “And families may not be able to be at the bedside with patients.”

To rapidly expand the palliative care workforce and meet patient needs, Dr. Shalev and colleagues recruited 16 psychiatry trainees from NYP, Columbia University Irving Medical Center, and Weill Cornell Medicine to work at NYP/Columbia University Irving Medical Center’s section of adult palliative medicine. Senior general psychiatry residents, child and adolescent psychiatry fellows, addiction psychiatry fellows, and postresidency T32 research fellows became part of a psychiatry-palliative care liaison team, offering psychosocial support and care goal strategies to patients and families.

Already well-versed in serious illness communication and psychosocial aspects of medical illness, the residents and fellows received additional training and education about SARS-CoV-2 and goals-of-care conversations. Child and adolescent psychiatry fellows participated in a communication workshop about the virus at Weill Cornell Medicine.

Working closely with the medical center’s palliative care service, the liaison team did consults around the clock at the ED under the supervision of a consultation-liaison (C-L) psychiatrist specializing in primary palliative care skills. The team managed 16 cases a day during the peak of New York’s COVID-19 outbreak, operating on a rotating schedule of one to three shifts weekly. Some shifts took place remotely to reduce exposure to the virus.

“We were fortunate that New York Presbyterian was early and aggressive in ensuring all clinical staff had personal protective equipment” in the treatment of COVID-19 patients, Dr. Shalev said.

The C-L psychiatry coordinator served as a traffic controller of sorts, overseeing daily staffing changes, maintaining a psychiatry–palliative care liaison team–shared patient list, and ensuring follow-up and continuity on patient care. The rotating schedule freed up time for trainees to meet other research and outpatient obligations.

The liaison team held a meeting each morning and accompanied the adult palliative care service on its daily virtual rounds to help streamline case management and care coordination among the various palliative care channels. Modifications in personnel took place as cases started to recede. Overall, the team participated in 100 consultations.

The findings show that there is significant overlap in psychiatry and palliative care skill sets, Dr. Shalev said. “Furthermore, many patients benefiting from palliative care services have mental health needs. But there are gaps between psychiatry and palliative care, including a lack of collaboration and cross-training. Our model showed how easily our disciplines can work together to improve the care available to all patients,” he added.

Some things could have gone more smoothly. Working under the duress of a pandemic, project leaders didn’t have enough time to train and supervise the team about advanced symptom management. Psychiatry staff members also weren’t as comfortable with nonpsychiatric symptom management as serious illness communication and psychiatric symptom management. Dr. Shalev expects these growth areas to improve over time.

The model could easily translate to other facilities, he believes. “Psychiatrists and other mental health professionals have foundational communication skills that can be adapted to serious illness care and palliative care.” As of this writing, the liaison team was transitioning to a longer-term assignment involving patients on mechanical ventilation and their families.

The program increased access to care during a time of limited resources,and successfully combined psychiatric and palliative services – two specialties that, at times, can have conflicting recommendations, noted Maria I. Lapid, MD, a professor of psychiatry at the Mayo Clinic in Rochester, Minn., and a faculty member of the Mayo Clinic Center for Palliative Medicine, who was not part of the study. As urgent training for psychiatric trainees proved useful in the current crisis, long-term psychiatric programs will need to explore and consider how to integrate palliative care training into the psychiatric curriculum.

“Not only is this relevant in the current pandemic, but this will continue to be relevant in the context of the rapidly aging population” in the United States, said Dr. Lapid.

Dr. Shalev and colleagues declared no conflicts of interest in their study. Their research received no funds or grants from public, commercial, or nonprofit agencies.

SOURCE: Shalev D et al. J Pain Symptom Manage. 2020 Jun 13. doi.org/10.1016/j.jpainsymman.2020.06.009.

As SARS-CoV-2 cases surged in New York this past spring, one hospital system met the growing demand for palliative care in COVID-19 patients in acute care and emergency settings by training and redeploying psychiatry trainees, producing 100 consultations during a crisis period. Developers of this program wrote about their experience in the Journal of Pain and Symptom Management.

Research shows that psychiatrists can play an important, complementary role in palliative care, but not many models have explored this in practice. Over a 45-day period in March and April, New York Presbyterian/Columbia University Irving Medical Center saw an influx of 7,600 COVID-19 patients. Many were critically ill, and palliative care needs skyrocketed. Initial efforts to install a palliative care team at the emergency department and a proactive consultation model in the step-down units failed to meet demand for consults.

COVID-19 patients present unique challenges. Their clinical trajectory is less clear than those with cancer or other illnesses, Daniel Shalev, MD, a fellow in hospice and palliative medicine at Columbia University/New York State Psychiatric Institute, New York, and the study’s first author, said in an interview. “Ethical and systems issues around distribution of scarce resources may inflect patients’ and physicians’ responses,” Dr. Shalev said. “And families may not be able to be at the bedside with patients.”

To rapidly expand the palliative care workforce and meet patient needs, Dr. Shalev and colleagues recruited 16 psychiatry trainees from NYP, Columbia University Irving Medical Center, and Weill Cornell Medicine to work at NYP/Columbia University Irving Medical Center’s section of adult palliative medicine. Senior general psychiatry residents, child and adolescent psychiatry fellows, addiction psychiatry fellows, and postresidency T32 research fellows became part of a psychiatry-palliative care liaison team, offering psychosocial support and care goal strategies to patients and families.

Already well-versed in serious illness communication and psychosocial aspects of medical illness, the residents and fellows received additional training and education about SARS-CoV-2 and goals-of-care conversations. Child and adolescent psychiatry fellows participated in a communication workshop about the virus at Weill Cornell Medicine.

Working closely with the medical center’s palliative care service, the liaison team did consults around the clock at the ED under the supervision of a consultation-liaison (C-L) psychiatrist specializing in primary palliative care skills. The team managed 16 cases a day during the peak of New York’s COVID-19 outbreak, operating on a rotating schedule of one to three shifts weekly. Some shifts took place remotely to reduce exposure to the virus.

“We were fortunate that New York Presbyterian was early and aggressive in ensuring all clinical staff had personal protective equipment” in the treatment of COVID-19 patients, Dr. Shalev said.

The C-L psychiatry coordinator served as a traffic controller of sorts, overseeing daily staffing changes, maintaining a psychiatry–palliative care liaison team–shared patient list, and ensuring follow-up and continuity on patient care. The rotating schedule freed up time for trainees to meet other research and outpatient obligations.

The liaison team held a meeting each morning and accompanied the adult palliative care service on its daily virtual rounds to help streamline case management and care coordination among the various palliative care channels. Modifications in personnel took place as cases started to recede. Overall, the team participated in 100 consultations.

The findings show that there is significant overlap in psychiatry and palliative care skill sets, Dr. Shalev said. “Furthermore, many patients benefiting from palliative care services have mental health needs. But there are gaps between psychiatry and palliative care, including a lack of collaboration and cross-training. Our model showed how easily our disciplines can work together to improve the care available to all patients,” he added.

Some things could have gone more smoothly. Working under the duress of a pandemic, project leaders didn’t have enough time to train and supervise the team about advanced symptom management. Psychiatry staff members also weren’t as comfortable with nonpsychiatric symptom management as serious illness communication and psychiatric symptom management. Dr. Shalev expects these growth areas to improve over time.

The model could easily translate to other facilities, he believes. “Psychiatrists and other mental health professionals have foundational communication skills that can be adapted to serious illness care and palliative care.” As of this writing, the liaison team was transitioning to a longer-term assignment involving patients on mechanical ventilation and their families.

The program increased access to care during a time of limited resources,and successfully combined psychiatric and palliative services – two specialties that, at times, can have conflicting recommendations, noted Maria I. Lapid, MD, a professor of psychiatry at the Mayo Clinic in Rochester, Minn., and a faculty member of the Mayo Clinic Center for Palliative Medicine, who was not part of the study. As urgent training for psychiatric trainees proved useful in the current crisis, long-term psychiatric programs will need to explore and consider how to integrate palliative care training into the psychiatric curriculum.

“Not only is this relevant in the current pandemic, but this will continue to be relevant in the context of the rapidly aging population” in the United States, said Dr. Lapid.

Dr. Shalev and colleagues declared no conflicts of interest in their study. Their research received no funds or grants from public, commercial, or nonprofit agencies.

SOURCE: Shalev D et al. J Pain Symptom Manage. 2020 Jun 13. doi.org/10.1016/j.jpainsymman.2020.06.009.

As SARS-CoV-2 cases surged in New York this past spring, one hospital system met the growing demand for palliative care in COVID-19 patients in acute care and emergency settings by training and redeploying psychiatry trainees, producing 100 consultations during a crisis period. Developers of this program wrote about their experience in the Journal of Pain and Symptom Management.

Research shows that psychiatrists can play an important, complementary role in palliative care, but not many models have explored this in practice. Over a 45-day period in March and April, New York Presbyterian/Columbia University Irving Medical Center saw an influx of 7,600 COVID-19 patients. Many were critically ill, and palliative care needs skyrocketed. Initial efforts to install a palliative care team at the emergency department and a proactive consultation model in the step-down units failed to meet demand for consults.

COVID-19 patients present unique challenges. Their clinical trajectory is less clear than those with cancer or other illnesses, Daniel Shalev, MD, a fellow in hospice and palliative medicine at Columbia University/New York State Psychiatric Institute, New York, and the study’s first author, said in an interview. “Ethical and systems issues around distribution of scarce resources may inflect patients’ and physicians’ responses,” Dr. Shalev said. “And families may not be able to be at the bedside with patients.”

To rapidly expand the palliative care workforce and meet patient needs, Dr. Shalev and colleagues recruited 16 psychiatry trainees from NYP, Columbia University Irving Medical Center, and Weill Cornell Medicine to work at NYP/Columbia University Irving Medical Center’s section of adult palliative medicine. Senior general psychiatry residents, child and adolescent psychiatry fellows, addiction psychiatry fellows, and postresidency T32 research fellows became part of a psychiatry-palliative care liaison team, offering psychosocial support and care goal strategies to patients and families.

Already well-versed in serious illness communication and psychosocial aspects of medical illness, the residents and fellows received additional training and education about SARS-CoV-2 and goals-of-care conversations. Child and adolescent psychiatry fellows participated in a communication workshop about the virus at Weill Cornell Medicine.

Working closely with the medical center’s palliative care service, the liaison team did consults around the clock at the ED under the supervision of a consultation-liaison (C-L) psychiatrist specializing in primary palliative care skills. The team managed 16 cases a day during the peak of New York’s COVID-19 outbreak, operating on a rotating schedule of one to three shifts weekly. Some shifts took place remotely to reduce exposure to the virus.

“We were fortunate that New York Presbyterian was early and aggressive in ensuring all clinical staff had personal protective equipment” in the treatment of COVID-19 patients, Dr. Shalev said.

The C-L psychiatry coordinator served as a traffic controller of sorts, overseeing daily staffing changes, maintaining a psychiatry–palliative care liaison team–shared patient list, and ensuring follow-up and continuity on patient care. The rotating schedule freed up time for trainees to meet other research and outpatient obligations.

The liaison team held a meeting each morning and accompanied the adult palliative care service on its daily virtual rounds to help streamline case management and care coordination among the various palliative care channels. Modifications in personnel took place as cases started to recede. Overall, the team participated in 100 consultations.

The findings show that there is significant overlap in psychiatry and palliative care skill sets, Dr. Shalev said. “Furthermore, many patients benefiting from palliative care services have mental health needs. But there are gaps between psychiatry and palliative care, including a lack of collaboration and cross-training. Our model showed how easily our disciplines can work together to improve the care available to all patients,” he added.

Some things could have gone more smoothly. Working under the duress of a pandemic, project leaders didn’t have enough time to train and supervise the team about advanced symptom management. Psychiatry staff members also weren’t as comfortable with nonpsychiatric symptom management as serious illness communication and psychiatric symptom management. Dr. Shalev expects these growth areas to improve over time.

The model could easily translate to other facilities, he believes. “Psychiatrists and other mental health professionals have foundational communication skills that can be adapted to serious illness care and palliative care.” As of this writing, the liaison team was transitioning to a longer-term assignment involving patients on mechanical ventilation and their families.

The program increased access to care during a time of limited resources,and successfully combined psychiatric and palliative services – two specialties that, at times, can have conflicting recommendations, noted Maria I. Lapid, MD, a professor of psychiatry at the Mayo Clinic in Rochester, Minn., and a faculty member of the Mayo Clinic Center for Palliative Medicine, who was not part of the study. As urgent training for psychiatric trainees proved useful in the current crisis, long-term psychiatric programs will need to explore and consider how to integrate palliative care training into the psychiatric curriculum.

“Not only is this relevant in the current pandemic, but this will continue to be relevant in the context of the rapidly aging population” in the United States, said Dr. Lapid.

Dr. Shalev and colleagues declared no conflicts of interest in their study. Their research received no funds or grants from public, commercial, or nonprofit agencies.

SOURCE: Shalev D et al. J Pain Symptom Manage. 2020 Jun 13. doi.org/10.1016/j.jpainsymman.2020.06.009.

A 90-year-old man was admitted from the Emergency Department (ED) to our inpatient service for difficulty urinating and hematuria. In the ED, a complete blood count (CBC) with differential and a urinalysis were performed. CBC showed a mild normocytic anemia, consistent with the patient’s known chronic kidney disease. The urinalysis revealed moderate blood, trace ketones, proteinuria, small leukocyte esterases, positive nitrites, and more than 182 red blood cells—findings suspicious for a urinary tract infection. Computed tomography of the abdomen and pelvis was notable for a soft-tissue mass in the bladder.

He had a history of coronary artery disease (treated with stent placement), atrial fibrillation, congestive heart failure, hypothyroidism, gastroesophageal reflux disease, gastrointestinal bleeding, chronic obstructive pulmonary disease, a 60-pack-per-year history of tobacco dependence, chronic kidney disease, prostate cancer, benign prostatic hypertrophy, peripheral vascular disease, and gout. Medications included digoxin, metoprolol, torsemide, aspirin, levothyroxine, fluticasone, albuterol, omeprazole, diclofenac, escitalopram, and minocycline.

About 5 years earlier, doctors had discovered a popliteal thrombosis that required emergent thrombectomy of the infragenicular popliteal artery, thromboembolectomy of the right posterior tibial artery, graft angioplasty of the right posterior tibial artery, and right anterior fasciotomy for compartment syndrome.

Ten months later, an abscess formed at the incision site. His physician irrigated the popliteal wound and prescribed intravenous (IV) vancomycin. However, the patient developed an allergy and IV daptomycin was initiated and followed by chronic antibiotic suppression with oral minocycline 100 mg bid for about 3.5 years. Skin discoloration appeared within a year of starting the minocycline.

During his hospitalization on our service, we noted black pigmentation of both legs (FIGURE). He had intact strength and sensation in his legs, 1+ pitting edema, no pain upon palpation, and 2+ distal pulses. The patient was well appearing and in no acute distress.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

 

 

Diagnosis: Minocycline-induced hyperpigmentation

The patient’s clinical presentation of chronic blue-black hyperpigmentation on the anterior shins of both legs after a prolonged antibiotic course led us to conclude that this was an adverse effect of minocycline. Commonly, doctors use minocycline to treat acne, rosacea, and rheumatoid arthritis. In this case, it was used to provide chronic antimicrobial suppression.

Not an uncommon reaction for a patient like ours. One small study conducted in an orthopedic patient population found that 54% of patients receiving long-term minocycline suppression developed hyperpigmentation after a mean follow-up of nearly 5 years.¹ The hyperpigmentation is solely cosmetic and without known clinical complications, but it can be distressing for patients.

There are 3 types of minocycline-­induced hyperpigmentation:

• Type I is a circumscribed blue-black pigmentation that manifests in skin that previously was inflamed or scarred, such as facial acne scars.² Histopathologic findings include black pigment granules in macrophages and throughout the dermis that stain with Perls Prussian blue iron.³
• Type II (which our patient had) is circumscribed blue-black pigmentation that appears in previously normal skin of the forearms or lower legs—especially the shins.³ On histopathology, black pigment granules are found in the dermis with macrophages that stain with Perls Prussian blue iron and Fontana-Masson.³
• Type III is a diffuse muddy brown hyperpigmentation in previously normal, sun-exposed skin.² Histopathologic findings include increased melanin in basal keratinocytes and dermal melanophages that stain with Fontana-Masson.³

Monitor patients taking minocycline for early signs of pigmentation.

Types II and III may be related to cumulative dosing, whereas type I can occur at any point during treatment.²

Differential includes pigmentation disorders

The differential diagnosis includes Addison disease, argyria, hemochromatosis, and polycythemia vera, which all can cause diffuse blue-gray patches.⁴ Brown-violet pigmentation on sun-exposed areas, redness, and itching are more typical of Riehl melanosis.⁴

Continue to: Diltiazem

Diltiazem can produce slate-gray to blue-gray reticulated hyperpigmentation.⁵ Other drugs that can induce slate-gray macules or patches include amiodarone, chlorpromazine, imipramine, and desipramine.⁵

Treatment is simple, resolution takes time

The treatment for this condition is cessation of minocycline use. Pigmentation fades slowly and may persist for years. There has been successful treatment of type I and III minocycline-induced hyperpigmentation with the alexandrite 755 nm Q-switched laser combined with fractional photothermolysis.^3,6 Unfortunately, insurance coverage is limited because these treatments are cosmetic in nature.

Given that hyperpigmentation is a known adverse effect of minocycline use, it’s important to counsel patients about the possibility prior to initiating treatment. It’s also important to monitor for signs of changing pigmentation to prevent psychological distress.

In this case, a biopsy was deemed unnecessary, as the antibiotic was the most likely cause of the pigmentation. The patient’s outpatient dermatologist recommended changing therapy if a medically appropriate alternative was available. Doxycycline would have been a reasonable alternative; however, the patient died shortly after his presentation to our hospital due to his multiple comorbidities.

CORRESPONDENCE
Bich-May Nguyen, MD, MPH, 14023 Southwest Freeway, Sugar Land, TX 77478; Bich-May.Nguyen@memorialhermann.org

A 90-year-old man was admitted from the Emergency Department (ED) to our inpatient service for difficulty urinating and hematuria. In the ED, a complete blood count (CBC) with differential and a urinalysis were performed. CBC showed a mild normocytic anemia, consistent with the patient’s known chronic kidney disease. The urinalysis revealed moderate blood, trace ketones, proteinuria, small leukocyte esterases, positive nitrites, and more than 182 red blood cells—findings suspicious for a urinary tract infection. Computed tomography of the abdomen and pelvis was notable for a soft-tissue mass in the bladder.

He had a history of coronary artery disease (treated with stent placement), atrial fibrillation, congestive heart failure, hypothyroidism, gastroesophageal reflux disease, gastrointestinal bleeding, chronic obstructive pulmonary disease, a 60-pack-per-year history of tobacco dependence, chronic kidney disease, prostate cancer, benign prostatic hypertrophy, peripheral vascular disease, and gout. Medications included digoxin, metoprolol, torsemide, aspirin, levothyroxine, fluticasone, albuterol, omeprazole, diclofenac, escitalopram, and minocycline.

About 5 years earlier, doctors had discovered a popliteal thrombosis that required emergent thrombectomy of the infragenicular popliteal artery, thromboembolectomy of the right posterior tibial artery, graft angioplasty of the right posterior tibial artery, and right anterior fasciotomy for compartment syndrome.

Ten months later, an abscess formed at the incision site. His physician irrigated the popliteal wound and prescribed intravenous (IV) vancomycin. However, the patient developed an allergy and IV daptomycin was initiated and followed by chronic antibiotic suppression with oral minocycline 100 mg bid for about 3.5 years. Skin discoloration appeared within a year of starting the minocycline.

During his hospitalization on our service, we noted black pigmentation of both legs (FIGURE). He had intact strength and sensation in his legs, 1+ pitting edema, no pain upon palpation, and 2+ distal pulses. The patient was well appearing and in no acute distress.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

 

 

Diagnosis: Minocycline-induced hyperpigmentation

The patient’s clinical presentation of chronic blue-black hyperpigmentation on the anterior shins of both legs after a prolonged antibiotic course led us to conclude that this was an adverse effect of minocycline. Commonly, doctors use minocycline to treat acne, rosacea, and rheumatoid arthritis. In this case, it was used to provide chronic antimicrobial suppression.

Not an uncommon reaction for a patient like ours. One small study conducted in an orthopedic patient population found that 54% of patients receiving long-term minocycline suppression developed hyperpigmentation after a mean follow-up of nearly 5 years.¹ The hyperpigmentation is solely cosmetic and without known clinical complications, but it can be distressing for patients.

There are 3 types of minocycline-­induced hyperpigmentation:

• Type I is a circumscribed blue-black pigmentation that manifests in skin that previously was inflamed or scarred, such as facial acne scars.² Histopathologic findings include black pigment granules in macrophages and throughout the dermis that stain with Perls Prussian blue iron.³
• Type II (which our patient had) is circumscribed blue-black pigmentation that appears in previously normal skin of the forearms or lower legs—especially the shins.³ On histopathology, black pigment granules are found in the dermis with macrophages that stain with Perls Prussian blue iron and Fontana-Masson.³
• Type III is a diffuse muddy brown hyperpigmentation in previously normal, sun-exposed skin.² Histopathologic findings include increased melanin in basal keratinocytes and dermal melanophages that stain with Fontana-Masson.³

Monitor patients taking minocycline for early signs of pigmentation.

Types II and III may be related to cumulative dosing, whereas type I can occur at any point during treatment.²

Differential includes pigmentation disorders

The differential diagnosis includes Addison disease, argyria, hemochromatosis, and polycythemia vera, which all can cause diffuse blue-gray patches.⁴ Brown-violet pigmentation on sun-exposed areas, redness, and itching are more typical of Riehl melanosis.⁴

Continue to: Diltiazem

Diltiazem can produce slate-gray to blue-gray reticulated hyperpigmentation.⁵ Other drugs that can induce slate-gray macules or patches include amiodarone, chlorpromazine, imipramine, and desipramine.⁵

Treatment is simple, resolution takes time

The treatment for this condition is cessation of minocycline use. Pigmentation fades slowly and may persist for years. There has been successful treatment of type I and III minocycline-induced hyperpigmentation with the alexandrite 755 nm Q-switched laser combined with fractional photothermolysis.^3,6 Unfortunately, insurance coverage is limited because these treatments are cosmetic in nature.

Given that hyperpigmentation is a known adverse effect of minocycline use, it’s important to counsel patients about the possibility prior to initiating treatment. It’s also important to monitor for signs of changing pigmentation to prevent psychological distress.

In this case, a biopsy was deemed unnecessary, as the antibiotic was the most likely cause of the pigmentation. The patient’s outpatient dermatologist recommended changing therapy if a medically appropriate alternative was available. Doxycycline would have been a reasonable alternative; however, the patient died shortly after his presentation to our hospital due to his multiple comorbidities.

CORRESPONDENCE
Bich-May Nguyen, MD, MPH, 14023 Southwest Freeway, Sugar Land, TX 77478; Bich-May.Nguyen@memorialhermann.org

A 90-year-old man was admitted from the Emergency Department (ED) to our inpatient service for difficulty urinating and hematuria. In the ED, a complete blood count (CBC) with differential and a urinalysis were performed. CBC showed a mild normocytic anemia, consistent with the patient’s known chronic kidney disease. The urinalysis revealed moderate blood, trace ketones, proteinuria, small leukocyte esterases, positive nitrites, and more than 182 red blood cells—findings suspicious for a urinary tract infection. Computed tomography of the abdomen and pelvis was notable for a soft-tissue mass in the bladder.

He had a history of coronary artery disease (treated with stent placement), atrial fibrillation, congestive heart failure, hypothyroidism, gastroesophageal reflux disease, gastrointestinal bleeding, chronic obstructive pulmonary disease, a 60-pack-per-year history of tobacco dependence, chronic kidney disease, prostate cancer, benign prostatic hypertrophy, peripheral vascular disease, and gout. Medications included digoxin, metoprolol, torsemide, aspirin, levothyroxine, fluticasone, albuterol, omeprazole, diclofenac, escitalopram, and minocycline.

About 5 years earlier, doctors had discovered a popliteal thrombosis that required emergent thrombectomy of the infragenicular popliteal artery, thromboembolectomy of the right posterior tibial artery, graft angioplasty of the right posterior tibial artery, and right anterior fasciotomy for compartment syndrome.

Ten months later, an abscess formed at the incision site. His physician irrigated the popliteal wound and prescribed intravenous (IV) vancomycin. However, the patient developed an allergy and IV daptomycin was initiated and followed by chronic antibiotic suppression with oral minocycline 100 mg bid for about 3.5 years. Skin discoloration appeared within a year of starting the minocycline.

During his hospitalization on our service, we noted black pigmentation of both legs (FIGURE). He had intact strength and sensation in his legs, 1+ pitting edema, no pain upon palpation, and 2+ distal pulses. The patient was well appearing and in no acute distress.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

 

 

Diagnosis: Minocycline-induced hyperpigmentation

The patient’s clinical presentation of chronic blue-black hyperpigmentation on the anterior shins of both legs after a prolonged antibiotic course led us to conclude that this was an adverse effect of minocycline. Commonly, doctors use minocycline to treat acne, rosacea, and rheumatoid arthritis. In this case, it was used to provide chronic antimicrobial suppression.

Not an uncommon reaction for a patient like ours. One small study conducted in an orthopedic patient population found that 54% of patients receiving long-term minocycline suppression developed hyperpigmentation after a mean follow-up of nearly 5 years.¹ The hyperpigmentation is solely cosmetic and without known clinical complications, but it can be distressing for patients.

There are 3 types of minocycline-­induced hyperpigmentation:

• Type I is a circumscribed blue-black pigmentation that manifests in skin that previously was inflamed or scarred, such as facial acne scars.² Histopathologic findings include black pigment granules in macrophages and throughout the dermis that stain with Perls Prussian blue iron.³
• Type II (which our patient had) is circumscribed blue-black pigmentation that appears in previously normal skin of the forearms or lower legs—especially the shins.³ On histopathology, black pigment granules are found in the dermis with macrophages that stain with Perls Prussian blue iron and Fontana-Masson.³
• Type III is a diffuse muddy brown hyperpigmentation in previously normal, sun-exposed skin.² Histopathologic findings include increased melanin in basal keratinocytes and dermal melanophages that stain with Fontana-Masson.³

Monitor patients taking minocycline for early signs of pigmentation.

Types II and III may be related to cumulative dosing, whereas type I can occur at any point during treatment.²

Differential includes pigmentation disorders

The differential diagnosis includes Addison disease, argyria, hemochromatosis, and polycythemia vera, which all can cause diffuse blue-gray patches.⁴ Brown-violet pigmentation on sun-exposed areas, redness, and itching are more typical of Riehl melanosis.⁴

Continue to: Diltiazem

Diltiazem can produce slate-gray to blue-gray reticulated hyperpigmentation.⁵ Other drugs that can induce slate-gray macules or patches include amiodarone, chlorpromazine, imipramine, and desipramine.⁵

Treatment is simple, resolution takes time

The treatment for this condition is cessation of minocycline use. Pigmentation fades slowly and may persist for years. There has been successful treatment of type I and III minocycline-induced hyperpigmentation with the alexandrite 755 nm Q-switched laser combined with fractional photothermolysis.^3,6 Unfortunately, insurance coverage is limited because these treatments are cosmetic in nature.

Given that hyperpigmentation is a known adverse effect of minocycline use, it’s important to counsel patients about the possibility prior to initiating treatment. It’s also important to monitor for signs of changing pigmentation to prevent psychological distress.

In this case, a biopsy was deemed unnecessary, as the antibiotic was the most likely cause of the pigmentation. The patient’s outpatient dermatologist recommended changing therapy if a medically appropriate alternative was available. Doxycycline would have been a reasonable alternative; however, the patient died shortly after his presentation to our hospital due to his multiple comorbidities.

CORRESPONDENCE
Bich-May Nguyen, MD, MPH, 14023 Southwest Freeway, Sugar Land, TX 77478; Bich-May.Nguyen@memorialhermann.org

After careful consideration, CHEST has decided to cancel the live, in-person CHEST Annual Meeting in Chicago, Illinois, this October and replace it with a 100% virtual event. The COVID-19 pandemic has provided the opportunity to look at different approaches for delivering education, and over the past several months, CHEST has done just that.

Due to the pandemic, we moved the CHEST Congress 2020, originally scheduled to take place in Bologna, Italy, to June 2021. On June 30, in partnership with the Italian Delegation, the CHEST Virtual Congress event took place with over 3,200 people registered, spanning over 100 countries. This event featured a robust program that included an international COVID panel, additional educational sessions, over 300 recorded poster presentations, and live, interactive games that kept attendees engaged throughout the day. There was also a surprise welcome message delivered by Dr. Anthony Fauci, the Director of the National Institute of Allergy and Infectious Diseases. We are excited to use the success of this virtual event as an opportunity to expand our knowledge and expertise, and deliver a fun, memorable CHEST 2020.

This October, CHEST will bring you the premier virtual education event in pulmonary, critical care, and sleep medicine, all from the comfort and safety of your home or institution. This year’s virtual Annual Meeting will include live, interactive education, including panel and case-based discussions, virtual networking opportunities, CHEST GAMES, and the space for you to connect, learn, and recharge with your peers…virtually.

Top faculty from across the field will bring you the latest in clinical developments related to the diagnosis, treatment, and management of pulmonary diseases, critical care complications, and sleep disorders. Nonclinical topics, like cultural diversity and burnout, that feature more prominently than ever in day-to-day practice, will be given equal weight. Sessions like, Being Me: Understanding ‘Otherness’ and Issues of Diversity, will rely on audience interaction to address scenarios involving bias and racism faced by the panel of presenters and members of the audience.

Crucial and quickly evolving information on COVID-19 will be front and center, including complications with COVID-19 recovery, COVID-19 management in complex situations, and additional discussions on updated drug trials, treatment plans, and practice management changes. We will focus on other challenges the pandemic has highlighted, helping educators with sessions such as APCCMPD: Education Lessons During a Pandemic and sharing key reminders to all on the fundamentals of pandemic preparation with When the Theoretical Becomes Real: Lessons from a Pandemic.

It is more important than ever to stay up to date on developments in health and medicine, but CHEST is putting equal weight on ensuring the experience of CHEST 2020 is a respite from the mental and physical exhaustion our community is experiencing during these unprecedented times. As ever, we will ensure you meet your educational needs. But together, we will also focus on supporting you in building resilience and giving you the tools to continue to find joy in medicine, even amidst the chaos of a pandemic. Thank you for your continued trust in CHEST, and we look forward to “seeing” you at CHEST 2020 October 18-21!

After careful consideration, CHEST has decided to cancel the live, in-person CHEST Annual Meeting in Chicago, Illinois, this October and replace it with a 100% virtual event. The COVID-19 pandemic has provided the opportunity to look at different approaches for delivering education, and over the past several months, CHEST has done just that.

Due to the pandemic, we moved the CHEST Congress 2020, originally scheduled to take place in Bologna, Italy, to June 2021. On June 30, in partnership with the Italian Delegation, the CHEST Virtual Congress event took place with over 3,200 people registered, spanning over 100 countries. This event featured a robust program that included an international COVID panel, additional educational sessions, over 300 recorded poster presentations, and live, interactive games that kept attendees engaged throughout the day. There was also a surprise welcome message delivered by Dr. Anthony Fauci, the Director of the National Institute of Allergy and Infectious Diseases. We are excited to use the success of this virtual event as an opportunity to expand our knowledge and expertise, and deliver a fun, memorable CHEST 2020.

This October, CHEST will bring you the premier virtual education event in pulmonary, critical care, and sleep medicine, all from the comfort and safety of your home or institution. This year’s virtual Annual Meeting will include live, interactive education, including panel and case-based discussions, virtual networking opportunities, CHEST GAMES, and the space for you to connect, learn, and recharge with your peers…virtually.

Top faculty from across the field will bring you the latest in clinical developments related to the diagnosis, treatment, and management of pulmonary diseases, critical care complications, and sleep disorders. Nonclinical topics, like cultural diversity and burnout, that feature more prominently than ever in day-to-day practice, will be given equal weight. Sessions like, Being Me: Understanding ‘Otherness’ and Issues of Diversity, will rely on audience interaction to address scenarios involving bias and racism faced by the panel of presenters and members of the audience.

Crucial and quickly evolving information on COVID-19 will be front and center, including complications with COVID-19 recovery, COVID-19 management in complex situations, and additional discussions on updated drug trials, treatment plans, and practice management changes. We will focus on other challenges the pandemic has highlighted, helping educators with sessions such as APCCMPD: Education Lessons During a Pandemic and sharing key reminders to all on the fundamentals of pandemic preparation with When the Theoretical Becomes Real: Lessons from a Pandemic.

It is more important than ever to stay up to date on developments in health and medicine, but CHEST is putting equal weight on ensuring the experience of CHEST 2020 is a respite from the mental and physical exhaustion our community is experiencing during these unprecedented times. As ever, we will ensure you meet your educational needs. But together, we will also focus on supporting you in building resilience and giving you the tools to continue to find joy in medicine, even amidst the chaos of a pandemic. Thank you for your continued trust in CHEST, and we look forward to “seeing” you at CHEST 2020 October 18-21!

After careful consideration, CHEST has decided to cancel the live, in-person CHEST Annual Meeting in Chicago, Illinois, this October and replace it with a 100% virtual event. The COVID-19 pandemic has provided the opportunity to look at different approaches for delivering education, and over the past several months, CHEST has done just that.

Due to the pandemic, we moved the CHEST Congress 2020, originally scheduled to take place in Bologna, Italy, to June 2021. On June 30, in partnership with the Italian Delegation, the CHEST Virtual Congress event took place with over 3,200 people registered, spanning over 100 countries. This event featured a robust program that included an international COVID panel, additional educational sessions, over 300 recorded poster presentations, and live, interactive games that kept attendees engaged throughout the day. There was also a surprise welcome message delivered by Dr. Anthony Fauci, the Director of the National Institute of Allergy and Infectious Diseases. We are excited to use the success of this virtual event as an opportunity to expand our knowledge and expertise, and deliver a fun, memorable CHEST 2020.

This October, CHEST will bring you the premier virtual education event in pulmonary, critical care, and sleep medicine, all from the comfort and safety of your home or institution. This year’s virtual Annual Meeting will include live, interactive education, including panel and case-based discussions, virtual networking opportunities, CHEST GAMES, and the space for you to connect, learn, and recharge with your peers…virtually.

Top faculty from across the field will bring you the latest in clinical developments related to the diagnosis, treatment, and management of pulmonary diseases, critical care complications, and sleep disorders. Nonclinical topics, like cultural diversity and burnout, that feature more prominently than ever in day-to-day practice, will be given equal weight. Sessions like, Being Me: Understanding ‘Otherness’ and Issues of Diversity, will rely on audience interaction to address scenarios involving bias and racism faced by the panel of presenters and members of the audience.

Crucial and quickly evolving information on COVID-19 will be front and center, including complications with COVID-19 recovery, COVID-19 management in complex situations, and additional discussions on updated drug trials, treatment plans, and practice management changes. We will focus on other challenges the pandemic has highlighted, helping educators with sessions such as APCCMPD: Education Lessons During a Pandemic and sharing key reminders to all on the fundamentals of pandemic preparation with When the Theoretical Becomes Real: Lessons from a Pandemic.

It is more important than ever to stay up to date on developments in health and medicine, but CHEST is putting equal weight on ensuring the experience of CHEST 2020 is a respite from the mental and physical exhaustion our community is experiencing during these unprecedented times. As ever, we will ensure you meet your educational needs. But together, we will also focus on supporting you in building resilience and giving you the tools to continue to find joy in medicine, even amidst the chaos of a pandemic. Thank you for your continued trust in CHEST, and we look forward to “seeing” you at CHEST 2020 October 18-21!

ILLUSTRATIVE CASE

A 35-year-old healthy woman without a history of high-grade precancerous cervical lesions, immunodeficiency, or exposure to diethylstilbestrol presents to your office for her routine health visit. During your conversation with her, she shares, “I read on the Internet that I only need to be tested for human papillomavirus, but I’m wondering how I’ll be checked for cervical cancer.” She asks for your opinion about cervical cancer screening methods.

The National Cancer Institute predicts that there will be 13,800 new cases of cervical cancer this year, with an estimated 4290 deaths.³ This type of cancer is primarily caused by high-risk human papillomavirus (hrHPV) infections. Fortunately, high-grade precancerous cervical lesions and cervical cancer can be detected with routine Papanicolaou (Pap) smears, which have led to a substantial decrease in the number of deaths from cervical cancer in the United States—from 2.8 per 100,000 women in 2000 to 2.3 deaths per 100,000 women in 2015.³ In addition to hrHPV infection, risk factors for cervical cancer include low socioeconomic status, cigarette smoking, marrying before 18 years of age, young age at first coitus, multiple sexual partners, multiple sexual partners of a partner, and multiple childbirths.⁴

Cervical cancer is associated with numerous negative outcomes, including a decrease in quality of life, decreased libido, poor mental health, infertility, negative body image, and death.⁵ This is particularly true among women of lower socioeconomic status or whose language differs from that of their primary health care provider.^1,5

Given the enormous impact cervical cancer screening has made on the detection and mortality rate of this devastating disease,^4,5 it is crucial to identify the types of screening tests and screening intervals that lead to the greatest benefit and least harm for all patient populations. The US Preventive Services Task Force (USPSTF) previously addressed this issue in 2012, concluding that cytology alone every 3 years for women ages 21 to 65 years and cytology alone every 3 years or co-testing with cytology and hrHPV every 5 years in women ages 30 to 65 years was of substantial benefit (strength of recommendation [SOR]: A).⁶

STUDY SUMMARY

Another option for some women: hrHPV testing alone every 5 years

In this 2018 systematic review and modeling study by the USPSTF, randomized controlled trials (RCTs) and cohort studies that compared cytology to hrHPV testing alone or co-testing (cytology with hrHPV) were used to determine the optimal frequency of, and age group for, cervical cancer screening that would yield the least harm and the most benefit from each of these screening methods.^7-9

Similar to the previous recommendation, the USPSTF found that screening women < 21 years or > 65 years if previously adequately screened (defined as 3 consecutive negative screenings or 2 negative screenings within the past 10 years with the most recent being within the past 5 years) led to more harm than benefit. They therefore concluded that women in these age groups should not be screened routinely (SOR: D). The USPSTF also recommends against cervical cancer screening in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion or cervical cancer (SOR: D).

Any 1 of 3 screening methods is adequately sensitive for detecting precancerous high-grade cervical lesions or cervical cancer in women ages 30 to 65 years.

However, for women ages 21 to 65 years, the USPSTF found that screening substantially reduces cervical cancer incidence and mortality, and that for women ages 21 to 29 years, screening every 3 years with cytology alone offers the best balance of benefits and harms (SOR: A). For women ages 30 to 65 years, the USPSTF recommends screening every 3 years with cytology alone or every 5 years with either primary hrHPV testing or co-testing (hrHPV with cytology) (SOR: A). The recommendations apply to all ­asymptomatic women with a cervix; exceptions include those with a history of a high-grade precancerous cervical lesion or cancer, in utero exposure to diethylstilbestrol, or a compromised immune system.

Continue to: The change

The change in this current set of recommendations by the USPSTF is the inclusion of screening with hrHPV alone every 5 years as an additional cervical cancer screening option for women ages 30 to 65 years. The decision to include this option was based largely on a decision analysis model commissioned by the USPSTF and reviewed along with clinical trials and cohort studies. The modeling studies found that both primary hrHPV testing alone and co-testing every 5 years prevented a similar number of cervical cancer cases and required a similar number of colposcopies.

Finally, the USPSTF emphasized that screening alone is not sufficient for the prevention of cervical cancer and that efforts should be made to create equitable access to follow-up of abnormal results and the provision of appropriate treatment.^1,2

WHAT’S NEW

When it comes to cervical cancer screening, 3 solid options now exist

The previous USPSTF recommendation concluded that women ages 30 to 65 years should be screened with either cytology alone every 3 years or co-testing (cytology and hrHPV) every 5 years. This systematic review and modeling study concluded that any one of the stated screening methods would be adequately sensitive for detecting precancerous high-grade cervical lesions or cervical cancer: cytology every 3 years, primary hrHPV every 5 years, or co-testing every 5 years.^7-9

CAVEATS

No studies comparing hrHPVto co-testing and no meta-analysis

No studies were found that directly compared primary hrHPV testing with co-testing.¹ A meta-analysis could not be performed due to the methodological differences in RCTs and cohort studies reviewed. The new recommendation is unique in its reliance on modeling to simulate a direct comparison of these 2 screening methods.

CHALLENGES TO IMPLEMENTATION

Getting the word out and increasing comfort levels

The principal challenge to implementation lies in practitioners’ knowledge of this new recommendation and a possible low comfort level with ordering hrHPV testing alone. Patients will need to be engaged in shared decision-making to understand and make use of the 3 options.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

ILLUSTRATIVE CASE

A 35-year-old healthy woman without a history of high-grade precancerous cervical lesions, immunodeficiency, or exposure to diethylstilbestrol presents to your office for her routine health visit. During your conversation with her, she shares, “I read on the Internet that I only need to be tested for human papillomavirus, but I’m wondering how I’ll be checked for cervical cancer.” She asks for your opinion about cervical cancer screening methods.

The National Cancer Institute predicts that there will be 13,800 new cases of cervical cancer this year, with an estimated 4290 deaths.³ This type of cancer is primarily caused by high-risk human papillomavirus (hrHPV) infections. Fortunately, high-grade precancerous cervical lesions and cervical cancer can be detected with routine Papanicolaou (Pap) smears, which have led to a substantial decrease in the number of deaths from cervical cancer in the United States—from 2.8 per 100,000 women in 2000 to 2.3 deaths per 100,000 women in 2015.³ In addition to hrHPV infection, risk factors for cervical cancer include low socioeconomic status, cigarette smoking, marrying before 18 years of age, young age at first coitus, multiple sexual partners, multiple sexual partners of a partner, and multiple childbirths.⁴

Cervical cancer is associated with numerous negative outcomes, including a decrease in quality of life, decreased libido, poor mental health, infertility, negative body image, and death.⁵ This is particularly true among women of lower socioeconomic status or whose language differs from that of their primary health care provider.^1,5

Given the enormous impact cervical cancer screening has made on the detection and mortality rate of this devastating disease,^4,5 it is crucial to identify the types of screening tests and screening intervals that lead to the greatest benefit and least harm for all patient populations. The US Preventive Services Task Force (USPSTF) previously addressed this issue in 2012, concluding that cytology alone every 3 years for women ages 21 to 65 years and cytology alone every 3 years or co-testing with cytology and hrHPV every 5 years in women ages 30 to 65 years was of substantial benefit (strength of recommendation [SOR]: A).⁶

STUDY SUMMARY

Another option for some women: hrHPV testing alone every 5 years

In this 2018 systematic review and modeling study by the USPSTF, randomized controlled trials (RCTs) and cohort studies that compared cytology to hrHPV testing alone or co-testing (cytology with hrHPV) were used to determine the optimal frequency of, and age group for, cervical cancer screening that would yield the least harm and the most benefit from each of these screening methods.^7-9

Similar to the previous recommendation, the USPSTF found that screening women < 21 years or > 65 years if previously adequately screened (defined as 3 consecutive negative screenings or 2 negative screenings within the past 10 years with the most recent being within the past 5 years) led to more harm than benefit. They therefore concluded that women in these age groups should not be screened routinely (SOR: D). The USPSTF also recommends against cervical cancer screening in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion or cervical cancer (SOR: D).

Any 1 of 3 screening methods is adequately sensitive for detecting precancerous high-grade cervical lesions or cervical cancer in women ages 30 to 65 years.

However, for women ages 21 to 65 years, the USPSTF found that screening substantially reduces cervical cancer incidence and mortality, and that for women ages 21 to 29 years, screening every 3 years with cytology alone offers the best balance of benefits and harms (SOR: A). For women ages 30 to 65 years, the USPSTF recommends screening every 3 years with cytology alone or every 5 years with either primary hrHPV testing or co-testing (hrHPV with cytology) (SOR: A). The recommendations apply to all ­asymptomatic women with a cervix; exceptions include those with a history of a high-grade precancerous cervical lesion or cancer, in utero exposure to diethylstilbestrol, or a compromised immune system.

Continue to: The change

The change in this current set of recommendations by the USPSTF is the inclusion of screening with hrHPV alone every 5 years as an additional cervical cancer screening option for women ages 30 to 65 years. The decision to include this option was based largely on a decision analysis model commissioned by the USPSTF and reviewed along with clinical trials and cohort studies. The modeling studies found that both primary hrHPV testing alone and co-testing every 5 years prevented a similar number of cervical cancer cases and required a similar number of colposcopies.

Finally, the USPSTF emphasized that screening alone is not sufficient for the prevention of cervical cancer and that efforts should be made to create equitable access to follow-up of abnormal results and the provision of appropriate treatment.^1,2

WHAT’S NEW

When it comes to cervical cancer screening, 3 solid options now exist

The previous USPSTF recommendation concluded that women ages 30 to 65 years should be screened with either cytology alone every 3 years or co-testing (cytology and hrHPV) every 5 years. This systematic review and modeling study concluded that any one of the stated screening methods would be adequately sensitive for detecting precancerous high-grade cervical lesions or cervical cancer: cytology every 3 years, primary hrHPV every 5 years, or co-testing every 5 years.^7-9

CAVEATS

No studies comparing hrHPVto co-testing and no meta-analysis

No studies were found that directly compared primary hrHPV testing with co-testing.¹ A meta-analysis could not be performed due to the methodological differences in RCTs and cohort studies reviewed. The new recommendation is unique in its reliance on modeling to simulate a direct comparison of these 2 screening methods.

CHALLENGES TO IMPLEMENTATION

Getting the word out and increasing comfort levels

The principal challenge to implementation lies in practitioners’ knowledge of this new recommendation and a possible low comfort level with ordering hrHPV testing alone. Patients will need to be engaged in shared decision-making to understand and make use of the 3 options.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

ILLUSTRATIVE CASE

A 35-year-old healthy woman without a history of high-grade precancerous cervical lesions, immunodeficiency, or exposure to diethylstilbestrol presents to your office for her routine health visit. During your conversation with her, she shares, “I read on the Internet that I only need to be tested for human papillomavirus, but I’m wondering how I’ll be checked for cervical cancer.” She asks for your opinion about cervical cancer screening methods.

The National Cancer Institute predicts that there will be 13,800 new cases of cervical cancer this year, with an estimated 4290 deaths.³ This type of cancer is primarily caused by high-risk human papillomavirus (hrHPV) infections. Fortunately, high-grade precancerous cervical lesions and cervical cancer can be detected with routine Papanicolaou (Pap) smears, which have led to a substantial decrease in the number of deaths from cervical cancer in the United States—from 2.8 per 100,000 women in 2000 to 2.3 deaths per 100,000 women in 2015.³ In addition to hrHPV infection, risk factors for cervical cancer include low socioeconomic status, cigarette smoking, marrying before 18 years of age, young age at first coitus, multiple sexual partners, multiple sexual partners of a partner, and multiple childbirths.⁴

Cervical cancer is associated with numerous negative outcomes, including a decrease in quality of life, decreased libido, poor mental health, infertility, negative body image, and death.⁵ This is particularly true among women of lower socioeconomic status or whose language differs from that of their primary health care provider.^1,5

Given the enormous impact cervical cancer screening has made on the detection and mortality rate of this devastating disease,^4,5 it is crucial to identify the types of screening tests and screening intervals that lead to the greatest benefit and least harm for all patient populations. The US Preventive Services Task Force (USPSTF) previously addressed this issue in 2012, concluding that cytology alone every 3 years for women ages 21 to 65 years and cytology alone every 3 years or co-testing with cytology and hrHPV every 5 years in women ages 30 to 65 years was of substantial benefit (strength of recommendation [SOR]: A).⁶

STUDY SUMMARY

Another option for some women: hrHPV testing alone every 5 years

In this 2018 systematic review and modeling study by the USPSTF, randomized controlled trials (RCTs) and cohort studies that compared cytology to hrHPV testing alone or co-testing (cytology with hrHPV) were used to determine the optimal frequency of, and age group for, cervical cancer screening that would yield the least harm and the most benefit from each of these screening methods.^7-9

Similar to the previous recommendation, the USPSTF found that screening women < 21 years or > 65 years if previously adequately screened (defined as 3 consecutive negative screenings or 2 negative screenings within the past 10 years with the most recent being within the past 5 years) led to more harm than benefit. They therefore concluded that women in these age groups should not be screened routinely (SOR: D). The USPSTF also recommends against cervical cancer screening in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion or cervical cancer (SOR: D).

Any 1 of 3 screening methods is adequately sensitive for detecting precancerous high-grade cervical lesions or cervical cancer in women ages 30 to 65 years.

However, for women ages 21 to 65 years, the USPSTF found that screening substantially reduces cervical cancer incidence and mortality, and that for women ages 21 to 29 years, screening every 3 years with cytology alone offers the best balance of benefits and harms (SOR: A). For women ages 30 to 65 years, the USPSTF recommends screening every 3 years with cytology alone or every 5 years with either primary hrHPV testing or co-testing (hrHPV with cytology) (SOR: A). The recommendations apply to all ­asymptomatic women with a cervix; exceptions include those with a history of a high-grade precancerous cervical lesion or cancer, in utero exposure to diethylstilbestrol, or a compromised immune system.

Continue to: The change

The change in this current set of recommendations by the USPSTF is the inclusion of screening with hrHPV alone every 5 years as an additional cervical cancer screening option for women ages 30 to 65 years. The decision to include this option was based largely on a decision analysis model commissioned by the USPSTF and reviewed along with clinical trials and cohort studies. The modeling studies found that both primary hrHPV testing alone and co-testing every 5 years prevented a similar number of cervical cancer cases and required a similar number of colposcopies.

Finally, the USPSTF emphasized that screening alone is not sufficient for the prevention of cervical cancer and that efforts should be made to create equitable access to follow-up of abnormal results and the provision of appropriate treatment.^1,2

WHAT’S NEW

When it comes to cervical cancer screening, 3 solid options now exist

The previous USPSTF recommendation concluded that women ages 30 to 65 years should be screened with either cytology alone every 3 years or co-testing (cytology and hrHPV) every 5 years. This systematic review and modeling study concluded that any one of the stated screening methods would be adequately sensitive for detecting precancerous high-grade cervical lesions or cervical cancer: cytology every 3 years, primary hrHPV every 5 years, or co-testing every 5 years.^7-9

CAVEATS

No studies comparing hrHPVto co-testing and no meta-analysis

No studies were found that directly compared primary hrHPV testing with co-testing.¹ A meta-analysis could not be performed due to the methodological differences in RCTs and cohort studies reviewed. The new recommendation is unique in its reliance on modeling to simulate a direct comparison of these 2 screening methods.

CHALLENGES TO IMPLEMENTATION

Getting the word out and increasing comfort levels

The principal challenge to implementation lies in practitioners’ knowledge of this new recommendation and a possible low comfort level with ordering hrHPV testing alone. Patients will need to be engaged in shared decision-making to understand and make use of the 3 options.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

An uneven distribution of board-certified pediatric dermatologists exists in the United States, which has resulted in children with unmet dermatologic needs in many densely populated areas. In fact, nine states do not have a single pediatric dermatologist.

The findings come from a cross-sectional analysis of national data presented by Sepideh Ashrafzadeh at the virtual annual meeting of the Society for Pediatric Dermatology.

“Nearly 82% of pediatricians report that their patients have difficulty accessing pediatric dermatologists [and] over 25% of pediatric dermatologists have a wait time of greater than 10 weeks for new patient appointments,” Ms. Ashrafzadeh, a student at Harvard Medical School, Boston, and associates wrote in their poster abstract. “While the shortage of pediatric dermatologists is well documented, little is known about the distribution of pediatric dermatologists across the U.S., which in turn affects families’ travel time and access to pediatric dermatologists. Defining the specific regions with greatest need for pediatric dermatology can help shape recruitment efforts and initiatives to increase access to pediatric dermatologists in areas with the greatest need.”

For the current study, the researchers drew from the SPD Directory in March 2020 to identify all U.S. board-certified pediatric dermatologists. They used the 2020 American Board of Pediatrics Directory and the 2020 Centers for Medicaid & Medicare Physician Compare Database to identify pediatric generalists, which were defined as pediatricians and family medicine physicians. They used the 2018 American Community Survey, published by the U.S. Census Bureau, to obtain the number of children ages 0-17 years in each county and state.

Next, Ms. Ashrafzadeh and colleagues tabulated the number of children, pediatric dermatologists, and pediatric generalists in each county and state, and calculated ratios of pediatric dermatologists and generalists to number of children. The Gini index, a standardized scale where 0 signifies equal distribution and 1 signifies complete maldistribution, was calculated for pediatric dermatologists and generalists relative to the population of children at the state level.

Of the 317 pediatric dermatologists included in the analysis, 243 (77%) were female, 194 (61%) worked in an academic center, and 311 (98%) worked in a metropolitan county. A pediatric dermatologist was present in 41 of 50 states (82%) and in 142 of 3,228 counties (4%). There was not a single pediatric dermatologist in 73 out of 158 counties (46%) with over 100,000 children, 19 out of 66 counties (29%) with over 200,000 children, and 4 out of 13 counties (31%) with over 500,000 children. Nine states had no pediatric dermatologists: Delaware, Idaho, Maine, Mississippi, Montana, Nevada, North Dakota, South Dakota, and Wyoming. States with the greatest density of pediatric dermatologists (range, 10.1-15.2 pediatric dermatologists per 1,000,000 children) were Wisconsin, Massachusetts, Rhode Island, and New Hampshire. The Gini index for the distribution of pediatric dermatologists relative to the population of children was 0.488, compared with 0.132 for that of pediatric generalists.

“To address the unmet pediatric dermatology need, educators and policymakers can create initiatives to recruit pediatric dermatologists and expand access to telehealth pediatric dermatology services in these high priority states and counties,” the researchers wrote in their abstract. “Future studies need to be done quantifying travel distances to pediatric dermatologists across the US as travel distances can further identify areas that are in great need of pediatric dermatologists.”

They acknowledged certain limitations of the study, including the fact that they may have missed board-certified pediatric dermatologists who are not listed in the SPD Directory. Ms. Ashrafzadeh and colleagues reported having no financial disclosures.

dbrunk@mdedge.com

An uneven distribution of board-certified pediatric dermatologists exists in the United States, which has resulted in children with unmet dermatologic needs in many densely populated areas. In fact, nine states do not have a single pediatric dermatologist.

The findings come from a cross-sectional analysis of national data presented by Sepideh Ashrafzadeh at the virtual annual meeting of the Society for Pediatric Dermatology.

“Nearly 82% of pediatricians report that their patients have difficulty accessing pediatric dermatologists [and] over 25% of pediatric dermatologists have a wait time of greater than 10 weeks for new patient appointments,” Ms. Ashrafzadeh, a student at Harvard Medical School, Boston, and associates wrote in their poster abstract. “While the shortage of pediatric dermatologists is well documented, little is known about the distribution of pediatric dermatologists across the U.S., which in turn affects families’ travel time and access to pediatric dermatologists. Defining the specific regions with greatest need for pediatric dermatology can help shape recruitment efforts and initiatives to increase access to pediatric dermatologists in areas with the greatest need.”

For the current study, the researchers drew from the SPD Directory in March 2020 to identify all U.S. board-certified pediatric dermatologists. They used the 2020 American Board of Pediatrics Directory and the 2020 Centers for Medicaid & Medicare Physician Compare Database to identify pediatric generalists, which were defined as pediatricians and family medicine physicians. They used the 2018 American Community Survey, published by the U.S. Census Bureau, to obtain the number of children ages 0-17 years in each county and state.

Next, Ms. Ashrafzadeh and colleagues tabulated the number of children, pediatric dermatologists, and pediatric generalists in each county and state, and calculated ratios of pediatric dermatologists and generalists to number of children. The Gini index, a standardized scale where 0 signifies equal distribution and 1 signifies complete maldistribution, was calculated for pediatric dermatologists and generalists relative to the population of children at the state level.

Of the 317 pediatric dermatologists included in the analysis, 243 (77%) were female, 194 (61%) worked in an academic center, and 311 (98%) worked in a metropolitan county. A pediatric dermatologist was present in 41 of 50 states (82%) and in 142 of 3,228 counties (4%). There was not a single pediatric dermatologist in 73 out of 158 counties (46%) with over 100,000 children, 19 out of 66 counties (29%) with over 200,000 children, and 4 out of 13 counties (31%) with over 500,000 children. Nine states had no pediatric dermatologists: Delaware, Idaho, Maine, Mississippi, Montana, Nevada, North Dakota, South Dakota, and Wyoming. States with the greatest density of pediatric dermatologists (range, 10.1-15.2 pediatric dermatologists per 1,000,000 children) were Wisconsin, Massachusetts, Rhode Island, and New Hampshire. The Gini index for the distribution of pediatric dermatologists relative to the population of children was 0.488, compared with 0.132 for that of pediatric generalists.

“To address the unmet pediatric dermatology need, educators and policymakers can create initiatives to recruit pediatric dermatologists and expand access to telehealth pediatric dermatology services in these high priority states and counties,” the researchers wrote in their abstract. “Future studies need to be done quantifying travel distances to pediatric dermatologists across the US as travel distances can further identify areas that are in great need of pediatric dermatologists.”

They acknowledged certain limitations of the study, including the fact that they may have missed board-certified pediatric dermatologists who are not listed in the SPD Directory. Ms. Ashrafzadeh and colleagues reported having no financial disclosures.

dbrunk@mdedge.com

An uneven distribution of board-certified pediatric dermatologists exists in the United States, which has resulted in children with unmet dermatologic needs in many densely populated areas. In fact, nine states do not have a single pediatric dermatologist.

The findings come from a cross-sectional analysis of national data presented by Sepideh Ashrafzadeh at the virtual annual meeting of the Society for Pediatric Dermatology.

“Nearly 82% of pediatricians report that their patients have difficulty accessing pediatric dermatologists [and] over 25% of pediatric dermatologists have a wait time of greater than 10 weeks for new patient appointments,” Ms. Ashrafzadeh, a student at Harvard Medical School, Boston, and associates wrote in their poster abstract. “While the shortage of pediatric dermatologists is well documented, little is known about the distribution of pediatric dermatologists across the U.S., which in turn affects families’ travel time and access to pediatric dermatologists. Defining the specific regions with greatest need for pediatric dermatology can help shape recruitment efforts and initiatives to increase access to pediatric dermatologists in areas with the greatest need.”

For the current study, the researchers drew from the SPD Directory in March 2020 to identify all U.S. board-certified pediatric dermatologists. They used the 2020 American Board of Pediatrics Directory and the 2020 Centers for Medicaid & Medicare Physician Compare Database to identify pediatric generalists, which were defined as pediatricians and family medicine physicians. They used the 2018 American Community Survey, published by the U.S. Census Bureau, to obtain the number of children ages 0-17 years in each county and state.

Next, Ms. Ashrafzadeh and colleagues tabulated the number of children, pediatric dermatologists, and pediatric generalists in each county and state, and calculated ratios of pediatric dermatologists and generalists to number of children. The Gini index, a standardized scale where 0 signifies equal distribution and 1 signifies complete maldistribution, was calculated for pediatric dermatologists and generalists relative to the population of children at the state level.

Of the 317 pediatric dermatologists included in the analysis, 243 (77%) were female, 194 (61%) worked in an academic center, and 311 (98%) worked in a metropolitan county. A pediatric dermatologist was present in 41 of 50 states (82%) and in 142 of 3,228 counties (4%). There was not a single pediatric dermatologist in 73 out of 158 counties (46%) with over 100,000 children, 19 out of 66 counties (29%) with over 200,000 children, and 4 out of 13 counties (31%) with over 500,000 children. Nine states had no pediatric dermatologists: Delaware, Idaho, Maine, Mississippi, Montana, Nevada, North Dakota, South Dakota, and Wyoming. States with the greatest density of pediatric dermatologists (range, 10.1-15.2 pediatric dermatologists per 1,000,000 children) were Wisconsin, Massachusetts, Rhode Island, and New Hampshire. The Gini index for the distribution of pediatric dermatologists relative to the population of children was 0.488, compared with 0.132 for that of pediatric generalists.

“To address the unmet pediatric dermatology need, educators and policymakers can create initiatives to recruit pediatric dermatologists and expand access to telehealth pediatric dermatology services in these high priority states and counties,” the researchers wrote in their abstract. “Future studies need to be done quantifying travel distances to pediatric dermatologists across the US as travel distances can further identify areas that are in great need of pediatric dermatologists.”

They acknowledged certain limitations of the study, including the fact that they may have missed board-certified pediatric dermatologists who are not listed in the SPD Directory. Ms. Ashrafzadeh and colleagues reported having no financial disclosures.

dbrunk@mdedge.com

Young adult smokers who stop smoking in the first year after an initial myocardial infarction are far less likely to die over the next 10 years than their peers who continue to smoke. Yet nearly two-thirds keep smoking after the event, according to new data from the Partners YOUNG-MI Registry.

“Smoking is one of the most common risk factors for developing an MI at a young age. ... This reinforces the need to have more young individuals avoid, or quit, the use of tobacco,” Ron Blankstein, MD, Brigham and Women’s Hospital and Harvard Medical School, Boston, said in an interview.

Yet, the finding that 62% of young adults continue to smoke 1 year after MI points to an “enormous need for better smoking cessation efforts following a heart attack,” he said.
 

“Powerful” message for clinicians

“This study joins an incredibly powerful body of evidence that says if you quit smoking, you’re going to live longer,” said Michael Fiore, MD, MPH, MBA, director of the University of Wisconsin Center for Tobacco Research and Intervention, Madison, who wasn’t involved in the study.

“As physicians, there is nothing we can do that will have a greater impact for our patients than quitting smoking. The study is a powerful call for clinicians to intervene with their patients that smoke – both if you have an MI or if you don’t,” Dr. Fiore told this news organization.

The study involved 2,072 individuals 50 years or younger (median age, 45 years; 81% male) who were hospitalized for an initial MI at two large academic medical centers in Boston. Of these, 33.9% were never-smokers, 13.6% were former smokers, and 52.5% were smokers at the time of their MI.

During a median follow-up of 10.2 years, those who quit smoking had a significantly lower rate of death from any cause (unadjusted hazard ratio, 0.35; 95% confidence interval, 0.19-0.63; P < .001) and a cardiovascular cause (HR, 0.29; 95% CI, 0.11-0.79; P = .02), relative to those who continued to smoke.

The results remained statistically significant in a propensity-matched analysis for both all-cause (HR, 0.30; 95% CI, 0.16-0.56; P < .001) and CV mortality (HR, 0.19; 95% CI, 0.06-0.56; P = .003).

“Although patients who quit smoking were similar to those who continued to smoke with respect to their baseline characteristics, smoking cessation was associated with an approximate 70%-80% reduction in all-cause and CV mortality,” the authors note in their article, published online July 8 in JAMA Network Open.

They say it’s also noteworthy that long-term death rates of never-smokers and former smokers who quit before the MI were nearly identical.

‘A failure of our health care system’

The bottom line, said Dr. Blankstein, is that it is “never too late to quit, and those who experience an MI should do so right away. Our health care system must help promote such efforts, as there is immense room for improvement.”

Dr. Fiore said: “When I see an article like this, it just reminds me that, if you’re really thinking about staying healthy, there is nothing better you can do to improve the quality and longevity of your life than quitting smoking.”

The observation that many patients continue to smoke after MI is a “failure of our health care system, and it’s an individual failure in that these individuals are not able to overcome their powerful nicotine dependence. It’s an unfortunate occurrence that’s resulting in unnecessary deaths,” said Dr. Fiore.

There is no “magic bullet” to overcome nicotine addiction, but there are approved treatments that can “substantially boost quit rates,” he noted.

The two most effective smoking-cessation treatments are varenicline (Chantix) and combination nicotine replacement therapy, a patch combined ideally with nicotine mini lozenges, particularly when combined with some brief counseling, said Fiore.

He encourages cardiologists to get their patients to commit to quitting and then link them to resources such as 1-800-QUIT-NOW or SmokeFree.gov.

Funding for the study was provided by grants from the National Heart, Lung, and Blood Institute. Dr. Blankstein reported receiving research support from Amgen and Astellas. Dr. Fiore had no relevant disclosures.

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

Young adult smokers who stop smoking in the first year after an initial myocardial infarction are far less likely to die over the next 10 years than their peers who continue to smoke. Yet nearly two-thirds keep smoking after the event, according to new data from the Partners YOUNG-MI Registry.

“Smoking is one of the most common risk factors for developing an MI at a young age. ... This reinforces the need to have more young individuals avoid, or quit, the use of tobacco,” Ron Blankstein, MD, Brigham and Women’s Hospital and Harvard Medical School, Boston, said in an interview.

Yet, the finding that 62% of young adults continue to smoke 1 year after MI points to an “enormous need for better smoking cessation efforts following a heart attack,” he said.
 

“Powerful” message for clinicians

“This study joins an incredibly powerful body of evidence that says if you quit smoking, you’re going to live longer,” said Michael Fiore, MD, MPH, MBA, director of the University of Wisconsin Center for Tobacco Research and Intervention, Madison, who wasn’t involved in the study.

“As physicians, there is nothing we can do that will have a greater impact for our patients than quitting smoking. The study is a powerful call for clinicians to intervene with their patients that smoke – both if you have an MI or if you don’t,” Dr. Fiore told this news organization.

The study involved 2,072 individuals 50 years or younger (median age, 45 years; 81% male) who were hospitalized for an initial MI at two large academic medical centers in Boston. Of these, 33.9% were never-smokers, 13.6% were former smokers, and 52.5% were smokers at the time of their MI.

During a median follow-up of 10.2 years, those who quit smoking had a significantly lower rate of death from any cause (unadjusted hazard ratio, 0.35; 95% confidence interval, 0.19-0.63; P < .001) and a cardiovascular cause (HR, 0.29; 95% CI, 0.11-0.79; P = .02), relative to those who continued to smoke.

The results remained statistically significant in a propensity-matched analysis for both all-cause (HR, 0.30; 95% CI, 0.16-0.56; P < .001) and CV mortality (HR, 0.19; 95% CI, 0.06-0.56; P = .003).

“Although patients who quit smoking were similar to those who continued to smoke with respect to their baseline characteristics, smoking cessation was associated with an approximate 70%-80% reduction in all-cause and CV mortality,” the authors note in their article, published online July 8 in JAMA Network Open.

They say it’s also noteworthy that long-term death rates of never-smokers and former smokers who quit before the MI were nearly identical.

‘A failure of our health care system’

The bottom line, said Dr. Blankstein, is that it is “never too late to quit, and those who experience an MI should do so right away. Our health care system must help promote such efforts, as there is immense room for improvement.”

Dr. Fiore said: “When I see an article like this, it just reminds me that, if you’re really thinking about staying healthy, there is nothing better you can do to improve the quality and longevity of your life than quitting smoking.”

The observation that many patients continue to smoke after MI is a “failure of our health care system, and it’s an individual failure in that these individuals are not able to overcome their powerful nicotine dependence. It’s an unfortunate occurrence that’s resulting in unnecessary deaths,” said Dr. Fiore.

There is no “magic bullet” to overcome nicotine addiction, but there are approved treatments that can “substantially boost quit rates,” he noted.

The two most effective smoking-cessation treatments are varenicline (Chantix) and combination nicotine replacement therapy, a patch combined ideally with nicotine mini lozenges, particularly when combined with some brief counseling, said Fiore.

He encourages cardiologists to get their patients to commit to quitting and then link them to resources such as 1-800-QUIT-NOW or SmokeFree.gov.

Funding for the study was provided by grants from the National Heart, Lung, and Blood Institute. Dr. Blankstein reported receiving research support from Amgen and Astellas. Dr. Fiore had no relevant disclosures.

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

Young adult smokers who stop smoking in the first year after an initial myocardial infarction are far less likely to die over the next 10 years than their peers who continue to smoke. Yet nearly two-thirds keep smoking after the event, according to new data from the Partners YOUNG-MI Registry.

“Smoking is one of the most common risk factors for developing an MI at a young age. ... This reinforces the need to have more young individuals avoid, or quit, the use of tobacco,” Ron Blankstein, MD, Brigham and Women’s Hospital and Harvard Medical School, Boston, said in an interview.

Yet, the finding that 62% of young adults continue to smoke 1 year after MI points to an “enormous need for better smoking cessation efforts following a heart attack,” he said.
 

“Powerful” message for clinicians

“This study joins an incredibly powerful body of evidence that says if you quit smoking, you’re going to live longer,” said Michael Fiore, MD, MPH, MBA, director of the University of Wisconsin Center for Tobacco Research and Intervention, Madison, who wasn’t involved in the study.

“As physicians, there is nothing we can do that will have a greater impact for our patients than quitting smoking. The study is a powerful call for clinicians to intervene with their patients that smoke – both if you have an MI or if you don’t,” Dr. Fiore told this news organization.

The study involved 2,072 individuals 50 years or younger (median age, 45 years; 81% male) who were hospitalized for an initial MI at two large academic medical centers in Boston. Of these, 33.9% were never-smokers, 13.6% were former smokers, and 52.5% were smokers at the time of their MI.

During a median follow-up of 10.2 years, those who quit smoking had a significantly lower rate of death from any cause (unadjusted hazard ratio, 0.35; 95% confidence interval, 0.19-0.63; P < .001) and a cardiovascular cause (HR, 0.29; 95% CI, 0.11-0.79; P = .02), relative to those who continued to smoke.

The results remained statistically significant in a propensity-matched analysis for both all-cause (HR, 0.30; 95% CI, 0.16-0.56; P < .001) and CV mortality (HR, 0.19; 95% CI, 0.06-0.56; P = .003).

“Although patients who quit smoking were similar to those who continued to smoke with respect to their baseline characteristics, smoking cessation was associated with an approximate 70%-80% reduction in all-cause and CV mortality,” the authors note in their article, published online July 8 in JAMA Network Open.

They say it’s also noteworthy that long-term death rates of never-smokers and former smokers who quit before the MI were nearly identical.

‘A failure of our health care system’

The bottom line, said Dr. Blankstein, is that it is “never too late to quit, and those who experience an MI should do so right away. Our health care system must help promote such efforts, as there is immense room for improvement.”

Dr. Fiore said: “When I see an article like this, it just reminds me that, if you’re really thinking about staying healthy, there is nothing better you can do to improve the quality and longevity of your life than quitting smoking.”

The observation that many patients continue to smoke after MI is a “failure of our health care system, and it’s an individual failure in that these individuals are not able to overcome their powerful nicotine dependence. It’s an unfortunate occurrence that’s resulting in unnecessary deaths,” said Dr. Fiore.

There is no “magic bullet” to overcome nicotine addiction, but there are approved treatments that can “substantially boost quit rates,” he noted.

The two most effective smoking-cessation treatments are varenicline (Chantix) and combination nicotine replacement therapy, a patch combined ideally with nicotine mini lozenges, particularly when combined with some brief counseling, said Fiore.

He encourages cardiologists to get their patients to commit to quitting and then link them to resources such as 1-800-QUIT-NOW or SmokeFree.gov.

Funding for the study was provided by grants from the National Heart, Lung, and Blood Institute. Dr. Blankstein reported receiving research support from Amgen and Astellas. Dr. Fiore had no relevant disclosures.

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

Greetings. I hope that you are well and are enjoying the summer as best you can during these challenging times. Since the “CHEST year” has drawn to a close recently, I would like to offer my reflections, which were recently shared with the Board of Regents, as well as a glimpse of what is ahead for CHEST. There is just so much great work I want to share.

This past year has posed a number of challenges. COVID-19 has caused us to interact differently on both a social and a business level. CHEST Headquarters has been closed, and we have not had a live-learning course for more than 4 months. But our work has not faltered. We have been extremely productive during this period and have once again demonstrated our resiliency and innovative spirit; in our vernacular, we “Crushed It.”

While COVID-19 has presented us with a number of obstacles, it has presented us with a number of opportunities, and we have taken advantage of them. During this pandemic, CHEST has truly demonstrated its ability to provide a connection at a critical time, giving this phrase new meaning and urgency. We have created a new resource center for clinicians, developed patient education and awareness campaigns to support the public through this crisis, launched a webinar series, developed scientific guidance statements, and more. At the same time, we have invested in our technology and educational infrastructure to grow our capabilities and position CHEST for long-term success.

Prior to COVID-19, we spent a significant amount of time among the CHEST staff, Presidents, and Boards drafting and reviewing a concise strategy statement for CHEST to provide focus and clarity to its efforts and derive and tie together future strategies specific to learning, technology, and more. From this statement, we derived four key areas requiring our continued and explicit focus to achieve this goal:

• People: Ensure we attract, retain, and incentivize the right people (staff, leaders, and volunteers).

• Products: Foster an environment of innovation and product development resulting in overall revenue growth, as well as revenue from new products and services.

• Education: Ensure that CHEST education products and services are robust, differentiated, and scalable..

• Growth: Meet or exceed revenue and margin targets.

As long as the mission and strategy of the organization does not deviate, these goals should not change. However, how we go about executing on achieving these goals each year will depend on the context of our environment and be shaped by the specific initiatives planned affecting our People, Products, Education, and building toward Growth. This consistency is important to sustain a vibrant, aligned, and productive organization.

Beyond this groundwork, I also would like to list a series of things that, together, CHEST accomplished over the last year.

• Reviewed existing contracts and, where appropriate, renegotiated major contracts to ensure terms more favorable for CHEST.
• Hired and on-boarded a Chief Learning Officer to place greater emphasis on expanding CHEST educational programs. Analyzed current educational products and have begun repositioning our educational efforts to better serve our learners.
• Refined the one CHEST concept, realigned responsibilities throughout the organization in general, and the CHEST Foundation, in particular, to enhance resource readiness and productivity. Clarified relationship with industry by continuing to implement our Industry Partnership Guidelines and streamline efforts with our partners.
• Continued rollout and execution of our international event strategy. Successfully developed and held a program for CHEST Congress 2020 Italy with our CHEST Italian Delegation, in a virtual format, due to COVID, while enabling us to build momentum for a rescheduled meeting in 2021. We had over 2,000 virtual registrants from over 100 countries, and there was a thank you given to all attendees by Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, to start off the program – what a success!
• Accelerated our digital transformation with an educational focus on virtual Board Review, CHEST 2020 Annual Meeting, online simulation.
• Forecasting strong financial outlook and improving financial reporting for FY19-20. Successful 2019 annual meeting:

o Total attendance 8,593—the largest attendance to date.

o Simulation Session Registration 979

o Exhibiting companies 160 SOLD OUT

o CHEST Annual Meeting 2019 delivered largest number of APPs and fellows attending in the last 5 years.

• Reintroduced CHEST into the advocacy and health policy arena through the successful acquisition of NAMDRC.

CHEST’s operating financial performance is solid, and well thought out efforts have kept CHEST on a growth trajectory over the last 7 years. During this same period (since 2011/12), our staff headcount has grown from 85 to a projected 121 this year; the new expertise and capabilities we have brought on board, combined with our highly talented and committed staff team, have contributed to this tremendous growth.

Our future is bright. These 2 two years have been very exciting for me both professionally and personally. I am grateful for the opportunity to work with all of you and serve as your CEO/EVP because together, we truly are making a significant difference in moving CHEST forward and crushing lung disease.

I know you are as proud of CHEST’s efforts this year as I am.

Thank you.

Greetings. I hope that you are well and are enjoying the summer as best you can during these challenging times. Since the “CHEST year” has drawn to a close recently, I would like to offer my reflections, which were recently shared with the Board of Regents, as well as a glimpse of what is ahead for CHEST. There is just so much great work I want to share.

This past year has posed a number of challenges. COVID-19 has caused us to interact differently on both a social and a business level. CHEST Headquarters has been closed, and we have not had a live-learning course for more than 4 months. But our work has not faltered. We have been extremely productive during this period and have once again demonstrated our resiliency and innovative spirit; in our vernacular, we “Crushed It.”

While COVID-19 has presented us with a number of obstacles, it has presented us with a number of opportunities, and we have taken advantage of them. During this pandemic, CHEST has truly demonstrated its ability to provide a connection at a critical time, giving this phrase new meaning and urgency. We have created a new resource center for clinicians, developed patient education and awareness campaigns to support the public through this crisis, launched a webinar series, developed scientific guidance statements, and more. At the same time, we have invested in our technology and educational infrastructure to grow our capabilities and position CHEST for long-term success.

Prior to COVID-19, we spent a significant amount of time among the CHEST staff, Presidents, and Boards drafting and reviewing a concise strategy statement for CHEST to provide focus and clarity to its efforts and derive and tie together future strategies specific to learning, technology, and more. From this statement, we derived four key areas requiring our continued and explicit focus to achieve this goal:

• People: Ensure we attract, retain, and incentivize the right people (staff, leaders, and volunteers).

• Products: Foster an environment of innovation and product development resulting in overall revenue growth, as well as revenue from new products and services.

• Education: Ensure that CHEST education products and services are robust, differentiated, and scalable..

• Growth: Meet or exceed revenue and margin targets.

As long as the mission and strategy of the organization does not deviate, these goals should not change. However, how we go about executing on achieving these goals each year will depend on the context of our environment and be shaped by the specific initiatives planned affecting our People, Products, Education, and building toward Growth. This consistency is important to sustain a vibrant, aligned, and productive organization.

Beyond this groundwork, I also would like to list a series of things that, together, CHEST accomplished over the last year.

• Reviewed existing contracts and, where appropriate, renegotiated major contracts to ensure terms more favorable for CHEST.
• Hired and on-boarded a Chief Learning Officer to place greater emphasis on expanding CHEST educational programs. Analyzed current educational products and have begun repositioning our educational efforts to better serve our learners.
• Refined the one CHEST concept, realigned responsibilities throughout the organization in general, and the CHEST Foundation, in particular, to enhance resource readiness and productivity. Clarified relationship with industry by continuing to implement our Industry Partnership Guidelines and streamline efforts with our partners.
• Continued rollout and execution of our international event strategy. Successfully developed and held a program for CHEST Congress 2020 Italy with our CHEST Italian Delegation, in a virtual format, due to COVID, while enabling us to build momentum for a rescheduled meeting in 2021. We had over 2,000 virtual registrants from over 100 countries, and there was a thank you given to all attendees by Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, to start off the program – what a success!
• Accelerated our digital transformation with an educational focus on virtual Board Review, CHEST 2020 Annual Meeting, online simulation.
• Forecasting strong financial outlook and improving financial reporting for FY19-20. Successful 2019 annual meeting:

o Total attendance 8,593—the largest attendance to date.

o Simulation Session Registration 979

o Exhibiting companies 160 SOLD OUT

o CHEST Annual Meeting 2019 delivered largest number of APPs and fellows attending in the last 5 years.

• Reintroduced CHEST into the advocacy and health policy arena through the successful acquisition of NAMDRC.

CHEST’s operating financial performance is solid, and well thought out efforts have kept CHEST on a growth trajectory over the last 7 years. During this same period (since 2011/12), our staff headcount has grown from 85 to a projected 121 this year; the new expertise and capabilities we have brought on board, combined with our highly talented and committed staff team, have contributed to this tremendous growth.

Our future is bright. These 2 two years have been very exciting for me both professionally and personally. I am grateful for the opportunity to work with all of you and serve as your CEO/EVP because together, we truly are making a significant difference in moving CHEST forward and crushing lung disease.

I know you are as proud of CHEST’s efforts this year as I am.

Thank you.

Greetings. I hope that you are well and are enjoying the summer as best you can during these challenging times. Since the “CHEST year” has drawn to a close recently, I would like to offer my reflections, which were recently shared with the Board of Regents, as well as a glimpse of what is ahead for CHEST. There is just so much great work I want to share.

This past year has posed a number of challenges. COVID-19 has caused us to interact differently on both a social and a business level. CHEST Headquarters has been closed, and we have not had a live-learning course for more than 4 months. But our work has not faltered. We have been extremely productive during this period and have once again demonstrated our resiliency and innovative spirit; in our vernacular, we “Crushed It.”

While COVID-19 has presented us with a number of obstacles, it has presented us with a number of opportunities, and we have taken advantage of them. During this pandemic, CHEST has truly demonstrated its ability to provide a connection at a critical time, giving this phrase new meaning and urgency. We have created a new resource center for clinicians, developed patient education and awareness campaigns to support the public through this crisis, launched a webinar series, developed scientific guidance statements, and more. At the same time, we have invested in our technology and educational infrastructure to grow our capabilities and position CHEST for long-term success.

Prior to COVID-19, we spent a significant amount of time among the CHEST staff, Presidents, and Boards drafting and reviewing a concise strategy statement for CHEST to provide focus and clarity to its efforts and derive and tie together future strategies specific to learning, technology, and more. From this statement, we derived four key areas requiring our continued and explicit focus to achieve this goal:

• People: Ensure we attract, retain, and incentivize the right people (staff, leaders, and volunteers).

• Products: Foster an environment of innovation and product development resulting in overall revenue growth, as well as revenue from new products and services.

• Education: Ensure that CHEST education products and services are robust, differentiated, and scalable..

• Growth: Meet or exceed revenue and margin targets.

As long as the mission and strategy of the organization does not deviate, these goals should not change. However, how we go about executing on achieving these goals each year will depend on the context of our environment and be shaped by the specific initiatives planned affecting our People, Products, Education, and building toward Growth. This consistency is important to sustain a vibrant, aligned, and productive organization.

Beyond this groundwork, I also would like to list a series of things that, together, CHEST accomplished over the last year.

• Reviewed existing contracts and, where appropriate, renegotiated major contracts to ensure terms more favorable for CHEST.
• Hired and on-boarded a Chief Learning Officer to place greater emphasis on expanding CHEST educational programs. Analyzed current educational products and have begun repositioning our educational efforts to better serve our learners.
• Refined the one CHEST concept, realigned responsibilities throughout the organization in general, and the CHEST Foundation, in particular, to enhance resource readiness and productivity. Clarified relationship with industry by continuing to implement our Industry Partnership Guidelines and streamline efforts with our partners.
• Continued rollout and execution of our international event strategy. Successfully developed and held a program for CHEST Congress 2020 Italy with our CHEST Italian Delegation, in a virtual format, due to COVID, while enabling us to build momentum for a rescheduled meeting in 2021. We had over 2,000 virtual registrants from over 100 countries, and there was a thank you given to all attendees by Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, to start off the program – what a success!
• Accelerated our digital transformation with an educational focus on virtual Board Review, CHEST 2020 Annual Meeting, online simulation.
• Forecasting strong financial outlook and improving financial reporting for FY19-20. Successful 2019 annual meeting:

o Total attendance 8,593—the largest attendance to date.

o Simulation Session Registration 979

o Exhibiting companies 160 SOLD OUT

o CHEST Annual Meeting 2019 delivered largest number of APPs and fellows attending in the last 5 years.

• Reintroduced CHEST into the advocacy and health policy arena through the successful acquisition of NAMDRC.

CHEST’s operating financial performance is solid, and well thought out efforts have kept CHEST on a growth trajectory over the last 7 years. During this same period (since 2011/12), our staff headcount has grown from 85 to a projected 121 this year; the new expertise and capabilities we have brought on board, combined with our highly talented and committed staff team, have contributed to this tremendous growth.

Our future is bright. These 2 two years have been very exciting for me both professionally and personally. I am grateful for the opportunity to work with all of you and serve as your CEO/EVP because together, we truly are making a significant difference in moving CHEST forward and crushing lung disease.

I know you are as proud of CHEST’s efforts this year as I am.

Thank you.

Dear Colleagues,

We are now near 6 months into living with COVID-19. In Texas, we are experiencing the surge that much of the Northeast saw in March and April. The COVID-19 Task Force led by Dr. Steve Simpson (CHEST President-Elect) and with representation from the Critical Care, Chest Infections, and Disaster Response and Global Health NetWorks continues to meet regularly to keep our members updated on the latest research and rapidly changing clinical management of COVID-19 illness and the sequelae. COVID-19 has put our medical profession and our subspecialty under considerable stress, and CHEST has launched a new longitudinal Wellness Center led by Dr. Alex Niven, from Mayo Clinic, Rochester. These new resources will feature a wellness webinar series focused on mental health and wellness for clinicians during COVID-19 and beyond. CHEST received overwhelming positive feedback from members and attendees to the Women & Pulmonary Virtual Happy Hour that focused on sharing stories and building community. Many leaders have suggested other such topics and efforts that may be useful to the CHEST community. The CHEST Wellness Center will launch on July 15.

In addition to COVID-19 activities, our nation and the world have compelled a new powerful look at race relations, disparities, and diversity. I represented CHEST at a “White Coats for Black Lives” event in San Antonio. Following our nation’s call for racial equality, CHEST released a Statement of Equity that received overwhelmingly positive feedback and response from members via email and on social media. This statement clearly resonated with the CHEST community. We are asking our leadership and members to consider ways in which CHEST might continue to raise awareness and continue with efforts related to diversity and equity. CHEST also hosted an excellent webinar moderated by Dr. Demondes Haynes and Dr. Nneka Sederstrom in late June that offered a direct and meaningful dialogue on issues facing clinicians and patients of color, and the responsibility of those in leadership positions. CHEST leadership stand firm that racism and inequality are public health issues and are working to define how we further our efforts in this arena.

On June 17, CHEST held a 1-day Virtual CHEST Congress in conjunction with our the CHEST Italian Delegation, as COVID-19 prevented us from safely holding the live Congress in Bologna. We had 3,250 registered attendees. I was so impressed at what a virtual platform can deliver, complete with great educational sessions, including much on COVID-19, as well as capturing the CHEST experience with games, bocce, jeopardy etc! This gave CHEST an opportunity to explore further virtual-based education to reach our wider global audience. CHEST will still be holding an in-person Congress in Bologna, June 24-26, 2021.

CHEST will host three entirely virtual Board Review Courses this August in the areas of Pulmonary, Critical Care, and Pediatric Pulmonary Medicine. These courses will include a combination of pre-recorded lectures and live, interactive sessions. Audience response systems and SEEK questions will still be utilized. There’s still time to register, so don’t miss it! With time being a major commodity at present, all attendees will receive year-long access to all material!

I know you have been wondering about CHEST 2020, and as you have heard by now, CHEST 2020 in Chicago will be a virtual meeting. I am sure that this announcement came as no big surprise, but is certainly disappointing. As you can imagine this was a difficult decision, but one that was necessary based upon our new reality. It was compounded by limitations on the convention center venue under the Illinois reopening plan, and the fact that a large number of our faculty, as well as our attendees, are under a travel ban for the remainder of 2020 that will not allow them to travel to Chicago. The abstract and case report deadline closed June 1, and despite these circumstances, we saw our highest number of submissions to date! Late abstracts were due on July 17. We will be presenting standalone and complementary online offerings to ensure seamless delivery of critical education in formats that cater easily to our newly formed habits.

Thanks to our dedicated Scientific Program Committee Chair, Dr. Victor Test, and staff, we had already begun preparing for virtual CHEST Annual Meeting 2020. Here’s what you can expect:

• A memorable experience

• A highly interactive education program that includes audience Q&A, discussion threads, and audience response systems

• Opportunities for one-on-one discussions, networking, and access to faculty

• Industry-sponsored programs and a virtual exhibit hall

• Access to hundreds of narrated poster presentations, case reports, and research abstracts

• Competitive educational gaming where attendees can participate, win, or watch

• Dedicated COVID-19 update sessions

• CME and MOC credits

If you have already registered for CHEST 2020, you will have the option to transfer your registration to this new model. Our main focus is delivering the virtual program with the highest level of service that you have come to expect from CHEST and respect for our member’s time and current situation. I know Dr. Victor Test and the program committee will deliver a superb educational experience in a virtual meeting setting. Thank you for your support and understanding as we continue to evolve our events to meet the needs of our members while adapting to the best delivery methods.

Since so many fellows were unable to hold their live graduation events, and celebrations, we decided to send them off with a virtual event! On June 30 we held a Joint CHEST/ATS Respiratory Community Graduation Ceremony–for graduating fellows, and to welcome new fellows to our profession. The ceremony consisted of a combination of live and recorded messages from key leaders from both organizations. In addition, there was a keynote address from Dr. Rana Awdish, a critical care physician at Henry Ford Hospital in Detroit, who authored the bestselling book “In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope.” I encourage you to watch the video on the Early Career Professionals page on our Chestnet.org website.

The National Association for Medical Direction of Respiratory Care (NAMDRC) merger with CHEST was finalized at the end of May. Look for more advocacy-related actions coming from CHEST. The newly formed Health Policy and Advocacy Committee is helping to set CHEST’s advocacy agendas in the legislative and regulatory arenas, engaging with policymakers and educating CHEST members on governmental affairs relevant to CHEST’s mission. Did you see the inaugural CHEST published, on-line issue of Washington Watchline, a newsletter that aims to keep CHEST members informed about governmental activities that affect physicians who provide clinical care in respiratory, critical care, and sleep medicine? Follow Washington Watchline to learn more about CHEST’s advocacy around regulatory, legislative, and payment issues that relate to the delivery of health care in support of CHEST’s mission. One of the features was Telemedicine, which many of us are now using and is likely to be a part of many of our practices going forward.

With new COVID-19 surges throughout many parts of the United States, CHEST has continued our volunteer matching program for areas of need, including to the Navaho Nations, where CHEST matched 20 volunteers and has had more than a half-dozen inquiries from our members. In addition, in conjunction with the Foundation, CHEST has partnered with American Mask Rally and started a campaign to distribute masks to frontline essential workers in underserved communities. CHEST received a generous donation from AstraZeneca and Glaxo Smith Kline to help in the global fight against COVID-19 to provide current and accurate information and education to frontline clinicians to allow them to provide the best patient outcomes. CHEST also partnered with the American Thoracic Society to launch a joint PSA/ media campaign entitled For My Lung Health Campaign, to provide credible resources for underserved Black and Latino communities, as these communities are disproportionally affected by COVID-19. At the time of this writing, over a million people have seen the related video, featuring tips for taking control of one’s health in these difficult and uncertain times.

So, in closing, thank you all for what you do in these challenging times. 2020 will certainly be a year to remember! Stay safe and stay well!

Stephanie




 

Dear Colleagues,

We are now near 6 months into living with COVID-19. In Texas, we are experiencing the surge that much of the Northeast saw in March and April. The COVID-19 Task Force led by Dr. Steve Simpson (CHEST President-Elect) and with representation from the Critical Care, Chest Infections, and Disaster Response and Global Health NetWorks continues to meet regularly to keep our members updated on the latest research and rapidly changing clinical management of COVID-19 illness and the sequelae. COVID-19 has put our medical profession and our subspecialty under considerable stress, and CHEST has launched a new longitudinal Wellness Center led by Dr. Alex Niven, from Mayo Clinic, Rochester. These new resources will feature a wellness webinar series focused on mental health and wellness for clinicians during COVID-19 and beyond. CHEST received overwhelming positive feedback from members and attendees to the Women & Pulmonary Virtual Happy Hour that focused on sharing stories and building community. Many leaders have suggested other such topics and efforts that may be useful to the CHEST community. The CHEST Wellness Center will launch on July 15.

In addition to COVID-19 activities, our nation and the world have compelled a new powerful look at race relations, disparities, and diversity. I represented CHEST at a “White Coats for Black Lives” event in San Antonio. Following our nation’s call for racial equality, CHEST released a Statement of Equity that received overwhelmingly positive feedback and response from members via email and on social media. This statement clearly resonated with the CHEST community. We are asking our leadership and members to consider ways in which CHEST might continue to raise awareness and continue with efforts related to diversity and equity. CHEST also hosted an excellent webinar moderated by Dr. Demondes Haynes and Dr. Nneka Sederstrom in late June that offered a direct and meaningful dialogue on issues facing clinicians and patients of color, and the responsibility of those in leadership positions. CHEST leadership stand firm that racism and inequality are public health issues and are working to define how we further our efforts in this arena.

On June 17, CHEST held a 1-day Virtual CHEST Congress in conjunction with our the CHEST Italian Delegation, as COVID-19 prevented us from safely holding the live Congress in Bologna. We had 3,250 registered attendees. I was so impressed at what a virtual platform can deliver, complete with great educational sessions, including much on COVID-19, as well as capturing the CHEST experience with games, bocce, jeopardy etc! This gave CHEST an opportunity to explore further virtual-based education to reach our wider global audience. CHEST will still be holding an in-person Congress in Bologna, June 24-26, 2021.

CHEST will host three entirely virtual Board Review Courses this August in the areas of Pulmonary, Critical Care, and Pediatric Pulmonary Medicine. These courses will include a combination of pre-recorded lectures and live, interactive sessions. Audience response systems and SEEK questions will still be utilized. There’s still time to register, so don’t miss it! With time being a major commodity at present, all attendees will receive year-long access to all material!

I know you have been wondering about CHEST 2020, and as you have heard by now, CHEST 2020 in Chicago will be a virtual meeting. I am sure that this announcement came as no big surprise, but is certainly disappointing. As you can imagine this was a difficult decision, but one that was necessary based upon our new reality. It was compounded by limitations on the convention center venue under the Illinois reopening plan, and the fact that a large number of our faculty, as well as our attendees, are under a travel ban for the remainder of 2020 that will not allow them to travel to Chicago. The abstract and case report deadline closed June 1, and despite these circumstances, we saw our highest number of submissions to date! Late abstracts were due on July 17. We will be presenting standalone and complementary online offerings to ensure seamless delivery of critical education in formats that cater easily to our newly formed habits.

Thanks to our dedicated Scientific Program Committee Chair, Dr. Victor Test, and staff, we had already begun preparing for virtual CHEST Annual Meeting 2020. Here’s what you can expect:

• A memorable experience

• A highly interactive education program that includes audience Q&A, discussion threads, and audience response systems

• Opportunities for one-on-one discussions, networking, and access to faculty

• Industry-sponsored programs and a virtual exhibit hall

• Access to hundreds of narrated poster presentations, case reports, and research abstracts

• Competitive educational gaming where attendees can participate, win, or watch

• Dedicated COVID-19 update sessions

• CME and MOC credits

If you have already registered for CHEST 2020, you will have the option to transfer your registration to this new model. Our main focus is delivering the virtual program with the highest level of service that you have come to expect from CHEST and respect for our member’s time and current situation. I know Dr. Victor Test and the program committee will deliver a superb educational experience in a virtual meeting setting. Thank you for your support and understanding as we continue to evolve our events to meet the needs of our members while adapting to the best delivery methods.

Since so many fellows were unable to hold their live graduation events, and celebrations, we decided to send them off with a virtual event! On June 30 we held a Joint CHEST/ATS Respiratory Community Graduation Ceremony–for graduating fellows, and to welcome new fellows to our profession. The ceremony consisted of a combination of live and recorded messages from key leaders from both organizations. In addition, there was a keynote address from Dr. Rana Awdish, a critical care physician at Henry Ford Hospital in Detroit, who authored the bestselling book “In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope.” I encourage you to watch the video on the Early Career Professionals page on our Chestnet.org website.

The National Association for Medical Direction of Respiratory Care (NAMDRC) merger with CHEST was finalized at the end of May. Look for more advocacy-related actions coming from CHEST. The newly formed Health Policy and Advocacy Committee is helping to set CHEST’s advocacy agendas in the legislative and regulatory arenas, engaging with policymakers and educating CHEST members on governmental affairs relevant to CHEST’s mission. Did you see the inaugural CHEST published, on-line issue of Washington Watchline, a newsletter that aims to keep CHEST members informed about governmental activities that affect physicians who provide clinical care in respiratory, critical care, and sleep medicine? Follow Washington Watchline to learn more about CHEST’s advocacy around regulatory, legislative, and payment issues that relate to the delivery of health care in support of CHEST’s mission. One of the features was Telemedicine, which many of us are now using and is likely to be a part of many of our practices going forward.

With new COVID-19 surges throughout many parts of the United States, CHEST has continued our volunteer matching program for areas of need, including to the Navaho Nations, where CHEST matched 20 volunteers and has had more than a half-dozen inquiries from our members. In addition, in conjunction with the Foundation, CHEST has partnered with American Mask Rally and started a campaign to distribute masks to frontline essential workers in underserved communities. CHEST received a generous donation from AstraZeneca and Glaxo Smith Kline to help in the global fight against COVID-19 to provide current and accurate information and education to frontline clinicians to allow them to provide the best patient outcomes. CHEST also partnered with the American Thoracic Society to launch a joint PSA/ media campaign entitled For My Lung Health Campaign, to provide credible resources for underserved Black and Latino communities, as these communities are disproportionally affected by COVID-19. At the time of this writing, over a million people have seen the related video, featuring tips for taking control of one’s health in these difficult and uncertain times.

So, in closing, thank you all for what you do in these challenging times. 2020 will certainly be a year to remember! Stay safe and stay well!

Stephanie




 

Dear Colleagues,

We are now near 6 months into living with COVID-19. In Texas, we are experiencing the surge that much of the Northeast saw in March and April. The COVID-19 Task Force led by Dr. Steve Simpson (CHEST President-Elect) and with representation from the Critical Care, Chest Infections, and Disaster Response and Global Health NetWorks continues to meet regularly to keep our members updated on the latest research and rapidly changing clinical management of COVID-19 illness and the sequelae. COVID-19 has put our medical profession and our subspecialty under considerable stress, and CHEST has launched a new longitudinal Wellness Center led by Dr. Alex Niven, from Mayo Clinic, Rochester. These new resources will feature a wellness webinar series focused on mental health and wellness for clinicians during COVID-19 and beyond. CHEST received overwhelming positive feedback from members and attendees to the Women & Pulmonary Virtual Happy Hour that focused on sharing stories and building community. Many leaders have suggested other such topics and efforts that may be useful to the CHEST community. The CHEST Wellness Center will launch on July 15.

In addition to COVID-19 activities, our nation and the world have compelled a new powerful look at race relations, disparities, and diversity. I represented CHEST at a “White Coats for Black Lives” event in San Antonio. Following our nation’s call for racial equality, CHEST released a Statement of Equity that received overwhelmingly positive feedback and response from members via email and on social media. This statement clearly resonated with the CHEST community. We are asking our leadership and members to consider ways in which CHEST might continue to raise awareness and continue with efforts related to diversity and equity. CHEST also hosted an excellent webinar moderated by Dr. Demondes Haynes and Dr. Nneka Sederstrom in late June that offered a direct and meaningful dialogue on issues facing clinicians and patients of color, and the responsibility of those in leadership positions. CHEST leadership stand firm that racism and inequality are public health issues and are working to define how we further our efforts in this arena.

On June 17, CHEST held a 1-day Virtual CHEST Congress in conjunction with our the CHEST Italian Delegation, as COVID-19 prevented us from safely holding the live Congress in Bologna. We had 3,250 registered attendees. I was so impressed at what a virtual platform can deliver, complete with great educational sessions, including much on COVID-19, as well as capturing the CHEST experience with games, bocce, jeopardy etc! This gave CHEST an opportunity to explore further virtual-based education to reach our wider global audience. CHEST will still be holding an in-person Congress in Bologna, June 24-26, 2021.

CHEST will host three entirely virtual Board Review Courses this August in the areas of Pulmonary, Critical Care, and Pediatric Pulmonary Medicine. These courses will include a combination of pre-recorded lectures and live, interactive sessions. Audience response systems and SEEK questions will still be utilized. There’s still time to register, so don’t miss it! With time being a major commodity at present, all attendees will receive year-long access to all material!

I know you have been wondering about CHEST 2020, and as you have heard by now, CHEST 2020 in Chicago will be a virtual meeting. I am sure that this announcement came as no big surprise, but is certainly disappointing. As you can imagine this was a difficult decision, but one that was necessary based upon our new reality. It was compounded by limitations on the convention center venue under the Illinois reopening plan, and the fact that a large number of our faculty, as well as our attendees, are under a travel ban for the remainder of 2020 that will not allow them to travel to Chicago. The abstract and case report deadline closed June 1, and despite these circumstances, we saw our highest number of submissions to date! Late abstracts were due on July 17. We will be presenting standalone and complementary online offerings to ensure seamless delivery of critical education in formats that cater easily to our newly formed habits.

Thanks to our dedicated Scientific Program Committee Chair, Dr. Victor Test, and staff, we had already begun preparing for virtual CHEST Annual Meeting 2020. Here’s what you can expect:

• A memorable experience

• A highly interactive education program that includes audience Q&A, discussion threads, and audience response systems

• Opportunities for one-on-one discussions, networking, and access to faculty

• Industry-sponsored programs and a virtual exhibit hall

• Access to hundreds of narrated poster presentations, case reports, and research abstracts

• Competitive educational gaming where attendees can participate, win, or watch

• Dedicated COVID-19 update sessions

• CME and MOC credits

If you have already registered for CHEST 2020, you will have the option to transfer your registration to this new model. Our main focus is delivering the virtual program with the highest level of service that you have come to expect from CHEST and respect for our member’s time and current situation. I know Dr. Victor Test and the program committee will deliver a superb educational experience in a virtual meeting setting. Thank you for your support and understanding as we continue to evolve our events to meet the needs of our members while adapting to the best delivery methods.

Since so many fellows were unable to hold their live graduation events, and celebrations, we decided to send them off with a virtual event! On June 30 we held a Joint CHEST/ATS Respiratory Community Graduation Ceremony–for graduating fellows, and to welcome new fellows to our profession. The ceremony consisted of a combination of live and recorded messages from key leaders from both organizations. In addition, there was a keynote address from Dr. Rana Awdish, a critical care physician at Henry Ford Hospital in Detroit, who authored the bestselling book “In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope.” I encourage you to watch the video on the Early Career Professionals page on our Chestnet.org website.

The National Association for Medical Direction of Respiratory Care (NAMDRC) merger with CHEST was finalized at the end of May. Look for more advocacy-related actions coming from CHEST. The newly formed Health Policy and Advocacy Committee is helping to set CHEST’s advocacy agendas in the legislative and regulatory arenas, engaging with policymakers and educating CHEST members on governmental affairs relevant to CHEST’s mission. Did you see the inaugural CHEST published, on-line issue of Washington Watchline, a newsletter that aims to keep CHEST members informed about governmental activities that affect physicians who provide clinical care in respiratory, critical care, and sleep medicine? Follow Washington Watchline to learn more about CHEST’s advocacy around regulatory, legislative, and payment issues that relate to the delivery of health care in support of CHEST’s mission. One of the features was Telemedicine, which many of us are now using and is likely to be a part of many of our practices going forward.

With new COVID-19 surges throughout many parts of the United States, CHEST has continued our volunteer matching program for areas of need, including to the Navaho Nations, where CHEST matched 20 volunteers and has had more than a half-dozen inquiries from our members. In addition, in conjunction with the Foundation, CHEST has partnered with American Mask Rally and started a campaign to distribute masks to frontline essential workers in underserved communities. CHEST received a generous donation from AstraZeneca and Glaxo Smith Kline to help in the global fight against COVID-19 to provide current and accurate information and education to frontline clinicians to allow them to provide the best patient outcomes. CHEST also partnered with the American Thoracic Society to launch a joint PSA/ media campaign entitled For My Lung Health Campaign, to provide credible resources for underserved Black and Latino communities, as these communities are disproportionally affected by COVID-19. At the time of this writing, over a million people have seen the related video, featuring tips for taking control of one’s health in these difficult and uncertain times.

So, in closing, thank you all for what you do in these challenging times. 2020 will certainly be a year to remember! Stay safe and stay well!

Stephanie




 

The benefits of continuous positive airway pressure therapy for patients with obstructive sleep apnea are well documented, but it only works if patients can adhere to the therapy.

A large national study of older Medicare patients with obstructive sleep apnea (OSA) has identified lower socioeconomic status and comorbidities as independent risk factors for nonadherence to continuous positive airway pressure (CPAP) therapy.

“[The] present results represent the largest study to date of rates and predictors of CPAP adherence among older adults in the United States. In our national sample of Medicare beneficiaries, adherence rates were generally lower than previously reported in smaller, clinic-based studies,” Emerson M. Wickwire, PhD, of the Sleep Disorders Center and division of pulmonary and critical care medicine at the University of Maryland, Baltimore, and colleagues wrote in Sleep.

Dr. Wickwire and colleagues estimated CPAP machine adherence using a 5% sample of Medicare claims data, identifying 3,229 Medicare beneficiaries with OSA who began CPAP therapy between 2009 and 2011. Individuals in the sample were aged at least 65 years with a new diagnosis of OSA, 88.1% of beneficiaries were white, and 52.3% were male.

The researchers applied objective adherence criteria set by the Centers for Medicare & Medicaid Services, which defines CPAP adherence as a patient using CPAP for at least 4 hours on 70% of nights, or CPAP use for 21 of 30 consecutive days within 90 days after beginning therapy.

Using CPAP machine charges as a measure of who adhered to therapy, they found 1,420 of 3,229 individuals (44%) achieved adherence under these criteria, which included making 13 monthly payments during their CPAP machine’s “rent-to-own” period. Partial adherence was found in 997 individuals (30.9%) who made between 4-12 payments on their CPAP machine, while 812 individuals (25.2%) made 4 payments or fewer on their CPAP machines, which the researchers classified as nonadherence. Nonadherers tended to be slightly younger (mean, 72.5 years vs. 79.2 years; P < .001) and had a higher number of comorbidities (35.2% vs. 30.4%; P = .002), compared with individuals with high adherence. Anxiety (odds ratio, 1.34; 95% confidence interval, 1.12-1.61), anemia (OR, 1.16; 95% CI, 1.02-1.32), fibromyalgia (OR, 1.19; 95% CI, 1.03-1.38), traumatic brain injury (OR, 1.58; 95% CI, 1.21-2.07), and Medicaid eligibility (OR, 1.48; 95% CI, 1.24-1.75) were all independently associated with lower CPAP adherence. Medicaid eligibility was considered an indicator of lower socioeconomic status.

Krishna M. Sundar, MD, FCCP, director at the Sleep-Wake Center in the University of Utah pulmonary division in Salt Lake City and CHEST Physician editorial board member, said in an interview that studies have shown early signs of adherence within the first few weeks are an important indicator of overall adherence to CPAP therapy. However, the use of CPAP machine payments in the study by Dr. Wickwire and colleagues was a novel way to track adherence.

Some of the issues with nonadherence may be related to challenges in using the technology, but it is the clinician’s role to communicate with patients about the effectiveness of CPAP and identifying reasons for nonadherence while also attempting to tease out the subtle socioeconomic factors related to nonadherence, Dr. Sundar noted. “We need to alter our practice to make sure that we communicate with these patients and better understand what are the social factors in getting the CPAP or utilizing CPAP, and also following these patients more closely, especially in the first month of starting CPAP therapy.

“Just because somebody has severe sleep apnea and other comorbid conditions does not mean that they’re going to wear the CPAP,” he said. “So, the fact that socioeconomic factors play an equal if not more important role in terms of predicting CPAP adherence. That is an important takeaway.”

Octavian C. Ioachimescu, MD, FCCP, of Emory University, Atlanta, and the Atlanta Veteran Affairs Administration and CHEST Physician editorial board member, said in an interview that the study raises a major question of what is next. “What can we offer to these patients, and what is the real-world compliance to that ‘next-best’ modality?” Dr. Ioachimescu said. “What are the outcomes of these individuals in the point-of-care environment, or ‘real world?’ ”

The analysis by the authors adds the perspective of a “real-world depiction of clinical care for patients with OSA,” Dr. Ioachimescu said. “One major lesson of such an analysis is that the health care goal setting that is referential to initial, randomized, well-controlled studies on highly selected patient populations need to be reassessed periodically from the point of view of actual results in the clinics.”

Clinicians may need to borrow ideas from other therapeutic fields to help improve patient adherence, he said. “[W]e may be able to develop and implement in the future peer involvement, behavioral and cognitive approaches, motivational enhancement interventions, as well as elements of acceptance and commitment techniques, all in the larger context of more integrated and in the same time individualized approaches to therapy.”

The investigators concluded that, “relative to Medicare-only beneficiaries, those eligible for both Medicare and Medicaid were significantly less likely to adhere to CPAP. Future research should seek to develop a deeper understanding of the mechanisms through which [socioeconomic status] and other social determinants impact patient experience throughout the OSA diagnostic and treatment process, including receiving, acclimating, and adhering to CPAP therapy.”

Dr. Sundar concurred with this assessment and said more research is needed on factors impacting adherence such as poverty, homelessness, and home support systems. “It’s not just coordinating with the patient. Clearly, more work is needed in understanding the social aspects of CPAP adherence.”

This study was funded in part by an investigator-initiated grant provided by ResMed to Dr. Wickmire’s institution, the University of Maryland, Baltimore. Dr. Wickmire reported being a scientific consultant to DayZz, Eisai, Merck, and Purdue and holds shares in WellTap. Dr. Oldstone is a ResMed employee and shareholder. Dr. Sundar reported being a cofounder of Hypnoscure, which creates software for population management of sleep apnea, and an investigator in trials where ResMed and Respironics devices were used. Dr. Ioachimescu reported no relevant financial disclosures.

SOURCE: Wickwire EM et al. Sleep. 2020 Jun 23. doi: 10.1093/sleep/zsaa122.

The benefits of continuous positive airway pressure therapy for patients with obstructive sleep apnea are well documented, but it only works if patients can adhere to the therapy.

A large national study of older Medicare patients with obstructive sleep apnea (OSA) has identified lower socioeconomic status and comorbidities as independent risk factors for nonadherence to continuous positive airway pressure (CPAP) therapy.

“[The] present results represent the largest study to date of rates and predictors of CPAP adherence among older adults in the United States. In our national sample of Medicare beneficiaries, adherence rates were generally lower than previously reported in smaller, clinic-based studies,” Emerson M. Wickwire, PhD, of the Sleep Disorders Center and division of pulmonary and critical care medicine at the University of Maryland, Baltimore, and colleagues wrote in Sleep.

Dr. Wickwire and colleagues estimated CPAP machine adherence using a 5% sample of Medicare claims data, identifying 3,229 Medicare beneficiaries with OSA who began CPAP therapy between 2009 and 2011. Individuals in the sample were aged at least 65 years with a new diagnosis of OSA, 88.1% of beneficiaries were white, and 52.3% were male.

The researchers applied objective adherence criteria set by the Centers for Medicare & Medicaid Services, which defines CPAP adherence as a patient using CPAP for at least 4 hours on 70% of nights, or CPAP use for 21 of 30 consecutive days within 90 days after beginning therapy.

Using CPAP machine charges as a measure of who adhered to therapy, they found 1,420 of 3,229 individuals (44%) achieved adherence under these criteria, which included making 13 monthly payments during their CPAP machine’s “rent-to-own” period. Partial adherence was found in 997 individuals (30.9%) who made between 4-12 payments on their CPAP machine, while 812 individuals (25.2%) made 4 payments or fewer on their CPAP machines, which the researchers classified as nonadherence. Nonadherers tended to be slightly younger (mean, 72.5 years vs. 79.2 years; P < .001) and had a higher number of comorbidities (35.2% vs. 30.4%; P = .002), compared with individuals with high adherence. Anxiety (odds ratio, 1.34; 95% confidence interval, 1.12-1.61), anemia (OR, 1.16; 95% CI, 1.02-1.32), fibromyalgia (OR, 1.19; 95% CI, 1.03-1.38), traumatic brain injury (OR, 1.58; 95% CI, 1.21-2.07), and Medicaid eligibility (OR, 1.48; 95% CI, 1.24-1.75) were all independently associated with lower CPAP adherence. Medicaid eligibility was considered an indicator of lower socioeconomic status.

Krishna M. Sundar, MD, FCCP, director at the Sleep-Wake Center in the University of Utah pulmonary division in Salt Lake City and CHEST Physician editorial board member, said in an interview that studies have shown early signs of adherence within the first few weeks are an important indicator of overall adherence to CPAP therapy. However, the use of CPAP machine payments in the study by Dr. Wickwire and colleagues was a novel way to track adherence.

Some of the issues with nonadherence may be related to challenges in using the technology, but it is the clinician’s role to communicate with patients about the effectiveness of CPAP and identifying reasons for nonadherence while also attempting to tease out the subtle socioeconomic factors related to nonadherence, Dr. Sundar noted. “We need to alter our practice to make sure that we communicate with these patients and better understand what are the social factors in getting the CPAP or utilizing CPAP, and also following these patients more closely, especially in the first month of starting CPAP therapy.

“Just because somebody has severe sleep apnea and other comorbid conditions does not mean that they’re going to wear the CPAP,” he said. “So, the fact that socioeconomic factors play an equal if not more important role in terms of predicting CPAP adherence. That is an important takeaway.”

Octavian C. Ioachimescu, MD, FCCP, of Emory University, Atlanta, and the Atlanta Veteran Affairs Administration and CHEST Physician editorial board member, said in an interview that the study raises a major question of what is next. “What can we offer to these patients, and what is the real-world compliance to that ‘next-best’ modality?” Dr. Ioachimescu said. “What are the outcomes of these individuals in the point-of-care environment, or ‘real world?’ ”

The analysis by the authors adds the perspective of a “real-world depiction of clinical care for patients with OSA,” Dr. Ioachimescu said. “One major lesson of such an analysis is that the health care goal setting that is referential to initial, randomized, well-controlled studies on highly selected patient populations need to be reassessed periodically from the point of view of actual results in the clinics.”

Clinicians may need to borrow ideas from other therapeutic fields to help improve patient adherence, he said. “[W]e may be able to develop and implement in the future peer involvement, behavioral and cognitive approaches, motivational enhancement interventions, as well as elements of acceptance and commitment techniques, all in the larger context of more integrated and in the same time individualized approaches to therapy.”

The investigators concluded that, “relative to Medicare-only beneficiaries, those eligible for both Medicare and Medicaid were significantly less likely to adhere to CPAP. Future research should seek to develop a deeper understanding of the mechanisms through which [socioeconomic status] and other social determinants impact patient experience throughout the OSA diagnostic and treatment process, including receiving, acclimating, and adhering to CPAP therapy.”

Dr. Sundar concurred with this assessment and said more research is needed on factors impacting adherence such as poverty, homelessness, and home support systems. “It’s not just coordinating with the patient. Clearly, more work is needed in understanding the social aspects of CPAP adherence.”

This study was funded in part by an investigator-initiated grant provided by ResMed to Dr. Wickmire’s institution, the University of Maryland, Baltimore. Dr. Wickmire reported being a scientific consultant to DayZz, Eisai, Merck, and Purdue and holds shares in WellTap. Dr. Oldstone is a ResMed employee and shareholder. Dr. Sundar reported being a cofounder of Hypnoscure, which creates software for population management of sleep apnea, and an investigator in trials where ResMed and Respironics devices were used. Dr. Ioachimescu reported no relevant financial disclosures.

SOURCE: Wickwire EM et al. Sleep. 2020 Jun 23. doi: 10.1093/sleep/zsaa122.

The benefits of continuous positive airway pressure therapy for patients with obstructive sleep apnea are well documented, but it only works if patients can adhere to the therapy.

A large national study of older Medicare patients with obstructive sleep apnea (OSA) has identified lower socioeconomic status and comorbidities as independent risk factors for nonadherence to continuous positive airway pressure (CPAP) therapy.

“[The] present results represent the largest study to date of rates and predictors of CPAP adherence among older adults in the United States. In our national sample of Medicare beneficiaries, adherence rates were generally lower than previously reported in smaller, clinic-based studies,” Emerson M. Wickwire, PhD, of the Sleep Disorders Center and division of pulmonary and critical care medicine at the University of Maryland, Baltimore, and colleagues wrote in Sleep.

Dr. Wickwire and colleagues estimated CPAP machine adherence using a 5% sample of Medicare claims data, identifying 3,229 Medicare beneficiaries with OSA who began CPAP therapy between 2009 and 2011. Individuals in the sample were aged at least 65 years with a new diagnosis of OSA, 88.1% of beneficiaries were white, and 52.3% were male.

The researchers applied objective adherence criteria set by the Centers for Medicare & Medicaid Services, which defines CPAP adherence as a patient using CPAP for at least 4 hours on 70% of nights, or CPAP use for 21 of 30 consecutive days within 90 days after beginning therapy.

Using CPAP machine charges as a measure of who adhered to therapy, they found 1,420 of 3,229 individuals (44%) achieved adherence under these criteria, which included making 13 monthly payments during their CPAP machine’s “rent-to-own” period. Partial adherence was found in 997 individuals (30.9%) who made between 4-12 payments on their CPAP machine, while 812 individuals (25.2%) made 4 payments or fewer on their CPAP machines, which the researchers classified as nonadherence. Nonadherers tended to be slightly younger (mean, 72.5 years vs. 79.2 years; P < .001) and had a higher number of comorbidities (35.2% vs. 30.4%; P = .002), compared with individuals with high adherence. Anxiety (odds ratio, 1.34; 95% confidence interval, 1.12-1.61), anemia (OR, 1.16; 95% CI, 1.02-1.32), fibromyalgia (OR, 1.19; 95% CI, 1.03-1.38), traumatic brain injury (OR, 1.58; 95% CI, 1.21-2.07), and Medicaid eligibility (OR, 1.48; 95% CI, 1.24-1.75) were all independently associated with lower CPAP adherence. Medicaid eligibility was considered an indicator of lower socioeconomic status.

Krishna M. Sundar, MD, FCCP, director at the Sleep-Wake Center in the University of Utah pulmonary division in Salt Lake City and CHEST Physician editorial board member, said in an interview that studies have shown early signs of adherence within the first few weeks are an important indicator of overall adherence to CPAP therapy. However, the use of CPAP machine payments in the study by Dr. Wickwire and colleagues was a novel way to track adherence.

Some of the issues with nonadherence may be related to challenges in using the technology, but it is the clinician’s role to communicate with patients about the effectiveness of CPAP and identifying reasons for nonadherence while also attempting to tease out the subtle socioeconomic factors related to nonadherence, Dr. Sundar noted. “We need to alter our practice to make sure that we communicate with these patients and better understand what are the social factors in getting the CPAP or utilizing CPAP, and also following these patients more closely, especially in the first month of starting CPAP therapy.

“Just because somebody has severe sleep apnea and other comorbid conditions does not mean that they’re going to wear the CPAP,” he said. “So, the fact that socioeconomic factors play an equal if not more important role in terms of predicting CPAP adherence. That is an important takeaway.”

Octavian C. Ioachimescu, MD, FCCP, of Emory University, Atlanta, and the Atlanta Veteran Affairs Administration and CHEST Physician editorial board member, said in an interview that the study raises a major question of what is next. “What can we offer to these patients, and what is the real-world compliance to that ‘next-best’ modality?” Dr. Ioachimescu said. “What are the outcomes of these individuals in the point-of-care environment, or ‘real world?’ ”

The analysis by the authors adds the perspective of a “real-world depiction of clinical care for patients with OSA,” Dr. Ioachimescu said. “One major lesson of such an analysis is that the health care goal setting that is referential to initial, randomized, well-controlled studies on highly selected patient populations need to be reassessed periodically from the point of view of actual results in the clinics.”

Clinicians may need to borrow ideas from other therapeutic fields to help improve patient adherence, he said. “[W]e may be able to develop and implement in the future peer involvement, behavioral and cognitive approaches, motivational enhancement interventions, as well as elements of acceptance and commitment techniques, all in the larger context of more integrated and in the same time individualized approaches to therapy.”

The investigators concluded that, “relative to Medicare-only beneficiaries, those eligible for both Medicare and Medicaid were significantly less likely to adhere to CPAP. Future research should seek to develop a deeper understanding of the mechanisms through which [socioeconomic status] and other social determinants impact patient experience throughout the OSA diagnostic and treatment process, including receiving, acclimating, and adhering to CPAP therapy.”

Dr. Sundar concurred with this assessment and said more research is needed on factors impacting adherence such as poverty, homelessness, and home support systems. “It’s not just coordinating with the patient. Clearly, more work is needed in understanding the social aspects of CPAP adherence.”

This study was funded in part by an investigator-initiated grant provided by ResMed to Dr. Wickmire’s institution, the University of Maryland, Baltimore. Dr. Wickmire reported being a scientific consultant to DayZz, Eisai, Merck, and Purdue and holds shares in WellTap. Dr. Oldstone is a ResMed employee and shareholder. Dr. Sundar reported being a cofounder of Hypnoscure, which creates software for population management of sleep apnea, and an investigator in trials where ResMed and Respironics devices were used. Dr. Ioachimescu reported no relevant financial disclosures.

SOURCE: Wickwire EM et al. Sleep. 2020 Jun 23. doi: 10.1093/sleep/zsaa122.