ColCORONA: More questions than answers for colchicine in COVID-19

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Changed
Thu, 08/26/2021 - 15:51

Science by press release and preprint has cooled clinician enthusiasm for the use of colchicine in nonhospitalized patients with COVID-19, despite a pressing need for early treatments.

Photo by Jimmy Hamelin
Dr. Jean Claude Tardif

As previously reported by this news organization, a Jan. 22 press release announced that the massive ColCORONA study missed its primary endpoint of hospitalization or death among 4,488 newly diagnosed patients at increased risk for hospitalization.

But it also touted that use of the anti-inflammatory drug significantly reduced the primary endpoint in 4,159 of those patients with polymerase chain reaction–confirmed COVID and led to reductions of 25%, 50%, and 44%, respectively, for hospitalizations, ventilations, and death.

Lead investigator Jean-Claude Tardif, MD, director of the Montreal Heart Institute Research Centre, deemed the findings a “medical breakthrough.”

When the preprint released a few days later, however, newly revealed confidence intervals showed colchicine did not meaningfully reduce the need for mechanical ventilation (odds ratio, 0.50; 95% confidence interval, 0.23-1.07) or death alone (OR, 0.56; 95% CI, 0.19-1.66).

Further, the significant benefit on the primary outcome came at the cost of a fivefold increase in pulmonary embolism (11 vs. 2; P = .01), which was not mentioned in the press release.

“Whether this represents a real phenomenon or simply the play of chance is not known,” Dr. Tardif and colleagues noted later in the preprint.

Dr. Aaron Glatt

“I read the preprint on colchicine and I have so many questions,” Aaron E. Glatt, MD, spokesperson for the Infectious Diseases Society of America and chief of infectious diseases, Mount Sinai South Nassau, Hewlett, N.Y., said in an interview. “I’ve been burned too many times with COVID and prefer to see better data.

“People sometimes say if you wait for perfect data, people are going to die,” he said. “Yeah, but we have no idea if people are going to die from getting this drug more than not getting it. That’s what concerns me. How many pulmonary emboli are going to be fatal versus the slight benefit that the study showed?”

The pushback to the non–peer-reviewed data on social media and via emails was so strong that Dr. Tardif posted a nearly 2,000-word letter responding to the many questions at play.

Chief among them was why the trial, originally planned for 6,000 patients, was stopped early by the investigators without consultation with the data safety monitoring board (DSMB).

The explanation in the letter that logistical issues like running the study call center, budget constraints, and a perceived need to quickly communicate the results left some calling foul that the study wasn’t allowed to finish and come to a more definitive conclusion.

“I can be a little bit sympathetic to their cause but at the same time the DSMB should have said no,” said David Boulware, MD, MPH, who led a recent hydroxychloroquine trial in COVID-19. “The problem is we’re sort of left in limbo, where some people kind of believe it and some say it’s not really a thing. So it’s not really moving the needle, as far as guidelines go.”

Dr. James L. Januzzi

Indeed, a Twitter poll by cardiologist James Januzzi Jr., MD, captured the uncertainty, with 28% of respondents saying the trial was “neutral,” 58% saying “maybe but meh,” and 14% saying “colchicine for all.”

Another poll cheekily asked whether ColCORONA was the Gamestop/Reddit equivalent of COVID.

“The press release really didn’t help things because it very much oversold the effect. That, I think, poisoned the well,” said Dr. Boulware, professor of medicine in infectious diseases at the University of Minnesota, Minneapolis.

“The question I’m left with is not whether colchicine works, but who does it work in,” he said. “That’s really the fundamental question because it does seem that there are probably high-risk groups in their trial and others where they benefit, whereas other groups don’t benefit. In the subgroup analysis, there was absolutely no beneficial effect in women.”

According to the authors, the number needed to treat to prevent one death or hospitalization was 71 overall, but 29 for patients with diabetes, 31 for those aged 70 years and older, 53 for patients with respiratory disease, and 25 for those with coronary disease or heart failure.

Men are at higher risk overall for poor outcomes. But “the authors didn’t present a multivariable analysis, so it is unclear if another factor, such as a differential prevalence of smoking or cardiovascular risk factors, contributed to the differential benefit,” Rachel Bender Ignacio, MD, MPH, infectious disease specialist, University of Washington, Seattle, said in an interview.

Importantly, in this pragmatic study, duration and severity of symptoms were not reported, observed Dr. Bender Ignacio, who is also a STOP-COVID-2 investigator. “We don’t yet have data as to whether colchicine shortens duration or severity of symptoms or prevents long COVID, so we need more data on that.”

The overall risk for serious adverse events was lower in the colchicine group, but the difference in pulmonary embolism (PE) was striking, she said. This could be caused by a real biologic effect, or it’s possible that persons with shortness of breath and hypoxia, without evident viral pneumonia on chest x-ray after a positive COVID-19 test, were more likely to receive a CT-PE study.

The press release also failed to include information, later noted in the preprint, that the MHI has submitted two patents related to colchicine: “Methods of treating a coronavirus infection using colchicine” and “Early administration of low-dose colchicine after myocardial infarction.”

Reached for clarification, MHI communications adviser Camille Turbide said in an interview that the first patent “simply refers to the novel concept of preventing complications of COVID-19, such as admission to the hospital, with colchicine as tested in the ColCORONA study.”

The second patent, she said, refers to the “novel concept that administering colchicine early after a major adverse cardiovascular event is better than waiting several days,” as supported by the COLCOT study, which Dr. Tardif also led.

The patents are being reviewed by authorities and “Dr. Tardif has waived his rights in these patents and does not stand to benefit financially at all if colchicine becomes used as a treatment for COVID-19,” Ms. Turbide said.

Dr. Tardif did not respond to interview requests for this story. Dr. Glatt said conflicts of interest must be assessed and are “something that is of great concern in any scientific study.”

Cardiologist Steve Nissen, MD, of the Cleveland Clinic said in an interview that, “despite the negative results, the study does suggest that colchicine might have a benefit and should be studied in future trials. These findings are not sufficient evidence to suggest use of the drug in patients infected with COVID-19.”

He noted that adverse effects like diarrhea were expected but that the excess PE was unexpected and needs greater clarification.

“Stopping the trial for administrative reasons is puzzling and undermined the ability of the trial to give a reliable answer,” Dr. Nissen said. “This is a reasonable pilot study that should be viewed as hypothesis generating but inconclusive.”

Several sources said a new trial is unlikely, particularly given the cost and 28 trials already evaluating colchicine. Among these are RECOVERY and COLCOVID, testing whether colchicine can reduce the duration of hospitalization or death in hospitalized patients with COVID-19.

Because there are so many trials ongoing right now, including for antivirals and other immunomodulators, it’s important that, if colchicine comes to routine clinical use, it provides access to treatment for those not able or willing to access clinical trials, rather than impeding clinical trial enrollment, Dr. Bender Ignacio suggested.

“We have already learned the lesson in the pandemic that early adoption of potentially promising therapies can negatively impact our ability to study and develop other promising treatments,” she said.

The trial was coordinated by the Montreal Heart Institute and funded by the government of Quebec; the National Heart, Lung, and Blood Institute of the National Institutes of Health; Montreal philanthropist Sophie Desmarais, and the COVID-19 Therapeutics Accelerator launched by the Bill & Melinda Gates Foundation, Wellcome, and Mastercard. CGI, Dacima, and Pharmascience of Montreal were also collaborators. Dr. Glatt reported no conflicts of interest. Dr. Boulware reported receiving $18 in food and beverages from Gilead Sciences in 2018.
 

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

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Science by press release and preprint has cooled clinician enthusiasm for the use of colchicine in nonhospitalized patients with COVID-19, despite a pressing need for early treatments.

Photo by Jimmy Hamelin
Dr. Jean Claude Tardif

As previously reported by this news organization, a Jan. 22 press release announced that the massive ColCORONA study missed its primary endpoint of hospitalization or death among 4,488 newly diagnosed patients at increased risk for hospitalization.

But it also touted that use of the anti-inflammatory drug significantly reduced the primary endpoint in 4,159 of those patients with polymerase chain reaction–confirmed COVID and led to reductions of 25%, 50%, and 44%, respectively, for hospitalizations, ventilations, and death.

Lead investigator Jean-Claude Tardif, MD, director of the Montreal Heart Institute Research Centre, deemed the findings a “medical breakthrough.”

When the preprint released a few days later, however, newly revealed confidence intervals showed colchicine did not meaningfully reduce the need for mechanical ventilation (odds ratio, 0.50; 95% confidence interval, 0.23-1.07) or death alone (OR, 0.56; 95% CI, 0.19-1.66).

Further, the significant benefit on the primary outcome came at the cost of a fivefold increase in pulmonary embolism (11 vs. 2; P = .01), which was not mentioned in the press release.

“Whether this represents a real phenomenon or simply the play of chance is not known,” Dr. Tardif and colleagues noted later in the preprint.

Dr. Aaron Glatt

“I read the preprint on colchicine and I have so many questions,” Aaron E. Glatt, MD, spokesperson for the Infectious Diseases Society of America and chief of infectious diseases, Mount Sinai South Nassau, Hewlett, N.Y., said in an interview. “I’ve been burned too many times with COVID and prefer to see better data.

“People sometimes say if you wait for perfect data, people are going to die,” he said. “Yeah, but we have no idea if people are going to die from getting this drug more than not getting it. That’s what concerns me. How many pulmonary emboli are going to be fatal versus the slight benefit that the study showed?”

The pushback to the non–peer-reviewed data on social media and via emails was so strong that Dr. Tardif posted a nearly 2,000-word letter responding to the many questions at play.

Chief among them was why the trial, originally planned for 6,000 patients, was stopped early by the investigators without consultation with the data safety monitoring board (DSMB).

The explanation in the letter that logistical issues like running the study call center, budget constraints, and a perceived need to quickly communicate the results left some calling foul that the study wasn’t allowed to finish and come to a more definitive conclusion.

“I can be a little bit sympathetic to their cause but at the same time the DSMB should have said no,” said David Boulware, MD, MPH, who led a recent hydroxychloroquine trial in COVID-19. “The problem is we’re sort of left in limbo, where some people kind of believe it and some say it’s not really a thing. So it’s not really moving the needle, as far as guidelines go.”

Dr. James L. Januzzi

Indeed, a Twitter poll by cardiologist James Januzzi Jr., MD, captured the uncertainty, with 28% of respondents saying the trial was “neutral,” 58% saying “maybe but meh,” and 14% saying “colchicine for all.”

Another poll cheekily asked whether ColCORONA was the Gamestop/Reddit equivalent of COVID.

“The press release really didn’t help things because it very much oversold the effect. That, I think, poisoned the well,” said Dr. Boulware, professor of medicine in infectious diseases at the University of Minnesota, Minneapolis.

“The question I’m left with is not whether colchicine works, but who does it work in,” he said. “That’s really the fundamental question because it does seem that there are probably high-risk groups in their trial and others where they benefit, whereas other groups don’t benefit. In the subgroup analysis, there was absolutely no beneficial effect in women.”

According to the authors, the number needed to treat to prevent one death or hospitalization was 71 overall, but 29 for patients with diabetes, 31 for those aged 70 years and older, 53 for patients with respiratory disease, and 25 for those with coronary disease or heart failure.

Men are at higher risk overall for poor outcomes. But “the authors didn’t present a multivariable analysis, so it is unclear if another factor, such as a differential prevalence of smoking or cardiovascular risk factors, contributed to the differential benefit,” Rachel Bender Ignacio, MD, MPH, infectious disease specialist, University of Washington, Seattle, said in an interview.

Importantly, in this pragmatic study, duration and severity of symptoms were not reported, observed Dr. Bender Ignacio, who is also a STOP-COVID-2 investigator. “We don’t yet have data as to whether colchicine shortens duration or severity of symptoms or prevents long COVID, so we need more data on that.”

The overall risk for serious adverse events was lower in the colchicine group, but the difference in pulmonary embolism (PE) was striking, she said. This could be caused by a real biologic effect, or it’s possible that persons with shortness of breath and hypoxia, without evident viral pneumonia on chest x-ray after a positive COVID-19 test, were more likely to receive a CT-PE study.

The press release also failed to include information, later noted in the preprint, that the MHI has submitted two patents related to colchicine: “Methods of treating a coronavirus infection using colchicine” and “Early administration of low-dose colchicine after myocardial infarction.”

Reached for clarification, MHI communications adviser Camille Turbide said in an interview that the first patent “simply refers to the novel concept of preventing complications of COVID-19, such as admission to the hospital, with colchicine as tested in the ColCORONA study.”

The second patent, she said, refers to the “novel concept that administering colchicine early after a major adverse cardiovascular event is better than waiting several days,” as supported by the COLCOT study, which Dr. Tardif also led.

The patents are being reviewed by authorities and “Dr. Tardif has waived his rights in these patents and does not stand to benefit financially at all if colchicine becomes used as a treatment for COVID-19,” Ms. Turbide said.

Dr. Tardif did not respond to interview requests for this story. Dr. Glatt said conflicts of interest must be assessed and are “something that is of great concern in any scientific study.”

Cardiologist Steve Nissen, MD, of the Cleveland Clinic said in an interview that, “despite the negative results, the study does suggest that colchicine might have a benefit and should be studied in future trials. These findings are not sufficient evidence to suggest use of the drug in patients infected with COVID-19.”

He noted that adverse effects like diarrhea were expected but that the excess PE was unexpected and needs greater clarification.

“Stopping the trial for administrative reasons is puzzling and undermined the ability of the trial to give a reliable answer,” Dr. Nissen said. “This is a reasonable pilot study that should be viewed as hypothesis generating but inconclusive.”

Several sources said a new trial is unlikely, particularly given the cost and 28 trials already evaluating colchicine. Among these are RECOVERY and COLCOVID, testing whether colchicine can reduce the duration of hospitalization or death in hospitalized patients with COVID-19.

Because there are so many trials ongoing right now, including for antivirals and other immunomodulators, it’s important that, if colchicine comes to routine clinical use, it provides access to treatment for those not able or willing to access clinical trials, rather than impeding clinical trial enrollment, Dr. Bender Ignacio suggested.

“We have already learned the lesson in the pandemic that early adoption of potentially promising therapies can negatively impact our ability to study and develop other promising treatments,” she said.

The trial was coordinated by the Montreal Heart Institute and funded by the government of Quebec; the National Heart, Lung, and Blood Institute of the National Institutes of Health; Montreal philanthropist Sophie Desmarais, and the COVID-19 Therapeutics Accelerator launched by the Bill & Melinda Gates Foundation, Wellcome, and Mastercard. CGI, Dacima, and Pharmascience of Montreal were also collaborators. Dr. Glatt reported no conflicts of interest. Dr. Boulware reported receiving $18 in food and beverages from Gilead Sciences in 2018.
 

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

Science by press release and preprint has cooled clinician enthusiasm for the use of colchicine in nonhospitalized patients with COVID-19, despite a pressing need for early treatments.

Photo by Jimmy Hamelin
Dr. Jean Claude Tardif

As previously reported by this news organization, a Jan. 22 press release announced that the massive ColCORONA study missed its primary endpoint of hospitalization or death among 4,488 newly diagnosed patients at increased risk for hospitalization.

But it also touted that use of the anti-inflammatory drug significantly reduced the primary endpoint in 4,159 of those patients with polymerase chain reaction–confirmed COVID and led to reductions of 25%, 50%, and 44%, respectively, for hospitalizations, ventilations, and death.

Lead investigator Jean-Claude Tardif, MD, director of the Montreal Heart Institute Research Centre, deemed the findings a “medical breakthrough.”

When the preprint released a few days later, however, newly revealed confidence intervals showed colchicine did not meaningfully reduce the need for mechanical ventilation (odds ratio, 0.50; 95% confidence interval, 0.23-1.07) or death alone (OR, 0.56; 95% CI, 0.19-1.66).

Further, the significant benefit on the primary outcome came at the cost of a fivefold increase in pulmonary embolism (11 vs. 2; P = .01), which was not mentioned in the press release.

“Whether this represents a real phenomenon or simply the play of chance is not known,” Dr. Tardif and colleagues noted later in the preprint.

Dr. Aaron Glatt

“I read the preprint on colchicine and I have so many questions,” Aaron E. Glatt, MD, spokesperson for the Infectious Diseases Society of America and chief of infectious diseases, Mount Sinai South Nassau, Hewlett, N.Y., said in an interview. “I’ve been burned too many times with COVID and prefer to see better data.

“People sometimes say if you wait for perfect data, people are going to die,” he said. “Yeah, but we have no idea if people are going to die from getting this drug more than not getting it. That’s what concerns me. How many pulmonary emboli are going to be fatal versus the slight benefit that the study showed?”

The pushback to the non–peer-reviewed data on social media and via emails was so strong that Dr. Tardif posted a nearly 2,000-word letter responding to the many questions at play.

Chief among them was why the trial, originally planned for 6,000 patients, was stopped early by the investigators without consultation with the data safety monitoring board (DSMB).

The explanation in the letter that logistical issues like running the study call center, budget constraints, and a perceived need to quickly communicate the results left some calling foul that the study wasn’t allowed to finish and come to a more definitive conclusion.

“I can be a little bit sympathetic to their cause but at the same time the DSMB should have said no,” said David Boulware, MD, MPH, who led a recent hydroxychloroquine trial in COVID-19. “The problem is we’re sort of left in limbo, where some people kind of believe it and some say it’s not really a thing. So it’s not really moving the needle, as far as guidelines go.”

Dr. James L. Januzzi

Indeed, a Twitter poll by cardiologist James Januzzi Jr., MD, captured the uncertainty, with 28% of respondents saying the trial was “neutral,” 58% saying “maybe but meh,” and 14% saying “colchicine for all.”

Another poll cheekily asked whether ColCORONA was the Gamestop/Reddit equivalent of COVID.

“The press release really didn’t help things because it very much oversold the effect. That, I think, poisoned the well,” said Dr. Boulware, professor of medicine in infectious diseases at the University of Minnesota, Minneapolis.

“The question I’m left with is not whether colchicine works, but who does it work in,” he said. “That’s really the fundamental question because it does seem that there are probably high-risk groups in their trial and others where they benefit, whereas other groups don’t benefit. In the subgroup analysis, there was absolutely no beneficial effect in women.”

According to the authors, the number needed to treat to prevent one death or hospitalization was 71 overall, but 29 for patients with diabetes, 31 for those aged 70 years and older, 53 for patients with respiratory disease, and 25 for those with coronary disease or heart failure.

Men are at higher risk overall for poor outcomes. But “the authors didn’t present a multivariable analysis, so it is unclear if another factor, such as a differential prevalence of smoking or cardiovascular risk factors, contributed to the differential benefit,” Rachel Bender Ignacio, MD, MPH, infectious disease specialist, University of Washington, Seattle, said in an interview.

Importantly, in this pragmatic study, duration and severity of symptoms were not reported, observed Dr. Bender Ignacio, who is also a STOP-COVID-2 investigator. “We don’t yet have data as to whether colchicine shortens duration or severity of symptoms or prevents long COVID, so we need more data on that.”

The overall risk for serious adverse events was lower in the colchicine group, but the difference in pulmonary embolism (PE) was striking, she said. This could be caused by a real biologic effect, or it’s possible that persons with shortness of breath and hypoxia, without evident viral pneumonia on chest x-ray after a positive COVID-19 test, were more likely to receive a CT-PE study.

The press release also failed to include information, later noted in the preprint, that the MHI has submitted two patents related to colchicine: “Methods of treating a coronavirus infection using colchicine” and “Early administration of low-dose colchicine after myocardial infarction.”

Reached for clarification, MHI communications adviser Camille Turbide said in an interview that the first patent “simply refers to the novel concept of preventing complications of COVID-19, such as admission to the hospital, with colchicine as tested in the ColCORONA study.”

The second patent, she said, refers to the “novel concept that administering colchicine early after a major adverse cardiovascular event is better than waiting several days,” as supported by the COLCOT study, which Dr. Tardif also led.

The patents are being reviewed by authorities and “Dr. Tardif has waived his rights in these patents and does not stand to benefit financially at all if colchicine becomes used as a treatment for COVID-19,” Ms. Turbide said.

Dr. Tardif did not respond to interview requests for this story. Dr. Glatt said conflicts of interest must be assessed and are “something that is of great concern in any scientific study.”

Cardiologist Steve Nissen, MD, of the Cleveland Clinic said in an interview that, “despite the negative results, the study does suggest that colchicine might have a benefit and should be studied in future trials. These findings are not sufficient evidence to suggest use of the drug in patients infected with COVID-19.”

He noted that adverse effects like diarrhea were expected but that the excess PE was unexpected and needs greater clarification.

“Stopping the trial for administrative reasons is puzzling and undermined the ability of the trial to give a reliable answer,” Dr. Nissen said. “This is a reasonable pilot study that should be viewed as hypothesis generating but inconclusive.”

Several sources said a new trial is unlikely, particularly given the cost and 28 trials already evaluating colchicine. Among these are RECOVERY and COLCOVID, testing whether colchicine can reduce the duration of hospitalization or death in hospitalized patients with COVID-19.

Because there are so many trials ongoing right now, including for antivirals and other immunomodulators, it’s important that, if colchicine comes to routine clinical use, it provides access to treatment for those not able or willing to access clinical trials, rather than impeding clinical trial enrollment, Dr. Bender Ignacio suggested.

“We have already learned the lesson in the pandemic that early adoption of potentially promising therapies can negatively impact our ability to study and develop other promising treatments,” she said.

The trial was coordinated by the Montreal Heart Institute and funded by the government of Quebec; the National Heart, Lung, and Blood Institute of the National Institutes of Health; Montreal philanthropist Sophie Desmarais, and the COVID-19 Therapeutics Accelerator launched by the Bill & Melinda Gates Foundation, Wellcome, and Mastercard. CGI, Dacima, and Pharmascience of Montreal were also collaborators. Dr. Glatt reported no conflicts of interest. Dr. Boulware reported receiving $18 in food and beverages from Gilead Sciences in 2018.
 

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

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Finding a new approach to difficult diagnoses

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Thu, 02/11/2021 - 11:18

Reducing – or managing – uncertainty

Beyond its clinical objective, the Socrates Project also seeks to further the discovery of previously unrecognized disease processes.

Dr. Benjamin Singer

Many patients do not have a diagnosis that explains their signs and symptoms, despite a thorough evaluation, said Benjamin Singer, MD, assistant professor of pulmonology and critical care at Northwestern Medicine in Chicago. To address that problem, he and his colleagues launched the Socrates Project. The service is intended for difficult diagnoses and is based on Socratic principles, particularly the role of iterative hypothesis testing in the process of diagnosis.

“We began the Socrates Project to assist physicians caring for patients who lack a specific diagnosis. In creating this service, we have found ourselves to be doctors for doctors – formalizing the curbside consultation,” Dr. Singer said.

Northwestern Medicine launched the Socrates Project in 2015. It’s a physician-to-physician consultation service that assists doctors working to diagnose conditions that have so far eluded detection. “Our service’s goal is to improve patient care by providing an opinion to the referring physician on diagnostic possibilities for a particular case and ideas to reduce – or at least manage – diagnostic uncertainty,” they write. “Our service model is similar to a tumor board, which exists as an interdisciplinary group operating in parallel to the clinical services, to provide consensus-based recommendations.”

Hospitalists at other institutions may be interested in starting a similar type of service at their own institution or collaborating with institutions who offer this type of service, Dr. Singer said.

At Northwestern Medicine, they are at work on the project’s next steps. “We are working to generate systematic data about our practice, particularly the types of referrals and outcomes,” he said.
 

Reference

1. Singer BD, et al. The Socrates Project for Difficult Diagnosis at Northwestern Medicine. J Hosp Med. 2020 February;15(2):116-125. doi:10.12788/jhm.3335.

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Reducing – or managing – uncertainty

Reducing – or managing – uncertainty

Beyond its clinical objective, the Socrates Project also seeks to further the discovery of previously unrecognized disease processes.

Dr. Benjamin Singer

Many patients do not have a diagnosis that explains their signs and symptoms, despite a thorough evaluation, said Benjamin Singer, MD, assistant professor of pulmonology and critical care at Northwestern Medicine in Chicago. To address that problem, he and his colleagues launched the Socrates Project. The service is intended for difficult diagnoses and is based on Socratic principles, particularly the role of iterative hypothesis testing in the process of diagnosis.

“We began the Socrates Project to assist physicians caring for patients who lack a specific diagnosis. In creating this service, we have found ourselves to be doctors for doctors – formalizing the curbside consultation,” Dr. Singer said.

Northwestern Medicine launched the Socrates Project in 2015. It’s a physician-to-physician consultation service that assists doctors working to diagnose conditions that have so far eluded detection. “Our service’s goal is to improve patient care by providing an opinion to the referring physician on diagnostic possibilities for a particular case and ideas to reduce – or at least manage – diagnostic uncertainty,” they write. “Our service model is similar to a tumor board, which exists as an interdisciplinary group operating in parallel to the clinical services, to provide consensus-based recommendations.”

Hospitalists at other institutions may be interested in starting a similar type of service at their own institution or collaborating with institutions who offer this type of service, Dr. Singer said.

At Northwestern Medicine, they are at work on the project’s next steps. “We are working to generate systematic data about our practice, particularly the types of referrals and outcomes,” he said.
 

Reference

1. Singer BD, et al. The Socrates Project for Difficult Diagnosis at Northwestern Medicine. J Hosp Med. 2020 February;15(2):116-125. doi:10.12788/jhm.3335.

Beyond its clinical objective, the Socrates Project also seeks to further the discovery of previously unrecognized disease processes.

Dr. Benjamin Singer

Many patients do not have a diagnosis that explains their signs and symptoms, despite a thorough evaluation, said Benjamin Singer, MD, assistant professor of pulmonology and critical care at Northwestern Medicine in Chicago. To address that problem, he and his colleagues launched the Socrates Project. The service is intended for difficult diagnoses and is based on Socratic principles, particularly the role of iterative hypothesis testing in the process of diagnosis.

“We began the Socrates Project to assist physicians caring for patients who lack a specific diagnosis. In creating this service, we have found ourselves to be doctors for doctors – formalizing the curbside consultation,” Dr. Singer said.

Northwestern Medicine launched the Socrates Project in 2015. It’s a physician-to-physician consultation service that assists doctors working to diagnose conditions that have so far eluded detection. “Our service’s goal is to improve patient care by providing an opinion to the referring physician on diagnostic possibilities for a particular case and ideas to reduce – or at least manage – diagnostic uncertainty,” they write. “Our service model is similar to a tumor board, which exists as an interdisciplinary group operating in parallel to the clinical services, to provide consensus-based recommendations.”

Hospitalists at other institutions may be interested in starting a similar type of service at their own institution or collaborating with institutions who offer this type of service, Dr. Singer said.

At Northwestern Medicine, they are at work on the project’s next steps. “We are working to generate systematic data about our practice, particularly the types of referrals and outcomes,” he said.
 

Reference

1. Singer BD, et al. The Socrates Project for Difficult Diagnosis at Northwestern Medicine. J Hosp Med. 2020 February;15(2):116-125. doi:10.12788/jhm.3335.

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Researchers examine factors associated with opioid use among migraineurs

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Thu, 12/15/2022 - 15:42

Among patients with migraine who use prescription medications, the increasing use of prescription opioids is associated with chronic migraine, more severe disability, and anxiety and depression, according to an analysis published in the January issue of Headache . The use of prescription opioids also is associated with treatment-related variables such as poor acute treatment optimization and treatment in a pain clinic. The results indicate the continued need to educate patients and clinicians about the potential risks of opioids for migraineurs, according to the researchers.

Dr. Richard Lipton


In the Migraine in America Symptoms and Treatment (MAST) study, which the researchers analyzed for their investigation, one-third of migraineurs who use acute prescriptions reported using opioids. Among opioid users, 42% took opioids on 4 or more days per month. “These findings are like [those of] a previous report from the American Migraine Prevalence and Prevention study and more recent findings from the Observational Survey of the Epidemiology, Treatment, and Care of Migraine (OVERCOME) study,” said Richard Lipton, MD, Edwin S. Lowe professor and vice chair of neurology at Albert Einstein College of Medicine in the Bronx, New York. “High rates of opioid use are problematic because opioid use is associated with worsening of migraine over time.”

Opioids remain in widespread use for migraine, even though guidelines recommend against this treatment. Among migraineurs, opioid use is associated with more severe headache-related disability and greater use of health care resources. Opioid use also increases the risk of progressing from episodic migraine to chronic migraine.
 

A review of MAST data

Dr. Lipton and colleagues set out to identify the variables associated with the frequency of opioid use in people with migraine. Among the variables that they sought to examine were demographic characteristics, comorbidities, headache characteristics, medication use, and patterns of health care use. Dr. Lipton’s group hypothesized that migraine-related severity and burden would increase with increasing frequency of opioid use.

To conduct their research, the investigators examined data from the MAST study, a nationwide sample of American adults with migraine. They focused specifically on participants who reported receiving prescription acute medications. Participants eligible for this analysis reported 3 or more headache days in the previous 3 months and at least 1 monthly headache day in the previous month. In all, 15,133 participants met these criteria.

Dr. Lipton and colleagues categorized participants into four groups based on their frequency of opioid use. The groups had no opioid use, 3 or fewer monthly days of opioid use, 4 to 9 monthly days of opioid use, and 10 or more days of monthly opioid use. The last category is consistent with the International Classification of Headache Disorders-3 criteria for overuse of opioids in migraine.

At baseline, MAST participants provided information about variables such as gender, age, marital status, smoking status, education, and income. Participants also reported how many times in the previous 6 months they had visited a primary care doctor, a neurologist, a headache specialist, or a pain specialist. Dr. Lipton’s group calculated monthly headache days using the number of days during the previous 3 months affected by headache. The Migraine Disability Assessment (MIDAS) questionnaire was used to measure headache-related disability. The four-item Patient Health Questionnaire (PHQ-4) was used to screen for anxiety and depression, and the Migraine Treatment Optimization Questionnaire (mTOQ-4) evaluated participants’ treatment optimization.
 

 

 

Men predominated among opioid users

The investigators included 4,701 MAST participants in their analysis. The population’s mean age was 45 years, and 71.6% of participants were women. Of the entire sample, 67.5% reported no opioid use, and 32.5% reported opioid use. Of the total study population, 18.7% of patients took opioids 3 or fewer days per month, 6.5% took opioids 4 to 9 days per month, and 7.3% took opioids on 10 or more days per month.

Opioid users did not differ from nonusers on race or marital status. Men were overrepresented among all groups of opioid users, however. In addition, opioid use was more prevalent among participants with fewer than 4 years of college education (34.9%) than among participants with 4 or more years of college (30.8%). The proportion of participants with fewer than 4 years of college increased with increasing monthly opioid use. Furthermore, opioid use increased with decreasing household income. As opioid use increased, rates of employment decreased. Approximately 33% of the entire sample were obese, and the proportion of obese participants increased with increasing days per month of opioid use.

The most frequent setting during the previous 6 months for participants seeking care was primary care (49.7%). The next most frequent setting was neurology units (20.9%), pain clinics (8.3%), and headache clinics (7.7%). The prevalence of opioid use was 37.5% among participants with primary care visits, 37.3% among participants with neurologist visits, 43.0% among participants with headache clinic visits, and 53.5% with pain clinic visits.

About 15% of the population had chronic migraine. The prevalence of chronic migraine increased with increasing frequency of opioid use. About 49% of the sample had allodynia, and the prevalence of allodynia increased with increasing frequency of opioid use. Overall, disability was moderate to severe in 57.3% of participants. Participants who used opioids on 3 or fewer days per month had the lowest prevalence of moderate to severe disability (50.2%), and participants who used opioids on 10 or more days per month had the highest prevalence of moderate to severe disability (83.8%).

Approximately 21% of participants had anxiety or depression. The lowest prevalence of anxiety or depression was among participants who took opioids on 3 or fewer days per month (17.4%), and the highest prevalence was among participants who took opioids on 10 or more days per month (43.2%). About 39% of the population had very poor to poor treatment optimization. Among opioid nonusers, 35.6% had very poor to poor treatment optimization, and 59.4% of participants who used opioids on 10 or more days per month had very poor to poor treatment optimization.

Dr. Lipton and colleagues also examined the study population’s use of triptans. Overall, 51.5% of participants reported taking triptans. The prevalence of triptan use was highest among participants who did not use opioids (64.1%) and lowest among participants who used opioids on 3 or fewer days per month (20.5%). Triptan use increased as monthly days of opioid use increased.
 

Pain clinics and opioid prescription

“In the general population, women are more likely to receive opioids than men,” said Dr. Lipton. “This [finding] could reflect, in part, that women have more pain disorders than men and are more likely to seek medical care for pain than men.” In the current study, however, men with migraine were more likely to receive opioid prescriptions than were women with migraine. One potential explanation for this finding is that men with migraine are less likely to receive a migraine diagnosis, which might attenuate opioid prescribing, than women with migraine. “It may be that opioids are perceived to be serious drugs for serious pain, and that some physicians may be more likely to prescribe opioids to men because the disorder is taken more seriously in men than women,” said Dr. Lipton.

The observation that opioids were more likely to be prescribed for people treated in pain clinics “is consistent with my understanding of practice patterns,” he added. “Generally, neurologists strive to find effective acute treatment alternatives to opioids. The emergence of [drug classes known as] gepants and ditans provides a helpful set of alternatives to tritpans.”

Dr. Lipton and his colleagues plan further research into the treatment of migraineurs. “In a claims analysis, we showed that when people with migraine fail a triptan, they are most likely to get an opioid as their next drug,” he said. “Reasonable [clinicians] might disagree on the next step. The next step, in the absence of contraindications, could be a different oral triptan, a nonoral triptan, or a gepant or ditan. We are planning a randomized trial to probe this question.”
 

Why are opioids still being used?

The study’s reliance on patients’ self-report and its retrospective design are two of its weaknesses, said Alan M. Rapoport, MD, clinical professor of neurology at the University of California, Los Angeles, and editor-in-chief of Neurology Reviews. One strength, however, is that the stratified sampling methodology produced a study population that accurately reflects the demographic characteristics of the U.S. adult population, he added. Another strength is the investigators’ examination of opioid use by patient characteristics such as marital status, education, income, obesity, and smoking.

Given the harmful effects of opioids in migraine, it is hard to understand why as much as one-third of study participants using acute care medication for migraine were using opioids, said Dr. Rapoport. Using opioids for the acute treatment of migraine attacks often indicates inadequate treatment optimization, which leads to ongoing headache. As a consequence, patients may take more medication, which can increase headache frequency and lead to diagnoses of chronic migraine and medication overuse headache. Although the study found an association between the increased use of opioids and decreased household income and increased unemployment, smoking, and obesity, “it is not possible to assign causality to any of these associations, even though some would argue that decreased socioeconomic status was somehow related to more headache, disability, obesity, smoking, and unemployment,” he added.

“The paper suggests that future research should look at the risk factors for use of opioids and should determine if depression is a risk factor for or a consequence of opioid use,” said Dr. Rapoport. “Interventional studies designed to improve the acute care of migraine attacks might be able to reduce the use of opioids. I have not used opioids or butalbital-containing medication in my office for many years.”

This study was funded and sponsored by Dr. Reddy’s Laboratories group of companies, Princeton, N.J. Dr. Lipton has received grant support from the National Institutes of Health, the National Headache Foundation, and the Migraine Research Fund. He serves as a consultant, serves as an advisory board member, or has received honoraria from Alder, Allergan, American Headache Society, Autonomic Technologies, Biohaven, Dr. Reddy’s Laboratories, Eli Lilly, eNeura Therapeutics, Merck, Novartis, Pfizer, and Teva, Inc. He receives royalties from Wolff’s Headache, 8th Edition (New York: Oxford University Press, 2009) and holds stock options in eNeura Therapeutics and Biohaven.

SOURCE: Lipton RB, et al. Headache. https://doi.org/10.1111/head.14018. 2020;61(1):103-16.

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Among patients with migraine who use prescription medications, the increasing use of prescription opioids is associated with chronic migraine, more severe disability, and anxiety and depression, according to an analysis published in the January issue of Headache . The use of prescription opioids also is associated with treatment-related variables such as poor acute treatment optimization and treatment in a pain clinic. The results indicate the continued need to educate patients and clinicians about the potential risks of opioids for migraineurs, according to the researchers.

Dr. Richard Lipton


In the Migraine in America Symptoms and Treatment (MAST) study, which the researchers analyzed for their investigation, one-third of migraineurs who use acute prescriptions reported using opioids. Among opioid users, 42% took opioids on 4 or more days per month. “These findings are like [those of] a previous report from the American Migraine Prevalence and Prevention study and more recent findings from the Observational Survey of the Epidemiology, Treatment, and Care of Migraine (OVERCOME) study,” said Richard Lipton, MD, Edwin S. Lowe professor and vice chair of neurology at Albert Einstein College of Medicine in the Bronx, New York. “High rates of opioid use are problematic because opioid use is associated with worsening of migraine over time.”

Opioids remain in widespread use for migraine, even though guidelines recommend against this treatment. Among migraineurs, opioid use is associated with more severe headache-related disability and greater use of health care resources. Opioid use also increases the risk of progressing from episodic migraine to chronic migraine.
 

A review of MAST data

Dr. Lipton and colleagues set out to identify the variables associated with the frequency of opioid use in people with migraine. Among the variables that they sought to examine were demographic characteristics, comorbidities, headache characteristics, medication use, and patterns of health care use. Dr. Lipton’s group hypothesized that migraine-related severity and burden would increase with increasing frequency of opioid use.

To conduct their research, the investigators examined data from the MAST study, a nationwide sample of American adults with migraine. They focused specifically on participants who reported receiving prescription acute medications. Participants eligible for this analysis reported 3 or more headache days in the previous 3 months and at least 1 monthly headache day in the previous month. In all, 15,133 participants met these criteria.

Dr. Lipton and colleagues categorized participants into four groups based on their frequency of opioid use. The groups had no opioid use, 3 or fewer monthly days of opioid use, 4 to 9 monthly days of opioid use, and 10 or more days of monthly opioid use. The last category is consistent with the International Classification of Headache Disorders-3 criteria for overuse of opioids in migraine.

At baseline, MAST participants provided information about variables such as gender, age, marital status, smoking status, education, and income. Participants also reported how many times in the previous 6 months they had visited a primary care doctor, a neurologist, a headache specialist, or a pain specialist. Dr. Lipton’s group calculated monthly headache days using the number of days during the previous 3 months affected by headache. The Migraine Disability Assessment (MIDAS) questionnaire was used to measure headache-related disability. The four-item Patient Health Questionnaire (PHQ-4) was used to screen for anxiety and depression, and the Migraine Treatment Optimization Questionnaire (mTOQ-4) evaluated participants’ treatment optimization.
 

 

 

Men predominated among opioid users

The investigators included 4,701 MAST participants in their analysis. The population’s mean age was 45 years, and 71.6% of participants were women. Of the entire sample, 67.5% reported no opioid use, and 32.5% reported opioid use. Of the total study population, 18.7% of patients took opioids 3 or fewer days per month, 6.5% took opioids 4 to 9 days per month, and 7.3% took opioids on 10 or more days per month.

Opioid users did not differ from nonusers on race or marital status. Men were overrepresented among all groups of opioid users, however. In addition, opioid use was more prevalent among participants with fewer than 4 years of college education (34.9%) than among participants with 4 or more years of college (30.8%). The proportion of participants with fewer than 4 years of college increased with increasing monthly opioid use. Furthermore, opioid use increased with decreasing household income. As opioid use increased, rates of employment decreased. Approximately 33% of the entire sample were obese, and the proportion of obese participants increased with increasing days per month of opioid use.

The most frequent setting during the previous 6 months for participants seeking care was primary care (49.7%). The next most frequent setting was neurology units (20.9%), pain clinics (8.3%), and headache clinics (7.7%). The prevalence of opioid use was 37.5% among participants with primary care visits, 37.3% among participants with neurologist visits, 43.0% among participants with headache clinic visits, and 53.5% with pain clinic visits.

About 15% of the population had chronic migraine. The prevalence of chronic migraine increased with increasing frequency of opioid use. About 49% of the sample had allodynia, and the prevalence of allodynia increased with increasing frequency of opioid use. Overall, disability was moderate to severe in 57.3% of participants. Participants who used opioids on 3 or fewer days per month had the lowest prevalence of moderate to severe disability (50.2%), and participants who used opioids on 10 or more days per month had the highest prevalence of moderate to severe disability (83.8%).

Approximately 21% of participants had anxiety or depression. The lowest prevalence of anxiety or depression was among participants who took opioids on 3 or fewer days per month (17.4%), and the highest prevalence was among participants who took opioids on 10 or more days per month (43.2%). About 39% of the population had very poor to poor treatment optimization. Among opioid nonusers, 35.6% had very poor to poor treatment optimization, and 59.4% of participants who used opioids on 10 or more days per month had very poor to poor treatment optimization.

Dr. Lipton and colleagues also examined the study population’s use of triptans. Overall, 51.5% of participants reported taking triptans. The prevalence of triptan use was highest among participants who did not use opioids (64.1%) and lowest among participants who used opioids on 3 or fewer days per month (20.5%). Triptan use increased as monthly days of opioid use increased.
 

Pain clinics and opioid prescription

“In the general population, women are more likely to receive opioids than men,” said Dr. Lipton. “This [finding] could reflect, in part, that women have more pain disorders than men and are more likely to seek medical care for pain than men.” In the current study, however, men with migraine were more likely to receive opioid prescriptions than were women with migraine. One potential explanation for this finding is that men with migraine are less likely to receive a migraine diagnosis, which might attenuate opioid prescribing, than women with migraine. “It may be that opioids are perceived to be serious drugs for serious pain, and that some physicians may be more likely to prescribe opioids to men because the disorder is taken more seriously in men than women,” said Dr. Lipton.

The observation that opioids were more likely to be prescribed for people treated in pain clinics “is consistent with my understanding of practice patterns,” he added. “Generally, neurologists strive to find effective acute treatment alternatives to opioids. The emergence of [drug classes known as] gepants and ditans provides a helpful set of alternatives to tritpans.”

Dr. Lipton and his colleagues plan further research into the treatment of migraineurs. “In a claims analysis, we showed that when people with migraine fail a triptan, they are most likely to get an opioid as their next drug,” he said. “Reasonable [clinicians] might disagree on the next step. The next step, in the absence of contraindications, could be a different oral triptan, a nonoral triptan, or a gepant or ditan. We are planning a randomized trial to probe this question.”
 

Why are opioids still being used?

The study’s reliance on patients’ self-report and its retrospective design are two of its weaknesses, said Alan M. Rapoport, MD, clinical professor of neurology at the University of California, Los Angeles, and editor-in-chief of Neurology Reviews. One strength, however, is that the stratified sampling methodology produced a study population that accurately reflects the demographic characteristics of the U.S. adult population, he added. Another strength is the investigators’ examination of opioid use by patient characteristics such as marital status, education, income, obesity, and smoking.

Given the harmful effects of opioids in migraine, it is hard to understand why as much as one-third of study participants using acute care medication for migraine were using opioids, said Dr. Rapoport. Using opioids for the acute treatment of migraine attacks often indicates inadequate treatment optimization, which leads to ongoing headache. As a consequence, patients may take more medication, which can increase headache frequency and lead to diagnoses of chronic migraine and medication overuse headache. Although the study found an association between the increased use of opioids and decreased household income and increased unemployment, smoking, and obesity, “it is not possible to assign causality to any of these associations, even though some would argue that decreased socioeconomic status was somehow related to more headache, disability, obesity, smoking, and unemployment,” he added.

“The paper suggests that future research should look at the risk factors for use of opioids and should determine if depression is a risk factor for or a consequence of opioid use,” said Dr. Rapoport. “Interventional studies designed to improve the acute care of migraine attacks might be able to reduce the use of opioids. I have not used opioids or butalbital-containing medication in my office for many years.”

This study was funded and sponsored by Dr. Reddy’s Laboratories group of companies, Princeton, N.J. Dr. Lipton has received grant support from the National Institutes of Health, the National Headache Foundation, and the Migraine Research Fund. He serves as a consultant, serves as an advisory board member, or has received honoraria from Alder, Allergan, American Headache Society, Autonomic Technologies, Biohaven, Dr. Reddy’s Laboratories, Eli Lilly, eNeura Therapeutics, Merck, Novartis, Pfizer, and Teva, Inc. He receives royalties from Wolff’s Headache, 8th Edition (New York: Oxford University Press, 2009) and holds stock options in eNeura Therapeutics and Biohaven.

SOURCE: Lipton RB, et al. Headache. https://doi.org/10.1111/head.14018. 2020;61(1):103-16.

Among patients with migraine who use prescription medications, the increasing use of prescription opioids is associated with chronic migraine, more severe disability, and anxiety and depression, according to an analysis published in the January issue of Headache . The use of prescription opioids also is associated with treatment-related variables such as poor acute treatment optimization and treatment in a pain clinic. The results indicate the continued need to educate patients and clinicians about the potential risks of opioids for migraineurs, according to the researchers.

Dr. Richard Lipton


In the Migraine in America Symptoms and Treatment (MAST) study, which the researchers analyzed for their investigation, one-third of migraineurs who use acute prescriptions reported using opioids. Among opioid users, 42% took opioids on 4 or more days per month. “These findings are like [those of] a previous report from the American Migraine Prevalence and Prevention study and more recent findings from the Observational Survey of the Epidemiology, Treatment, and Care of Migraine (OVERCOME) study,” said Richard Lipton, MD, Edwin S. Lowe professor and vice chair of neurology at Albert Einstein College of Medicine in the Bronx, New York. “High rates of opioid use are problematic because opioid use is associated with worsening of migraine over time.”

Opioids remain in widespread use for migraine, even though guidelines recommend against this treatment. Among migraineurs, opioid use is associated with more severe headache-related disability and greater use of health care resources. Opioid use also increases the risk of progressing from episodic migraine to chronic migraine.
 

A review of MAST data

Dr. Lipton and colleagues set out to identify the variables associated with the frequency of opioid use in people with migraine. Among the variables that they sought to examine were demographic characteristics, comorbidities, headache characteristics, medication use, and patterns of health care use. Dr. Lipton’s group hypothesized that migraine-related severity and burden would increase with increasing frequency of opioid use.

To conduct their research, the investigators examined data from the MAST study, a nationwide sample of American adults with migraine. They focused specifically on participants who reported receiving prescription acute medications. Participants eligible for this analysis reported 3 or more headache days in the previous 3 months and at least 1 monthly headache day in the previous month. In all, 15,133 participants met these criteria.

Dr. Lipton and colleagues categorized participants into four groups based on their frequency of opioid use. The groups had no opioid use, 3 or fewer monthly days of opioid use, 4 to 9 monthly days of opioid use, and 10 or more days of monthly opioid use. The last category is consistent with the International Classification of Headache Disorders-3 criteria for overuse of opioids in migraine.

At baseline, MAST participants provided information about variables such as gender, age, marital status, smoking status, education, and income. Participants also reported how many times in the previous 6 months they had visited a primary care doctor, a neurologist, a headache specialist, or a pain specialist. Dr. Lipton’s group calculated monthly headache days using the number of days during the previous 3 months affected by headache. The Migraine Disability Assessment (MIDAS) questionnaire was used to measure headache-related disability. The four-item Patient Health Questionnaire (PHQ-4) was used to screen for anxiety and depression, and the Migraine Treatment Optimization Questionnaire (mTOQ-4) evaluated participants’ treatment optimization.
 

 

 

Men predominated among opioid users

The investigators included 4,701 MAST participants in their analysis. The population’s mean age was 45 years, and 71.6% of participants were women. Of the entire sample, 67.5% reported no opioid use, and 32.5% reported opioid use. Of the total study population, 18.7% of patients took opioids 3 or fewer days per month, 6.5% took opioids 4 to 9 days per month, and 7.3% took opioids on 10 or more days per month.

Opioid users did not differ from nonusers on race or marital status. Men were overrepresented among all groups of opioid users, however. In addition, opioid use was more prevalent among participants with fewer than 4 years of college education (34.9%) than among participants with 4 or more years of college (30.8%). The proportion of participants with fewer than 4 years of college increased with increasing monthly opioid use. Furthermore, opioid use increased with decreasing household income. As opioid use increased, rates of employment decreased. Approximately 33% of the entire sample were obese, and the proportion of obese participants increased with increasing days per month of opioid use.

The most frequent setting during the previous 6 months for participants seeking care was primary care (49.7%). The next most frequent setting was neurology units (20.9%), pain clinics (8.3%), and headache clinics (7.7%). The prevalence of opioid use was 37.5% among participants with primary care visits, 37.3% among participants with neurologist visits, 43.0% among participants with headache clinic visits, and 53.5% with pain clinic visits.

About 15% of the population had chronic migraine. The prevalence of chronic migraine increased with increasing frequency of opioid use. About 49% of the sample had allodynia, and the prevalence of allodynia increased with increasing frequency of opioid use. Overall, disability was moderate to severe in 57.3% of participants. Participants who used opioids on 3 or fewer days per month had the lowest prevalence of moderate to severe disability (50.2%), and participants who used opioids on 10 or more days per month had the highest prevalence of moderate to severe disability (83.8%).

Approximately 21% of participants had anxiety or depression. The lowest prevalence of anxiety or depression was among participants who took opioids on 3 or fewer days per month (17.4%), and the highest prevalence was among participants who took opioids on 10 or more days per month (43.2%). About 39% of the population had very poor to poor treatment optimization. Among opioid nonusers, 35.6% had very poor to poor treatment optimization, and 59.4% of participants who used opioids on 10 or more days per month had very poor to poor treatment optimization.

Dr. Lipton and colleagues also examined the study population’s use of triptans. Overall, 51.5% of participants reported taking triptans. The prevalence of triptan use was highest among participants who did not use opioids (64.1%) and lowest among participants who used opioids on 3 or fewer days per month (20.5%). Triptan use increased as monthly days of opioid use increased.
 

Pain clinics and opioid prescription

“In the general population, women are more likely to receive opioids than men,” said Dr. Lipton. “This [finding] could reflect, in part, that women have more pain disorders than men and are more likely to seek medical care for pain than men.” In the current study, however, men with migraine were more likely to receive opioid prescriptions than were women with migraine. One potential explanation for this finding is that men with migraine are less likely to receive a migraine diagnosis, which might attenuate opioid prescribing, than women with migraine. “It may be that opioids are perceived to be serious drugs for serious pain, and that some physicians may be more likely to prescribe opioids to men because the disorder is taken more seriously in men than women,” said Dr. Lipton.

The observation that opioids were more likely to be prescribed for people treated in pain clinics “is consistent with my understanding of practice patterns,” he added. “Generally, neurologists strive to find effective acute treatment alternatives to opioids. The emergence of [drug classes known as] gepants and ditans provides a helpful set of alternatives to tritpans.”

Dr. Lipton and his colleagues plan further research into the treatment of migraineurs. “In a claims analysis, we showed that when people with migraine fail a triptan, they are most likely to get an opioid as their next drug,” he said. “Reasonable [clinicians] might disagree on the next step. The next step, in the absence of contraindications, could be a different oral triptan, a nonoral triptan, or a gepant or ditan. We are planning a randomized trial to probe this question.”
 

Why are opioids still being used?

The study’s reliance on patients’ self-report and its retrospective design are two of its weaknesses, said Alan M. Rapoport, MD, clinical professor of neurology at the University of California, Los Angeles, and editor-in-chief of Neurology Reviews. One strength, however, is that the stratified sampling methodology produced a study population that accurately reflects the demographic characteristics of the U.S. adult population, he added. Another strength is the investigators’ examination of opioid use by patient characteristics such as marital status, education, income, obesity, and smoking.

Given the harmful effects of opioids in migraine, it is hard to understand why as much as one-third of study participants using acute care medication for migraine were using opioids, said Dr. Rapoport. Using opioids for the acute treatment of migraine attacks often indicates inadequate treatment optimization, which leads to ongoing headache. As a consequence, patients may take more medication, which can increase headache frequency and lead to diagnoses of chronic migraine and medication overuse headache. Although the study found an association between the increased use of opioids and decreased household income and increased unemployment, smoking, and obesity, “it is not possible to assign causality to any of these associations, even though some would argue that decreased socioeconomic status was somehow related to more headache, disability, obesity, smoking, and unemployment,” he added.

“The paper suggests that future research should look at the risk factors for use of opioids and should determine if depression is a risk factor for or a consequence of opioid use,” said Dr. Rapoport. “Interventional studies designed to improve the acute care of migraine attacks might be able to reduce the use of opioids. I have not used opioids or butalbital-containing medication in my office for many years.”

This study was funded and sponsored by Dr. Reddy’s Laboratories group of companies, Princeton, N.J. Dr. Lipton has received grant support from the National Institutes of Health, the National Headache Foundation, and the Migraine Research Fund. He serves as a consultant, serves as an advisory board member, or has received honoraria from Alder, Allergan, American Headache Society, Autonomic Technologies, Biohaven, Dr. Reddy’s Laboratories, Eli Lilly, eNeura Therapeutics, Merck, Novartis, Pfizer, and Teva, Inc. He receives royalties from Wolff’s Headache, 8th Edition (New York: Oxford University Press, 2009) and holds stock options in eNeura Therapeutics and Biohaven.

SOURCE: Lipton RB, et al. Headache. https://doi.org/10.1111/head.14018. 2020;61(1):103-16.

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Expert calls for paradigm shift in lab monitoring of some dermatology drugs

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From time to time, Joslyn Kirby, MD, asks other physicians about their experience with certain medications used in dermatology, especially when something new hits the market.

“Sometimes I get an answer like, ‘The last time I used that medicine, my patient needed a liver transplant,’ ” Dr. Kirby, associate professor of dermatology, Penn State University, Hershey, said during the Orlando Dermatology Aesthetic and Clinical Conference. “It’s typically a story of something rare, uncommon, and awful. The challenge with an anecdote is that for all its power, it has a lower level of evidence. But it sticks with us and influences us more than a better level of evidence because it’s a situation and a story that we might relate to.”

Dr. Joslyn Kirby


Dr. Kirby said that when she thinks about managing side effects from drugs used in dermatology, it usually relates to something common and low-risk such as sore, dry skin with isotretinoin use. In contrast, if there is an uncommon but serious side effect, then mitigation rather than management is key. “I want to mitigate the risk – meaning warn my patient about it or be careful about how I select my patients when it is a serious side effect that happens infrequently,” she said. “The worst combination is a frequent and severe side effect. That is something we should avoid, for sure.”
 

Isotretinoin

But another aspect of prescribing a new drug for patients can be less clear-cut, Dr. Kirby continued, such as the rationale for routine lab monitoring. She began by discussing one of her male patients with moderate to severe acne. After he failed oral antibiotics and topical retinoids, she recommended isotretinoin, which carries a risk of hypertriglyceridemia-associated pancreatitis. “Early in my career, I was getting a lot of monthly labs in patients on this drug that were totally normal and not influencing my practice,” Dr. Kirby recalled. “We’ve seen studies coming out on isotretinoin lab monitoring, showing us that we can keep our patients safe and that we really don’t need to be checking labs as often, because lab changes are infrequent.”

In one of those studies, researchers evaluated 1,863 patients treated with isotretinoin for acne between Jan. 1, 2008, and June 30, 2017 (J Am Acad Dermatol. 2020 Jan;82[1]:72-9).Over time, fewer than 1% of patients screened developed grade 3 or greater triglyceride testing abnormalities, while fewer than 0.5% developed liver function testing (LFT) abnormalities. Authors of a separate systematic review concluded that for patients on isotretinoin therapy without elevated baseline triglycerides, or risk thereof, monitoring triglycerides is of little value (Br J Dermatol. 2017 Oct;177[4]:960-6). Of the 25 patients in the analysis who developed pancreatitis on isotretinoin, only 3 had elevated triglycerides at baseline.

“I was taught that I need to check triglycerides frequently due to the risk of pancreatitis developing with isotretinoin use,” Dr. Kirby said. “Lipid changes on therapy are expected, but they tend to peak early, meaning the first 3 months of treatment when we’re ramping up from a starting dose to a maintenance dose. It’s rare for somebody to be a late bloomer, meaning that they have totally normal labs in the first 3 months and then suddenly develop an abnormality. People are either going to demonstrate an abnormality early or not have one at all.”

When Dr. Kirby starts patients on isotretinoin, she orders baseline LFTs and a lipid panel and repeats them 60 days later. “If everything is fine or only mildly high, we don’t do more testing, only a review of systems,” she said. “This is valuable to our patients because fear of needles and fainting peak during adolescence.”
 

 

 

Spironolactone

The clinical use of regularly monitoring potassium levels in young women taking spironolactone for acne has also been questioned. The drug has been linked to an increased risk for hyperkalemia, but the prevalence is unclear. “I got a lot of normal potassium levels in these patients [when] I was in training and I really questioned, ‘Why am I doing this? What is the rationale?’ ” Dr. Kirby said.

In a study that informed her own practice, researchers reviewed the rate of hyperkalemia in 974 healthy young women taking spironolactone for acne or for an endocrine disorder with associated acne between Dec. 1, 2000, and March 31, 2014 (JAMA Dermatol. 2015 Sep;151[9]:941-4). Of the total of 1,802 serum potassium measurements taken during treatment, 13 (0.72%) were mildly elevated levels and none of the patients had a potassium level above 5.5 mEq/L. Retesting within 1 to 3 weeks in 6 of 13 patients with elevated levels found that potassium levels were normal. “The recommendation for spironolactone in healthy women is not to check the potassium level,” Dr. Kirby said, adding that she does counsel patients about the risk of breast tenderness (which can occur 5% to 40% of the time) and spotting (which can occur in 10% to 20% of patients). Gynecomastia can occur in 10% to 30% of men, which is one of the reasons she does not use spironolactone in male patients.
 

TB testing and biologics

Whether or not to test for TB in patients with psoriasis taking biologic therapies represents another conundrum, she continued. Patients taking biologics are at risk of reactivation of latent TB infection, but in her experience, package inserts contain language like “perform TB testing at baseline, then periodically,” or “use at baseline, then with active TB symptoms,” and “after treatment is discontinued.”

“What the inserts didn’t recommend was to perform TB testing every year, which is what my routine had been,” Dr. Kirby said. “In the United States, thankfully we don’t have a lot of TB.” In a study that informed her own practice, researchers at a single academic medical center retrospectively reviewed the TB seroconversion rate among 316 patients treated with second-generation biologics (J Am Acad Dermatol. 2020 Oct 1;S0190-9622[20]32676-1. doi: 10.1016/j.jaad.2020.09.075). It found that only six patients (2%) converted and had a positive TB test later during treatment with the biologic. “Of these six people, all had grown up outside the U.S., had traveled outside of the U.S., or were in a group living situation,” said Dr. Kirby, who was not affiliated with the study.

“This informs our rationale for how we can do this testing. If insurance requires it every year, fine. But if they don’t, I ask patients about travel, about their living situation, and how they’re feeling. If everything’s going great, I don’t order TB testing. I do favor the interferon-gamma release assays because they’re a lot more effective than PPDs [purified protein derivative skin tests]. Also, PPDs are difficult for patients who have a low rate of returning to have that test read.”
 

 

 

Terbinafine for onychomycosis

Dr. Kirby also discussed the rationale for ordering regular LFTs in patients taking terbinafine for onychomycosis. “There is a risk of drug-induced liver injury from taking terbinafine, but it’s rare,” she said. “Can we be thoughtful about which patients we expose?”

Evidence suggests that patients with hyperkeratosis greater than 2 mm, with nail matrix involvement, with 50% or more of the nail involved, or having concomitant peripheral vascular disease and diabetes are recalcitrant to treatment with terbinafine

(J Am Acad Dermatol. 2019 Apr;80[4]:853-67). “If we can frame this risk, then we can frame it for our patients,” she said. “We’re more likely to cause liver injury with an antibiotic. When it comes to an oral antifungal, itraconazole is more likely than terbinafine to cause liver injury. The rate of liver injury with terbinafine is only about 2 out of 100,000. It’s five times more likely with itraconazole and 21 times more likely with Augmentin.”



She recommends obtaining a baseline LFT in patients starting terbinafine therapy “to make sure their liver is normal from the start.” In addition, she advised, “let them know that there is a TB seroconversion risk of about 1 in 50,000 people, and that if it happens there would be symptomatic changes. They would maybe notice pruritus and have a darkening in their urine, and they’d have some flu-like symptoms, which would mean stop the drug and get some care.”

Dr. Kirby emphasized that a patient’s propensity for developing drug-induced liver injury from terbinafine use is not predictable from LFT monitoring. “What you’re more likely to find is an asymptomatic LFT rise in about 1% of people,” she said.

She disclosed that she has received honoraria from AbbVie, ChemoCentryx, Incyte, Janssen, Novartis, and UCB Pharma.

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From time to time, Joslyn Kirby, MD, asks other physicians about their experience with certain medications used in dermatology, especially when something new hits the market.

“Sometimes I get an answer like, ‘The last time I used that medicine, my patient needed a liver transplant,’ ” Dr. Kirby, associate professor of dermatology, Penn State University, Hershey, said during the Orlando Dermatology Aesthetic and Clinical Conference. “It’s typically a story of something rare, uncommon, and awful. The challenge with an anecdote is that for all its power, it has a lower level of evidence. But it sticks with us and influences us more than a better level of evidence because it’s a situation and a story that we might relate to.”

Dr. Joslyn Kirby


Dr. Kirby said that when she thinks about managing side effects from drugs used in dermatology, it usually relates to something common and low-risk such as sore, dry skin with isotretinoin use. In contrast, if there is an uncommon but serious side effect, then mitigation rather than management is key. “I want to mitigate the risk – meaning warn my patient about it or be careful about how I select my patients when it is a serious side effect that happens infrequently,” she said. “The worst combination is a frequent and severe side effect. That is something we should avoid, for sure.”
 

Isotretinoin

But another aspect of prescribing a new drug for patients can be less clear-cut, Dr. Kirby continued, such as the rationale for routine lab monitoring. She began by discussing one of her male patients with moderate to severe acne. After he failed oral antibiotics and topical retinoids, she recommended isotretinoin, which carries a risk of hypertriglyceridemia-associated pancreatitis. “Early in my career, I was getting a lot of monthly labs in patients on this drug that were totally normal and not influencing my practice,” Dr. Kirby recalled. “We’ve seen studies coming out on isotretinoin lab monitoring, showing us that we can keep our patients safe and that we really don’t need to be checking labs as often, because lab changes are infrequent.”

In one of those studies, researchers evaluated 1,863 patients treated with isotretinoin for acne between Jan. 1, 2008, and June 30, 2017 (J Am Acad Dermatol. 2020 Jan;82[1]:72-9).Over time, fewer than 1% of patients screened developed grade 3 or greater triglyceride testing abnormalities, while fewer than 0.5% developed liver function testing (LFT) abnormalities. Authors of a separate systematic review concluded that for patients on isotretinoin therapy without elevated baseline triglycerides, or risk thereof, monitoring triglycerides is of little value (Br J Dermatol. 2017 Oct;177[4]:960-6). Of the 25 patients in the analysis who developed pancreatitis on isotretinoin, only 3 had elevated triglycerides at baseline.

“I was taught that I need to check triglycerides frequently due to the risk of pancreatitis developing with isotretinoin use,” Dr. Kirby said. “Lipid changes on therapy are expected, but they tend to peak early, meaning the first 3 months of treatment when we’re ramping up from a starting dose to a maintenance dose. It’s rare for somebody to be a late bloomer, meaning that they have totally normal labs in the first 3 months and then suddenly develop an abnormality. People are either going to demonstrate an abnormality early or not have one at all.”

When Dr. Kirby starts patients on isotretinoin, she orders baseline LFTs and a lipid panel and repeats them 60 days later. “If everything is fine or only mildly high, we don’t do more testing, only a review of systems,” she said. “This is valuable to our patients because fear of needles and fainting peak during adolescence.”
 

 

 

Spironolactone

The clinical use of regularly monitoring potassium levels in young women taking spironolactone for acne has also been questioned. The drug has been linked to an increased risk for hyperkalemia, but the prevalence is unclear. “I got a lot of normal potassium levels in these patients [when] I was in training and I really questioned, ‘Why am I doing this? What is the rationale?’ ” Dr. Kirby said.

In a study that informed her own practice, researchers reviewed the rate of hyperkalemia in 974 healthy young women taking spironolactone for acne or for an endocrine disorder with associated acne between Dec. 1, 2000, and March 31, 2014 (JAMA Dermatol. 2015 Sep;151[9]:941-4). Of the total of 1,802 serum potassium measurements taken during treatment, 13 (0.72%) were mildly elevated levels and none of the patients had a potassium level above 5.5 mEq/L. Retesting within 1 to 3 weeks in 6 of 13 patients with elevated levels found that potassium levels were normal. “The recommendation for spironolactone in healthy women is not to check the potassium level,” Dr. Kirby said, adding that she does counsel patients about the risk of breast tenderness (which can occur 5% to 40% of the time) and spotting (which can occur in 10% to 20% of patients). Gynecomastia can occur in 10% to 30% of men, which is one of the reasons she does not use spironolactone in male patients.
 

TB testing and biologics

Whether or not to test for TB in patients with psoriasis taking biologic therapies represents another conundrum, she continued. Patients taking biologics are at risk of reactivation of latent TB infection, but in her experience, package inserts contain language like “perform TB testing at baseline, then periodically,” or “use at baseline, then with active TB symptoms,” and “after treatment is discontinued.”

“What the inserts didn’t recommend was to perform TB testing every year, which is what my routine had been,” Dr. Kirby said. “In the United States, thankfully we don’t have a lot of TB.” In a study that informed her own practice, researchers at a single academic medical center retrospectively reviewed the TB seroconversion rate among 316 patients treated with second-generation biologics (J Am Acad Dermatol. 2020 Oct 1;S0190-9622[20]32676-1. doi: 10.1016/j.jaad.2020.09.075). It found that only six patients (2%) converted and had a positive TB test later during treatment with the biologic. “Of these six people, all had grown up outside the U.S., had traveled outside of the U.S., or were in a group living situation,” said Dr. Kirby, who was not affiliated with the study.

“This informs our rationale for how we can do this testing. If insurance requires it every year, fine. But if they don’t, I ask patients about travel, about their living situation, and how they’re feeling. If everything’s going great, I don’t order TB testing. I do favor the interferon-gamma release assays because they’re a lot more effective than PPDs [purified protein derivative skin tests]. Also, PPDs are difficult for patients who have a low rate of returning to have that test read.”
 

 

 

Terbinafine for onychomycosis

Dr. Kirby also discussed the rationale for ordering regular LFTs in patients taking terbinafine for onychomycosis. “There is a risk of drug-induced liver injury from taking terbinafine, but it’s rare,” she said. “Can we be thoughtful about which patients we expose?”

Evidence suggests that patients with hyperkeratosis greater than 2 mm, with nail matrix involvement, with 50% or more of the nail involved, or having concomitant peripheral vascular disease and diabetes are recalcitrant to treatment with terbinafine

(J Am Acad Dermatol. 2019 Apr;80[4]:853-67). “If we can frame this risk, then we can frame it for our patients,” she said. “We’re more likely to cause liver injury with an antibiotic. When it comes to an oral antifungal, itraconazole is more likely than terbinafine to cause liver injury. The rate of liver injury with terbinafine is only about 2 out of 100,000. It’s five times more likely with itraconazole and 21 times more likely with Augmentin.”



She recommends obtaining a baseline LFT in patients starting terbinafine therapy “to make sure their liver is normal from the start.” In addition, she advised, “let them know that there is a TB seroconversion risk of about 1 in 50,000 people, and that if it happens there would be symptomatic changes. They would maybe notice pruritus and have a darkening in their urine, and they’d have some flu-like symptoms, which would mean stop the drug and get some care.”

Dr. Kirby emphasized that a patient’s propensity for developing drug-induced liver injury from terbinafine use is not predictable from LFT monitoring. “What you’re more likely to find is an asymptomatic LFT rise in about 1% of people,” she said.

She disclosed that she has received honoraria from AbbVie, ChemoCentryx, Incyte, Janssen, Novartis, and UCB Pharma.

From time to time, Joslyn Kirby, MD, asks other physicians about their experience with certain medications used in dermatology, especially when something new hits the market.

“Sometimes I get an answer like, ‘The last time I used that medicine, my patient needed a liver transplant,’ ” Dr. Kirby, associate professor of dermatology, Penn State University, Hershey, said during the Orlando Dermatology Aesthetic and Clinical Conference. “It’s typically a story of something rare, uncommon, and awful. The challenge with an anecdote is that for all its power, it has a lower level of evidence. But it sticks with us and influences us more than a better level of evidence because it’s a situation and a story that we might relate to.”

Dr. Joslyn Kirby


Dr. Kirby said that when she thinks about managing side effects from drugs used in dermatology, it usually relates to something common and low-risk such as sore, dry skin with isotretinoin use. In contrast, if there is an uncommon but serious side effect, then mitigation rather than management is key. “I want to mitigate the risk – meaning warn my patient about it or be careful about how I select my patients when it is a serious side effect that happens infrequently,” she said. “The worst combination is a frequent and severe side effect. That is something we should avoid, for sure.”
 

Isotretinoin

But another aspect of prescribing a new drug for patients can be less clear-cut, Dr. Kirby continued, such as the rationale for routine lab monitoring. She began by discussing one of her male patients with moderate to severe acne. After he failed oral antibiotics and topical retinoids, she recommended isotretinoin, which carries a risk of hypertriglyceridemia-associated pancreatitis. “Early in my career, I was getting a lot of monthly labs in patients on this drug that were totally normal and not influencing my practice,” Dr. Kirby recalled. “We’ve seen studies coming out on isotretinoin lab monitoring, showing us that we can keep our patients safe and that we really don’t need to be checking labs as often, because lab changes are infrequent.”

In one of those studies, researchers evaluated 1,863 patients treated with isotretinoin for acne between Jan. 1, 2008, and June 30, 2017 (J Am Acad Dermatol. 2020 Jan;82[1]:72-9).Over time, fewer than 1% of patients screened developed grade 3 or greater triglyceride testing abnormalities, while fewer than 0.5% developed liver function testing (LFT) abnormalities. Authors of a separate systematic review concluded that for patients on isotretinoin therapy without elevated baseline triglycerides, or risk thereof, monitoring triglycerides is of little value (Br J Dermatol. 2017 Oct;177[4]:960-6). Of the 25 patients in the analysis who developed pancreatitis on isotretinoin, only 3 had elevated triglycerides at baseline.

“I was taught that I need to check triglycerides frequently due to the risk of pancreatitis developing with isotretinoin use,” Dr. Kirby said. “Lipid changes on therapy are expected, but they tend to peak early, meaning the first 3 months of treatment when we’re ramping up from a starting dose to a maintenance dose. It’s rare for somebody to be a late bloomer, meaning that they have totally normal labs in the first 3 months and then suddenly develop an abnormality. People are either going to demonstrate an abnormality early or not have one at all.”

When Dr. Kirby starts patients on isotretinoin, she orders baseline LFTs and a lipid panel and repeats them 60 days later. “If everything is fine or only mildly high, we don’t do more testing, only a review of systems,” she said. “This is valuable to our patients because fear of needles and fainting peak during adolescence.”
 

 

 

Spironolactone

The clinical use of regularly monitoring potassium levels in young women taking spironolactone for acne has also been questioned. The drug has been linked to an increased risk for hyperkalemia, but the prevalence is unclear. “I got a lot of normal potassium levels in these patients [when] I was in training and I really questioned, ‘Why am I doing this? What is the rationale?’ ” Dr. Kirby said.

In a study that informed her own practice, researchers reviewed the rate of hyperkalemia in 974 healthy young women taking spironolactone for acne or for an endocrine disorder with associated acne between Dec. 1, 2000, and March 31, 2014 (JAMA Dermatol. 2015 Sep;151[9]:941-4). Of the total of 1,802 serum potassium measurements taken during treatment, 13 (0.72%) were mildly elevated levels and none of the patients had a potassium level above 5.5 mEq/L. Retesting within 1 to 3 weeks in 6 of 13 patients with elevated levels found that potassium levels were normal. “The recommendation for spironolactone in healthy women is not to check the potassium level,” Dr. Kirby said, adding that she does counsel patients about the risk of breast tenderness (which can occur 5% to 40% of the time) and spotting (which can occur in 10% to 20% of patients). Gynecomastia can occur in 10% to 30% of men, which is one of the reasons she does not use spironolactone in male patients.
 

TB testing and biologics

Whether or not to test for TB in patients with psoriasis taking biologic therapies represents another conundrum, she continued. Patients taking biologics are at risk of reactivation of latent TB infection, but in her experience, package inserts contain language like “perform TB testing at baseline, then periodically,” or “use at baseline, then with active TB symptoms,” and “after treatment is discontinued.”

“What the inserts didn’t recommend was to perform TB testing every year, which is what my routine had been,” Dr. Kirby said. “In the United States, thankfully we don’t have a lot of TB.” In a study that informed her own practice, researchers at a single academic medical center retrospectively reviewed the TB seroconversion rate among 316 patients treated with second-generation biologics (J Am Acad Dermatol. 2020 Oct 1;S0190-9622[20]32676-1. doi: 10.1016/j.jaad.2020.09.075). It found that only six patients (2%) converted and had a positive TB test later during treatment with the biologic. “Of these six people, all had grown up outside the U.S., had traveled outside of the U.S., or were in a group living situation,” said Dr. Kirby, who was not affiliated with the study.

“This informs our rationale for how we can do this testing. If insurance requires it every year, fine. But if they don’t, I ask patients about travel, about their living situation, and how they’re feeling. If everything’s going great, I don’t order TB testing. I do favor the interferon-gamma release assays because they’re a lot more effective than PPDs [purified protein derivative skin tests]. Also, PPDs are difficult for patients who have a low rate of returning to have that test read.”
 

 

 

Terbinafine for onychomycosis

Dr. Kirby also discussed the rationale for ordering regular LFTs in patients taking terbinafine for onychomycosis. “There is a risk of drug-induced liver injury from taking terbinafine, but it’s rare,” she said. “Can we be thoughtful about which patients we expose?”

Evidence suggests that patients with hyperkeratosis greater than 2 mm, with nail matrix involvement, with 50% or more of the nail involved, or having concomitant peripheral vascular disease and diabetes are recalcitrant to treatment with terbinafine

(J Am Acad Dermatol. 2019 Apr;80[4]:853-67). “If we can frame this risk, then we can frame it for our patients,” she said. “We’re more likely to cause liver injury with an antibiotic. When it comes to an oral antifungal, itraconazole is more likely than terbinafine to cause liver injury. The rate of liver injury with terbinafine is only about 2 out of 100,000. It’s five times more likely with itraconazole and 21 times more likely with Augmentin.”



She recommends obtaining a baseline LFT in patients starting terbinafine therapy “to make sure their liver is normal from the start.” In addition, she advised, “let them know that there is a TB seroconversion risk of about 1 in 50,000 people, and that if it happens there would be symptomatic changes. They would maybe notice pruritus and have a darkening in their urine, and they’d have some flu-like symptoms, which would mean stop the drug and get some care.”

Dr. Kirby emphasized that a patient’s propensity for developing drug-induced liver injury from terbinafine use is not predictable from LFT monitoring. “What you’re more likely to find is an asymptomatic LFT rise in about 1% of people,” she said.

She disclosed that she has received honoraria from AbbVie, ChemoCentryx, Incyte, Janssen, Novartis, and UCB Pharma.

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Treatment of horizontal neck lines

Article Type
Changed
Thu, 02/11/2021 - 11:02

The aging neck is a complicated, difficult to treat area often requiring a combination of treatments for noninvasive rejuvenation. The interplay of the neck subunits, as outlined in the recent article by Friedman and colleagues, requires multiple combination treatments, including fat removal, augmentation of deficient bony prominences, relaxation of hyperkinetic muscles, tissue tightening, suture anchoring, skin resurfacing, and treatment of dyschromia.

Courtesy Dr. Talakoub
Horizontal neck lines in a 23-year-old woman

Horizontal neck lines are linear etched lines or furrows that commonly appear at a young age and are not caused by the aging process. The anatomy of the neck and the manner in which it bends contributes to their development at an early age. It is hypothesized that variable adipose tissue thickness and fibromuscular bands contribute to deepening of these lines in overweight patients. The widespread use of cell phones, laptops, and tablets has increased their prevalence and this has become one of the most common concerns of patients aged under 30 years in my clinic.



Various treatments have been recommended for neck rejuvenation, including hyaluronic acid and dilute calcium hydroxylapatite. In my experience, neither of these treatments adequately resolves the horizontal neck lines, and more importantly, prevents them from reoccurring. In addition, given the variability in skin and adipose thickness in the anterior neck, side effects including lumps, irregular correction, and the Tyndall effect, are common, particularly with incorrect choice of filler and injection depth.

Dr. Naissan O. Wesley

The fibromuscular bands along the transverse neck lines pose one of the complexities in treatment with injectable filler. I have had significant improvement in the aesthetic outcome of my patients by using subcision along the transverse bands extensively prior to injection with hyaluronic acid fillers. The subcision is done with a 27-gauge needle to release the fibrous bands that tether the tissue down. If a patient has excess adipose tissue on either side of the bands, injectable fillers often do not improve the appearance of the lines and can make the neck appear heavier. The use of subcision followed by one to six treatments of deoxycholic acid in the adjacent adipose tissue prior to injection with a filler will help even out the contour of the neck, decrease adipose tissue bulges, release the fibrous bands, and fill the lines properly.

Working from home and on handheld devices has increased the appearance of neck lines in young populations. Despite the vast array of treatments in the aging neck, none have been very successful for this particular problem in the young. We need an improved understanding of these lines and better studies to investigate treatment options and long-term correction.

Dr. Lily Talakoub


References:

Friedman O et al. J Cosmet Dermatol. 2021 Feb;20(2):569-76.

Brandt FS and Boker A. Dermatol Clin. 2004 Apr;22(2):159-66.

Tseng F and Yu H. Plast Reconstr Surg Glob Open. 2019 Aug 19;7(8):e2366.

Dibernardo BE. J Cosmet Laser Ther. 2013 Apr;15(2):56-64.

Jones D et al. Dermatol Surg. 2016 Oct;4 Suppl 1(Suppl 1):S235-42.

Lee SK and Kim HS. J Cosmet Dermatol. 2018 Aug;17(4):590-5.

Chao YY et al. Dermatol Surg. 2011 Oct;37(10):1542-5.

Han TY et al. Dermatol Surg. 2011 Sep;37(9):1291-6.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.

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The aging neck is a complicated, difficult to treat area often requiring a combination of treatments for noninvasive rejuvenation. The interplay of the neck subunits, as outlined in the recent article by Friedman and colleagues, requires multiple combination treatments, including fat removal, augmentation of deficient bony prominences, relaxation of hyperkinetic muscles, tissue tightening, suture anchoring, skin resurfacing, and treatment of dyschromia.

Courtesy Dr. Talakoub
Horizontal neck lines in a 23-year-old woman

Horizontal neck lines are linear etched lines or furrows that commonly appear at a young age and are not caused by the aging process. The anatomy of the neck and the manner in which it bends contributes to their development at an early age. It is hypothesized that variable adipose tissue thickness and fibromuscular bands contribute to deepening of these lines in overweight patients. The widespread use of cell phones, laptops, and tablets has increased their prevalence and this has become one of the most common concerns of patients aged under 30 years in my clinic.



Various treatments have been recommended for neck rejuvenation, including hyaluronic acid and dilute calcium hydroxylapatite. In my experience, neither of these treatments adequately resolves the horizontal neck lines, and more importantly, prevents them from reoccurring. In addition, given the variability in skin and adipose thickness in the anterior neck, side effects including lumps, irregular correction, and the Tyndall effect, are common, particularly with incorrect choice of filler and injection depth.

Dr. Naissan O. Wesley

The fibromuscular bands along the transverse neck lines pose one of the complexities in treatment with injectable filler. I have had significant improvement in the aesthetic outcome of my patients by using subcision along the transverse bands extensively prior to injection with hyaluronic acid fillers. The subcision is done with a 27-gauge needle to release the fibrous bands that tether the tissue down. If a patient has excess adipose tissue on either side of the bands, injectable fillers often do not improve the appearance of the lines and can make the neck appear heavier. The use of subcision followed by one to six treatments of deoxycholic acid in the adjacent adipose tissue prior to injection with a filler will help even out the contour of the neck, decrease adipose tissue bulges, release the fibrous bands, and fill the lines properly.

Working from home and on handheld devices has increased the appearance of neck lines in young populations. Despite the vast array of treatments in the aging neck, none have been very successful for this particular problem in the young. We need an improved understanding of these lines and better studies to investigate treatment options and long-term correction.

Dr. Lily Talakoub


References:

Friedman O et al. J Cosmet Dermatol. 2021 Feb;20(2):569-76.

Brandt FS and Boker A. Dermatol Clin. 2004 Apr;22(2):159-66.

Tseng F and Yu H. Plast Reconstr Surg Glob Open. 2019 Aug 19;7(8):e2366.

Dibernardo BE. J Cosmet Laser Ther. 2013 Apr;15(2):56-64.

Jones D et al. Dermatol Surg. 2016 Oct;4 Suppl 1(Suppl 1):S235-42.

Lee SK and Kim HS. J Cosmet Dermatol. 2018 Aug;17(4):590-5.

Chao YY et al. Dermatol Surg. 2011 Oct;37(10):1542-5.

Han TY et al. Dermatol Surg. 2011 Sep;37(9):1291-6.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.

The aging neck is a complicated, difficult to treat area often requiring a combination of treatments for noninvasive rejuvenation. The interplay of the neck subunits, as outlined in the recent article by Friedman and colleagues, requires multiple combination treatments, including fat removal, augmentation of deficient bony prominences, relaxation of hyperkinetic muscles, tissue tightening, suture anchoring, skin resurfacing, and treatment of dyschromia.

Courtesy Dr. Talakoub
Horizontal neck lines in a 23-year-old woman

Horizontal neck lines are linear etched lines or furrows that commonly appear at a young age and are not caused by the aging process. The anatomy of the neck and the manner in which it bends contributes to their development at an early age. It is hypothesized that variable adipose tissue thickness and fibromuscular bands contribute to deepening of these lines in overweight patients. The widespread use of cell phones, laptops, and tablets has increased their prevalence and this has become one of the most common concerns of patients aged under 30 years in my clinic.



Various treatments have been recommended for neck rejuvenation, including hyaluronic acid and dilute calcium hydroxylapatite. In my experience, neither of these treatments adequately resolves the horizontal neck lines, and more importantly, prevents them from reoccurring. In addition, given the variability in skin and adipose thickness in the anterior neck, side effects including lumps, irregular correction, and the Tyndall effect, are common, particularly with incorrect choice of filler and injection depth.

Dr. Naissan O. Wesley

The fibromuscular bands along the transverse neck lines pose one of the complexities in treatment with injectable filler. I have had significant improvement in the aesthetic outcome of my patients by using subcision along the transverse bands extensively prior to injection with hyaluronic acid fillers. The subcision is done with a 27-gauge needle to release the fibrous bands that tether the tissue down. If a patient has excess adipose tissue on either side of the bands, injectable fillers often do not improve the appearance of the lines and can make the neck appear heavier. The use of subcision followed by one to six treatments of deoxycholic acid in the adjacent adipose tissue prior to injection with a filler will help even out the contour of the neck, decrease adipose tissue bulges, release the fibrous bands, and fill the lines properly.

Working from home and on handheld devices has increased the appearance of neck lines in young populations. Despite the vast array of treatments in the aging neck, none have been very successful for this particular problem in the young. We need an improved understanding of these lines and better studies to investigate treatment options and long-term correction.

Dr. Lily Talakoub


References:

Friedman O et al. J Cosmet Dermatol. 2021 Feb;20(2):569-76.

Brandt FS and Boker A. Dermatol Clin. 2004 Apr;22(2):159-66.

Tseng F and Yu H. Plast Reconstr Surg Glob Open. 2019 Aug 19;7(8):e2366.

Dibernardo BE. J Cosmet Laser Ther. 2013 Apr;15(2):56-64.

Jones D et al. Dermatol Surg. 2016 Oct;4 Suppl 1(Suppl 1):S235-42.

Lee SK and Kim HS. J Cosmet Dermatol. 2018 Aug;17(4):590-5.

Chao YY et al. Dermatol Surg. 2011 Oct;37(10):1542-5.

Han TY et al. Dermatol Surg. 2011 Sep;37(9):1291-6.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.

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PFO closure reduces migraine: New meta-analysis

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Changed
Thu, 12/15/2022 - 15:42

A meta-analysis of two randomized studies evaluating patent foramen ovale (PFO) closure as a treatment strategy for migraine has shown significant benefits in several key endpoints, prompting the authors to conclude the approach warrants reevaluation.
 

The pooled analysis of patient-level data from the PRIMA and PREMIUM studies, both of which evaluated the Amplatzer PFO Occluder device (Abbott Vascular), showed that PFO closure significantly reduced the mean number of monthly migraine days and monthly migraine attacks and resulted in a greater number of patients who experienced complete migraine cessation.

The study, led by Mohammad K. Mojadidi, MD, Virginia Commonwealth University, Richmond, was published online in the Journal of the American College of Cardiology on Feb. 8, 2021.

Commenting on the article, the coauthor of an accompanying editorial, Zubair Ahmed, MD, of the Cleveland Clinic said the meta-analysis gave some useful new information but is not enough to recommend PFO closure routinely for patients with migraine.

“This meta-analysis looked at different endpoints that are more relevant to current clinical practice than those in the two original studies, and the results show that we shouldn’t rule out PFO closure as a treatment strategy for some migraine patients,” Dr. Ahmed stated. “But we’re still not sure exactly which patients are most likely to benefit from this approach, and we need additional studies to gain more understanding on that.”

The study authors noted that there is an established link between the presence of PFO and migraine, especially migraine with aura. In observational studies of PFO closure for cryptogenic stroke, the vast majority of patients who also had migraine reported a more than 50% reduction in migraine days per month after PFO closure.

However, two recent randomized clinical trials evaluating the Amplatzer PFO Occluder device for reducing the frequency and duration of episodic migraine headaches did not meet their respective primary endpoints, although they did show significant benefit of PFO closure in most of their secondary endpoints.

The current meta-analysis pooled individual participant data from the two trials to increase the power to detect the effect of percutaneous PFO closure for treating patients with episodic migraine compared with medical therapy alone.

In the two studies including a total of 337 patients, 176 were randomized to PFO closure and 161 to medical treatment only. At 12 months, three of the four efficacy endpoints evaluated in the meta-analysis were significantly reduced in the PFO-closure group. These were mean reduction of monthly migraine days (–3.1 days vs. –1.9 days; P = .02), mean reduction of monthly migraine attacks (–2.0 vs. –1.4; P = .01), and number of patients who experienced complete cessation of migraine (9% vs. 0.7%; P < .001).

The responder rate, defined as more than a 50% reduction in migraine attacks, showed a trend towards an increase in the PFO-closure group but did not achieve statistical significance (38% vs. 29%; P = .13).  

For the safety analysis, nine procedure-related and four device-related adverse events occurred in 245 patients who eventually received devices. All events were transient and resolved.
 

Better effect in patients with aura

Patients with migraine with aura, in particular frequent aura, had a significantly greater reduction in migraine days and a higher incidence of complete migraine cessation following PFO closure versus no closure, the authors reported.

 

 

In those without aura, PFO closure did not significantly reduce migraine days or improve complete headache cessation. However, some patients without aura did respond to PFO closure, which was statistically significant for reduction of migraine attacks (–2.0 vs. –1.0; P = .03).

“The interaction between the brain that is susceptible to migraine and the plethora of potential triggers is complex. A PFO may be the potential pathway for a variety of chemical triggers, such as serotonin from platelets, and although less frequent, some people with migraine without aura may trigger their migraine through this mechanism,” the researchers suggested. This hypothesis will be tested in the RELIEF trial, which is now being planned.

In the accompanying editorial, Dr. Ahmed and coauthor Robert J. Sommer, MD, Columbia University Medical Center, New York, pointed out that the meta-analysis demonstrates benefit of PFO closure in the migraine population for the first time.

“Moreover, the investigators defined a population of patients who may benefit most from PFO closure, those with migraine with frequent aura, suggesting that these may be different physiologically than other migraine subtypes. The analysis also places the PRIMA and PREMIUM outcomes in the context of endpoints that are more practical and are more commonly assessed in current clinical trials,” the editorialists noted.
 

Many unanswered questions

But the editorialists highlighted several significant limitations of the analysis, including “pooling of patient cohorts, methods, and outcome measures that might not be entirely comparable,” which they say could have introduced bias.

They also pointed out that the underlying pathophysiological mechanism linking migraine symptoms to PFO remains unknown. They explain that the mechanism is thought to involve the right-to-left passage of systemic venous blood, with some component – which would normally be eliminated or reduced on passage through the pulmonary vasculature – reaching the cerebral circulation via the PFO in supranormal concentrations and acting as a trigger for migraine activity in patients with susceptible brains.

But not all patients with migraine who have PFO benefit from PFO closure, they noted, and therefore presumably have PFO-unrelated migraines. There is no verified way to distinguish between these two groups at present.

“Once we learn to identify the subset of migraine patients in whom PFOs are actually causal of headache symptoms, screening and treatment of PFO for migraine can become a reality,” they wrote.

Although the meta-analysis is a step in the right direction, “it is not a home run,” Dr. Ahmed elaborated. “This was a post hoc analysis of two studies, neither of which showed significant benefits on their primary endpoints. That weakens the findings somewhat.”

He added: “At present, PFO closure is not routinely recommended as a migraine treatment strategy as we haven’t been sure which patients are most likely to benefit. And while this meta-analysis suggests patients with aura may be more likely to benefit, one quarter of patients without aura in the PREMIUM trial responded to PFO closure, so it’s not just about aura.

“There are still many unanswered questions.

“I don’t think the new information from this meta-analysis is enough to persuade me to change my practice, but it is a small building block in the overall picture and suggests this may be a suitable strategy for some patients in future,” he concluded.

The study had no outside funding. Participant-level data were provided by Abbott. Several coauthors were on the steering committee for the PREMIUM or PRIMA trials. Dr. Ahmed reported receiving consulting fees from, Amgen, AbbVie, electroCore, and Eli Lilly; serving on advisory boards for Amgen and Supernus; serving as a speaker for AbbVie; and receiving funding for an investigator-initiated trial from Teva and Eli Lilly.

 

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

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A meta-analysis of two randomized studies evaluating patent foramen ovale (PFO) closure as a treatment strategy for migraine has shown significant benefits in several key endpoints, prompting the authors to conclude the approach warrants reevaluation.
 

The pooled analysis of patient-level data from the PRIMA and PREMIUM studies, both of which evaluated the Amplatzer PFO Occluder device (Abbott Vascular), showed that PFO closure significantly reduced the mean number of monthly migraine days and monthly migraine attacks and resulted in a greater number of patients who experienced complete migraine cessation.

The study, led by Mohammad K. Mojadidi, MD, Virginia Commonwealth University, Richmond, was published online in the Journal of the American College of Cardiology on Feb. 8, 2021.

Commenting on the article, the coauthor of an accompanying editorial, Zubair Ahmed, MD, of the Cleveland Clinic said the meta-analysis gave some useful new information but is not enough to recommend PFO closure routinely for patients with migraine.

“This meta-analysis looked at different endpoints that are more relevant to current clinical practice than those in the two original studies, and the results show that we shouldn’t rule out PFO closure as a treatment strategy for some migraine patients,” Dr. Ahmed stated. “But we’re still not sure exactly which patients are most likely to benefit from this approach, and we need additional studies to gain more understanding on that.”

The study authors noted that there is an established link between the presence of PFO and migraine, especially migraine with aura. In observational studies of PFO closure for cryptogenic stroke, the vast majority of patients who also had migraine reported a more than 50% reduction in migraine days per month after PFO closure.

However, two recent randomized clinical trials evaluating the Amplatzer PFO Occluder device for reducing the frequency and duration of episodic migraine headaches did not meet their respective primary endpoints, although they did show significant benefit of PFO closure in most of their secondary endpoints.

The current meta-analysis pooled individual participant data from the two trials to increase the power to detect the effect of percutaneous PFO closure for treating patients with episodic migraine compared with medical therapy alone.

In the two studies including a total of 337 patients, 176 were randomized to PFO closure and 161 to medical treatment only. At 12 months, three of the four efficacy endpoints evaluated in the meta-analysis were significantly reduced in the PFO-closure group. These were mean reduction of monthly migraine days (–3.1 days vs. –1.9 days; P = .02), mean reduction of monthly migraine attacks (–2.0 vs. –1.4; P = .01), and number of patients who experienced complete cessation of migraine (9% vs. 0.7%; P < .001).

The responder rate, defined as more than a 50% reduction in migraine attacks, showed a trend towards an increase in the PFO-closure group but did not achieve statistical significance (38% vs. 29%; P = .13).  

For the safety analysis, nine procedure-related and four device-related adverse events occurred in 245 patients who eventually received devices. All events were transient and resolved.
 

Better effect in patients with aura

Patients with migraine with aura, in particular frequent aura, had a significantly greater reduction in migraine days and a higher incidence of complete migraine cessation following PFO closure versus no closure, the authors reported.

 

 

In those without aura, PFO closure did not significantly reduce migraine days or improve complete headache cessation. However, some patients without aura did respond to PFO closure, which was statistically significant for reduction of migraine attacks (–2.0 vs. –1.0; P = .03).

“The interaction between the brain that is susceptible to migraine and the plethora of potential triggers is complex. A PFO may be the potential pathway for a variety of chemical triggers, such as serotonin from platelets, and although less frequent, some people with migraine without aura may trigger their migraine through this mechanism,” the researchers suggested. This hypothesis will be tested in the RELIEF trial, which is now being planned.

In the accompanying editorial, Dr. Ahmed and coauthor Robert J. Sommer, MD, Columbia University Medical Center, New York, pointed out that the meta-analysis demonstrates benefit of PFO closure in the migraine population for the first time.

“Moreover, the investigators defined a population of patients who may benefit most from PFO closure, those with migraine with frequent aura, suggesting that these may be different physiologically than other migraine subtypes. The analysis also places the PRIMA and PREMIUM outcomes in the context of endpoints that are more practical and are more commonly assessed in current clinical trials,” the editorialists noted.
 

Many unanswered questions

But the editorialists highlighted several significant limitations of the analysis, including “pooling of patient cohorts, methods, and outcome measures that might not be entirely comparable,” which they say could have introduced bias.

They also pointed out that the underlying pathophysiological mechanism linking migraine symptoms to PFO remains unknown. They explain that the mechanism is thought to involve the right-to-left passage of systemic venous blood, with some component – which would normally be eliminated or reduced on passage through the pulmonary vasculature – reaching the cerebral circulation via the PFO in supranormal concentrations and acting as a trigger for migraine activity in patients with susceptible brains.

But not all patients with migraine who have PFO benefit from PFO closure, they noted, and therefore presumably have PFO-unrelated migraines. There is no verified way to distinguish between these two groups at present.

“Once we learn to identify the subset of migraine patients in whom PFOs are actually causal of headache symptoms, screening and treatment of PFO for migraine can become a reality,” they wrote.

Although the meta-analysis is a step in the right direction, “it is not a home run,” Dr. Ahmed elaborated. “This was a post hoc analysis of two studies, neither of which showed significant benefits on their primary endpoints. That weakens the findings somewhat.”

He added: “At present, PFO closure is not routinely recommended as a migraine treatment strategy as we haven’t been sure which patients are most likely to benefit. And while this meta-analysis suggests patients with aura may be more likely to benefit, one quarter of patients without aura in the PREMIUM trial responded to PFO closure, so it’s not just about aura.

“There are still many unanswered questions.

“I don’t think the new information from this meta-analysis is enough to persuade me to change my practice, but it is a small building block in the overall picture and suggests this may be a suitable strategy for some patients in future,” he concluded.

The study had no outside funding. Participant-level data were provided by Abbott. Several coauthors were on the steering committee for the PREMIUM or PRIMA trials. Dr. Ahmed reported receiving consulting fees from, Amgen, AbbVie, electroCore, and Eli Lilly; serving on advisory boards for Amgen and Supernus; serving as a speaker for AbbVie; and receiving funding for an investigator-initiated trial from Teva and Eli Lilly.

 

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

A meta-analysis of two randomized studies evaluating patent foramen ovale (PFO) closure as a treatment strategy for migraine has shown significant benefits in several key endpoints, prompting the authors to conclude the approach warrants reevaluation.
 

The pooled analysis of patient-level data from the PRIMA and PREMIUM studies, both of which evaluated the Amplatzer PFO Occluder device (Abbott Vascular), showed that PFO closure significantly reduced the mean number of monthly migraine days and monthly migraine attacks and resulted in a greater number of patients who experienced complete migraine cessation.

The study, led by Mohammad K. Mojadidi, MD, Virginia Commonwealth University, Richmond, was published online in the Journal of the American College of Cardiology on Feb. 8, 2021.

Commenting on the article, the coauthor of an accompanying editorial, Zubair Ahmed, MD, of the Cleveland Clinic said the meta-analysis gave some useful new information but is not enough to recommend PFO closure routinely for patients with migraine.

“This meta-analysis looked at different endpoints that are more relevant to current clinical practice than those in the two original studies, and the results show that we shouldn’t rule out PFO closure as a treatment strategy for some migraine patients,” Dr. Ahmed stated. “But we’re still not sure exactly which patients are most likely to benefit from this approach, and we need additional studies to gain more understanding on that.”

The study authors noted that there is an established link between the presence of PFO and migraine, especially migraine with aura. In observational studies of PFO closure for cryptogenic stroke, the vast majority of patients who also had migraine reported a more than 50% reduction in migraine days per month after PFO closure.

However, two recent randomized clinical trials evaluating the Amplatzer PFO Occluder device for reducing the frequency and duration of episodic migraine headaches did not meet their respective primary endpoints, although they did show significant benefit of PFO closure in most of their secondary endpoints.

The current meta-analysis pooled individual participant data from the two trials to increase the power to detect the effect of percutaneous PFO closure for treating patients with episodic migraine compared with medical therapy alone.

In the two studies including a total of 337 patients, 176 were randomized to PFO closure and 161 to medical treatment only. At 12 months, three of the four efficacy endpoints evaluated in the meta-analysis were significantly reduced in the PFO-closure group. These were mean reduction of monthly migraine days (–3.1 days vs. –1.9 days; P = .02), mean reduction of monthly migraine attacks (–2.0 vs. –1.4; P = .01), and number of patients who experienced complete cessation of migraine (9% vs. 0.7%; P < .001).

The responder rate, defined as more than a 50% reduction in migraine attacks, showed a trend towards an increase in the PFO-closure group but did not achieve statistical significance (38% vs. 29%; P = .13).  

For the safety analysis, nine procedure-related and four device-related adverse events occurred in 245 patients who eventually received devices. All events were transient and resolved.
 

Better effect in patients with aura

Patients with migraine with aura, in particular frequent aura, had a significantly greater reduction in migraine days and a higher incidence of complete migraine cessation following PFO closure versus no closure, the authors reported.

 

 

In those without aura, PFO closure did not significantly reduce migraine days or improve complete headache cessation. However, some patients without aura did respond to PFO closure, which was statistically significant for reduction of migraine attacks (–2.0 vs. –1.0; P = .03).

“The interaction between the brain that is susceptible to migraine and the plethora of potential triggers is complex. A PFO may be the potential pathway for a variety of chemical triggers, such as serotonin from platelets, and although less frequent, some people with migraine without aura may trigger their migraine through this mechanism,” the researchers suggested. This hypothesis will be tested in the RELIEF trial, which is now being planned.

In the accompanying editorial, Dr. Ahmed and coauthor Robert J. Sommer, MD, Columbia University Medical Center, New York, pointed out that the meta-analysis demonstrates benefit of PFO closure in the migraine population for the first time.

“Moreover, the investigators defined a population of patients who may benefit most from PFO closure, those with migraine with frequent aura, suggesting that these may be different physiologically than other migraine subtypes. The analysis also places the PRIMA and PREMIUM outcomes in the context of endpoints that are more practical and are more commonly assessed in current clinical trials,” the editorialists noted.
 

Many unanswered questions

But the editorialists highlighted several significant limitations of the analysis, including “pooling of patient cohorts, methods, and outcome measures that might not be entirely comparable,” which they say could have introduced bias.

They also pointed out that the underlying pathophysiological mechanism linking migraine symptoms to PFO remains unknown. They explain that the mechanism is thought to involve the right-to-left passage of systemic venous blood, with some component – which would normally be eliminated or reduced on passage through the pulmonary vasculature – reaching the cerebral circulation via the PFO in supranormal concentrations and acting as a trigger for migraine activity in patients with susceptible brains.

But not all patients with migraine who have PFO benefit from PFO closure, they noted, and therefore presumably have PFO-unrelated migraines. There is no verified way to distinguish between these two groups at present.

“Once we learn to identify the subset of migraine patients in whom PFOs are actually causal of headache symptoms, screening and treatment of PFO for migraine can become a reality,” they wrote.

Although the meta-analysis is a step in the right direction, “it is not a home run,” Dr. Ahmed elaborated. “This was a post hoc analysis of two studies, neither of which showed significant benefits on their primary endpoints. That weakens the findings somewhat.”

He added: “At present, PFO closure is not routinely recommended as a migraine treatment strategy as we haven’t been sure which patients are most likely to benefit. And while this meta-analysis suggests patients with aura may be more likely to benefit, one quarter of patients without aura in the PREMIUM trial responded to PFO closure, so it’s not just about aura.

“There are still many unanswered questions.

“I don’t think the new information from this meta-analysis is enough to persuade me to change my practice, but it is a small building block in the overall picture and suggests this may be a suitable strategy for some patients in future,” he concluded.

The study had no outside funding. Participant-level data were provided by Abbott. Several coauthors were on the steering committee for the PREMIUM or PRIMA trials. Dr. Ahmed reported receiving consulting fees from, Amgen, AbbVie, electroCore, and Eli Lilly; serving on advisory boards for Amgen and Supernus; serving as a speaker for AbbVie; and receiving funding for an investigator-initiated trial from Teva and Eli Lilly.

 

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

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Brain connectivity patterns reliably identify ADHD

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Functional brain connectivity patterns are a stable biomarker of attention-deficit/hyperactivity disorder, new research suggests.

Dr. Christopher McNorgan

By applying a machine-learning approach to brain-imaging data, investigators were able to identify with 99% accuracy the adult study participants who had been diagnosed with ADHD in childhood.

“Even though the symptoms of ADHD may be less apparent in adulthood, the brain-wiring signature seems to be persistent,” study investigator Christopher McNorgan, PhD, of the department of psychology, State University of New York at Buffalo told this news organization.

The findings were published online Dec. 17, 2020, in Frontiers of Psychology.
 

Deep-learning neural networks

The researchers analyzed archived functional magnetic resonance imaging (fMRI) and behavioral data for 80 adults (mean age, 24 years; 64 male). Of these participants, 55 were diagnosed with ADHD in childhood and 25 were not.

The fMRI data were obtained during a response inhibition task that tested the individual’s ability to not respond automatically; for example, not saying “Simon Says” after someone else makes the comment.

The behavioral data included scores on the Iowa Gambling Task (IGT), which is used to measure impulsivity and risk taking.

“Usually, but not always, people with ADHD make riskier choices on this task,” Dr. McNorgan noted.

The investigators measured the amount of interconnectedness among different brain regions during the response inhibition task, which was repeated four times.

Patterns of interconnectivity were then fed into a deep-learning neural network that learned which patterns belonged to the ADHD group vs. those without ADHD (control group) and which patterns belonged to the high vs. low scorers on the IGT.
 

Caveats, cautionary notes

“The trained models are then tested on brain patterns they had never seen before, and we found the models would make the correct ADHD diagnosis and could tell apart the high and low scorers on the IGT 99% of the time,” Dr. McNorgan reported.

“The trained classifiers make predictions by calculating probabilities, and the neural networks learned how each of the brain connections contributes towards the final classification probability. We identified the set of brain connections that had the greatest influence on these probability calculations,” he noted.

Because the network classified both ADHD diagnosis and gambling task performance, the researchers were able to distinguish between connections that predicted ADHD when gambling performance was poor, as is typical for patients with ADHD, and those predicting ADHD when gambling performance was uncharacteristically good.

While more work is needed, the findings have potential clinical relevance, Dr. McNorgan said.

“ADHD can be difficult to diagnose reliably. If expense wasn’t an issue, fMRI may be able to help make diagnosis more reliable and objective,” he added.

Dr. McNorgan admitted that it might not be cost effective to use fMRI in this manner. However, because individuals with ADHD have different behavioral profiles, such as scoring atypically well on the IGT, additional studies using this approach may help identify brain networks “that are more or less active in those with ADHD that show a particular diagnostic trait,” he said.

“This could help inform what treatments might be more effective for those individuals,” Dr. McNorgan said.

Of course, he added, “clinicians’ diagnostic expertise is still required, as I would not base an ADHD diagnosis solely on the results of a single brain scan.”
 

 

 

No cross-validation

Commenting on the findings for this news organization, Vince Calhoun, PhD, neuroscientist and founding director of the Center for Translational Research in Neuroimaging and Data Science, Atlanta, a joint effort between Georgia State, Georgia Tech, and Emory University, noted some study limitations.

One cautionary note is that the investigators “appear to select relevant regions to include in the model based on activation to the task, then computed the predictions using the subset of regions that showed strong activation. The issue is this was done on the same data, so there was no cross-validation of this ‘feature selection’ step,” said Dr. Calhoun, who was not involved with the research. “This is a type of circularity which can lead to inflated accuracies,” he added.

Dr. Calhoun also noted that “multiple ADHD classification studies” have reported accuracies above 90%. In addition, there were only 80 participants in the current dataset.

“That’s relatively small for making strong claims about high accuracies as has been reported elsewhere,” he said.

Dr. McNorgan and Dr. Calhoun have reported no relevant financial relationships.

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

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Functional brain connectivity patterns are a stable biomarker of attention-deficit/hyperactivity disorder, new research suggests.

Dr. Christopher McNorgan

By applying a machine-learning approach to brain-imaging data, investigators were able to identify with 99% accuracy the adult study participants who had been diagnosed with ADHD in childhood.

“Even though the symptoms of ADHD may be less apparent in adulthood, the brain-wiring signature seems to be persistent,” study investigator Christopher McNorgan, PhD, of the department of psychology, State University of New York at Buffalo told this news organization.

The findings were published online Dec. 17, 2020, in Frontiers of Psychology.
 

Deep-learning neural networks

The researchers analyzed archived functional magnetic resonance imaging (fMRI) and behavioral data for 80 adults (mean age, 24 years; 64 male). Of these participants, 55 were diagnosed with ADHD in childhood and 25 were not.

The fMRI data were obtained during a response inhibition task that tested the individual’s ability to not respond automatically; for example, not saying “Simon Says” after someone else makes the comment.

The behavioral data included scores on the Iowa Gambling Task (IGT), which is used to measure impulsivity and risk taking.

“Usually, but not always, people with ADHD make riskier choices on this task,” Dr. McNorgan noted.

The investigators measured the amount of interconnectedness among different brain regions during the response inhibition task, which was repeated four times.

Patterns of interconnectivity were then fed into a deep-learning neural network that learned which patterns belonged to the ADHD group vs. those without ADHD (control group) and which patterns belonged to the high vs. low scorers on the IGT.
 

Caveats, cautionary notes

“The trained models are then tested on brain patterns they had never seen before, and we found the models would make the correct ADHD diagnosis and could tell apart the high and low scorers on the IGT 99% of the time,” Dr. McNorgan reported.

“The trained classifiers make predictions by calculating probabilities, and the neural networks learned how each of the brain connections contributes towards the final classification probability. We identified the set of brain connections that had the greatest influence on these probability calculations,” he noted.

Because the network classified both ADHD diagnosis and gambling task performance, the researchers were able to distinguish between connections that predicted ADHD when gambling performance was poor, as is typical for patients with ADHD, and those predicting ADHD when gambling performance was uncharacteristically good.

While more work is needed, the findings have potential clinical relevance, Dr. McNorgan said.

“ADHD can be difficult to diagnose reliably. If expense wasn’t an issue, fMRI may be able to help make diagnosis more reliable and objective,” he added.

Dr. McNorgan admitted that it might not be cost effective to use fMRI in this manner. However, because individuals with ADHD have different behavioral profiles, such as scoring atypically well on the IGT, additional studies using this approach may help identify brain networks “that are more or less active in those with ADHD that show a particular diagnostic trait,” he said.

“This could help inform what treatments might be more effective for those individuals,” Dr. McNorgan said.

Of course, he added, “clinicians’ diagnostic expertise is still required, as I would not base an ADHD diagnosis solely on the results of a single brain scan.”
 

 

 

No cross-validation

Commenting on the findings for this news organization, Vince Calhoun, PhD, neuroscientist and founding director of the Center for Translational Research in Neuroimaging and Data Science, Atlanta, a joint effort between Georgia State, Georgia Tech, and Emory University, noted some study limitations.

One cautionary note is that the investigators “appear to select relevant regions to include in the model based on activation to the task, then computed the predictions using the subset of regions that showed strong activation. The issue is this was done on the same data, so there was no cross-validation of this ‘feature selection’ step,” said Dr. Calhoun, who was not involved with the research. “This is a type of circularity which can lead to inflated accuracies,” he added.

Dr. Calhoun also noted that “multiple ADHD classification studies” have reported accuracies above 90%. In addition, there were only 80 participants in the current dataset.

“That’s relatively small for making strong claims about high accuracies as has been reported elsewhere,” he said.

Dr. McNorgan and Dr. Calhoun have reported no relevant financial relationships.

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

Functional brain connectivity patterns are a stable biomarker of attention-deficit/hyperactivity disorder, new research suggests.

Dr. Christopher McNorgan

By applying a machine-learning approach to brain-imaging data, investigators were able to identify with 99% accuracy the adult study participants who had been diagnosed with ADHD in childhood.

“Even though the symptoms of ADHD may be less apparent in adulthood, the brain-wiring signature seems to be persistent,” study investigator Christopher McNorgan, PhD, of the department of psychology, State University of New York at Buffalo told this news organization.

The findings were published online Dec. 17, 2020, in Frontiers of Psychology.
 

Deep-learning neural networks

The researchers analyzed archived functional magnetic resonance imaging (fMRI) and behavioral data for 80 adults (mean age, 24 years; 64 male). Of these participants, 55 were diagnosed with ADHD in childhood and 25 were not.

The fMRI data were obtained during a response inhibition task that tested the individual’s ability to not respond automatically; for example, not saying “Simon Says” after someone else makes the comment.

The behavioral data included scores on the Iowa Gambling Task (IGT), which is used to measure impulsivity and risk taking.

“Usually, but not always, people with ADHD make riskier choices on this task,” Dr. McNorgan noted.

The investigators measured the amount of interconnectedness among different brain regions during the response inhibition task, which was repeated four times.

Patterns of interconnectivity were then fed into a deep-learning neural network that learned which patterns belonged to the ADHD group vs. those without ADHD (control group) and which patterns belonged to the high vs. low scorers on the IGT.
 

Caveats, cautionary notes

“The trained models are then tested on brain patterns they had never seen before, and we found the models would make the correct ADHD diagnosis and could tell apart the high and low scorers on the IGT 99% of the time,” Dr. McNorgan reported.

“The trained classifiers make predictions by calculating probabilities, and the neural networks learned how each of the brain connections contributes towards the final classification probability. We identified the set of brain connections that had the greatest influence on these probability calculations,” he noted.

Because the network classified both ADHD diagnosis and gambling task performance, the researchers were able to distinguish between connections that predicted ADHD when gambling performance was poor, as is typical for patients with ADHD, and those predicting ADHD when gambling performance was uncharacteristically good.

While more work is needed, the findings have potential clinical relevance, Dr. McNorgan said.

“ADHD can be difficult to diagnose reliably. If expense wasn’t an issue, fMRI may be able to help make diagnosis more reliable and objective,” he added.

Dr. McNorgan admitted that it might not be cost effective to use fMRI in this manner. However, because individuals with ADHD have different behavioral profiles, such as scoring atypically well on the IGT, additional studies using this approach may help identify brain networks “that are more or less active in those with ADHD that show a particular diagnostic trait,” he said.

“This could help inform what treatments might be more effective for those individuals,” Dr. McNorgan said.

Of course, he added, “clinicians’ diagnostic expertise is still required, as I would not base an ADHD diagnosis solely on the results of a single brain scan.”
 

 

 

No cross-validation

Commenting on the findings for this news organization, Vince Calhoun, PhD, neuroscientist and founding director of the Center for Translational Research in Neuroimaging and Data Science, Atlanta, a joint effort between Georgia State, Georgia Tech, and Emory University, noted some study limitations.

One cautionary note is that the investigators “appear to select relevant regions to include in the model based on activation to the task, then computed the predictions using the subset of regions that showed strong activation. The issue is this was done on the same data, so there was no cross-validation of this ‘feature selection’ step,” said Dr. Calhoun, who was not involved with the research. “This is a type of circularity which can lead to inflated accuracies,” he added.

Dr. Calhoun also noted that “multiple ADHD classification studies” have reported accuracies above 90%. In addition, there were only 80 participants in the current dataset.

“That’s relatively small for making strong claims about high accuracies as has been reported elsewhere,” he said.

Dr. McNorgan and Dr. Calhoun have reported no relevant financial relationships.

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

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Child with yellow nodule

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Child with yellow nodule

Yellow nodule on child's forehead

The characteristic orange-yellow color is the tip-off to the diagnosis of juvenile xanthogranuloma (JXG). It manifests as asymptomatic solitary or scattered papules or nodules, congenitally, or most commonly during the first year of life.

JXG is an unusual non-Langerhans cell histiocytosis that more commonly affects males. The etiology of JXG is unclear; it is presumed to be due to physical or infectious stimuli that produce a granulomatous histiocytic reaction. JXG typically manifests on the head, neck, upper extremities, and trunk. The appearance of JXG may be similar to that of Langerhans cell histiocytosis. If necessary, the diagnosis of JXG can be confirmed with a skin biopsy, which will reveal Touton-type giant cells and foamy histiocytes.

JXG is a benign and self-limiting disorder and spontaneously regresses within a few years. In rare cases, it can be systemic. If there are multiple lesions, relevant history, or physical exam features suggesting space-occupying lesions, imaging should be performed to rule out lesions in internal organs or structures. Treatment is indicated when there is systemic or symptomatic ocular involvement and may include surgical excision, radiotherapy, and/or systemic chemotherapy. In this case, the patient’s JXG management involved routine monitoring in anticipation of spontaneous resolution.

Image courtesy of John Durkin, MD, FAAD, Department of Dermatology, University of New Mexico School of Medicine, Albuquerque. Text courtesy of Kerry Song, BS, University of New Mexico School of Medicine, and Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

References

Collie JS, Harper CD, Fillman EP. Juvenile Xanthogranuloma. In: StatPearls [Internet]. StatPearls Publishing; 2020 Jan. Accessed January 29, 2021. https://www.ncbi.nlm.nih.gov/books/NBK526103/#_NBK526103_pubdet

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Yellow nodule on child's forehead

The characteristic orange-yellow color is the tip-off to the diagnosis of juvenile xanthogranuloma (JXG). It manifests as asymptomatic solitary or scattered papules or nodules, congenitally, or most commonly during the first year of life.

JXG is an unusual non-Langerhans cell histiocytosis that more commonly affects males. The etiology of JXG is unclear; it is presumed to be due to physical or infectious stimuli that produce a granulomatous histiocytic reaction. JXG typically manifests on the head, neck, upper extremities, and trunk. The appearance of JXG may be similar to that of Langerhans cell histiocytosis. If necessary, the diagnosis of JXG can be confirmed with a skin biopsy, which will reveal Touton-type giant cells and foamy histiocytes.

JXG is a benign and self-limiting disorder and spontaneously regresses within a few years. In rare cases, it can be systemic. If there are multiple lesions, relevant history, or physical exam features suggesting space-occupying lesions, imaging should be performed to rule out lesions in internal organs or structures. Treatment is indicated when there is systemic or symptomatic ocular involvement and may include surgical excision, radiotherapy, and/or systemic chemotherapy. In this case, the patient’s JXG management involved routine monitoring in anticipation of spontaneous resolution.

Image courtesy of John Durkin, MD, FAAD, Department of Dermatology, University of New Mexico School of Medicine, Albuquerque. Text courtesy of Kerry Song, BS, University of New Mexico School of Medicine, and Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

Yellow nodule on child's forehead

The characteristic orange-yellow color is the tip-off to the diagnosis of juvenile xanthogranuloma (JXG). It manifests as asymptomatic solitary or scattered papules or nodules, congenitally, or most commonly during the first year of life.

JXG is an unusual non-Langerhans cell histiocytosis that more commonly affects males. The etiology of JXG is unclear; it is presumed to be due to physical or infectious stimuli that produce a granulomatous histiocytic reaction. JXG typically manifests on the head, neck, upper extremities, and trunk. The appearance of JXG may be similar to that of Langerhans cell histiocytosis. If necessary, the diagnosis of JXG can be confirmed with a skin biopsy, which will reveal Touton-type giant cells and foamy histiocytes.

JXG is a benign and self-limiting disorder and spontaneously regresses within a few years. In rare cases, it can be systemic. If there are multiple lesions, relevant history, or physical exam features suggesting space-occupying lesions, imaging should be performed to rule out lesions in internal organs or structures. Treatment is indicated when there is systemic or symptomatic ocular involvement and may include surgical excision, radiotherapy, and/or systemic chemotherapy. In this case, the patient’s JXG management involved routine monitoring in anticipation of spontaneous resolution.

Image courtesy of John Durkin, MD, FAAD, Department of Dermatology, University of New Mexico School of Medicine, Albuquerque. Text courtesy of Kerry Song, BS, University of New Mexico School of Medicine, and Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

References

Collie JS, Harper CD, Fillman EP. Juvenile Xanthogranuloma. In: StatPearls [Internet]. StatPearls Publishing; 2020 Jan. Accessed January 29, 2021. https://www.ncbi.nlm.nih.gov/books/NBK526103/#_NBK526103_pubdet

References

Collie JS, Harper CD, Fillman EP. Juvenile Xanthogranuloma. In: StatPearls [Internet]. StatPearls Publishing; 2020 Jan. Accessed January 29, 2021. https://www.ncbi.nlm.nih.gov/books/NBK526103/#_NBK526103_pubdet

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Home O2 in COPD. Eradicating COVID-19. mRNA and beyond. COVID-19 treatment, so far. Awake proning in COVID-19. Home ventilation. Interprofessional team approach to palliative extubation.

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Changed
Fri, 02/12/2021 - 15:32

 

Airways disorders


Updated guidelines on the use of home O2 in COPD: A much-needed respite

Dr. Kadambari Vijaykumar

The use of long-term oxygen therapy (LTOT, oxygen prescribed for at least 15 h/day) in patients with COPD and chronic hypoxemia has been standard of care based on trials from the 1980s that conferred a survival benefit with the use of continuous oxygen (Ann Internal Med. 1980;93[3]:391-8). More recently, LTOT has not shown to improve survival or delay time to the hospitalization in patients with stable COPD and resting or exercise-induced moderate desaturation (N Engl J Med. 2016;375[17]:1617-27). Thus far, existing recommendations had been semi-inclusive in patient selection. A fundamental lack of evidence-based clinical practice guidelines prompted additional research into patient selection, portable oxygen technology, advocacy for improved oxygen therapy financing, and updating of policies (Jacobs et al., Ann Am Thorac Soc. 2018;15[12]:1369-81). With over a million patients in the United States being prescribed home oxygen and reported disconnect in-home oxygen needs/experiences across disease processes, lifestyles, and oxygen supply requirements, the 2020 American Thoracic Society (ATS) workshop on optimizing home oxygen therapy sought to answer critical questions in the use of LTOT for COPD patients (AlMutairi, et al. Respir Care. 2018;63[11]:1321-30; Jacobs, et al. Am J Respir Crit Care Med. 2020;202[10]:e121-e141).

Dr. Dharani Kumari Narendra
Based on a thorough systematic review of available literature, the committee made strong recommendations (moderate-quality evidence) for LTOT use in COPD with severe chronic resting hypoxemia (PaO2 ≤ 55 mm Hg or SpO2 ≤ 88%), conditional recommendations for the following: (1) Against LTOT use in COPD with moderate chronic resting hypoxemia [SpO2 89%-93% (low-quality evidence)]; (2) Ambulatory oxygen use in adults with COPD with severe exertional hypoxemia (moderate-quality evidence); and (3) Liquid oxygen use in patients who are mobile outside the home and require >3 L/min of continuous-flow oxygen during exertion (very-low-quality evidence). The review identified a dire need to develop a more robust evidence-based practice and incorporate shared decision-making while highlighting the deficit of conclusive data supporting supplemental oxygen for patients with exertional desaturation.

Kadambari Vijaykumar, MD
Fellow-in-Training Member

Dharani Kumari Narendra, MBBS, FCCP
Steering Committee Member

 

 

Chest infections


Eradicating COVID-19 scourge: It is up to all of us— get vaccinated!

Dr. Marcus I. Restrepo

2021 brings hope, spurred by the availability of several effective COVID-19 vaccines – unprecedented scientific advances, considering that these vaccines were developed in record time. We have stark choices: while some individuals ignore scientific evidence and refuse to take the vaccine, we from the Chest Infections NetWork urge an alternative and imperative choice. As health providers caring for COVID-19 patients, we first-hand witness the horrors of dying alone in a hospital bed – far away from beloved ones. I have a sticker on my car that says: If you do not like your mask, you will not like my ventilator. With the advent of vaccines, I plan on replacing this sticker: If you do not want to get vaccinated, you will not like my ventilator. When the vaccine became available at my institution, I was the first to roll up my sleeve and feel the pinch in my upper arm. I urge you all to do the same. Make a difference, do your part – get vaccinated.

Marcos I. Restrepo, MD, MSc, PhD
Chair

 

Clinical pulmonary medicine


COVID-19 vaccines – mRNA and beyond

We currently have two COVID-19 mRNA vaccines with US FDA emergency use authorization (EUA) for use in individuals less than or equal to age 18 years – Pfizer and Moderna. They work by introducing mRNA into a muscle cell that instructs the host cell ribosomes to express Sars-CoV-2 spike proteins, thereby triggering a systemic immune response.

Dr. Mary Jo Farmer
Phase 3 trial demonstrated vaccine efficacy of 95% with both vaccines. Besides injection site pain, common side effects were fatigue, headache, chills, and myalgias, more frequent after dose two.

Both are two-dose regimens, with Pfizer’s 21 days apart and requires storage at -75 C, and Moderna’s 28 days apart, requiring storage at -20 C.
Dr. Shyam Subramanian
With reports of anaphylaxis reactions, CDC has issued a warning with a contraindication to the vaccine if there is severe allergic reaction after the first dose or a history of allergy to any of its components, including polyethylene glycol (PEG), or polysorbate, due to potential cross-reactive hypersensitivity with PEG.

Presently in development are three more vaccines. AstraZeneca (AZ) and Johnson & Johnson (JnJ) use an adenovirus vector. Both vaccines are stable at standard refrigerator temperatures. AZ’s results were mixed – with two, full-size doses efficacy at 62% effective, but with a half-dose followed by a full dose, efficacy was 90%. Novavax candidate works differently - it’s a protein subunit vaccine and uses a lab-made version of the SARS-CoV-2 spike protein, mixed with an adjuvant to help trigger the immune system. Results from all trials are eagerly awaited.

Mary Jo S. Farmer, MD, PhD, FCCP
Steering Committee Member


Shyam Subramanian, MD, FCCP
Chair

 

 

Clinical research and quality improvement
 

COVID-19 treatment, so far!

COVID-19 has turned rapidly into a fatal illness, causing over 1.8 million deaths worldwide so far. The pandemic has also showed us the power of adaptive trials, multi-arm trials, and the role for collaboration across the global scientific community. A few significant studies are worth mentioning.

Dr. Muhammad Hayat Syed
Initial therapies were with hydroxychloroquine and azithromycin, but showed no clinical improvement (Cavalcanti AB. N Engl J Med. 2020;383[21]:2041). Remdesivir, now standard of care, is based on the ACTT-1 trial, a double-blind randomized controlled trial (RCT), showing improved recovery time (Beigel JH, et al. N Engl J Med. 2020;383[19]:1813). The RECOVERY trial, a large clinical trial in the United Kingdom, demonstrated a mortality benefit (rate ratio 0.83) with dexamethasone at 28 days in those with moderate to severe COVID-19 pneumonia. Lopinavir-ritonavir combination failed to show benefit in the same trial (Horby P, et al. N Engl J Med. 2020 Jul 17. doi: 10.1056/NEJMoa2021436). Baricitinib has been shown to decrease recovery time, especially in patients with high oxygen need (Kalil AC, et al. N Engl J Med. 2020 Dec 11. doi: 10.1056/NEJMoa2031994).

Possible future therapies include antiviral monoclonal antibodies, bamlanivimab (Chen P, et al. N Engl J Med. 2020; online ahead of print); early convalescent plasma (Libster R, et al. N Engl J Med. 2021 Jan 6. doi: 10.1056/NEJMoa2033700); and casirivimab-imdevimab (Baum A, et al. Science. 2020 Nov 27 doi: 10.1126/science.abe2402). Development of mRNA COVID-19 vaccines can help with primary prevention and herd immunity (Polack FP, et al. N Engl J Med. 2020;383[27]:2603; Baden LR, et al. N Engl J Med. 2020; Dec 30; doi: 10.1056/NEJMoa2035389).

We are starting to understand why COVID-19 infection is more pathogenic in some, how to predict development of severe disease, and how to best treat respiratory failure. Defeating the pandemic will require ongoing international collaboration in research, development, and resource allocation.

Muhammad Hayat Syed, MBBS

Ankita Agarwal, MD
Fellows-in-Training Members

 

 

Critical care

Awake proning in COVID-19

Prone positioning has been shown to improve pulmonary mechanics in intubated patients with acute respiratory distress syndrome (ARDS). Proposed mechanisms for these benefits include shape matching, reversing the pleural pressure gradient, homogenizing distribution of pleural pressures, reducing the impact of the heart and abdomen on the lungs, and maintaining distribution of perfusion. Application of prone positioning has also been shown to reduce mortality in severe ARDS (Guérin, et al. N Engl J Med. 2013;368(23):2159-68). With the COVID-19 pandemic, clinicians have extrapolated that nonintubated patients with severe hypoxia may benefit from awake proning in the hopes of improving oxygenation and decreasing need for intubation. But, what’s the evidence so far?

Dr. Kathryn Pendleton
In small studies, awake proning has been shown to improve oxygenation (PaO2/FIO2 ratio) and work of breathing in patients with COVID-19 who were severely hypoxic and could tolerate proning receiving high flow nasal oxygen (HFNO) or noninvasive ventilation (Weatherald, et al. J Crit Care. 2021;61:63-70). However, other studies were less conclusive. In a study by Elharrar, et al (JAMA. 2020;323(22):2336-2338), oxygenation only improved in 25% of those who were proned, and this improvement was not sustained in half of patients after they were re-supined. Additionally, a recent prospective, observational study from Spain did not show benefit to awake proning in patients receiving HFNO with respect to need for intubation or risk of mortality (Ferrando, et al. Crit Care. 2020;24(1):597).
Dr. Viren Kaul
It remains unclear whether these physiologic and short-term clinical benefits will prevent the need for mechanical ventilation and/or improve long-term outcomes, including mortality. The other nuances of application of prone positioning in spontaneously breathing patients, such as the optimal duration, positioning, clinical setting, termination criteria, and adverse effects will only become clearer with time and more robust studies. Currently, more than 60 studies examining the role of prone positioning in COVID-19 were enrolling or recently completed. Hopefully, more robust trials will provide evidence about the effectiveness of this therapy in this population. Finally, head over to CHEST’s COVID-19 Resource Center to access a downloadable infographic describing the application of prone positioning.

Kathryn Pendleton, MD

Viren Kaul, MD
Steering Committee Members

 

Home-Based Mechanical Ventilation and Neuromuscular Disease


New horizons in home ventilation

Phasing out a particular ventilator (Philips Respironics Trilogy 100 ventilator) has everyone on a steep learning curve with the replacement (Trilogy EVO). Most features are replicated in the EVO, including volume/pressure control and pressure-supported modes, mouthpiece ventilation, active/passive circuit capability, and portability (11.5 lb). Upgrades include longer battery life (15 hours; 7.5 hours internal/7.5 hours detachable) and use in pediatric patients now greater than or equal to 2.5 kg.

Dr. Janet Hilbert
A significant improvement in the workhorse AVAPS-AE mode is the addition of inspiratory time control on patient-initiated breaths. In AVAPS-AE (without PC-enabled), patient-initiated breaths remain flow-cycled; however, the inspiratory time control can be achieved using Timax/Timin setting for patients with neuromuscular respiratory failure and COPD (Coleman et al. Ann Am Thorac Soc. 2019;16(9):1091-98; Nicholson, et al. Ann Am Thorac Soc. 2017;14(7):1139-46).Pressure control (PC) can now be enabled in AVAPS-AE to allow fixed Ti for both patient-initiated and device-initiated breaths, advantageous in neuromuscular disease and obesity-hypoventilation syndrome(Nicholson, et al., Ann Am Thorac Soc. 2017;14(7):1139-46; Selim, et al.,Chest. 2018;153(1):251-65).

Other significant improvements include lower flow trigger sensitivity to accommodate patients with severe respiratory muscle weakness, a fast start AVAPS with rapid breath-to-breath 3 cm H20 increases for the first minute to rapidly reach target tidal volume, and breath-to-breath auto-EPAP sensing of upper airway resistance to maintain airway patency for patients with upper airway obstruction.

Internal bluetooth transmission to cloud-based monitoring (Care OrchestratorTM) expands access to patients without wi-fi or cellular service. New monitoring modules, SpO2 and EtCO2, and transcutaneous CO2 monitoring (Sentec), transmit to cloud-based monitoring (EVO EtCs2 spring 2021).

These welcome improvements allow clinicians to better match ventilator settings to the patients’ evolving physiology and provide flexibility and connectivity to optimize long-term care.

Karin Provost, DO, PhD
Steering Committee Member

Janet Hilbert, MD
NetWork Member


Online resources
EVO e-learning curriculum

 

 

Interprofessional team


Interprofessional team approach to palliative extubation

The emotional burden of caring for patients at the end of life affects all members of the care team. Palliative (or compassionate) extubation consists of the withdrawal of mechanical ventilation when the absolute priority in care delivery is to afford comfort and allow for natural death to occur. Rapid withdrawal of ventilatory support may lead to significant respiratory distress, and the critical care team has an obligation to ensure patient comfort during the dying process (Truog RD, et al. Crit Care Med. 2008;36[3]:953). Registered nurses (RN) are primarily responsible for the titration of sedation/analgesia and should be included in discussions regarding medication selection. It is imperative that neuromuscular blockade is absent, and benzodiazepines and/or opioids should be initiated prior to palliative extubation (Lanken PN, et al. Am J Respir Crit Care Med. 2008;177:912). Respiratory therapists (RT) are responsible for endotracheal tube removal despite rare participation in end-of-life discussions (Grandhige AP, et al. Respir Care. 2016;61[7]:891). It is recommended that an experienced physician, RN, and RT be readily available to respond quickly to any signs of distress (Downar J, et al. Intensive Care Med. 2016;42:1003). Regular debriefing sessions exploring team actions and communication dynamics are advised following end-of-life care (Ho A, et al. J Interprof Care. 2016;30[6]:795-803). Palliative extubation demands meticulous planning and clear communication among all team members (physician, RN, RT) and the patient’s family. Poor planning may result in physical and emotional suffering for the patient and difficult bereavement for the family (Coradazi A, et al. Hos Pal Med Int J. 2019;3[1]:10-14). Interprofessional team-based care results from intentional teams that exhibit collective identity and shared responsibility for the patients they serve (Core Competencies for Interprofessional Education Collaborative Practice, 2016). An inclusive and interprofessional approach to withdrawal of mechanical ventilation is key to both quality patient care and provider wellbeing.

Rebecca Anna Gersten, MD
Steering Committee Member

Samantha Davis, MS, RRT
Steering Committee Member

Munish Luthra, MD, FCCP
Vice-Chair Committee

Publications
Topics
Sections

 

Airways disorders


Updated guidelines on the use of home O2 in COPD: A much-needed respite

Dr. Kadambari Vijaykumar

The use of long-term oxygen therapy (LTOT, oxygen prescribed for at least 15 h/day) in patients with COPD and chronic hypoxemia has been standard of care based on trials from the 1980s that conferred a survival benefit with the use of continuous oxygen (Ann Internal Med. 1980;93[3]:391-8). More recently, LTOT has not shown to improve survival or delay time to the hospitalization in patients with stable COPD and resting or exercise-induced moderate desaturation (N Engl J Med. 2016;375[17]:1617-27). Thus far, existing recommendations had been semi-inclusive in patient selection. A fundamental lack of evidence-based clinical practice guidelines prompted additional research into patient selection, portable oxygen technology, advocacy for improved oxygen therapy financing, and updating of policies (Jacobs et al., Ann Am Thorac Soc. 2018;15[12]:1369-81). With over a million patients in the United States being prescribed home oxygen and reported disconnect in-home oxygen needs/experiences across disease processes, lifestyles, and oxygen supply requirements, the 2020 American Thoracic Society (ATS) workshop on optimizing home oxygen therapy sought to answer critical questions in the use of LTOT for COPD patients (AlMutairi, et al. Respir Care. 2018;63[11]:1321-30; Jacobs, et al. Am J Respir Crit Care Med. 2020;202[10]:e121-e141).

Dr. Dharani Kumari Narendra
Based on a thorough systematic review of available literature, the committee made strong recommendations (moderate-quality evidence) for LTOT use in COPD with severe chronic resting hypoxemia (PaO2 ≤ 55 mm Hg or SpO2 ≤ 88%), conditional recommendations for the following: (1) Against LTOT use in COPD with moderate chronic resting hypoxemia [SpO2 89%-93% (low-quality evidence)]; (2) Ambulatory oxygen use in adults with COPD with severe exertional hypoxemia (moderate-quality evidence); and (3) Liquid oxygen use in patients who are mobile outside the home and require >3 L/min of continuous-flow oxygen during exertion (very-low-quality evidence). The review identified a dire need to develop a more robust evidence-based practice and incorporate shared decision-making while highlighting the deficit of conclusive data supporting supplemental oxygen for patients with exertional desaturation.

Kadambari Vijaykumar, MD
Fellow-in-Training Member

Dharani Kumari Narendra, MBBS, FCCP
Steering Committee Member

 

 

Chest infections


Eradicating COVID-19 scourge: It is up to all of us— get vaccinated!

Dr. Marcus I. Restrepo

2021 brings hope, spurred by the availability of several effective COVID-19 vaccines – unprecedented scientific advances, considering that these vaccines were developed in record time. We have stark choices: while some individuals ignore scientific evidence and refuse to take the vaccine, we from the Chest Infections NetWork urge an alternative and imperative choice. As health providers caring for COVID-19 patients, we first-hand witness the horrors of dying alone in a hospital bed – far away from beloved ones. I have a sticker on my car that says: If you do not like your mask, you will not like my ventilator. With the advent of vaccines, I plan on replacing this sticker: If you do not want to get vaccinated, you will not like my ventilator. When the vaccine became available at my institution, I was the first to roll up my sleeve and feel the pinch in my upper arm. I urge you all to do the same. Make a difference, do your part – get vaccinated.

Marcos I. Restrepo, MD, MSc, PhD
Chair

 

Clinical pulmonary medicine


COVID-19 vaccines – mRNA and beyond

We currently have two COVID-19 mRNA vaccines with US FDA emergency use authorization (EUA) for use in individuals less than or equal to age 18 years – Pfizer and Moderna. They work by introducing mRNA into a muscle cell that instructs the host cell ribosomes to express Sars-CoV-2 spike proteins, thereby triggering a systemic immune response.

Dr. Mary Jo Farmer
Phase 3 trial demonstrated vaccine efficacy of 95% with both vaccines. Besides injection site pain, common side effects were fatigue, headache, chills, and myalgias, more frequent after dose two.

Both are two-dose regimens, with Pfizer’s 21 days apart and requires storage at -75 C, and Moderna’s 28 days apart, requiring storage at -20 C.
Dr. Shyam Subramanian
With reports of anaphylaxis reactions, CDC has issued a warning with a contraindication to the vaccine if there is severe allergic reaction after the first dose or a history of allergy to any of its components, including polyethylene glycol (PEG), or polysorbate, due to potential cross-reactive hypersensitivity with PEG.

Presently in development are three more vaccines. AstraZeneca (AZ) and Johnson & Johnson (JnJ) use an adenovirus vector. Both vaccines are stable at standard refrigerator temperatures. AZ’s results were mixed – with two, full-size doses efficacy at 62% effective, but with a half-dose followed by a full dose, efficacy was 90%. Novavax candidate works differently - it’s a protein subunit vaccine and uses a lab-made version of the SARS-CoV-2 spike protein, mixed with an adjuvant to help trigger the immune system. Results from all trials are eagerly awaited.

Mary Jo S. Farmer, MD, PhD, FCCP
Steering Committee Member


Shyam Subramanian, MD, FCCP
Chair

 

 

Clinical research and quality improvement
 

COVID-19 treatment, so far!

COVID-19 has turned rapidly into a fatal illness, causing over 1.8 million deaths worldwide so far. The pandemic has also showed us the power of adaptive trials, multi-arm trials, and the role for collaboration across the global scientific community. A few significant studies are worth mentioning.

Dr. Muhammad Hayat Syed
Initial therapies were with hydroxychloroquine and azithromycin, but showed no clinical improvement (Cavalcanti AB. N Engl J Med. 2020;383[21]:2041). Remdesivir, now standard of care, is based on the ACTT-1 trial, a double-blind randomized controlled trial (RCT), showing improved recovery time (Beigel JH, et al. N Engl J Med. 2020;383[19]:1813). The RECOVERY trial, a large clinical trial in the United Kingdom, demonstrated a mortality benefit (rate ratio 0.83) with dexamethasone at 28 days in those with moderate to severe COVID-19 pneumonia. Lopinavir-ritonavir combination failed to show benefit in the same trial (Horby P, et al. N Engl J Med. 2020 Jul 17. doi: 10.1056/NEJMoa2021436). Baricitinib has been shown to decrease recovery time, especially in patients with high oxygen need (Kalil AC, et al. N Engl J Med. 2020 Dec 11. doi: 10.1056/NEJMoa2031994).

Possible future therapies include antiviral monoclonal antibodies, bamlanivimab (Chen P, et al. N Engl J Med. 2020; online ahead of print); early convalescent plasma (Libster R, et al. N Engl J Med. 2021 Jan 6. doi: 10.1056/NEJMoa2033700); and casirivimab-imdevimab (Baum A, et al. Science. 2020 Nov 27 doi: 10.1126/science.abe2402). Development of mRNA COVID-19 vaccines can help with primary prevention and herd immunity (Polack FP, et al. N Engl J Med. 2020;383[27]:2603; Baden LR, et al. N Engl J Med. 2020; Dec 30; doi: 10.1056/NEJMoa2035389).

We are starting to understand why COVID-19 infection is more pathogenic in some, how to predict development of severe disease, and how to best treat respiratory failure. Defeating the pandemic will require ongoing international collaboration in research, development, and resource allocation.

Muhammad Hayat Syed, MBBS

Ankita Agarwal, MD
Fellows-in-Training Members

 

 

Critical care

Awake proning in COVID-19

Prone positioning has been shown to improve pulmonary mechanics in intubated patients with acute respiratory distress syndrome (ARDS). Proposed mechanisms for these benefits include shape matching, reversing the pleural pressure gradient, homogenizing distribution of pleural pressures, reducing the impact of the heart and abdomen on the lungs, and maintaining distribution of perfusion. Application of prone positioning has also been shown to reduce mortality in severe ARDS (Guérin, et al. N Engl J Med. 2013;368(23):2159-68). With the COVID-19 pandemic, clinicians have extrapolated that nonintubated patients with severe hypoxia may benefit from awake proning in the hopes of improving oxygenation and decreasing need for intubation. But, what’s the evidence so far?

Dr. Kathryn Pendleton
In small studies, awake proning has been shown to improve oxygenation (PaO2/FIO2 ratio) and work of breathing in patients with COVID-19 who were severely hypoxic and could tolerate proning receiving high flow nasal oxygen (HFNO) or noninvasive ventilation (Weatherald, et al. J Crit Care. 2021;61:63-70). However, other studies were less conclusive. In a study by Elharrar, et al (JAMA. 2020;323(22):2336-2338), oxygenation only improved in 25% of those who were proned, and this improvement was not sustained in half of patients after they were re-supined. Additionally, a recent prospective, observational study from Spain did not show benefit to awake proning in patients receiving HFNO with respect to need for intubation or risk of mortality (Ferrando, et al. Crit Care. 2020;24(1):597).
Dr. Viren Kaul
It remains unclear whether these physiologic and short-term clinical benefits will prevent the need for mechanical ventilation and/or improve long-term outcomes, including mortality. The other nuances of application of prone positioning in spontaneously breathing patients, such as the optimal duration, positioning, clinical setting, termination criteria, and adverse effects will only become clearer with time and more robust studies. Currently, more than 60 studies examining the role of prone positioning in COVID-19 were enrolling or recently completed. Hopefully, more robust trials will provide evidence about the effectiveness of this therapy in this population. Finally, head over to CHEST’s COVID-19 Resource Center to access a downloadable infographic describing the application of prone positioning.

Kathryn Pendleton, MD

Viren Kaul, MD
Steering Committee Members

 

Home-Based Mechanical Ventilation and Neuromuscular Disease


New horizons in home ventilation

Phasing out a particular ventilator (Philips Respironics Trilogy 100 ventilator) has everyone on a steep learning curve with the replacement (Trilogy EVO). Most features are replicated in the EVO, including volume/pressure control and pressure-supported modes, mouthpiece ventilation, active/passive circuit capability, and portability (11.5 lb). Upgrades include longer battery life (15 hours; 7.5 hours internal/7.5 hours detachable) and use in pediatric patients now greater than or equal to 2.5 kg.

Dr. Janet Hilbert
A significant improvement in the workhorse AVAPS-AE mode is the addition of inspiratory time control on patient-initiated breaths. In AVAPS-AE (without PC-enabled), patient-initiated breaths remain flow-cycled; however, the inspiratory time control can be achieved using Timax/Timin setting for patients with neuromuscular respiratory failure and COPD (Coleman et al. Ann Am Thorac Soc. 2019;16(9):1091-98; Nicholson, et al. Ann Am Thorac Soc. 2017;14(7):1139-46).Pressure control (PC) can now be enabled in AVAPS-AE to allow fixed Ti for both patient-initiated and device-initiated breaths, advantageous in neuromuscular disease and obesity-hypoventilation syndrome(Nicholson, et al., Ann Am Thorac Soc. 2017;14(7):1139-46; Selim, et al.,Chest. 2018;153(1):251-65).

Other significant improvements include lower flow trigger sensitivity to accommodate patients with severe respiratory muscle weakness, a fast start AVAPS with rapid breath-to-breath 3 cm H20 increases for the first minute to rapidly reach target tidal volume, and breath-to-breath auto-EPAP sensing of upper airway resistance to maintain airway patency for patients with upper airway obstruction.

Internal bluetooth transmission to cloud-based monitoring (Care OrchestratorTM) expands access to patients without wi-fi or cellular service. New monitoring modules, SpO2 and EtCO2, and transcutaneous CO2 monitoring (Sentec), transmit to cloud-based monitoring (EVO EtCs2 spring 2021).

These welcome improvements allow clinicians to better match ventilator settings to the patients’ evolving physiology and provide flexibility and connectivity to optimize long-term care.

Karin Provost, DO, PhD
Steering Committee Member

Janet Hilbert, MD
NetWork Member


Online resources
EVO e-learning curriculum

 

 

Interprofessional team


Interprofessional team approach to palliative extubation

The emotional burden of caring for patients at the end of life affects all members of the care team. Palliative (or compassionate) extubation consists of the withdrawal of mechanical ventilation when the absolute priority in care delivery is to afford comfort and allow for natural death to occur. Rapid withdrawal of ventilatory support may lead to significant respiratory distress, and the critical care team has an obligation to ensure patient comfort during the dying process (Truog RD, et al. Crit Care Med. 2008;36[3]:953). Registered nurses (RN) are primarily responsible for the titration of sedation/analgesia and should be included in discussions regarding medication selection. It is imperative that neuromuscular blockade is absent, and benzodiazepines and/or opioids should be initiated prior to palliative extubation (Lanken PN, et al. Am J Respir Crit Care Med. 2008;177:912). Respiratory therapists (RT) are responsible for endotracheal tube removal despite rare participation in end-of-life discussions (Grandhige AP, et al. Respir Care. 2016;61[7]:891). It is recommended that an experienced physician, RN, and RT be readily available to respond quickly to any signs of distress (Downar J, et al. Intensive Care Med. 2016;42:1003). Regular debriefing sessions exploring team actions and communication dynamics are advised following end-of-life care (Ho A, et al. J Interprof Care. 2016;30[6]:795-803). Palliative extubation demands meticulous planning and clear communication among all team members (physician, RN, RT) and the patient’s family. Poor planning may result in physical and emotional suffering for the patient and difficult bereavement for the family (Coradazi A, et al. Hos Pal Med Int J. 2019;3[1]:10-14). Interprofessional team-based care results from intentional teams that exhibit collective identity and shared responsibility for the patients they serve (Core Competencies for Interprofessional Education Collaborative Practice, 2016). An inclusive and interprofessional approach to withdrawal of mechanical ventilation is key to both quality patient care and provider wellbeing.

Rebecca Anna Gersten, MD
Steering Committee Member

Samantha Davis, MS, RRT
Steering Committee Member

Munish Luthra, MD, FCCP
Vice-Chair Committee

 

Airways disorders


Updated guidelines on the use of home O2 in COPD: A much-needed respite

Dr. Kadambari Vijaykumar

The use of long-term oxygen therapy (LTOT, oxygen prescribed for at least 15 h/day) in patients with COPD and chronic hypoxemia has been standard of care based on trials from the 1980s that conferred a survival benefit with the use of continuous oxygen (Ann Internal Med. 1980;93[3]:391-8). More recently, LTOT has not shown to improve survival or delay time to the hospitalization in patients with stable COPD and resting or exercise-induced moderate desaturation (N Engl J Med. 2016;375[17]:1617-27). Thus far, existing recommendations had been semi-inclusive in patient selection. A fundamental lack of evidence-based clinical practice guidelines prompted additional research into patient selection, portable oxygen technology, advocacy for improved oxygen therapy financing, and updating of policies (Jacobs et al., Ann Am Thorac Soc. 2018;15[12]:1369-81). With over a million patients in the United States being prescribed home oxygen and reported disconnect in-home oxygen needs/experiences across disease processes, lifestyles, and oxygen supply requirements, the 2020 American Thoracic Society (ATS) workshop on optimizing home oxygen therapy sought to answer critical questions in the use of LTOT for COPD patients (AlMutairi, et al. Respir Care. 2018;63[11]:1321-30; Jacobs, et al. Am J Respir Crit Care Med. 2020;202[10]:e121-e141).

Dr. Dharani Kumari Narendra
Based on a thorough systematic review of available literature, the committee made strong recommendations (moderate-quality evidence) for LTOT use in COPD with severe chronic resting hypoxemia (PaO2 ≤ 55 mm Hg or SpO2 ≤ 88%), conditional recommendations for the following: (1) Against LTOT use in COPD with moderate chronic resting hypoxemia [SpO2 89%-93% (low-quality evidence)]; (2) Ambulatory oxygen use in adults with COPD with severe exertional hypoxemia (moderate-quality evidence); and (3) Liquid oxygen use in patients who are mobile outside the home and require >3 L/min of continuous-flow oxygen during exertion (very-low-quality evidence). The review identified a dire need to develop a more robust evidence-based practice and incorporate shared decision-making while highlighting the deficit of conclusive data supporting supplemental oxygen for patients with exertional desaturation.

Kadambari Vijaykumar, MD
Fellow-in-Training Member

Dharani Kumari Narendra, MBBS, FCCP
Steering Committee Member

 

 

Chest infections


Eradicating COVID-19 scourge: It is up to all of us— get vaccinated!

Dr. Marcus I. Restrepo

2021 brings hope, spurred by the availability of several effective COVID-19 vaccines – unprecedented scientific advances, considering that these vaccines were developed in record time. We have stark choices: while some individuals ignore scientific evidence and refuse to take the vaccine, we from the Chest Infections NetWork urge an alternative and imperative choice. As health providers caring for COVID-19 patients, we first-hand witness the horrors of dying alone in a hospital bed – far away from beloved ones. I have a sticker on my car that says: If you do not like your mask, you will not like my ventilator. With the advent of vaccines, I plan on replacing this sticker: If you do not want to get vaccinated, you will not like my ventilator. When the vaccine became available at my institution, I was the first to roll up my sleeve and feel the pinch in my upper arm. I urge you all to do the same. Make a difference, do your part – get vaccinated.

Marcos I. Restrepo, MD, MSc, PhD
Chair

 

Clinical pulmonary medicine


COVID-19 vaccines – mRNA and beyond

We currently have two COVID-19 mRNA vaccines with US FDA emergency use authorization (EUA) for use in individuals less than or equal to age 18 years – Pfizer and Moderna. They work by introducing mRNA into a muscle cell that instructs the host cell ribosomes to express Sars-CoV-2 spike proteins, thereby triggering a systemic immune response.

Dr. Mary Jo Farmer
Phase 3 trial demonstrated vaccine efficacy of 95% with both vaccines. Besides injection site pain, common side effects were fatigue, headache, chills, and myalgias, more frequent after dose two.

Both are two-dose regimens, with Pfizer’s 21 days apart and requires storage at -75 C, and Moderna’s 28 days apart, requiring storage at -20 C.
Dr. Shyam Subramanian
With reports of anaphylaxis reactions, CDC has issued a warning with a contraindication to the vaccine if there is severe allergic reaction after the first dose or a history of allergy to any of its components, including polyethylene glycol (PEG), or polysorbate, due to potential cross-reactive hypersensitivity with PEG.

Presently in development are three more vaccines. AstraZeneca (AZ) and Johnson & Johnson (JnJ) use an adenovirus vector. Both vaccines are stable at standard refrigerator temperatures. AZ’s results were mixed – with two, full-size doses efficacy at 62% effective, but with a half-dose followed by a full dose, efficacy was 90%. Novavax candidate works differently - it’s a protein subunit vaccine and uses a lab-made version of the SARS-CoV-2 spike protein, mixed with an adjuvant to help trigger the immune system. Results from all trials are eagerly awaited.

Mary Jo S. Farmer, MD, PhD, FCCP
Steering Committee Member


Shyam Subramanian, MD, FCCP
Chair

 

 

Clinical research and quality improvement
 

COVID-19 treatment, so far!

COVID-19 has turned rapidly into a fatal illness, causing over 1.8 million deaths worldwide so far. The pandemic has also showed us the power of adaptive trials, multi-arm trials, and the role for collaboration across the global scientific community. A few significant studies are worth mentioning.

Dr. Muhammad Hayat Syed
Initial therapies were with hydroxychloroquine and azithromycin, but showed no clinical improvement (Cavalcanti AB. N Engl J Med. 2020;383[21]:2041). Remdesivir, now standard of care, is based on the ACTT-1 trial, a double-blind randomized controlled trial (RCT), showing improved recovery time (Beigel JH, et al. N Engl J Med. 2020;383[19]:1813). The RECOVERY trial, a large clinical trial in the United Kingdom, demonstrated a mortality benefit (rate ratio 0.83) with dexamethasone at 28 days in those with moderate to severe COVID-19 pneumonia. Lopinavir-ritonavir combination failed to show benefit in the same trial (Horby P, et al. N Engl J Med. 2020 Jul 17. doi: 10.1056/NEJMoa2021436). Baricitinib has been shown to decrease recovery time, especially in patients with high oxygen need (Kalil AC, et al. N Engl J Med. 2020 Dec 11. doi: 10.1056/NEJMoa2031994).

Possible future therapies include antiviral monoclonal antibodies, bamlanivimab (Chen P, et al. N Engl J Med. 2020; online ahead of print); early convalescent plasma (Libster R, et al. N Engl J Med. 2021 Jan 6. doi: 10.1056/NEJMoa2033700); and casirivimab-imdevimab (Baum A, et al. Science. 2020 Nov 27 doi: 10.1126/science.abe2402). Development of mRNA COVID-19 vaccines can help with primary prevention and herd immunity (Polack FP, et al. N Engl J Med. 2020;383[27]:2603; Baden LR, et al. N Engl J Med. 2020; Dec 30; doi: 10.1056/NEJMoa2035389).

We are starting to understand why COVID-19 infection is more pathogenic in some, how to predict development of severe disease, and how to best treat respiratory failure. Defeating the pandemic will require ongoing international collaboration in research, development, and resource allocation.

Muhammad Hayat Syed, MBBS

Ankita Agarwal, MD
Fellows-in-Training Members

 

 

Critical care

Awake proning in COVID-19

Prone positioning has been shown to improve pulmonary mechanics in intubated patients with acute respiratory distress syndrome (ARDS). Proposed mechanisms for these benefits include shape matching, reversing the pleural pressure gradient, homogenizing distribution of pleural pressures, reducing the impact of the heart and abdomen on the lungs, and maintaining distribution of perfusion. Application of prone positioning has also been shown to reduce mortality in severe ARDS (Guérin, et al. N Engl J Med. 2013;368(23):2159-68). With the COVID-19 pandemic, clinicians have extrapolated that nonintubated patients with severe hypoxia may benefit from awake proning in the hopes of improving oxygenation and decreasing need for intubation. But, what’s the evidence so far?

Dr. Kathryn Pendleton
In small studies, awake proning has been shown to improve oxygenation (PaO2/FIO2 ratio) and work of breathing in patients with COVID-19 who were severely hypoxic and could tolerate proning receiving high flow nasal oxygen (HFNO) or noninvasive ventilation (Weatherald, et al. J Crit Care. 2021;61:63-70). However, other studies were less conclusive. In a study by Elharrar, et al (JAMA. 2020;323(22):2336-2338), oxygenation only improved in 25% of those who were proned, and this improvement was not sustained in half of patients after they were re-supined. Additionally, a recent prospective, observational study from Spain did not show benefit to awake proning in patients receiving HFNO with respect to need for intubation or risk of mortality (Ferrando, et al. Crit Care. 2020;24(1):597).
Dr. Viren Kaul
It remains unclear whether these physiologic and short-term clinical benefits will prevent the need for mechanical ventilation and/or improve long-term outcomes, including mortality. The other nuances of application of prone positioning in spontaneously breathing patients, such as the optimal duration, positioning, clinical setting, termination criteria, and adverse effects will only become clearer with time and more robust studies. Currently, more than 60 studies examining the role of prone positioning in COVID-19 were enrolling or recently completed. Hopefully, more robust trials will provide evidence about the effectiveness of this therapy in this population. Finally, head over to CHEST’s COVID-19 Resource Center to access a downloadable infographic describing the application of prone positioning.

Kathryn Pendleton, MD

Viren Kaul, MD
Steering Committee Members

 

Home-Based Mechanical Ventilation and Neuromuscular Disease


New horizons in home ventilation

Phasing out a particular ventilator (Philips Respironics Trilogy 100 ventilator) has everyone on a steep learning curve with the replacement (Trilogy EVO). Most features are replicated in the EVO, including volume/pressure control and pressure-supported modes, mouthpiece ventilation, active/passive circuit capability, and portability (11.5 lb). Upgrades include longer battery life (15 hours; 7.5 hours internal/7.5 hours detachable) and use in pediatric patients now greater than or equal to 2.5 kg.

Dr. Janet Hilbert
A significant improvement in the workhorse AVAPS-AE mode is the addition of inspiratory time control on patient-initiated breaths. In AVAPS-AE (without PC-enabled), patient-initiated breaths remain flow-cycled; however, the inspiratory time control can be achieved using Timax/Timin setting for patients with neuromuscular respiratory failure and COPD (Coleman et al. Ann Am Thorac Soc. 2019;16(9):1091-98; Nicholson, et al. Ann Am Thorac Soc. 2017;14(7):1139-46).Pressure control (PC) can now be enabled in AVAPS-AE to allow fixed Ti for both patient-initiated and device-initiated breaths, advantageous in neuromuscular disease and obesity-hypoventilation syndrome(Nicholson, et al., Ann Am Thorac Soc. 2017;14(7):1139-46; Selim, et al.,Chest. 2018;153(1):251-65).

Other significant improvements include lower flow trigger sensitivity to accommodate patients with severe respiratory muscle weakness, a fast start AVAPS with rapid breath-to-breath 3 cm H20 increases for the first minute to rapidly reach target tidal volume, and breath-to-breath auto-EPAP sensing of upper airway resistance to maintain airway patency for patients with upper airway obstruction.

Internal bluetooth transmission to cloud-based monitoring (Care OrchestratorTM) expands access to patients without wi-fi or cellular service. New monitoring modules, SpO2 and EtCO2, and transcutaneous CO2 monitoring (Sentec), transmit to cloud-based monitoring (EVO EtCs2 spring 2021).

These welcome improvements allow clinicians to better match ventilator settings to the patients’ evolving physiology and provide flexibility and connectivity to optimize long-term care.

Karin Provost, DO, PhD
Steering Committee Member

Janet Hilbert, MD
NetWork Member


Online resources
EVO e-learning curriculum

 

 

Interprofessional team


Interprofessional team approach to palliative extubation

The emotional burden of caring for patients at the end of life affects all members of the care team. Palliative (or compassionate) extubation consists of the withdrawal of mechanical ventilation when the absolute priority in care delivery is to afford comfort and allow for natural death to occur. Rapid withdrawal of ventilatory support may lead to significant respiratory distress, and the critical care team has an obligation to ensure patient comfort during the dying process (Truog RD, et al. Crit Care Med. 2008;36[3]:953). Registered nurses (RN) are primarily responsible for the titration of sedation/analgesia and should be included in discussions regarding medication selection. It is imperative that neuromuscular blockade is absent, and benzodiazepines and/or opioids should be initiated prior to palliative extubation (Lanken PN, et al. Am J Respir Crit Care Med. 2008;177:912). Respiratory therapists (RT) are responsible for endotracheal tube removal despite rare participation in end-of-life discussions (Grandhige AP, et al. Respir Care. 2016;61[7]:891). It is recommended that an experienced physician, RN, and RT be readily available to respond quickly to any signs of distress (Downar J, et al. Intensive Care Med. 2016;42:1003). Regular debriefing sessions exploring team actions and communication dynamics are advised following end-of-life care (Ho A, et al. J Interprof Care. 2016;30[6]:795-803). Palliative extubation demands meticulous planning and clear communication among all team members (physician, RN, RT) and the patient’s family. Poor planning may result in physical and emotional suffering for the patient and difficult bereavement for the family (Coradazi A, et al. Hos Pal Med Int J. 2019;3[1]:10-14). Interprofessional team-based care results from intentional teams that exhibit collective identity and shared responsibility for the patients they serve (Core Competencies for Interprofessional Education Collaborative Practice, 2016). An inclusive and interprofessional approach to withdrawal of mechanical ventilation is key to both quality patient care and provider wellbeing.

Rebecca Anna Gersten, MD
Steering Committee Member

Samantha Davis, MS, RRT
Steering Committee Member

Munish Luthra, MD, FCCP
Vice-Chair Committee

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In case you missed it ...CHEST Annual Meeting 2020 Award Recipients

Article Type
Changed
Thu, 02/11/2021 - 00:15

 

ANNUAL AWARDS

Master FCCP

Nancy A. Collop MD, Master FCCP



College Medalist Award

Neil R. MacIntyre, MD, FCCP



Distinguished Service Award

Lisa K. Moores, MD, FCCP



Master Clinician Educator

William F. Kelly, MD, FCCP

David A. Schulman, MD, MPH, FCCP



Early Career Clinician Educator

Subani Chandra, MD, FCCP



Alfred Soffer Award for Editorial Excellence

Barbara Anderson, CHEST Staff

Laura Lipsey, CHEST Staff



Presidential Citation

Mangala Narasimhan, DO, FCCP

Renli Qiao, MD, PhD, FCCP
 

HONOR LECTURE AND MEMORIAL AWARDS

Edward C. Rosenow III, MD, Master FCCP/Master Teacher Endowed Honor Lecture Evolving Therapies in ANCA-Associated Vasculitides

Joseph P. Lynch, III, MD, FCCP

The lecture is generously funded by the CHEST Foundation.Distinguished Scientist Honor Lecture in Cardiopulmonary PhysiologyHelping the Dyspneic Patient: Clinical Physiology Matters!

Denis E. O’Donnell, MD, MBBCh, FCCP

The lecture is generously funded by the CHEST Foundation.Presidential Honor LectureCOPD Management: We’ve Come So Far

Darcy D. Marciniuk, MD, Master FCCP



Thomas L. Petty, MD, Master FCCP Memorial LectureReal World Research - What Would Dr. Petty Say?

Mary Hart, RRT, MS, FCCP

The lecture is generously funded by the CHEST Foundation.Margaret Pfrommer Endowed Memorial Lecture in Home-Based Mechanical VentilationNavigating to Home NIV Nirvana: What Would Margaret Do?

Peter C. Gay, MD, MS, FCCP

The Margaret Pfrommer Endowed Memorial Lecture in Home-Based Mechanical Ventilation is generously supported by International Ventilator Users Network of Post-Polio Health International and the CHEST Foundation.Pasquale Ciaglia Memorial Lecture in Interventional MedicineRaising the Bar: The Interventional Pulmonary Outcomes Group

Lonny B. Yarmus, DO, MBA, FCCP

The lecture is generously funded by the CHEST Foundation.

Roger C. Bone Memorial Lecture in Critical CareTo SIRS with Love: Dr. Roger Bone’s Continued Influence on Early Sepsis Care

Emanuel P. Rivers, MD, MPH, FCCP

The lecture is generously funded by the CHEST Foundation.Murray Kornfeld Memorial Founders LectureOur Pneumonia Journey: The Lungs and Beyond

Marcos I. Restrepo, MD, PhD, FCCP

The lecture is generously funded by the CHEST Foundation.

CHEST FOUNDATION GRANT AWARDS

The GlaxoSmithKline Distinguished Scholar in Respiratory Health

Deepa Gotur, MD, FCCP

Cytokine Release in SARS COV2 Viral Illness and Trends of Inflammasome Expression in Acute Respiratory Distress Syndrome Manifestations and ManagementThis grant is supported by an endowed fund from GlaxoSmithKline.CHEST Foundation and the Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency

Paul R. Ellis, MBChB

Cardiovascular Outcomes and Phenotypes in Pulmonary Exacerbations of Alpha-1 AntitrypsinThis grant is jointly supported by the CHEST Foundation and the Alpha-1 Foundation.CHEST Foundation Research Grant in Women’s Lung Health

Shannon E. Kay, MD

Sex-specific Gene Expression in AsthmaThis grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease

Davide Biondini, MD, PhD

Role of the Immune Check Points (CTLA-4 and PD-1) in the Development or Evasion of Smoking-Induced Chronic Obstructive Pulmonary Disease



Andrew J. Gangemi, MD

Are Sleep Health, Nicotine Metabolism, and Airway Inflammation Mechanisms for Differences in Lung Function between African American and Non-Hispanic White Smokers? A Proof-of-Concept ExaminationThese grants are supported by AstraZeneca LP.CHEST Foundation Research Grant in Critical Care

Mounica Vallurupalli, MD

Evaluating the Impact of Clonal Hematopoiesis on Host Immune Response During Sepsis

This grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Lung Cancer

Stefanie Mason, MD

Implications of Longitudinal Muscle-Mass Trajectories in Lung CancerThis grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Venous Thromboembolism

Jansen N. Seheult, MD, MBBCh

Untangling the NET: Neutrophil Activation as the Driver of Venous Thromboembolism in Coronavirus Disease 2019This grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Nontuberculous Mycobacteria Diseases

Bryan A. Garcia, MD

Longitudinal Proteomic Endotyping of Patients with Nontuberculous Mycobacterial Lung InfectionsThis grant is supported by Insmed Incorporated.CHEST Foundation Research Grant in Cystic Fibrosis

Jeffrey Barry, MD

Eosinophilia as a Biomarker for Worse Outcomes in Cystic Fibrosis



Kristina Montemayor, MD

The Association of Sex Hormones and Respiratory Morbidity in Individuals with Cystic FibrosisThese grants are supported by Vertex Pharmaceuticals.John R. Addrizzo, MD, FCCP Research Grant in Sarcoidosis

 

 

Changwan Ryu, MD

Extracellular Matrix Proteins as a Biomarker for Stage IV SarcoidosisThis grant is in honor of John R. Addrizzo, MD, FCCP and is jointly supported by the Addrizzo family and the CHEST Foundation.CHEST Foundation Research Grant in Severe Asthma

Isaretta L. Riley, MD, MPH

Coping with Asthma through Life Management (CALM)This grant is funded by AstraZeneca LP.CHEST Foundation Research Grant in Pulmonary Fibrosis

Sarah Beshay, MD

COPA Syndrome-Associated Mutations in Lung Transplant Recipients for Pulmonary Fibrosis



Erica D. Farrand, MD

The Future of Telehealth in Interstitial Lung DiseaseThese grants are supported by Boehringer Ingelheim Pharmaceuticals and Genentech, Inc.CHEST Foundation Research Grant in Sleep Medicine

Tetyana Kendzerska, MD, PhD

The Role of Sleep and Circadian Disturbances in Cancer Development and Progression: A Historical Multicenter Clinical Cohort Study



Nancy Stewart, DO

Improving COPD/OSA Overlap Syndrome Pre-Discharge Care DeliveryThese grants are funded by Jazz Pharmaceuticals, Inc.CHEST Foundation and Association of Critical Care Medicine Program Directors Award Research Grant in Medical Education

Ilana R. Krumm, MD

What’s good about Soul Food? Discovering and Analyzing Elements of an ICU Team Group Discussion Which Improve Provider WellnessThis grant is jointly supported by the CHEST Foundation and APCCMPD.CHEST Foundation and American Thoracic Society Research Grant in Diversity

Thomas S. Valley, MD, MSc

Understanding Differences in Delivery of Care Processes for Respiratory Failure by Race/EthnicityThis grant is jointly supported by the CHEST Foundation and ATS.CHEST Foundation Research Grant in COVID-19

David Furfaro, MD

Subphenotypes, Inflammatory Profiles, and Antibody Response in COVID-19 ARDSThis grant is supported by the CHEST Foundation.CHEST Foundation and American Thoracic Society Grant in COVID-19 and Diversity

Peter D. Jackson, MD

The Effect of the COVID-19 Pandemic on Tuberculosis Care in UgandaThis grant is jointly supported by the CHEST Foundation and ATS.CHEST Foundation Research Grant in Ultrasonography and COVID-19

Marjan M. Islam, MD

Thoracic Ultrasound in COVID-19: A Prospective Study Using Lung and Diaphragm Ultrasound in Evaluating Dyspnea in ICU Survivors with COVID-19 in a Post-ICU Clinic



Siddharth Dugar, MBBS

Spontaneous Echo Contrast in Lower Extremity and Correlation with Venous Velocity and Subsequent Deep Venous Thrombosis in Critically Ill COVID-19 PatientsThis grant is jointly supported by the CHEST Foundation and FUJIFILM SonoSite.

CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP



Ivan Nemorin, MBA, MS, RRT

Healthier Homes for Children-Community Asthma Prevention Program



Joseph Huang, MD

East Africa Training Initiative (EATI)



Aninda Das, MD, MBBS

Screening for Childhood Tuberculosis in Children 0-4 years of Age with Moderate to Severe Malnutrition in a Rural District of West Bengal, India



Trishual Siddharthan, MD

Establishing a Pulmonary and Critical Care Training Program in Uganda



Marina Lima, MD, MSc

Asmaland: The First Gamified Pediatric Asthma Educational Program in Portuguese



Roberta M. Kato, MD

Lung Power



These grants are supported by the CHEST Foundation.Alfred Soffer Research Award Winners

Mazen O. Al-Qadi, MD: RESPIRATORY VARIATION IN RIGHT ATRIAL PRESSURE PREDICTS RIGHT VENTRICULAR DYSFUNCTION IN PATIENTS WITH PRE-CAPILLARY PULMONARY HYPERTENSION

Valerie G. Press, MD: COST SAVING SIMULATION FOR THE TRANSITION FROM NEBULIZER TO COMBINATION OF NEBULIZER AND METERED-DOSE INHALERS (MD)



Young Investigator Award Winners

Gabriel E. Ortiz Jaimes, MD: CORRELATION OF CARDIAC OUTPUT MEASUREMENT BY GOAL-DIRECTED ECHOCARDIOGRAPHY PERFORMED BY INTENSIVISTS VS PULMONARY ARTERY CATHETER

Palakkumar Patel, MD: IMPACT OF HAVING PULMONARY HYPERTENSION IN PATIENTS ADMITTED WITH ACUTE EXACERBATION OF COPD IN THEIR HEALTHCARE UTILIZATION AND READMISSION: A US POPULATION COHORT STUDY

 

 

Top 5 Abstract Posters

Winner: Amr Alwakeel, MD: IMPACT OF A PLEURAL CARE PROGRAM ON THE PATHWAY TO DEFINITIVE PALLIATION OF MALIGNANT PLEURAL EFFUSIONS: A PRE-AND POST STUDY

Winner: Konstantinos Zorbas, MD: A SIMPLE PREDICTION SCORE FOR POSTOPERATIVE DEATH AFTER DECORTICATION

Winner: Yichen Wang, MD, MSc: CORONAVIRUS-RELATED HOSPITAL ADMISSIONS IN THE UNITED STATES IN 2016-2017

Runner up: Daniel Ospina-Delgado, MD: CHARACTERIZATION OF LARYNGEAL DISORDERS IN PATIENTS WITH EXCESSIVE CENTRAL AIRWAY COLLAPSE

Runner up: Vishal Vashistha, MD: TREATMENT PATTERNS AMONG LOWER-INCOME INDIAN PATIENTS WITH METASTATIC NON-SMALL CELL LUNG CANCER HARBORING EGFR MUTATIONS OR ALK REARRANGEMENTS



Case Report Poster Winners

Faiza Khalid, MD: FORME FUSTE OF INTERMEDIATE SYNDROME (IMS) IN ORGANOPHOSPHATE POISOING (OPP): EXPERT OPINION GUIDELINE WITHOUT CLEAR END-POINT.

William Meng, MD: VINGT MILLE LIEUES SOUS LES MERS: A POISONOUS GUEST FROM THE BLUE SEA TOXIC INHALATION OF CORAL PALYTOXIN

Dhruv Amratia, MD: PULMONARY BLASTOMA: A RARE FORM OF LUNG CANCER

Melinda Becker, MD: ECMO-ASSISTED BRONCHOSCOPY FOR NEAR-COMPLETE TRACHEAL OBSTRUCTION

Brittany Blass, PA-C: A CASE OF AUTOIMMUNE PULMONARY ALVEOLAR PROTEINOSIS WITH UNDERLYING MONOCLONAL B-CELL LYMPHOCYTOSIS

Abigayle Sullivan, MD: BIRD FANCIER’S LUNG: AN UNDERDIAGNOSED CAUSE OF SHORTNESS OF BREATH

Nitin Gupta, DO: SUCCESSFUL EMERGENT CORONARY ARTERY BYPASS IN A WOMAN WITH POSTPARTUM SPONTANEOUS CORONARY ARTERY DISSECTION

Michelle Miles, DO: GI VARIANT OF LEMIERRE SYNDROME: COMPLETE OCCLUSION OF SUPERIOR MESENTERIC VEIN IN A 30-YEAR-OLD WITH APPENDICEAL ABSCESS

Adarsha Ojha, MD: BLEEDING LUNG AND BLOATING GUT: LANE HAMILTON SYNDROME

Abdul Siddiqui, MD: A CASE OF E-CIGARETTE OR VAPING PRODUCT USE-ASSOCIATED LUNG INJURY IN AN INFREQUENT VAPE USER

James Dugan, MD: EMPHYSEMA WITH PLACENTAL TRANSMOGRIFICATION AND LIPOMATOUS CHANGE

Daniel Condit, MD: DUPLICATE INFERIOR VENA CAVA AS A POTENTIAL PATHWAY FOR RECURRENT PULMONARY EMBOLISM


 

CHEST 2020 CHEST Challenge

1st Place



Case Western Reserve University (MetroHealth)



Enambir Josan, MD

Ishan Lalani, MD, MPH

Faisal Qadir, MD



Program Director: Ziad Shaman, MD, FCCP







2nd Place





SUNY Downstate



Suchit Khanijao, MD

Chetana Pendkar, MBBS

Ayla Zubair, MBBS



Program Director: Robert Foronjy, MD



3rd Place



NYP Brooklyn Methodist Hospital



John Gorski, MD

Sandi Khin, MD

Kinjal Patel, MD


 

Program Director: Anthony Saleh, MD, FCCP

Publications
Topics
Sections

 

ANNUAL AWARDS

Master FCCP

Nancy A. Collop MD, Master FCCP



College Medalist Award

Neil R. MacIntyre, MD, FCCP



Distinguished Service Award

Lisa K. Moores, MD, FCCP



Master Clinician Educator

William F. Kelly, MD, FCCP

David A. Schulman, MD, MPH, FCCP



Early Career Clinician Educator

Subani Chandra, MD, FCCP



Alfred Soffer Award for Editorial Excellence

Barbara Anderson, CHEST Staff

Laura Lipsey, CHEST Staff



Presidential Citation

Mangala Narasimhan, DO, FCCP

Renli Qiao, MD, PhD, FCCP
 

HONOR LECTURE AND MEMORIAL AWARDS

Edward C. Rosenow III, MD, Master FCCP/Master Teacher Endowed Honor Lecture Evolving Therapies in ANCA-Associated Vasculitides

Joseph P. Lynch, III, MD, FCCP

The lecture is generously funded by the CHEST Foundation.Distinguished Scientist Honor Lecture in Cardiopulmonary PhysiologyHelping the Dyspneic Patient: Clinical Physiology Matters!

Denis E. O’Donnell, MD, MBBCh, FCCP

The lecture is generously funded by the CHEST Foundation.Presidential Honor LectureCOPD Management: We’ve Come So Far

Darcy D. Marciniuk, MD, Master FCCP



Thomas L. Petty, MD, Master FCCP Memorial LectureReal World Research - What Would Dr. Petty Say?

Mary Hart, RRT, MS, FCCP

The lecture is generously funded by the CHEST Foundation.Margaret Pfrommer Endowed Memorial Lecture in Home-Based Mechanical VentilationNavigating to Home NIV Nirvana: What Would Margaret Do?

Peter C. Gay, MD, MS, FCCP

The Margaret Pfrommer Endowed Memorial Lecture in Home-Based Mechanical Ventilation is generously supported by International Ventilator Users Network of Post-Polio Health International and the CHEST Foundation.Pasquale Ciaglia Memorial Lecture in Interventional MedicineRaising the Bar: The Interventional Pulmonary Outcomes Group

Lonny B. Yarmus, DO, MBA, FCCP

The lecture is generously funded by the CHEST Foundation.

Roger C. Bone Memorial Lecture in Critical CareTo SIRS with Love: Dr. Roger Bone’s Continued Influence on Early Sepsis Care

Emanuel P. Rivers, MD, MPH, FCCP

The lecture is generously funded by the CHEST Foundation.Murray Kornfeld Memorial Founders LectureOur Pneumonia Journey: The Lungs and Beyond

Marcos I. Restrepo, MD, PhD, FCCP

The lecture is generously funded by the CHEST Foundation.

CHEST FOUNDATION GRANT AWARDS

The GlaxoSmithKline Distinguished Scholar in Respiratory Health

Deepa Gotur, MD, FCCP

Cytokine Release in SARS COV2 Viral Illness and Trends of Inflammasome Expression in Acute Respiratory Distress Syndrome Manifestations and ManagementThis grant is supported by an endowed fund from GlaxoSmithKline.CHEST Foundation and the Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency

Paul R. Ellis, MBChB

Cardiovascular Outcomes and Phenotypes in Pulmonary Exacerbations of Alpha-1 AntitrypsinThis grant is jointly supported by the CHEST Foundation and the Alpha-1 Foundation.CHEST Foundation Research Grant in Women’s Lung Health

Shannon E. Kay, MD

Sex-specific Gene Expression in AsthmaThis grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease

Davide Biondini, MD, PhD

Role of the Immune Check Points (CTLA-4 and PD-1) in the Development or Evasion of Smoking-Induced Chronic Obstructive Pulmonary Disease



Andrew J. Gangemi, MD

Are Sleep Health, Nicotine Metabolism, and Airway Inflammation Mechanisms for Differences in Lung Function between African American and Non-Hispanic White Smokers? A Proof-of-Concept ExaminationThese grants are supported by AstraZeneca LP.CHEST Foundation Research Grant in Critical Care

Mounica Vallurupalli, MD

Evaluating the Impact of Clonal Hematopoiesis on Host Immune Response During Sepsis

This grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Lung Cancer

Stefanie Mason, MD

Implications of Longitudinal Muscle-Mass Trajectories in Lung CancerThis grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Venous Thromboembolism

Jansen N. Seheult, MD, MBBCh

Untangling the NET: Neutrophil Activation as the Driver of Venous Thromboembolism in Coronavirus Disease 2019This grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Nontuberculous Mycobacteria Diseases

Bryan A. Garcia, MD

Longitudinal Proteomic Endotyping of Patients with Nontuberculous Mycobacterial Lung InfectionsThis grant is supported by Insmed Incorporated.CHEST Foundation Research Grant in Cystic Fibrosis

Jeffrey Barry, MD

Eosinophilia as a Biomarker for Worse Outcomes in Cystic Fibrosis



Kristina Montemayor, MD

The Association of Sex Hormones and Respiratory Morbidity in Individuals with Cystic FibrosisThese grants are supported by Vertex Pharmaceuticals.John R. Addrizzo, MD, FCCP Research Grant in Sarcoidosis

 

 

Changwan Ryu, MD

Extracellular Matrix Proteins as a Biomarker for Stage IV SarcoidosisThis grant is in honor of John R. Addrizzo, MD, FCCP and is jointly supported by the Addrizzo family and the CHEST Foundation.CHEST Foundation Research Grant in Severe Asthma

Isaretta L. Riley, MD, MPH

Coping with Asthma through Life Management (CALM)This grant is funded by AstraZeneca LP.CHEST Foundation Research Grant in Pulmonary Fibrosis

Sarah Beshay, MD

COPA Syndrome-Associated Mutations in Lung Transplant Recipients for Pulmonary Fibrosis



Erica D. Farrand, MD

The Future of Telehealth in Interstitial Lung DiseaseThese grants are supported by Boehringer Ingelheim Pharmaceuticals and Genentech, Inc.CHEST Foundation Research Grant in Sleep Medicine

Tetyana Kendzerska, MD, PhD

The Role of Sleep and Circadian Disturbances in Cancer Development and Progression: A Historical Multicenter Clinical Cohort Study



Nancy Stewart, DO

Improving COPD/OSA Overlap Syndrome Pre-Discharge Care DeliveryThese grants are funded by Jazz Pharmaceuticals, Inc.CHEST Foundation and Association of Critical Care Medicine Program Directors Award Research Grant in Medical Education

Ilana R. Krumm, MD

What’s good about Soul Food? Discovering and Analyzing Elements of an ICU Team Group Discussion Which Improve Provider WellnessThis grant is jointly supported by the CHEST Foundation and APCCMPD.CHEST Foundation and American Thoracic Society Research Grant in Diversity

Thomas S. Valley, MD, MSc

Understanding Differences in Delivery of Care Processes for Respiratory Failure by Race/EthnicityThis grant is jointly supported by the CHEST Foundation and ATS.CHEST Foundation Research Grant in COVID-19

David Furfaro, MD

Subphenotypes, Inflammatory Profiles, and Antibody Response in COVID-19 ARDSThis grant is supported by the CHEST Foundation.CHEST Foundation and American Thoracic Society Grant in COVID-19 and Diversity

Peter D. Jackson, MD

The Effect of the COVID-19 Pandemic on Tuberculosis Care in UgandaThis grant is jointly supported by the CHEST Foundation and ATS.CHEST Foundation Research Grant in Ultrasonography and COVID-19

Marjan M. Islam, MD

Thoracic Ultrasound in COVID-19: A Prospective Study Using Lung and Diaphragm Ultrasound in Evaluating Dyspnea in ICU Survivors with COVID-19 in a Post-ICU Clinic



Siddharth Dugar, MBBS

Spontaneous Echo Contrast in Lower Extremity and Correlation with Venous Velocity and Subsequent Deep Venous Thrombosis in Critically Ill COVID-19 PatientsThis grant is jointly supported by the CHEST Foundation and FUJIFILM SonoSite.

CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP



Ivan Nemorin, MBA, MS, RRT

Healthier Homes for Children-Community Asthma Prevention Program



Joseph Huang, MD

East Africa Training Initiative (EATI)



Aninda Das, MD, MBBS

Screening for Childhood Tuberculosis in Children 0-4 years of Age with Moderate to Severe Malnutrition in a Rural District of West Bengal, India



Trishual Siddharthan, MD

Establishing a Pulmonary and Critical Care Training Program in Uganda



Marina Lima, MD, MSc

Asmaland: The First Gamified Pediatric Asthma Educational Program in Portuguese



Roberta M. Kato, MD

Lung Power



These grants are supported by the CHEST Foundation.Alfred Soffer Research Award Winners

Mazen O. Al-Qadi, MD: RESPIRATORY VARIATION IN RIGHT ATRIAL PRESSURE PREDICTS RIGHT VENTRICULAR DYSFUNCTION IN PATIENTS WITH PRE-CAPILLARY PULMONARY HYPERTENSION

Valerie G. Press, MD: COST SAVING SIMULATION FOR THE TRANSITION FROM NEBULIZER TO COMBINATION OF NEBULIZER AND METERED-DOSE INHALERS (MD)



Young Investigator Award Winners

Gabriel E. Ortiz Jaimes, MD: CORRELATION OF CARDIAC OUTPUT MEASUREMENT BY GOAL-DIRECTED ECHOCARDIOGRAPHY PERFORMED BY INTENSIVISTS VS PULMONARY ARTERY CATHETER

Palakkumar Patel, MD: IMPACT OF HAVING PULMONARY HYPERTENSION IN PATIENTS ADMITTED WITH ACUTE EXACERBATION OF COPD IN THEIR HEALTHCARE UTILIZATION AND READMISSION: A US POPULATION COHORT STUDY

 

 

Top 5 Abstract Posters

Winner: Amr Alwakeel, MD: IMPACT OF A PLEURAL CARE PROGRAM ON THE PATHWAY TO DEFINITIVE PALLIATION OF MALIGNANT PLEURAL EFFUSIONS: A PRE-AND POST STUDY

Winner: Konstantinos Zorbas, MD: A SIMPLE PREDICTION SCORE FOR POSTOPERATIVE DEATH AFTER DECORTICATION

Winner: Yichen Wang, MD, MSc: CORONAVIRUS-RELATED HOSPITAL ADMISSIONS IN THE UNITED STATES IN 2016-2017

Runner up: Daniel Ospina-Delgado, MD: CHARACTERIZATION OF LARYNGEAL DISORDERS IN PATIENTS WITH EXCESSIVE CENTRAL AIRWAY COLLAPSE

Runner up: Vishal Vashistha, MD: TREATMENT PATTERNS AMONG LOWER-INCOME INDIAN PATIENTS WITH METASTATIC NON-SMALL CELL LUNG CANCER HARBORING EGFR MUTATIONS OR ALK REARRANGEMENTS



Case Report Poster Winners

Faiza Khalid, MD: FORME FUSTE OF INTERMEDIATE SYNDROME (IMS) IN ORGANOPHOSPHATE POISOING (OPP): EXPERT OPINION GUIDELINE WITHOUT CLEAR END-POINT.

William Meng, MD: VINGT MILLE LIEUES SOUS LES MERS: A POISONOUS GUEST FROM THE BLUE SEA TOXIC INHALATION OF CORAL PALYTOXIN

Dhruv Amratia, MD: PULMONARY BLASTOMA: A RARE FORM OF LUNG CANCER

Melinda Becker, MD: ECMO-ASSISTED BRONCHOSCOPY FOR NEAR-COMPLETE TRACHEAL OBSTRUCTION

Brittany Blass, PA-C: A CASE OF AUTOIMMUNE PULMONARY ALVEOLAR PROTEINOSIS WITH UNDERLYING MONOCLONAL B-CELL LYMPHOCYTOSIS

Abigayle Sullivan, MD: BIRD FANCIER’S LUNG: AN UNDERDIAGNOSED CAUSE OF SHORTNESS OF BREATH

Nitin Gupta, DO: SUCCESSFUL EMERGENT CORONARY ARTERY BYPASS IN A WOMAN WITH POSTPARTUM SPONTANEOUS CORONARY ARTERY DISSECTION

Michelle Miles, DO: GI VARIANT OF LEMIERRE SYNDROME: COMPLETE OCCLUSION OF SUPERIOR MESENTERIC VEIN IN A 30-YEAR-OLD WITH APPENDICEAL ABSCESS

Adarsha Ojha, MD: BLEEDING LUNG AND BLOATING GUT: LANE HAMILTON SYNDROME

Abdul Siddiqui, MD: A CASE OF E-CIGARETTE OR VAPING PRODUCT USE-ASSOCIATED LUNG INJURY IN AN INFREQUENT VAPE USER

James Dugan, MD: EMPHYSEMA WITH PLACENTAL TRANSMOGRIFICATION AND LIPOMATOUS CHANGE

Daniel Condit, MD: DUPLICATE INFERIOR VENA CAVA AS A POTENTIAL PATHWAY FOR RECURRENT PULMONARY EMBOLISM


 

CHEST 2020 CHEST Challenge

1st Place



Case Western Reserve University (MetroHealth)



Enambir Josan, MD

Ishan Lalani, MD, MPH

Faisal Qadir, MD



Program Director: Ziad Shaman, MD, FCCP







2nd Place





SUNY Downstate



Suchit Khanijao, MD

Chetana Pendkar, MBBS

Ayla Zubair, MBBS



Program Director: Robert Foronjy, MD



3rd Place



NYP Brooklyn Methodist Hospital



John Gorski, MD

Sandi Khin, MD

Kinjal Patel, MD


 

Program Director: Anthony Saleh, MD, FCCP

 

ANNUAL AWARDS

Master FCCP

Nancy A. Collop MD, Master FCCP



College Medalist Award

Neil R. MacIntyre, MD, FCCP



Distinguished Service Award

Lisa K. Moores, MD, FCCP



Master Clinician Educator

William F. Kelly, MD, FCCP

David A. Schulman, MD, MPH, FCCP



Early Career Clinician Educator

Subani Chandra, MD, FCCP



Alfred Soffer Award for Editorial Excellence

Barbara Anderson, CHEST Staff

Laura Lipsey, CHEST Staff



Presidential Citation

Mangala Narasimhan, DO, FCCP

Renli Qiao, MD, PhD, FCCP
 

HONOR LECTURE AND MEMORIAL AWARDS

Edward C. Rosenow III, MD, Master FCCP/Master Teacher Endowed Honor Lecture Evolving Therapies in ANCA-Associated Vasculitides

Joseph P. Lynch, III, MD, FCCP

The lecture is generously funded by the CHEST Foundation.Distinguished Scientist Honor Lecture in Cardiopulmonary PhysiologyHelping the Dyspneic Patient: Clinical Physiology Matters!

Denis E. O’Donnell, MD, MBBCh, FCCP

The lecture is generously funded by the CHEST Foundation.Presidential Honor LectureCOPD Management: We’ve Come So Far

Darcy D. Marciniuk, MD, Master FCCP



Thomas L. Petty, MD, Master FCCP Memorial LectureReal World Research - What Would Dr. Petty Say?

Mary Hart, RRT, MS, FCCP

The lecture is generously funded by the CHEST Foundation.Margaret Pfrommer Endowed Memorial Lecture in Home-Based Mechanical VentilationNavigating to Home NIV Nirvana: What Would Margaret Do?

Peter C. Gay, MD, MS, FCCP

The Margaret Pfrommer Endowed Memorial Lecture in Home-Based Mechanical Ventilation is generously supported by International Ventilator Users Network of Post-Polio Health International and the CHEST Foundation.Pasquale Ciaglia Memorial Lecture in Interventional MedicineRaising the Bar: The Interventional Pulmonary Outcomes Group

Lonny B. Yarmus, DO, MBA, FCCP

The lecture is generously funded by the CHEST Foundation.

Roger C. Bone Memorial Lecture in Critical CareTo SIRS with Love: Dr. Roger Bone’s Continued Influence on Early Sepsis Care

Emanuel P. Rivers, MD, MPH, FCCP

The lecture is generously funded by the CHEST Foundation.Murray Kornfeld Memorial Founders LectureOur Pneumonia Journey: The Lungs and Beyond

Marcos I. Restrepo, MD, PhD, FCCP

The lecture is generously funded by the CHEST Foundation.

CHEST FOUNDATION GRANT AWARDS

The GlaxoSmithKline Distinguished Scholar in Respiratory Health

Deepa Gotur, MD, FCCP

Cytokine Release in SARS COV2 Viral Illness and Trends of Inflammasome Expression in Acute Respiratory Distress Syndrome Manifestations and ManagementThis grant is supported by an endowed fund from GlaxoSmithKline.CHEST Foundation and the Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency

Paul R. Ellis, MBChB

Cardiovascular Outcomes and Phenotypes in Pulmonary Exacerbations of Alpha-1 AntitrypsinThis grant is jointly supported by the CHEST Foundation and the Alpha-1 Foundation.CHEST Foundation Research Grant in Women’s Lung Health

Shannon E. Kay, MD

Sex-specific Gene Expression in AsthmaThis grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease

Davide Biondini, MD, PhD

Role of the Immune Check Points (CTLA-4 and PD-1) in the Development or Evasion of Smoking-Induced Chronic Obstructive Pulmonary Disease



Andrew J. Gangemi, MD

Are Sleep Health, Nicotine Metabolism, and Airway Inflammation Mechanisms for Differences in Lung Function between African American and Non-Hispanic White Smokers? A Proof-of-Concept ExaminationThese grants are supported by AstraZeneca LP.CHEST Foundation Research Grant in Critical Care

Mounica Vallurupalli, MD

Evaluating the Impact of Clonal Hematopoiesis on Host Immune Response During Sepsis

This grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Lung Cancer

Stefanie Mason, MD

Implications of Longitudinal Muscle-Mass Trajectories in Lung CancerThis grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Venous Thromboembolism

Jansen N. Seheult, MD, MBBCh

Untangling the NET: Neutrophil Activation as the Driver of Venous Thromboembolism in Coronavirus Disease 2019This grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Nontuberculous Mycobacteria Diseases

Bryan A. Garcia, MD

Longitudinal Proteomic Endotyping of Patients with Nontuberculous Mycobacterial Lung InfectionsThis grant is supported by Insmed Incorporated.CHEST Foundation Research Grant in Cystic Fibrosis

Jeffrey Barry, MD

Eosinophilia as a Biomarker for Worse Outcomes in Cystic Fibrosis



Kristina Montemayor, MD

The Association of Sex Hormones and Respiratory Morbidity in Individuals with Cystic FibrosisThese grants are supported by Vertex Pharmaceuticals.John R. Addrizzo, MD, FCCP Research Grant in Sarcoidosis

 

 

Changwan Ryu, MD

Extracellular Matrix Proteins as a Biomarker for Stage IV SarcoidosisThis grant is in honor of John R. Addrizzo, MD, FCCP and is jointly supported by the Addrizzo family and the CHEST Foundation.CHEST Foundation Research Grant in Severe Asthma

Isaretta L. Riley, MD, MPH

Coping with Asthma through Life Management (CALM)This grant is funded by AstraZeneca LP.CHEST Foundation Research Grant in Pulmonary Fibrosis

Sarah Beshay, MD

COPA Syndrome-Associated Mutations in Lung Transplant Recipients for Pulmonary Fibrosis



Erica D. Farrand, MD

The Future of Telehealth in Interstitial Lung DiseaseThese grants are supported by Boehringer Ingelheim Pharmaceuticals and Genentech, Inc.CHEST Foundation Research Grant in Sleep Medicine

Tetyana Kendzerska, MD, PhD

The Role of Sleep and Circadian Disturbances in Cancer Development and Progression: A Historical Multicenter Clinical Cohort Study



Nancy Stewart, DO

Improving COPD/OSA Overlap Syndrome Pre-Discharge Care DeliveryThese grants are funded by Jazz Pharmaceuticals, Inc.CHEST Foundation and Association of Critical Care Medicine Program Directors Award Research Grant in Medical Education

Ilana R. Krumm, MD

What’s good about Soul Food? Discovering and Analyzing Elements of an ICU Team Group Discussion Which Improve Provider WellnessThis grant is jointly supported by the CHEST Foundation and APCCMPD.CHEST Foundation and American Thoracic Society Research Grant in Diversity

Thomas S. Valley, MD, MSc

Understanding Differences in Delivery of Care Processes for Respiratory Failure by Race/EthnicityThis grant is jointly supported by the CHEST Foundation and ATS.CHEST Foundation Research Grant in COVID-19

David Furfaro, MD

Subphenotypes, Inflammatory Profiles, and Antibody Response in COVID-19 ARDSThis grant is supported by the CHEST Foundation.CHEST Foundation and American Thoracic Society Grant in COVID-19 and Diversity

Peter D. Jackson, MD

The Effect of the COVID-19 Pandemic on Tuberculosis Care in UgandaThis grant is jointly supported by the CHEST Foundation and ATS.CHEST Foundation Research Grant in Ultrasonography and COVID-19

Marjan M. Islam, MD

Thoracic Ultrasound in COVID-19: A Prospective Study Using Lung and Diaphragm Ultrasound in Evaluating Dyspnea in ICU Survivors with COVID-19 in a Post-ICU Clinic



Siddharth Dugar, MBBS

Spontaneous Echo Contrast in Lower Extremity and Correlation with Venous Velocity and Subsequent Deep Venous Thrombosis in Critically Ill COVID-19 PatientsThis grant is jointly supported by the CHEST Foundation and FUJIFILM SonoSite.

CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP



Ivan Nemorin, MBA, MS, RRT

Healthier Homes for Children-Community Asthma Prevention Program



Joseph Huang, MD

East Africa Training Initiative (EATI)



Aninda Das, MD, MBBS

Screening for Childhood Tuberculosis in Children 0-4 years of Age with Moderate to Severe Malnutrition in a Rural District of West Bengal, India



Trishual Siddharthan, MD

Establishing a Pulmonary and Critical Care Training Program in Uganda



Marina Lima, MD, MSc

Asmaland: The First Gamified Pediatric Asthma Educational Program in Portuguese



Roberta M. Kato, MD

Lung Power



These grants are supported by the CHEST Foundation.Alfred Soffer Research Award Winners

Mazen O. Al-Qadi, MD: RESPIRATORY VARIATION IN RIGHT ATRIAL PRESSURE PREDICTS RIGHT VENTRICULAR DYSFUNCTION IN PATIENTS WITH PRE-CAPILLARY PULMONARY HYPERTENSION

Valerie G. Press, MD: COST SAVING SIMULATION FOR THE TRANSITION FROM NEBULIZER TO COMBINATION OF NEBULIZER AND METERED-DOSE INHALERS (MD)



Young Investigator Award Winners

Gabriel E. Ortiz Jaimes, MD: CORRELATION OF CARDIAC OUTPUT MEASUREMENT BY GOAL-DIRECTED ECHOCARDIOGRAPHY PERFORMED BY INTENSIVISTS VS PULMONARY ARTERY CATHETER

Palakkumar Patel, MD: IMPACT OF HAVING PULMONARY HYPERTENSION IN PATIENTS ADMITTED WITH ACUTE EXACERBATION OF COPD IN THEIR HEALTHCARE UTILIZATION AND READMISSION: A US POPULATION COHORT STUDY

 

 

Top 5 Abstract Posters

Winner: Amr Alwakeel, MD: IMPACT OF A PLEURAL CARE PROGRAM ON THE PATHWAY TO DEFINITIVE PALLIATION OF MALIGNANT PLEURAL EFFUSIONS: A PRE-AND POST STUDY

Winner: Konstantinos Zorbas, MD: A SIMPLE PREDICTION SCORE FOR POSTOPERATIVE DEATH AFTER DECORTICATION

Winner: Yichen Wang, MD, MSc: CORONAVIRUS-RELATED HOSPITAL ADMISSIONS IN THE UNITED STATES IN 2016-2017

Runner up: Daniel Ospina-Delgado, MD: CHARACTERIZATION OF LARYNGEAL DISORDERS IN PATIENTS WITH EXCESSIVE CENTRAL AIRWAY COLLAPSE

Runner up: Vishal Vashistha, MD: TREATMENT PATTERNS AMONG LOWER-INCOME INDIAN PATIENTS WITH METASTATIC NON-SMALL CELL LUNG CANCER HARBORING EGFR MUTATIONS OR ALK REARRANGEMENTS



Case Report Poster Winners

Faiza Khalid, MD: FORME FUSTE OF INTERMEDIATE SYNDROME (IMS) IN ORGANOPHOSPHATE POISOING (OPP): EXPERT OPINION GUIDELINE WITHOUT CLEAR END-POINT.

William Meng, MD: VINGT MILLE LIEUES SOUS LES MERS: A POISONOUS GUEST FROM THE BLUE SEA TOXIC INHALATION OF CORAL PALYTOXIN

Dhruv Amratia, MD: PULMONARY BLASTOMA: A RARE FORM OF LUNG CANCER

Melinda Becker, MD: ECMO-ASSISTED BRONCHOSCOPY FOR NEAR-COMPLETE TRACHEAL OBSTRUCTION

Brittany Blass, PA-C: A CASE OF AUTOIMMUNE PULMONARY ALVEOLAR PROTEINOSIS WITH UNDERLYING MONOCLONAL B-CELL LYMPHOCYTOSIS

Abigayle Sullivan, MD: BIRD FANCIER’S LUNG: AN UNDERDIAGNOSED CAUSE OF SHORTNESS OF BREATH

Nitin Gupta, DO: SUCCESSFUL EMERGENT CORONARY ARTERY BYPASS IN A WOMAN WITH POSTPARTUM SPONTANEOUS CORONARY ARTERY DISSECTION

Michelle Miles, DO: GI VARIANT OF LEMIERRE SYNDROME: COMPLETE OCCLUSION OF SUPERIOR MESENTERIC VEIN IN A 30-YEAR-OLD WITH APPENDICEAL ABSCESS

Adarsha Ojha, MD: BLEEDING LUNG AND BLOATING GUT: LANE HAMILTON SYNDROME

Abdul Siddiqui, MD: A CASE OF E-CIGARETTE OR VAPING PRODUCT USE-ASSOCIATED LUNG INJURY IN AN INFREQUENT VAPE USER

James Dugan, MD: EMPHYSEMA WITH PLACENTAL TRANSMOGRIFICATION AND LIPOMATOUS CHANGE

Daniel Condit, MD: DUPLICATE INFERIOR VENA CAVA AS A POTENTIAL PATHWAY FOR RECURRENT PULMONARY EMBOLISM


 

CHEST 2020 CHEST Challenge

1st Place



Case Western Reserve University (MetroHealth)



Enambir Josan, MD

Ishan Lalani, MD, MPH

Faisal Qadir, MD



Program Director: Ziad Shaman, MD, FCCP







2nd Place





SUNY Downstate



Suchit Khanijao, MD

Chetana Pendkar, MBBS

Ayla Zubair, MBBS



Program Director: Robert Foronjy, MD



3rd Place



NYP Brooklyn Methodist Hospital



John Gorski, MD

Sandi Khin, MD

Kinjal Patel, MD


 

Program Director: Anthony Saleh, MD, FCCP

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