Immunoglobulin A (IgA) nephropathy, also known as Berger disease, is a kidney disorder characterized by the deposition of IgA in the glomeruli, leading to inflammation and potential damage. It is the most common primary glomerulonephritis worldwide. Here are five things to know about IgA nephropathy.

1. Disease-modifying therapies for IgA nephropathy have become available only recently.

The past few years have brought development of the first disease-modifying therapies to reduce proteinuria for adults with primary IgA nephropathy who are at risk for rapid disease progression. In 2021, the US Food and Drug Administration (FDA) approved a targeted-release formulation of the corticosteroid budesonide for these patients. This formulation delivers the drug to the distal ileum, targeting Peyer patches — the site of IgA production — while minimizing the adverse effects associated with systemic corticosteroid therapy.

The FDA most recently approved sparsentan, a nonimmunosuppressive therapy that combines an endothelin type A receptor antagonist with an angiotensin II type 1 receptor antagonist, for the same indication in 2023.

In addition, several studies have reported benefits with the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors in the treatment of patients with IgA nephropathy at high risk for progression, although this use is still investigational.

2. The most common sign in patients with IgA nephropathy is blood in the urine.

The most common clinical manifestation of IgA nephropathy is microscopic or gross hematuria. Hematuria is often recurrent and may follow upper respiratory tract or other infections. The presence of blood in the urine may be episodic and can vary in severity.

Proteinuria is another key feature of IgA nephropathy. It may range from mild to moderate and, in some cases, can even progress to nephrotic-range proteinuria. The level of proteinuria is an important indicator of disease severity and prognosis. Persistent and significant proteinuria may be associated with an increased risk for progression to chronic kidney disease.

3. Five histologic features are widely used to predict clinical outcomes.

The Oxford classification of IgA nephropathy, or MEST score, published in 2009, comprises four histologic features that are independent predictors of clinical outcome: mesangial and endocapillary hypercellularity, segmental glomerulosclerosis, and interstitial fibrosis/tubular atrophy. In 2017, the IgA Nephropathy Classification Working Group added glomerular crescent formation to the Oxford classification, to form the MEST-C score.

If any of these features are seen, the prognosis can generally be assumed to be poor. Proteinuria, hypertension, elevated creatinine, and a decreased estimated glomerular filtration rate are some of the other factors that can contribute to poor clinical outcomes in patients with IgA nephropathy.

4. IgA nephropathy can eventually progress to end-stage kidney disease.

Progressive kidney dysfunction can occur in some individuals with IgA nephropathy. This may manifest as a gradual decline in glomerular filtration rate, leading to chronic kidney disease over time. In addition, up to 20% of patients progress to end-stage kidney disease within 10 years. The risk for renal impairment varies among individuals, and certain clinical and histologic features may influence the prognosis.

Hypertension is a common complication of IgA nephropathy. The mechanisms underlying hypertension in IgA nephropathy are complex and may involve alterations in the renin-angiotensin-aldosterone system and salt-water balance. Controlling blood pressure is important in managing IgA nephropathy to help slow the progression of kidney damage.

5. Definitive diagnosis requires a renal biopsy.

There are currently no validated diagnostic serum or urine biomarkers for IgA nephropathy, which, according to KDIGO (Kidney Disease: Improving Global Outcomes), requires a renal biopsy to make a definitive diagnosis. The characteristic finding is the deposition of IgA in the glomeruli, typically in the mesangial area. The biopsy can also provide information about the degree of inflammation, scarring, and other histologic features that help guide treatment decisions and predict outcomes.

Dr. Alper, associate professor, department of medicine, section of nephrology, Tulane University School of Medicine, New Orleans, has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

Immunoglobulin A (IgA) nephropathy, also known as Berger disease, is a kidney disorder characterized by the deposition of IgA in the glomeruli, leading to inflammation and potential damage. It is the most common primary glomerulonephritis worldwide. Here are five things to know about IgA nephropathy.

1. Disease-modifying therapies for IgA nephropathy have become available only recently.

The past few years have brought development of the first disease-modifying therapies to reduce proteinuria for adults with primary IgA nephropathy who are at risk for rapid disease progression. In 2021, the US Food and Drug Administration (FDA) approved a targeted-release formulation of the corticosteroid budesonide for these patients. This formulation delivers the drug to the distal ileum, targeting Peyer patches — the site of IgA production — while minimizing the adverse effects associated with systemic corticosteroid therapy.

The FDA most recently approved sparsentan, a nonimmunosuppressive therapy that combines an endothelin type A receptor antagonist with an angiotensin II type 1 receptor antagonist, for the same indication in 2023.

In addition, several studies have reported benefits with the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors in the treatment of patients with IgA nephropathy at high risk for progression, although this use is still investigational.

2. The most common sign in patients with IgA nephropathy is blood in the urine.

The most common clinical manifestation of IgA nephropathy is microscopic or gross hematuria. Hematuria is often recurrent and may follow upper respiratory tract or other infections. The presence of blood in the urine may be episodic and can vary in severity.

Proteinuria is another key feature of IgA nephropathy. It may range from mild to moderate and, in some cases, can even progress to nephrotic-range proteinuria. The level of proteinuria is an important indicator of disease severity and prognosis. Persistent and significant proteinuria may be associated with an increased risk for progression to chronic kidney disease.

3. Five histologic features are widely used to predict clinical outcomes.

The Oxford classification of IgA nephropathy, or MEST score, published in 2009, comprises four histologic features that are independent predictors of clinical outcome: mesangial and endocapillary hypercellularity, segmental glomerulosclerosis, and interstitial fibrosis/tubular atrophy. In 2017, the IgA Nephropathy Classification Working Group added glomerular crescent formation to the Oxford classification, to form the MEST-C score.

If any of these features are seen, the prognosis can generally be assumed to be poor. Proteinuria, hypertension, elevated creatinine, and a decreased estimated glomerular filtration rate are some of the other factors that can contribute to poor clinical outcomes in patients with IgA nephropathy.

4. IgA nephropathy can eventually progress to end-stage kidney disease.

Progressive kidney dysfunction can occur in some individuals with IgA nephropathy. This may manifest as a gradual decline in glomerular filtration rate, leading to chronic kidney disease over time. In addition, up to 20% of patients progress to end-stage kidney disease within 10 years. The risk for renal impairment varies among individuals, and certain clinical and histologic features may influence the prognosis.

Hypertension is a common complication of IgA nephropathy. The mechanisms underlying hypertension in IgA nephropathy are complex and may involve alterations in the renin-angiotensin-aldosterone system and salt-water balance. Controlling blood pressure is important in managing IgA nephropathy to help slow the progression of kidney damage.

5. Definitive diagnosis requires a renal biopsy.

There are currently no validated diagnostic serum or urine biomarkers for IgA nephropathy, which, according to KDIGO (Kidney Disease: Improving Global Outcomes), requires a renal biopsy to make a definitive diagnosis. The characteristic finding is the deposition of IgA in the glomeruli, typically in the mesangial area. The biopsy can also provide information about the degree of inflammation, scarring, and other histologic features that help guide treatment decisions and predict outcomes.

Dr. Alper, associate professor, department of medicine, section of nephrology, Tulane University School of Medicine, New Orleans, has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

Immunoglobulin A (IgA) nephropathy, also known as Berger disease, is a kidney disorder characterized by the deposition of IgA in the glomeruli, leading to inflammation and potential damage. It is the most common primary glomerulonephritis worldwide. Here are five things to know about IgA nephropathy.

1. Disease-modifying therapies for IgA nephropathy have become available only recently.

The past few years have brought development of the first disease-modifying therapies to reduce proteinuria for adults with primary IgA nephropathy who are at risk for rapid disease progression. In 2021, the US Food and Drug Administration (FDA) approved a targeted-release formulation of the corticosteroid budesonide for these patients. This formulation delivers the drug to the distal ileum, targeting Peyer patches — the site of IgA production — while minimizing the adverse effects associated with systemic corticosteroid therapy.

The FDA most recently approved sparsentan, a nonimmunosuppressive therapy that combines an endothelin type A receptor antagonist with an angiotensin II type 1 receptor antagonist, for the same indication in 2023.

In addition, several studies have reported benefits with the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors in the treatment of patients with IgA nephropathy at high risk for progression, although this use is still investigational.

2. The most common sign in patients with IgA nephropathy is blood in the urine.

The most common clinical manifestation of IgA nephropathy is microscopic or gross hematuria. Hematuria is often recurrent and may follow upper respiratory tract or other infections. The presence of blood in the urine may be episodic and can vary in severity.

Proteinuria is another key feature of IgA nephropathy. It may range from mild to moderate and, in some cases, can even progress to nephrotic-range proteinuria. The level of proteinuria is an important indicator of disease severity and prognosis. Persistent and significant proteinuria may be associated with an increased risk for progression to chronic kidney disease.

3. Five histologic features are widely used to predict clinical outcomes.

The Oxford classification of IgA nephropathy, or MEST score, published in 2009, comprises four histologic features that are independent predictors of clinical outcome: mesangial and endocapillary hypercellularity, segmental glomerulosclerosis, and interstitial fibrosis/tubular atrophy. In 2017, the IgA Nephropathy Classification Working Group added glomerular crescent formation to the Oxford classification, to form the MEST-C score.

If any of these features are seen, the prognosis can generally be assumed to be poor. Proteinuria, hypertension, elevated creatinine, and a decreased estimated glomerular filtration rate are some of the other factors that can contribute to poor clinical outcomes in patients with IgA nephropathy.

4. IgA nephropathy can eventually progress to end-stage kidney disease.

Progressive kidney dysfunction can occur in some individuals with IgA nephropathy. This may manifest as a gradual decline in glomerular filtration rate, leading to chronic kidney disease over time. In addition, up to 20% of patients progress to end-stage kidney disease within 10 years. The risk for renal impairment varies among individuals, and certain clinical and histologic features may influence the prognosis.

Hypertension is a common complication of IgA nephropathy. The mechanisms underlying hypertension in IgA nephropathy are complex and may involve alterations in the renin-angiotensin-aldosterone system and salt-water balance. Controlling blood pressure is important in managing IgA nephropathy to help slow the progression of kidney damage.

5. Definitive diagnosis requires a renal biopsy.

There are currently no validated diagnostic serum or urine biomarkers for IgA nephropathy, which, according to KDIGO (Kidney Disease: Improving Global Outcomes), requires a renal biopsy to make a definitive diagnosis. The characteristic finding is the deposition of IgA in the glomeruli, typically in the mesangial area. The biopsy can also provide information about the degree of inflammation, scarring, and other histologic features that help guide treatment decisions and predict outcomes.

Dr. Alper, associate professor, department of medicine, section of nephrology, Tulane University School of Medicine, New Orleans, has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

A retrospective analysis of Medicare data revealed that between 2000 and 2017, immunohistochemistry (IHC) claims associated with melanoma diagnoses grew from 11% to 51%. Rising utilization — and substantial geographic variation in practice patterns — argue for further research to optimize IHC use in the diagnoses of melanoma, according to the authors.

But with sparse guidance regarding best practices for IHC in melanoma diagnosis, concerns for appropriate use are rising, they wrote in their report, recently published in JAMA Dermatology.

Kenechukwu Ojukwu, MD, MPP, of the department of pathology and laboratory medicine, University of California, Los Angeles, and coinvestigators, searched the Surveillance, Epidemiology, and End Results (SEER)–Medicare database for incident in situ or invasive cutaneous melanoma in patients 65 years and older and accompanying IHC claims made during the month of diagnosis through 14 days afterward.

Among 132,547 melanomas in 116,117 patients, 43,396 (33%) had accompanying IHC claims. Such claims were less common with increasing age, declining from 44% in patients aged 65-74 years to 18% in patients 85 aged years and older. Although melanoma incidence increased throughout the period studied, melanoma mortality rates remained relatively stable.

By summary stage at diagnosis, IHC utilization ranged from 29% of in situ cases to 75% of distant cases. After the researchers controlled for year of diagnosis, IHC use was statistically significantly associated with all demographic, tumor, and geographic characteristics examined, except race and ethnicity. Across all the years of the study, regional usage ranged from a low of 22% in Detroit to a high of 44% in both Louisiana and San Jose-Monterey, California. Figures for 2017 ranged from 39% of cases in Kentucky and Atlanta to 68% in New Mexico.

“Given the extensive use of IHC in clinical practice,” the authors concluded, “studies examining the resulting outcomes of IHC on different domains, such as symptom burden, quality of life, and mortality, are crucial.”

The “notable” regional variation in IHC utilization suggests uncertainty about its optimal employment in clinical practice, and, they wrote, “these findings highlight the need for research to identify where IHC provides the most value and to develop guidelines regarding the appropriate use of IHC.”

In an accompanying JAMA Dermatology editorial, Alexandra Flamm, MD, wrote, “now is an exciting time to practice dermatopathology, with an increased number of ancillary tests, such as IHC, that can be used to diagnose malignant neoplasms more precisely and to more accurately determine prognosis and therapeutic options in this age of precision medicine”.

However, added Dr. Flamm, a dermatologist and dermatopathologist at New York University, New York City, the increasing number of ancillary tests is fueling awareness of appropriate use and the importance of ensuring high-quality, value-based healthcare. “With this increased scrutiny on the appropriateness of ancillary histopathologic testing within dermatopathology,” she wrote, “the need is growing for parameters that can be used to guide when to use IHC testing and other ancillary testing.” And using dermatopathologist-developed tools such as American Society of Dermatopathology guidelines for 11 IHC tests can help ensure that appropriate medical decision-making is taken into account when creating these tools, she added.

IHC Usage Growing

“The paper confirms what I already knew,” said Whitney High, MD, JD, who was not involved with the study and was asked to comment on the results. “Use of IHC in dermatopathology has increased substantially, and probably will continue to increase over time.” The societal burden of IHC costs represents a legitimate concern, said Dr. High, professor of dermatology and pathology and director of dermatopathology at the University of Colorado, Aurora.

“However,” he told this news organization, “the histologic diagnosis of melanoma is sometimes substantially subjective — and all physicians, including pathologists, even though they are not providing care in the physical presence of the patient, are fiduciaries.” If an IHC stain would meaningfully improve a patient’s care, he said, physicians should attempt to provide it, unless strictly disallowed by a payer. Controlling medical-care costs might be better left to professional societies to guide care standards over time, he noted.

Dr. High

A retrospective analysis of Medicare data revealed that between 2000 and 2017, immunohistochemistry (IHC) claims associated with melanoma diagnoses grew from 11% to 51%. Rising utilization — and substantial geographic variation in practice patterns — argue for further research to optimize IHC use in the diagnoses of melanoma, according to the authors.

But with sparse guidance regarding best practices for IHC in melanoma diagnosis, concerns for appropriate use are rising, they wrote in their report, recently published in JAMA Dermatology.

Kenechukwu Ojukwu, MD, MPP, of the department of pathology and laboratory medicine, University of California, Los Angeles, and coinvestigators, searched the Surveillance, Epidemiology, and End Results (SEER)–Medicare database for incident in situ or invasive cutaneous melanoma in patients 65 years and older and accompanying IHC claims made during the month of diagnosis through 14 days afterward.

Among 132,547 melanomas in 116,117 patients, 43,396 (33%) had accompanying IHC claims. Such claims were less common with increasing age, declining from 44% in patients aged 65-74 years to 18% in patients 85 aged years and older. Although melanoma incidence increased throughout the period studied, melanoma mortality rates remained relatively stable.

By summary stage at diagnosis, IHC utilization ranged from 29% of in situ cases to 75% of distant cases. After the researchers controlled for year of diagnosis, IHC use was statistically significantly associated with all demographic, tumor, and geographic characteristics examined, except race and ethnicity. Across all the years of the study, regional usage ranged from a low of 22% in Detroit to a high of 44% in both Louisiana and San Jose-Monterey, California. Figures for 2017 ranged from 39% of cases in Kentucky and Atlanta to 68% in New Mexico.

“Given the extensive use of IHC in clinical practice,” the authors concluded, “studies examining the resulting outcomes of IHC on different domains, such as symptom burden, quality of life, and mortality, are crucial.”

The “notable” regional variation in IHC utilization suggests uncertainty about its optimal employment in clinical practice, and, they wrote, “these findings highlight the need for research to identify where IHC provides the most value and to develop guidelines regarding the appropriate use of IHC.”

In an accompanying JAMA Dermatology editorial, Alexandra Flamm, MD, wrote, “now is an exciting time to practice dermatopathology, with an increased number of ancillary tests, such as IHC, that can be used to diagnose malignant neoplasms more precisely and to more accurately determine prognosis and therapeutic options in this age of precision medicine”.

However, added Dr. Flamm, a dermatologist and dermatopathologist at New York University, New York City, the increasing number of ancillary tests is fueling awareness of appropriate use and the importance of ensuring high-quality, value-based healthcare. “With this increased scrutiny on the appropriateness of ancillary histopathologic testing within dermatopathology,” she wrote, “the need is growing for parameters that can be used to guide when to use IHC testing and other ancillary testing.” And using dermatopathologist-developed tools such as American Society of Dermatopathology guidelines for 11 IHC tests can help ensure that appropriate medical decision-making is taken into account when creating these tools, she added.

IHC Usage Growing

“The paper confirms what I already knew,” said Whitney High, MD, JD, who was not involved with the study and was asked to comment on the results. “Use of IHC in dermatopathology has increased substantially, and probably will continue to increase over time.” The societal burden of IHC costs represents a legitimate concern, said Dr. High, professor of dermatology and pathology and director of dermatopathology at the University of Colorado, Aurora.

“However,” he told this news organization, “the histologic diagnosis of melanoma is sometimes substantially subjective — and all physicians, including pathologists, even though they are not providing care in the physical presence of the patient, are fiduciaries.” If an IHC stain would meaningfully improve a patient’s care, he said, physicians should attempt to provide it, unless strictly disallowed by a payer. Controlling medical-care costs might be better left to professional societies to guide care standards over time, he noted.

Dr. High

A retrospective analysis of Medicare data revealed that between 2000 and 2017, immunohistochemistry (IHC) claims associated with melanoma diagnoses grew from 11% to 51%. Rising utilization — and substantial geographic variation in practice patterns — argue for further research to optimize IHC use in the diagnoses of melanoma, according to the authors.

But with sparse guidance regarding best practices for IHC in melanoma diagnosis, concerns for appropriate use are rising, they wrote in their report, recently published in JAMA Dermatology.

Kenechukwu Ojukwu, MD, MPP, of the department of pathology and laboratory medicine, University of California, Los Angeles, and coinvestigators, searched the Surveillance, Epidemiology, and End Results (SEER)–Medicare database for incident in situ or invasive cutaneous melanoma in patients 65 years and older and accompanying IHC claims made during the month of diagnosis through 14 days afterward.

Among 132,547 melanomas in 116,117 patients, 43,396 (33%) had accompanying IHC claims. Such claims were less common with increasing age, declining from 44% in patients aged 65-74 years to 18% in patients 85 aged years and older. Although melanoma incidence increased throughout the period studied, melanoma mortality rates remained relatively stable.

By summary stage at diagnosis, IHC utilization ranged from 29% of in situ cases to 75% of distant cases. After the researchers controlled for year of diagnosis, IHC use was statistically significantly associated with all demographic, tumor, and geographic characteristics examined, except race and ethnicity. Across all the years of the study, regional usage ranged from a low of 22% in Detroit to a high of 44% in both Louisiana and San Jose-Monterey, California. Figures for 2017 ranged from 39% of cases in Kentucky and Atlanta to 68% in New Mexico.

“Given the extensive use of IHC in clinical practice,” the authors concluded, “studies examining the resulting outcomes of IHC on different domains, such as symptom burden, quality of life, and mortality, are crucial.”

The “notable” regional variation in IHC utilization suggests uncertainty about its optimal employment in clinical practice, and, they wrote, “these findings highlight the need for research to identify where IHC provides the most value and to develop guidelines regarding the appropriate use of IHC.”

In an accompanying JAMA Dermatology editorial, Alexandra Flamm, MD, wrote, “now is an exciting time to practice dermatopathology, with an increased number of ancillary tests, such as IHC, that can be used to diagnose malignant neoplasms more precisely and to more accurately determine prognosis and therapeutic options in this age of precision medicine”.

However, added Dr. Flamm, a dermatologist and dermatopathologist at New York University, New York City, the increasing number of ancillary tests is fueling awareness of appropriate use and the importance of ensuring high-quality, value-based healthcare. “With this increased scrutiny on the appropriateness of ancillary histopathologic testing within dermatopathology,” she wrote, “the need is growing for parameters that can be used to guide when to use IHC testing and other ancillary testing.” And using dermatopathologist-developed tools such as American Society of Dermatopathology guidelines for 11 IHC tests can help ensure that appropriate medical decision-making is taken into account when creating these tools, she added.

IHC Usage Growing

“The paper confirms what I already knew,” said Whitney High, MD, JD, who was not involved with the study and was asked to comment on the results. “Use of IHC in dermatopathology has increased substantially, and probably will continue to increase over time.” The societal burden of IHC costs represents a legitimate concern, said Dr. High, professor of dermatology and pathology and director of dermatopathology at the University of Colorado, Aurora.

“However,” he told this news organization, “the histologic diagnosis of melanoma is sometimes substantially subjective — and all physicians, including pathologists, even though they are not providing care in the physical presence of the patient, are fiduciaries.” If an IHC stain would meaningfully improve a patient’s care, he said, physicians should attempt to provide it, unless strictly disallowed by a payer. Controlling medical-care costs might be better left to professional societies to guide care standards over time, he noted.

Dr. High

CHEST

Evidence-based medicine (EBM) stems from making the best patient-centered decision from the highest-quality data available that comports with our understanding of pathophysiology. In some situations, clinicians are forced to draw conclusions from data that are imperfect and apply it to patients who are complex and dynamic. For most pathologies, available data provides some direction. There is, however, one pathophysiologic state that remains understudied, precarious, and common.

The Centers for Disease Control and Prevention (CDC) estimates that about 7.7% of the United States population has asthma. There were about 1 million ED visits in 2020, with asthma listed as the primary diagnosis, and only 94,000 required hospitalization.¹ There are many tools we employ that have greatly decreased inpatient admissions for asthma. The uptake of inhaled corticosteroids (ICS) has significantly reduced asthma-related morbidity and mortality and reduced exacerbations that require admission to a hospital. This treatment strategy is supported by the Global Initiative for Asthma (GINA) and National Asthma Education and Prevention Program (NAEPP) guidelines.^2,3 While we should celebrate the impact that EBM and ICS have had on asthma outcomes, we continue to struggle to control severe asthma.

Bronchodilator therapy in the hospital is ubiquitous. House staff and hospitalists click the bronchodilator order set early and often. However, the optimal frequency, dose, and duration of inhaled bronchodilator therapy for acute asthma exacerbation are unknown. Do frequency, dose, and duration change with exacerbation severity? Nothing gets ED, inpatient, or ICU physicians more jittery than the phrase “exacerbation of asthma on BiPap” or “intubated for asthma.” With its enormous clinical impact and notoriously difficult hospital and ICU course, the lack of evidence we have for managing these patients outside of the initial 24- to 48-hour visit is concerning. Neither NAEPP nor GINA provide management recommendations for the patient with severe asthma exacerbation that necessitates admission.

Albuterol is a commonly used medication for asthma and chronic obstructive airway disease. It is rapid acting and effective—few medications give patients (or clinicians) such instant satisfaction. As an internal medicine resident and pulmonary fellow, I ordered it countless times without ever looking at the dose. Sometimes, patients would come up from the emergency department after receiving a “continuous dose.” I would often wonder exactly what that meant. After some investigation, I found that in my hospital at the time, one dose of albuterol was 2.5 mg in 2 mL, and a continuous nebulization was four doses for a total of 10 mg.

Shrestha et al. found that high-dose albuterol (7.5 mg) administered continuously was superior to 2.5 mg albuterol delivered three times over 1.5 hours. There were demonstrable improvements in FEV₁ and no ICU admissions.⁴ This study is one of many that compared intermittent to continuous and high-dose vs low-dose albuterol in the emergency department. Most are small and occur over the first 24 hours of presentation to the hospital. They often use short-term changes in spirometry as their primary outcome measure. Being a pulmonary and critical care doctor, I see patients who require advanced rescue maneuvers such as noninvasive positive pressure ventilation (NIPPV) or other pharmacologic adjuncts, for which the current evidence is limited.

Because studies of inhaled bronchodilators in acute asthma exacerbation use spirometry as their primary outcome, those with more severe disease and higher acuity are excluded. Patients on NIPPV can’t perform spirometry. There is essentially no literature to guide treatment for a patient with asthma in the adult ICU. In pediatric intensive care units, there are some data to support either continuous or intermittent inhaled bronchodilator that extends beyond the initial ED visit up to about 60 hours.⁵ Much of the pediatric data revolve about the amount of albuterol given, which can be as high as 75 mg/hr though is typically closer to 10-20 mg/hr.⁶ This rate is continued until respiratory improvement occurs.

With poor evidence to guide us and no specific direction from major guidelines, how should providers manage severe asthma exacerbation? The amount of drug deposited in the lung varies by the device used to deliver it. For nebulization, only about 10% of the nebulized amount reaches the lungs for effect; this is a smaller amount compared with all other devices one could use, such as MDI or DPI.⁷ Once a patient with asthma reaches the emergency department, that person is usually placed on some form of nebulizer treatment. But based on local hospital protocols, the amount and duration can vary widely. Sometimes, in patients with severe exacerbation, there is trepidation to continuing albuterol therapy due to ongoing tachycardia. This seems reasonable given increased albuterol administration could beget an ongoing cycle of dyspnea and anxiety. It could also lead to choosing therapies that are less evidence based.

In closing, this seemingly mundane topic takes on new meaning when a patient is in severe exacerbation. Fortunately, providers are not often faced with the decision to wade into the evidence-free territory of severe asthma exacerbation that is unresponsive to first-line treatments. This narrative should serve as a general alert that this pathophysiologic state is understudied. When encountered, thoughtful consideration of pathology, physiology, and pharmacology is required to reverse it.

References

1. Centers for Disease Control and Prevention. (2023, May 10). Most recent national asthma data. Centers for Disease Control and Prevention. https://www.cdc.gov/asthma/most_recent_national_asthma_data.htm

2. Global Initiative for Asthma - GINA. (2023, August 15). 2023 GINA Main Report - Global Initiative for Asthma - GINA. https://ginasthma.org/2023-gina-main-report/

3. Kiley J, Mensah GA, Boyce CA, et al (A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group). 2020 Focused updates to the: Asthma Management Guidelines. US Department of Health and Human Services, NIH, NHLBI 2020.

4. Shrestha M, Bidadi K, Gourlay S, Hayes J. Continuous vs intermittent albuterol, at high and low doses, in the treatment of severe acute asthma in adults. Chest. 1996 Jul;110(1):42-7. doi: 10.1378/chest.110.1.42. PMID: 8681661.

5. Kulalert P, Phinyo P, Patumanond J, Smathakanee C, Chuenjit W, Nanthapisal S. Continuous versus intermittent short-acting β2-agonists nebulization as first-line therapy in hospitalized children with severe asthma exacerbation: a propensity score matching analysis. Asthma Res Pract. 2020 Jul 2;6:6. doi: 10.1186/s40733-020-00059-5. PMID: 32632352; PMCID: PMC7329360.

6. Phumeetham S, Bahk TJ, Abd-Allah S, Mathur M. Effect of high-dose continuous albuterol nebulization on clinical variables in children with status asthmaticus. Pediatr Crit Care Med. 2015 Feb;16(2):e41-6. doi: 10.1097/PCC.0000000000000314. PMID: 25560428.

7. Gardenhire DS, Burnett D, Strickland S, Myers, TR. A guide to aerosol delivery devices for respiratory therapists. American Association for Respiratory Care, Dallas, Texas 2017.

CHEST

Evidence-based medicine (EBM) stems from making the best patient-centered decision from the highest-quality data available that comports with our understanding of pathophysiology. In some situations, clinicians are forced to draw conclusions from data that are imperfect and apply it to patients who are complex and dynamic. For most pathologies, available data provides some direction. There is, however, one pathophysiologic state that remains understudied, precarious, and common.

The Centers for Disease Control and Prevention (CDC) estimates that about 7.7% of the United States population has asthma. There were about 1 million ED visits in 2020, with asthma listed as the primary diagnosis, and only 94,000 required hospitalization.¹ There are many tools we employ that have greatly decreased inpatient admissions for asthma. The uptake of inhaled corticosteroids (ICS) has significantly reduced asthma-related morbidity and mortality and reduced exacerbations that require admission to a hospital. This treatment strategy is supported by the Global Initiative for Asthma (GINA) and National Asthma Education and Prevention Program (NAEPP) guidelines.^2,3 While we should celebrate the impact that EBM and ICS have had on asthma outcomes, we continue to struggle to control severe asthma.

Bronchodilator therapy in the hospital is ubiquitous. House staff and hospitalists click the bronchodilator order set early and often. However, the optimal frequency, dose, and duration of inhaled bronchodilator therapy for acute asthma exacerbation are unknown. Do frequency, dose, and duration change with exacerbation severity? Nothing gets ED, inpatient, or ICU physicians more jittery than the phrase “exacerbation of asthma on BiPap” or “intubated for asthma.” With its enormous clinical impact and notoriously difficult hospital and ICU course, the lack of evidence we have for managing these patients outside of the initial 24- to 48-hour visit is concerning. Neither NAEPP nor GINA provide management recommendations for the patient with severe asthma exacerbation that necessitates admission.

Albuterol is a commonly used medication for asthma and chronic obstructive airway disease. It is rapid acting and effective—few medications give patients (or clinicians) such instant satisfaction. As an internal medicine resident and pulmonary fellow, I ordered it countless times without ever looking at the dose. Sometimes, patients would come up from the emergency department after receiving a “continuous dose.” I would often wonder exactly what that meant. After some investigation, I found that in my hospital at the time, one dose of albuterol was 2.5 mg in 2 mL, and a continuous nebulization was four doses for a total of 10 mg.

Shrestha et al. found that high-dose albuterol (7.5 mg) administered continuously was superior to 2.5 mg albuterol delivered three times over 1.5 hours. There were demonstrable improvements in FEV₁ and no ICU admissions.⁴ This study is one of many that compared intermittent to continuous and high-dose vs low-dose albuterol in the emergency department. Most are small and occur over the first 24 hours of presentation to the hospital. They often use short-term changes in spirometry as their primary outcome measure. Being a pulmonary and critical care doctor, I see patients who require advanced rescue maneuvers such as noninvasive positive pressure ventilation (NIPPV) or other pharmacologic adjuncts, for which the current evidence is limited.

Because studies of inhaled bronchodilators in acute asthma exacerbation use spirometry as their primary outcome, those with more severe disease and higher acuity are excluded. Patients on NIPPV can’t perform spirometry. There is essentially no literature to guide treatment for a patient with asthma in the adult ICU. In pediatric intensive care units, there are some data to support either continuous or intermittent inhaled bronchodilator that extends beyond the initial ED visit up to about 60 hours.⁵ Much of the pediatric data revolve about the amount of albuterol given, which can be as high as 75 mg/hr though is typically closer to 10-20 mg/hr.⁶ This rate is continued until respiratory improvement occurs.

With poor evidence to guide us and no specific direction from major guidelines, how should providers manage severe asthma exacerbation? The amount of drug deposited in the lung varies by the device used to deliver it. For nebulization, only about 10% of the nebulized amount reaches the lungs for effect; this is a smaller amount compared with all other devices one could use, such as MDI or DPI.⁷ Once a patient with asthma reaches the emergency department, that person is usually placed on some form of nebulizer treatment. But based on local hospital protocols, the amount and duration can vary widely. Sometimes, in patients with severe exacerbation, there is trepidation to continuing albuterol therapy due to ongoing tachycardia. This seems reasonable given increased albuterol administration could beget an ongoing cycle of dyspnea and anxiety. It could also lead to choosing therapies that are less evidence based.

In closing, this seemingly mundane topic takes on new meaning when a patient is in severe exacerbation. Fortunately, providers are not often faced with the decision to wade into the evidence-free territory of severe asthma exacerbation that is unresponsive to first-line treatments. This narrative should serve as a general alert that this pathophysiologic state is understudied. When encountered, thoughtful consideration of pathology, physiology, and pharmacology is required to reverse it.

References

1. Centers for Disease Control and Prevention. (2023, May 10). Most recent national asthma data. Centers for Disease Control and Prevention. https://www.cdc.gov/asthma/most_recent_national_asthma_data.htm

2. Global Initiative for Asthma - GINA. (2023, August 15). 2023 GINA Main Report - Global Initiative for Asthma - GINA. https://ginasthma.org/2023-gina-main-report/

3. Kiley J, Mensah GA, Boyce CA, et al (A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group). 2020 Focused updates to the: Asthma Management Guidelines. US Department of Health and Human Services, NIH, NHLBI 2020.

4. Shrestha M, Bidadi K, Gourlay S, Hayes J. Continuous vs intermittent albuterol, at high and low doses, in the treatment of severe acute asthma in adults. Chest. 1996 Jul;110(1):42-7. doi: 10.1378/chest.110.1.42. PMID: 8681661.

5. Kulalert P, Phinyo P, Patumanond J, Smathakanee C, Chuenjit W, Nanthapisal S. Continuous versus intermittent short-acting β2-agonists nebulization as first-line therapy in hospitalized children with severe asthma exacerbation: a propensity score matching analysis. Asthma Res Pract. 2020 Jul 2;6:6. doi: 10.1186/s40733-020-00059-5. PMID: 32632352; PMCID: PMC7329360.

6. Phumeetham S, Bahk TJ, Abd-Allah S, Mathur M. Effect of high-dose continuous albuterol nebulization on clinical variables in children with status asthmaticus. Pediatr Crit Care Med. 2015 Feb;16(2):e41-6. doi: 10.1097/PCC.0000000000000314. PMID: 25560428.

7. Gardenhire DS, Burnett D, Strickland S, Myers, TR. A guide to aerosol delivery devices for respiratory therapists. American Association for Respiratory Care, Dallas, Texas 2017.

CHEST

Evidence-based medicine (EBM) stems from making the best patient-centered decision from the highest-quality data available that comports with our understanding of pathophysiology. In some situations, clinicians are forced to draw conclusions from data that are imperfect and apply it to patients who are complex and dynamic. For most pathologies, available data provides some direction. There is, however, one pathophysiologic state that remains understudied, precarious, and common.

The Centers for Disease Control and Prevention (CDC) estimates that about 7.7% of the United States population has asthma. There were about 1 million ED visits in 2020, with asthma listed as the primary diagnosis, and only 94,000 required hospitalization.¹ There are many tools we employ that have greatly decreased inpatient admissions for asthma. The uptake of inhaled corticosteroids (ICS) has significantly reduced asthma-related morbidity and mortality and reduced exacerbations that require admission to a hospital. This treatment strategy is supported by the Global Initiative for Asthma (GINA) and National Asthma Education and Prevention Program (NAEPP) guidelines.^2,3 While we should celebrate the impact that EBM and ICS have had on asthma outcomes, we continue to struggle to control severe asthma.

Bronchodilator therapy in the hospital is ubiquitous. House staff and hospitalists click the bronchodilator order set early and often. However, the optimal frequency, dose, and duration of inhaled bronchodilator therapy for acute asthma exacerbation are unknown. Do frequency, dose, and duration change with exacerbation severity? Nothing gets ED, inpatient, or ICU physicians more jittery than the phrase “exacerbation of asthma on BiPap” or “intubated for asthma.” With its enormous clinical impact and notoriously difficult hospital and ICU course, the lack of evidence we have for managing these patients outside of the initial 24- to 48-hour visit is concerning. Neither NAEPP nor GINA provide management recommendations for the patient with severe asthma exacerbation that necessitates admission.

Albuterol is a commonly used medication for asthma and chronic obstructive airway disease. It is rapid acting and effective—few medications give patients (or clinicians) such instant satisfaction. As an internal medicine resident and pulmonary fellow, I ordered it countless times without ever looking at the dose. Sometimes, patients would come up from the emergency department after receiving a “continuous dose.” I would often wonder exactly what that meant. After some investigation, I found that in my hospital at the time, one dose of albuterol was 2.5 mg in 2 mL, and a continuous nebulization was four doses for a total of 10 mg.

Shrestha et al. found that high-dose albuterol (7.5 mg) administered continuously was superior to 2.5 mg albuterol delivered three times over 1.5 hours. There were demonstrable improvements in FEV₁ and no ICU admissions.⁴ This study is one of many that compared intermittent to continuous and high-dose vs low-dose albuterol in the emergency department. Most are small and occur over the first 24 hours of presentation to the hospital. They often use short-term changes in spirometry as their primary outcome measure. Being a pulmonary and critical care doctor, I see patients who require advanced rescue maneuvers such as noninvasive positive pressure ventilation (NIPPV) or other pharmacologic adjuncts, for which the current evidence is limited.

Because studies of inhaled bronchodilators in acute asthma exacerbation use spirometry as their primary outcome, those with more severe disease and higher acuity are excluded. Patients on NIPPV can’t perform spirometry. There is essentially no literature to guide treatment for a patient with asthma in the adult ICU. In pediatric intensive care units, there are some data to support either continuous or intermittent inhaled bronchodilator that extends beyond the initial ED visit up to about 60 hours.⁵ Much of the pediatric data revolve about the amount of albuterol given, which can be as high as 75 mg/hr though is typically closer to 10-20 mg/hr.⁶ This rate is continued until respiratory improvement occurs.

With poor evidence to guide us and no specific direction from major guidelines, how should providers manage severe asthma exacerbation? The amount of drug deposited in the lung varies by the device used to deliver it. For nebulization, only about 10% of the nebulized amount reaches the lungs for effect; this is a smaller amount compared with all other devices one could use, such as MDI or DPI.⁷ Once a patient with asthma reaches the emergency department, that person is usually placed on some form of nebulizer treatment. But based on local hospital protocols, the amount and duration can vary widely. Sometimes, in patients with severe exacerbation, there is trepidation to continuing albuterol therapy due to ongoing tachycardia. This seems reasonable given increased albuterol administration could beget an ongoing cycle of dyspnea and anxiety. It could also lead to choosing therapies that are less evidence based.

In closing, this seemingly mundane topic takes on new meaning when a patient is in severe exacerbation. Fortunately, providers are not often faced with the decision to wade into the evidence-free territory of severe asthma exacerbation that is unresponsive to first-line treatments. This narrative should serve as a general alert that this pathophysiologic state is understudied. When encountered, thoughtful consideration of pathology, physiology, and pharmacology is required to reverse it.

References

1. Centers for Disease Control and Prevention. (2023, May 10). Most recent national asthma data. Centers for Disease Control and Prevention. https://www.cdc.gov/asthma/most_recent_national_asthma_data.htm

2. Global Initiative for Asthma - GINA. (2023, August 15). 2023 GINA Main Report - Global Initiative for Asthma - GINA. https://ginasthma.org/2023-gina-main-report/

3. Kiley J, Mensah GA, Boyce CA, et al (A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group). 2020 Focused updates to the: Asthma Management Guidelines. US Department of Health and Human Services, NIH, NHLBI 2020.

4. Shrestha M, Bidadi K, Gourlay S, Hayes J. Continuous vs intermittent albuterol, at high and low doses, in the treatment of severe acute asthma in adults. Chest. 1996 Jul;110(1):42-7. doi: 10.1378/chest.110.1.42. PMID: 8681661.

5. Kulalert P, Phinyo P, Patumanond J, Smathakanee C, Chuenjit W, Nanthapisal S. Continuous versus intermittent short-acting β2-agonists nebulization as first-line therapy in hospitalized children with severe asthma exacerbation: a propensity score matching analysis. Asthma Res Pract. 2020 Jul 2;6:6. doi: 10.1186/s40733-020-00059-5. PMID: 32632352; PMCID: PMC7329360.

6. Phumeetham S, Bahk TJ, Abd-Allah S, Mathur M. Effect of high-dose continuous albuterol nebulization on clinical variables in children with status asthmaticus. Pediatr Crit Care Med. 2015 Feb;16(2):e41-6. doi: 10.1097/PCC.0000000000000314. PMID: 25560428.

7. Gardenhire DS, Burnett D, Strickland S, Myers, TR. A guide to aerosol delivery devices for respiratory therapists. American Association for Respiratory Care, Dallas, Texas 2017.

CHEST

Soon after moving to Pittsburgh for my pulmonary and critical care medicine fellowship in 2014, I began noticing a theme: So many of my patients expressed a sense that the air they breathed was harming them or was in some way responsible for the severity of their lung disease.

In this city, the legacy of the steel industry from the last century fostered economic prosperity but resulted in a profound legacy of pollution as well. Unfortunately, due to a combination of fossil fuel dependence for electricity generation and transportation, industrial particulate matter (PM) generation and greenhouse gas emissions, temperature inversions related to the topography of the region, and, most recently, smoke from Canadian wildfires in the summer of 2023, the air quality in Pittsburgh ranks among the 25 least healthy US cities. Our patients are bearing the burden of climate change.

My patients relay that because of the poor air quality in the neighborhood they live in, they feel sick. I remember a patient in clinic talking about how on the days he could see a film of particulate on all the cars and the street outside, he knew he would feel more shortness of breath. Patients share about how when they had lived in different neighborhoods in town or traveled outside of Pittsburgh, their breathing improved.

Patients tell me that their asthma or COPD that did not use to cause them frequent trouble is now less well controlled despite better therapies available. Patients who used to experience seasonal allergies in just the fall or the spring now are plagued by their allergy symptoms year-round because of a warming climate yielding excess pollen throughout all seasons.

A recent study of patients with pulmonary fibrosis demonstrated that exposure to excess PM_2.5 in this region resulted in more rapid clinical deterioration and premature death compared with patients with the same disease in other parts of North America with better air quality. The common denominator is human-generated climate change’s negative impact on health.

In particular, those who are already vulnerable because of underlying chronic disease or socioeconomic disparity are at greater risk and feel these repercussions disproportionately. Black and brown communities are more heavily exposed to air pollution due to the history of redlining and ongoing structural racism and, as a result, have worse health outcomes than other groups. There is an urgency and moral imperative for us as clinicians to address generations of environmental injustice.

While these themes floated around in the background during the early stage of my career as a pulmonologist, I didn’t have language or deep knowledge around these structural environmental issues. As a profession, we are gradually recognizing that the health impacts of climate change on which to advocate are within our wheelhouse as clinicians.

Our patients and our trainees are increasingly aware of these issues, and, as a result, we as currently practicing clinicians and educators must urgently learn about the lived experiences of our patients and how their diseases interplay with their exposures.

Nowadays, I think more about how to mitigate the impact of air pollution, which did not previously factor into my training or the early years of my clinical practice. We know that some patients, particularly those with underlying lung disease and young children, are at greater risk when exposed to more polluted air and may need to take different steps to limit their exposure. We now consider advising these patients with chronic respiratory disease to be aware of air quality advisories and limit their time outdoors on worse air quality days. We anticipate that when the air quality is worse, we will see more complications of cardiovascular and pulmonary disease.

As lifelong learners, we thirst for the latest data to incorporate into our clinical decision-making. Similarly, colleagues and I are now also voraciously reading and starting to have conversations with peers about the convergence of climate change and disease. But no matter how compelling and urgent these issues are, one clinician cannot tackle the massive threat of climate change and complexity of health care sustainability in isolation.

I am fortunate to work with several like-minded and highly motivated colleagues at my own institution. We have been able to organize effectively to spark local change toward reducing our system’s carbon emissions. Similarly, through professional organizations like CHEST, I have been able to collaborate with other pulmonary and critical care clinicians who share these passions and are doing similar advocacy work across the country. I am honored to serve as CHEST’s representative to the Medical Society Consortium on Climate and Health as another avenue to keep advancing this cause at scale in collaboration with advocates across all specialties.

While I worry every day for my patients, our communities, and my children as we face the accelerating threat of climate change, knowing that I am actively engaging in these efforts in pursuit of environmental justice and mitigating health care’s climate change contribution gives me a sense of empowerment and solidarity with others also striving to lessen our burden on the planet.

This article was adapted from the Winter 2024 online issue of CHEST Advocates. For the full article — and to engage with the other content from this issue — visit https://chestnet.org/chest-advocates.

CHEST

Soon after moving to Pittsburgh for my pulmonary and critical care medicine fellowship in 2014, I began noticing a theme: So many of my patients expressed a sense that the air they breathed was harming them or was in some way responsible for the severity of their lung disease.

In this city, the legacy of the steel industry from the last century fostered economic prosperity but resulted in a profound legacy of pollution as well. Unfortunately, due to a combination of fossil fuel dependence for electricity generation and transportation, industrial particulate matter (PM) generation and greenhouse gas emissions, temperature inversions related to the topography of the region, and, most recently, smoke from Canadian wildfires in the summer of 2023, the air quality in Pittsburgh ranks among the 25 least healthy US cities. Our patients are bearing the burden of climate change.

My patients relay that because of the poor air quality in the neighborhood they live in, they feel sick. I remember a patient in clinic talking about how on the days he could see a film of particulate on all the cars and the street outside, he knew he would feel more shortness of breath. Patients share about how when they had lived in different neighborhoods in town or traveled outside of Pittsburgh, their breathing improved.

Patients tell me that their asthma or COPD that did not use to cause them frequent trouble is now less well controlled despite better therapies available. Patients who used to experience seasonal allergies in just the fall or the spring now are plagued by their allergy symptoms year-round because of a warming climate yielding excess pollen throughout all seasons.

A recent study of patients with pulmonary fibrosis demonstrated that exposure to excess PM_2.5 in this region resulted in more rapid clinical deterioration and premature death compared with patients with the same disease in other parts of North America with better air quality. The common denominator is human-generated climate change’s negative impact on health.

In particular, those who are already vulnerable because of underlying chronic disease or socioeconomic disparity are at greater risk and feel these repercussions disproportionately. Black and brown communities are more heavily exposed to air pollution due to the history of redlining and ongoing structural racism and, as a result, have worse health outcomes than other groups. There is an urgency and moral imperative for us as clinicians to address generations of environmental injustice.

While these themes floated around in the background during the early stage of my career as a pulmonologist, I didn’t have language or deep knowledge around these structural environmental issues. As a profession, we are gradually recognizing that the health impacts of climate change on which to advocate are within our wheelhouse as clinicians.

Our patients and our trainees are increasingly aware of these issues, and, as a result, we as currently practicing clinicians and educators must urgently learn about the lived experiences of our patients and how their diseases interplay with their exposures.

Nowadays, I think more about how to mitigate the impact of air pollution, which did not previously factor into my training or the early years of my clinical practice. We know that some patients, particularly those with underlying lung disease and young children, are at greater risk when exposed to more polluted air and may need to take different steps to limit their exposure. We now consider advising these patients with chronic respiratory disease to be aware of air quality advisories and limit their time outdoors on worse air quality days. We anticipate that when the air quality is worse, we will see more complications of cardiovascular and pulmonary disease.

As lifelong learners, we thirst for the latest data to incorporate into our clinical decision-making. Similarly, colleagues and I are now also voraciously reading and starting to have conversations with peers about the convergence of climate change and disease. But no matter how compelling and urgent these issues are, one clinician cannot tackle the massive threat of climate change and complexity of health care sustainability in isolation.

I am fortunate to work with several like-minded and highly motivated colleagues at my own institution. We have been able to organize effectively to spark local change toward reducing our system’s carbon emissions. Similarly, through professional organizations like CHEST, I have been able to collaborate with other pulmonary and critical care clinicians who share these passions and are doing similar advocacy work across the country. I am honored to serve as CHEST’s representative to the Medical Society Consortium on Climate and Health as another avenue to keep advancing this cause at scale in collaboration with advocates across all specialties.

While I worry every day for my patients, our communities, and my children as we face the accelerating threat of climate change, knowing that I am actively engaging in these efforts in pursuit of environmental justice and mitigating health care’s climate change contribution gives me a sense of empowerment and solidarity with others also striving to lessen our burden on the planet.

This article was adapted from the Winter 2024 online issue of CHEST Advocates. For the full article — and to engage with the other content from this issue — visit https://chestnet.org/chest-advocates.

CHEST

Soon after moving to Pittsburgh for my pulmonary and critical care medicine fellowship in 2014, I began noticing a theme: So many of my patients expressed a sense that the air they breathed was harming them or was in some way responsible for the severity of their lung disease.

In this city, the legacy of the steel industry from the last century fostered economic prosperity but resulted in a profound legacy of pollution as well. Unfortunately, due to a combination of fossil fuel dependence for electricity generation and transportation, industrial particulate matter (PM) generation and greenhouse gas emissions, temperature inversions related to the topography of the region, and, most recently, smoke from Canadian wildfires in the summer of 2023, the air quality in Pittsburgh ranks among the 25 least healthy US cities. Our patients are bearing the burden of climate change.

My patients relay that because of the poor air quality in the neighborhood they live in, they feel sick. I remember a patient in clinic talking about how on the days he could see a film of particulate on all the cars and the street outside, he knew he would feel more shortness of breath. Patients share about how when they had lived in different neighborhoods in town or traveled outside of Pittsburgh, their breathing improved.

Patients tell me that their asthma or COPD that did not use to cause them frequent trouble is now less well controlled despite better therapies available. Patients who used to experience seasonal allergies in just the fall or the spring now are plagued by their allergy symptoms year-round because of a warming climate yielding excess pollen throughout all seasons.

A recent study of patients with pulmonary fibrosis demonstrated that exposure to excess PM_2.5 in this region resulted in more rapid clinical deterioration and premature death compared with patients with the same disease in other parts of North America with better air quality. The common denominator is human-generated climate change’s negative impact on health.

In particular, those who are already vulnerable because of underlying chronic disease or socioeconomic disparity are at greater risk and feel these repercussions disproportionately. Black and brown communities are more heavily exposed to air pollution due to the history of redlining and ongoing structural racism and, as a result, have worse health outcomes than other groups. There is an urgency and moral imperative for us as clinicians to address generations of environmental injustice.

While these themes floated around in the background during the early stage of my career as a pulmonologist, I didn’t have language or deep knowledge around these structural environmental issues. As a profession, we are gradually recognizing that the health impacts of climate change on which to advocate are within our wheelhouse as clinicians.

Our patients and our trainees are increasingly aware of these issues, and, as a result, we as currently practicing clinicians and educators must urgently learn about the lived experiences of our patients and how their diseases interplay with their exposures.

Nowadays, I think more about how to mitigate the impact of air pollution, which did not previously factor into my training or the early years of my clinical practice. We know that some patients, particularly those with underlying lung disease and young children, are at greater risk when exposed to more polluted air and may need to take different steps to limit their exposure. We now consider advising these patients with chronic respiratory disease to be aware of air quality advisories and limit their time outdoors on worse air quality days. We anticipate that when the air quality is worse, we will see more complications of cardiovascular and pulmonary disease.

As lifelong learners, we thirst for the latest data to incorporate into our clinical decision-making. Similarly, colleagues and I are now also voraciously reading and starting to have conversations with peers about the convergence of climate change and disease. But no matter how compelling and urgent these issues are, one clinician cannot tackle the massive threat of climate change and complexity of health care sustainability in isolation.

I am fortunate to work with several like-minded and highly motivated colleagues at my own institution. We have been able to organize effectively to spark local change toward reducing our system’s carbon emissions. Similarly, through professional organizations like CHEST, I have been able to collaborate with other pulmonary and critical care clinicians who share these passions and are doing similar advocacy work across the country. I am honored to serve as CHEST’s representative to the Medical Society Consortium on Climate and Health as another avenue to keep advancing this cause at scale in collaboration with advocates across all specialties.

While I worry every day for my patients, our communities, and my children as we face the accelerating threat of climate change, knowing that I am actively engaging in these efforts in pursuit of environmental justice and mitigating health care’s climate change contribution gives me a sense of empowerment and solidarity with others also striving to lessen our burden on the planet.

This article was adapted from the Winter 2024 online issue of CHEST Advocates. For the full article — and to engage with the other content from this issue — visit https://chestnet.org/chest-advocates.

CHEST

In his prior research, Chien-Ching Li, PhD, MPH, focused on promoting lung cancer screening in Chinese American men, a population that frequently smokes heavily. But last year, he applied for a CHEST grant that’s shifting his focus to another demographic: Chinese American women who do not smoke, especially those with limited English proficiency.

“They are developing lung cancer, and we don’t know why,” said Dr. Li, an associate professor of Health Systems Management at Rush University.

In the United States, Asian American women who don’t smoke, and never have, are twice as likely to be diagnosed with lung cancer as white women with similar nonsmoking habits. In fact, 57% of Asian American women diagnosed with lung cancer never smoked cigarettes.

What’s behind this rise in lung cancer in women who have never smoked compared with men, and particularly in Asian American women? One possibility: While Chinese American women may never smoke themselves, they frequently live with partners or family members who do. (About 28% of Chinese American men smoke heavily, Dr. Li said.)

“We think secondhand smoke might be one of the key risk factors, because they’re living with people who smoke,” Dr. Li said. His prior research shows that the majority of Chinese American men in greater Chicagoland—89%—are married, and many of them smoke or have a history of smoking.

With the CHEST grant Dr. Li received in October 2023, he’s working to increase awareness among Chinese American women about the risks of secondhand smoke and “reduce the health disparity in lung cancer among women,” Dr. Li said.
 

Developing culturally sensitive materials for a high-risk group

While many lung cancer reduction efforts focus on people who smoke, there are plenty of pamphlets designed to inform about the risks incurred when breathing in secondhand smoke.

These handouts, however, aren’t always available in languages spoken by Chinese Americans. Nor is it as simple as hiring a translator; doing so may make the pamphlets readable to the women, but it won’t necessarily make the text culturally appropriate.

This is what Dr. Li—along with his coinvestigators, Alicia Matthews, PhD, a professor of clinical psychology at Columbia University, and Hong Liu, PhD, of the Midwest Asian Health Association—seeks to change, with funding from the CHEST grant. Their goal is four-pronged:

1. Discovery: Dr. Li and his team are currently surveying Chinese American women who have never smoked but who live with people who smoke in greater Chicagoland. These surveys will help them learn more about what (if anything) this group knows about the health risks associated with secondhand smoke and other types of environmental smoke.

2. Identify: These surveys, along with focus group interviews with select participants, will help reveal barriers standing in the way of reducing the women’s exposure to secondhand smoke—as well as ways to encourage habits to reduce risk.

3. Develop: All the information gained through surveys and conversations will then be analyzed and used to craft targeted, translated, and culturally appropriate materials on secondhand smoke, conveying communication strategies the women can use to persuade their partners to quit smoking and ways to build a smoke-free household.

4. Evaluate: The effectiveness of the new materials will be tested to assess the change in the women’s knowledge, as well as any uptick in taking steps to reduce exposure or sign up for screening.
 

Using the CHEST grant as a building block to more grants—and more information

Dr. Li and his collaborators are still in the early stages of using the CHEST grant: gathering up participants and surveying them.

But there’s much ahead. With the CHEST grant in hand, Dr. Li plans to apply for grants from the National Institutes of Health (NIH): first, an NIH Exploratory/Developmental Research Grant Award (R21) to help achieve that fourth aim of evaluating how the intervention works. And next, they’ll apply for an NIH Research Project Grant Program (R01), which will fund an even larger trial.

“Not many studies focus on identifying the risk factors with lung cancer associated with Chinese American [women who have never smoked],” Dr. Li said. “This is why we want to focus on this area to provide more knowledge and make more contributions to research.”

Projects like this are made possible by generous contributions from CHEST donors. Support the future of chest medicine by visiting https://chestnet.org/donate.

CHEST

In his prior research, Chien-Ching Li, PhD, MPH, focused on promoting lung cancer screening in Chinese American men, a population that frequently smokes heavily. But last year, he applied for a CHEST grant that’s shifting his focus to another demographic: Chinese American women who do not smoke, especially those with limited English proficiency.

“They are developing lung cancer, and we don’t know why,” said Dr. Li, an associate professor of Health Systems Management at Rush University.

In the United States, Asian American women who don’t smoke, and never have, are twice as likely to be diagnosed with lung cancer as white women with similar nonsmoking habits. In fact, 57% of Asian American women diagnosed with lung cancer never smoked cigarettes.

What’s behind this rise in lung cancer in women who have never smoked compared with men, and particularly in Asian American women? One possibility: While Chinese American women may never smoke themselves, they frequently live with partners or family members who do. (About 28% of Chinese American men smoke heavily, Dr. Li said.)

“We think secondhand smoke might be one of the key risk factors, because they’re living with people who smoke,” Dr. Li said. His prior research shows that the majority of Chinese American men in greater Chicagoland—89%—are married, and many of them smoke or have a history of smoking.

With the CHEST grant Dr. Li received in October 2023, he’s working to increase awareness among Chinese American women about the risks of secondhand smoke and “reduce the health disparity in lung cancer among women,” Dr. Li said.
 

Developing culturally sensitive materials for a high-risk group

While many lung cancer reduction efforts focus on people who smoke, there are plenty of pamphlets designed to inform about the risks incurred when breathing in secondhand smoke.

These handouts, however, aren’t always available in languages spoken by Chinese Americans. Nor is it as simple as hiring a translator; doing so may make the pamphlets readable to the women, but it won’t necessarily make the text culturally appropriate.

This is what Dr. Li—along with his coinvestigators, Alicia Matthews, PhD, a professor of clinical psychology at Columbia University, and Hong Liu, PhD, of the Midwest Asian Health Association—seeks to change, with funding from the CHEST grant. Their goal is four-pronged:

1. Discovery: Dr. Li and his team are currently surveying Chinese American women who have never smoked but who live with people who smoke in greater Chicagoland. These surveys will help them learn more about what (if anything) this group knows about the health risks associated with secondhand smoke and other types of environmental smoke.

2. Identify: These surveys, along with focus group interviews with select participants, will help reveal barriers standing in the way of reducing the women’s exposure to secondhand smoke—as well as ways to encourage habits to reduce risk.

3. Develop: All the information gained through surveys and conversations will then be analyzed and used to craft targeted, translated, and culturally appropriate materials on secondhand smoke, conveying communication strategies the women can use to persuade their partners to quit smoking and ways to build a smoke-free household.

4. Evaluate: The effectiveness of the new materials will be tested to assess the change in the women’s knowledge, as well as any uptick in taking steps to reduce exposure or sign up for screening.
 

Using the CHEST grant as a building block to more grants—and more information

Dr. Li and his collaborators are still in the early stages of using the CHEST grant: gathering up participants and surveying them.

But there’s much ahead. With the CHEST grant in hand, Dr. Li plans to apply for grants from the National Institutes of Health (NIH): first, an NIH Exploratory/Developmental Research Grant Award (R21) to help achieve that fourth aim of evaluating how the intervention works. And next, they’ll apply for an NIH Research Project Grant Program (R01), which will fund an even larger trial.

“Not many studies focus on identifying the risk factors with lung cancer associated with Chinese American [women who have never smoked],” Dr. Li said. “This is why we want to focus on this area to provide more knowledge and make more contributions to research.”

Projects like this are made possible by generous contributions from CHEST donors. Support the future of chest medicine by visiting https://chestnet.org/donate.

CHEST

In his prior research, Chien-Ching Li, PhD, MPH, focused on promoting lung cancer screening in Chinese American men, a population that frequently smokes heavily. But last year, he applied for a CHEST grant that’s shifting his focus to another demographic: Chinese American women who do not smoke, especially those with limited English proficiency.

“They are developing lung cancer, and we don’t know why,” said Dr. Li, an associate professor of Health Systems Management at Rush University.

In the United States, Asian American women who don’t smoke, and never have, are twice as likely to be diagnosed with lung cancer as white women with similar nonsmoking habits. In fact, 57% of Asian American women diagnosed with lung cancer never smoked cigarettes.

What’s behind this rise in lung cancer in women who have never smoked compared with men, and particularly in Asian American women? One possibility: While Chinese American women may never smoke themselves, they frequently live with partners or family members who do. (About 28% of Chinese American men smoke heavily, Dr. Li said.)

“We think secondhand smoke might be one of the key risk factors, because they’re living with people who smoke,” Dr. Li said. His prior research shows that the majority of Chinese American men in greater Chicagoland—89%—are married, and many of them smoke or have a history of smoking.

With the CHEST grant Dr. Li received in October 2023, he’s working to increase awareness among Chinese American women about the risks of secondhand smoke and “reduce the health disparity in lung cancer among women,” Dr. Li said.
 

Developing culturally sensitive materials for a high-risk group

While many lung cancer reduction efforts focus on people who smoke, there are plenty of pamphlets designed to inform about the risks incurred when breathing in secondhand smoke.

These handouts, however, aren’t always available in languages spoken by Chinese Americans. Nor is it as simple as hiring a translator; doing so may make the pamphlets readable to the women, but it won’t necessarily make the text culturally appropriate.

This is what Dr. Li—along with his coinvestigators, Alicia Matthews, PhD, a professor of clinical psychology at Columbia University, and Hong Liu, PhD, of the Midwest Asian Health Association—seeks to change, with funding from the CHEST grant. Their goal is four-pronged:

1. Discovery: Dr. Li and his team are currently surveying Chinese American women who have never smoked but who live with people who smoke in greater Chicagoland. These surveys will help them learn more about what (if anything) this group knows about the health risks associated with secondhand smoke and other types of environmental smoke.

2. Identify: These surveys, along with focus group interviews with select participants, will help reveal barriers standing in the way of reducing the women’s exposure to secondhand smoke—as well as ways to encourage habits to reduce risk.

3. Develop: All the information gained through surveys and conversations will then be analyzed and used to craft targeted, translated, and culturally appropriate materials on secondhand smoke, conveying communication strategies the women can use to persuade their partners to quit smoking and ways to build a smoke-free household.

4. Evaluate: The effectiveness of the new materials will be tested to assess the change in the women’s knowledge, as well as any uptick in taking steps to reduce exposure or sign up for screening.
 

Using the CHEST grant as a building block to more grants—and more information

Dr. Li and his collaborators are still in the early stages of using the CHEST grant: gathering up participants and surveying them.

But there’s much ahead. With the CHEST grant in hand, Dr. Li plans to apply for grants from the National Institutes of Health (NIH): first, an NIH Exploratory/Developmental Research Grant Award (R21) to help achieve that fourth aim of evaluating how the intervention works. And next, they’ll apply for an NIH Research Project Grant Program (R01), which will fund an even larger trial.

“Not many studies focus on identifying the risk factors with lung cancer associated with Chinese American [women who have never smoked],” Dr. Li said. “This is why we want to focus on this area to provide more knowledge and make more contributions to research.”

Projects like this are made possible by generous contributions from CHEST donors. Support the future of chest medicine by visiting https://chestnet.org/donate.

Nonprofit hospitals created largely to serve the poor are adding concierge physician practices, charging patients annual membership fees of $2,000 or more for easier access to their doctors.

It’s a trend that began decades ago with physician practices. Thousands of doctors have shifted to the concierge model, in which they can increase their income while decreasing their patient load.

Northwestern Medicine in Chicago, Penn Medicine in Philadelphia, University Hospitals in the Cleveland area, and Baptist Health in Miami are among the large hospital systems offering concierge physician services. The fees, which can exceed $4,000 a year, are in addition to copayments, deductibles, and other charges not paid by patients’ insurance plans.

Critics of concierge medicine say the practice exacerbates primary care shortages, ensuring access only for the affluent, while driving up health care costs. But for tax-exempt hospitals, the financial benefits can be twofold. Concierge fees provide new revenue directly and serve as a tool to help recruit and retain physicians. Those doctors then provide lucrative referrals of their well-heeled patients to the hospitals that employ them.

“Hospitals are attracted to physicians that offer concierge services because their patients do not come with bad debts or a need for charity care, and most of them have private insurance which pays the hospital very well,” said Gerard Anderson, a hospital finance expert at Johns Hopkins University.

“They are the ideal patient, from the hospitals’ perspective.”

Concierge physicians typically limit their practices to a few hundred patients, compared with a couple of thousand for a traditional primary care doctor, so they can promise immediate access and longer visits.

“Every time we see these models expand, we are contracting the availability of primary care doctors for the general population,” said Jewel Mullen, associate dean for health equity at the University of Texas-Austin’s Dell Medical School. The former Connecticut health commissioner said concierge doctors join large hospital systems because of the institutions’ reputations, while hospitals sign up concierge physicians to ensure referrals to specialists and inpatient care. “It helps hospitals secure a bigger piece of their market,” she said.

Concierge physicians typically promise same-day or next-day appointments. Many provide patients their mobile phone number.

Aaron Klein, who oversees the concierge physician practices at Baptist Health, said the program was initially intended to serve donors.

“High-end donors wanted to make sure they have doctors to care for them,” he said.

Baptist opened its concierge program in 2019 and now has three practices across South Florida, where patients pay $2,500 a year.

“My philosophy is: It’s better to give world-class care to a few hundred patients rather than provide inadequate care to a few thousand patients,” Klein said.

Concierge physician practices started more than 20 years ago, mainly in upscale areas such as Boca Raton, Florida, and La Jolla, California. They catered mostly to wealthy retirees willing to pay extra for better physician access. Some of the first physician practices to enter the business were backed by private equity firms.

One of the largest, Boca Raton-based MDVIP, has more than 1,100 physicians and more than 390,000 patients. It was started in 2000, and since 2014 private equity firms have owned a majority stake in the company.

Some concierge physicians say their more attentive care means healthier patients. A study published last year by researchers at the University of California-Berkeley and University of Pennsylvania found no impact on mortality rates. What the study did find: higher costs.

Using Medicare claims data, the researchers found that concierge medicine enrollment corresponded with a 30%-50% increase in total health care spending by patients.

For hospitals, “this is an extension of them consolidating the market,” said Adam Leive, a study co-author and an assistant professor of public policy at UC Berkeley. Inova Health Care Services in Fairfax, Virginia, one of the state’s largest tax-exempt hospital chains, employs 18 concierge doctors, who each handle no more than 400 patients. Those patients pay $2,200 a year for the privilege.

George Salem, 70, of McLean, Virginia, has been a patient in Inova’s concierge practice for several years along with his wife. Earlier this year he slammed his finger in a hotel door, he said. As soon as he got home, he called his physician, who saw him immediately and stitched up the wound. He said he sees his doctor about 10 to 12 times a year.

“I loved my internist before, but it was impossible to get to see him,” Salem said. Immediate access to his doctor “very much gives me peace of mind,” he said.

Craig Cheifetz, a vice president at Inova who oversees the concierge program, said the hospital system took interest in the model after MDVIP began moving aggressively into the Washington, D.C., suburbs about a decade ago. Today, Inova’s program has 6,000 patients.

Cheifetz disputes the charge that concierge physician programs exacerbate primary care shortages. The model keeps doctors who were considering retiring early in the business with a lighter caseload, he said. And the fees amount to no more than a few dollars a day — about what some people spend on coffee, he said.

“Inova has an incredible primary care network for those who can’t afford the concierge care,” he said. “We are still providing all that is necessary in primary care for those who need it.”

Some hospitals are starting concierge physician practices far from their home locations. For example, Tampa General Hospital in Florida last year opened a concierge practice in upper-middle-class Palm Beach Gardens, a roughly three-hour drive from Tampa. Mount Sinai Health System in New York runs a concierge physician practice in West Palm Beach.

NCH Healthcare System in Naples, Florida, employs 12 concierge physicians who treat about 3,000 patients total. “We found a need in this community for those who wanted a more personalized health care experience,” said James Brinkert, regional administrator for the system. Members pay an annual fee of at least $3,500.

NCH patients whose doctors convert to concierge and who don’t want to pay the membership fee are referred to other primary care practices or to urgent care, Brinkert said.

KFF Health News  is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about  KFF .

Nonprofit hospitals created largely to serve the poor are adding concierge physician practices, charging patients annual membership fees of $2,000 or more for easier access to their doctors.

It’s a trend that began decades ago with physician practices. Thousands of doctors have shifted to the concierge model, in which they can increase their income while decreasing their patient load.

Northwestern Medicine in Chicago, Penn Medicine in Philadelphia, University Hospitals in the Cleveland area, and Baptist Health in Miami are among the large hospital systems offering concierge physician services. The fees, which can exceed $4,000 a year, are in addition to copayments, deductibles, and other charges not paid by patients’ insurance plans.

Critics of concierge medicine say the practice exacerbates primary care shortages, ensuring access only for the affluent, while driving up health care costs. But for tax-exempt hospitals, the financial benefits can be twofold. Concierge fees provide new revenue directly and serve as a tool to help recruit and retain physicians. Those doctors then provide lucrative referrals of their well-heeled patients to the hospitals that employ them.

“Hospitals are attracted to physicians that offer concierge services because their patients do not come with bad debts or a need for charity care, and most of them have private insurance which pays the hospital very well,” said Gerard Anderson, a hospital finance expert at Johns Hopkins University.

“They are the ideal patient, from the hospitals’ perspective.”

Concierge physicians typically limit their practices to a few hundred patients, compared with a couple of thousand for a traditional primary care doctor, so they can promise immediate access and longer visits.

“Every time we see these models expand, we are contracting the availability of primary care doctors for the general population,” said Jewel Mullen, associate dean for health equity at the University of Texas-Austin’s Dell Medical School. The former Connecticut health commissioner said concierge doctors join large hospital systems because of the institutions’ reputations, while hospitals sign up concierge physicians to ensure referrals to specialists and inpatient care. “It helps hospitals secure a bigger piece of their market,” she said.

Concierge physicians typically promise same-day or next-day appointments. Many provide patients their mobile phone number.

Aaron Klein, who oversees the concierge physician practices at Baptist Health, said the program was initially intended to serve donors.

“High-end donors wanted to make sure they have doctors to care for them,” he said.

Baptist opened its concierge program in 2019 and now has three practices across South Florida, where patients pay $2,500 a year.

“My philosophy is: It’s better to give world-class care to a few hundred patients rather than provide inadequate care to a few thousand patients,” Klein said.

Concierge physician practices started more than 20 years ago, mainly in upscale areas such as Boca Raton, Florida, and La Jolla, California. They catered mostly to wealthy retirees willing to pay extra for better physician access. Some of the first physician practices to enter the business were backed by private equity firms.

One of the largest, Boca Raton-based MDVIP, has more than 1,100 physicians and more than 390,000 patients. It was started in 2000, and since 2014 private equity firms have owned a majority stake in the company.

Some concierge physicians say their more attentive care means healthier patients. A study published last year by researchers at the University of California-Berkeley and University of Pennsylvania found no impact on mortality rates. What the study did find: higher costs.

Using Medicare claims data, the researchers found that concierge medicine enrollment corresponded with a 30%-50% increase in total health care spending by patients.

For hospitals, “this is an extension of them consolidating the market,” said Adam Leive, a study co-author and an assistant professor of public policy at UC Berkeley. Inova Health Care Services in Fairfax, Virginia, one of the state’s largest tax-exempt hospital chains, employs 18 concierge doctors, who each handle no more than 400 patients. Those patients pay $2,200 a year for the privilege.

George Salem, 70, of McLean, Virginia, has been a patient in Inova’s concierge practice for several years along with his wife. Earlier this year he slammed his finger in a hotel door, he said. As soon as he got home, he called his physician, who saw him immediately and stitched up the wound. He said he sees his doctor about 10 to 12 times a year.

“I loved my internist before, but it was impossible to get to see him,” Salem said. Immediate access to his doctor “very much gives me peace of mind,” he said.

Craig Cheifetz, a vice president at Inova who oversees the concierge program, said the hospital system took interest in the model after MDVIP began moving aggressively into the Washington, D.C., suburbs about a decade ago. Today, Inova’s program has 6,000 patients.

Cheifetz disputes the charge that concierge physician programs exacerbate primary care shortages. The model keeps doctors who were considering retiring early in the business with a lighter caseload, he said. And the fees amount to no more than a few dollars a day — about what some people spend on coffee, he said.

“Inova has an incredible primary care network for those who can’t afford the concierge care,” he said. “We are still providing all that is necessary in primary care for those who need it.”

Some hospitals are starting concierge physician practices far from their home locations. For example, Tampa General Hospital in Florida last year opened a concierge practice in upper-middle-class Palm Beach Gardens, a roughly three-hour drive from Tampa. Mount Sinai Health System in New York runs a concierge physician practice in West Palm Beach.

NCH Healthcare System in Naples, Florida, employs 12 concierge physicians who treat about 3,000 patients total. “We found a need in this community for those who wanted a more personalized health care experience,” said James Brinkert, regional administrator for the system. Members pay an annual fee of at least $3,500.

NCH patients whose doctors convert to concierge and who don’t want to pay the membership fee are referred to other primary care practices or to urgent care, Brinkert said.

KFF Health News  is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about  KFF .

Nonprofit hospitals created largely to serve the poor are adding concierge physician practices, charging patients annual membership fees of $2,000 or more for easier access to their doctors.

It’s a trend that began decades ago with physician practices. Thousands of doctors have shifted to the concierge model, in which they can increase their income while decreasing their patient load.

Northwestern Medicine in Chicago, Penn Medicine in Philadelphia, University Hospitals in the Cleveland area, and Baptist Health in Miami are among the large hospital systems offering concierge physician services. The fees, which can exceed $4,000 a year, are in addition to copayments, deductibles, and other charges not paid by patients’ insurance plans.

Critics of concierge medicine say the practice exacerbates primary care shortages, ensuring access only for the affluent, while driving up health care costs. But for tax-exempt hospitals, the financial benefits can be twofold. Concierge fees provide new revenue directly and serve as a tool to help recruit and retain physicians. Those doctors then provide lucrative referrals of their well-heeled patients to the hospitals that employ them.

“Hospitals are attracted to physicians that offer concierge services because their patients do not come with bad debts or a need for charity care, and most of them have private insurance which pays the hospital very well,” said Gerard Anderson, a hospital finance expert at Johns Hopkins University.

“They are the ideal patient, from the hospitals’ perspective.”

Concierge physicians typically limit their practices to a few hundred patients, compared with a couple of thousand for a traditional primary care doctor, so they can promise immediate access and longer visits.

“Every time we see these models expand, we are contracting the availability of primary care doctors for the general population,” said Jewel Mullen, associate dean for health equity at the University of Texas-Austin’s Dell Medical School. The former Connecticut health commissioner said concierge doctors join large hospital systems because of the institutions’ reputations, while hospitals sign up concierge physicians to ensure referrals to specialists and inpatient care. “It helps hospitals secure a bigger piece of their market,” she said.

Concierge physicians typically promise same-day or next-day appointments. Many provide patients their mobile phone number.

Aaron Klein, who oversees the concierge physician practices at Baptist Health, said the program was initially intended to serve donors.

“High-end donors wanted to make sure they have doctors to care for them,” he said.

Baptist opened its concierge program in 2019 and now has three practices across South Florida, where patients pay $2,500 a year.

“My philosophy is: It’s better to give world-class care to a few hundred patients rather than provide inadequate care to a few thousand patients,” Klein said.

Concierge physician practices started more than 20 years ago, mainly in upscale areas such as Boca Raton, Florida, and La Jolla, California. They catered mostly to wealthy retirees willing to pay extra for better physician access. Some of the first physician practices to enter the business were backed by private equity firms.

One of the largest, Boca Raton-based MDVIP, has more than 1,100 physicians and more than 390,000 patients. It was started in 2000, and since 2014 private equity firms have owned a majority stake in the company.

Some concierge physicians say their more attentive care means healthier patients. A study published last year by researchers at the University of California-Berkeley and University of Pennsylvania found no impact on mortality rates. What the study did find: higher costs.

Using Medicare claims data, the researchers found that concierge medicine enrollment corresponded with a 30%-50% increase in total health care spending by patients.

For hospitals, “this is an extension of them consolidating the market,” said Adam Leive, a study co-author and an assistant professor of public policy at UC Berkeley. Inova Health Care Services in Fairfax, Virginia, one of the state’s largest tax-exempt hospital chains, employs 18 concierge doctors, who each handle no more than 400 patients. Those patients pay $2,200 a year for the privilege.

George Salem, 70, of McLean, Virginia, has been a patient in Inova’s concierge practice for several years along with his wife. Earlier this year he slammed his finger in a hotel door, he said. As soon as he got home, he called his physician, who saw him immediately and stitched up the wound. He said he sees his doctor about 10 to 12 times a year.

“I loved my internist before, but it was impossible to get to see him,” Salem said. Immediate access to his doctor “very much gives me peace of mind,” he said.

Craig Cheifetz, a vice president at Inova who oversees the concierge program, said the hospital system took interest in the model after MDVIP began moving aggressively into the Washington, D.C., suburbs about a decade ago. Today, Inova’s program has 6,000 patients.

Cheifetz disputes the charge that concierge physician programs exacerbate primary care shortages. The model keeps doctors who were considering retiring early in the business with a lighter caseload, he said. And the fees amount to no more than a few dollars a day — about what some people spend on coffee, he said.

“Inova has an incredible primary care network for those who can’t afford the concierge care,” he said. “We are still providing all that is necessary in primary care for those who need it.”

Some hospitals are starting concierge physician practices far from their home locations. For example, Tampa General Hospital in Florida last year opened a concierge practice in upper-middle-class Palm Beach Gardens, a roughly three-hour drive from Tampa. Mount Sinai Health System in New York runs a concierge physician practice in West Palm Beach.

NCH Healthcare System in Naples, Florida, employs 12 concierge physicians who treat about 3,000 patients total. “We found a need in this community for those who wanted a more personalized health care experience,” said James Brinkert, regional administrator for the system. Members pay an annual fee of at least $3,500.

NCH patients whose doctors convert to concierge and who don’t want to pay the membership fee are referred to other primary care practices or to urgent care, Brinkert said.

KFF Health News  is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about  KFF .

The Epstein-Barr virus (EBV) is our constant companion, infecting an estimated 90%-95% of adults. Many of us are first infected as children, when the germ may trigger cold and flu symptoms. EBV also causes mononucleosis, or kissing disease, a glandular fever that has afflicted generations of amorous young people.

Post infection, EBV settles in for the long haul and remains in the body until death. It’s thought to be largely innocuous, but EBV is now implicated as a cause of several types of cancer — including lymphoma and nasopharyngeal tumors – and multiple sclerosis (MS). In 2022, a landmark study in Science suggested that previous EBV infection is the primary cause of MS.

While there aren’t many implications for current treatment, greater insight into the origin story of MS may eventually help neurologists better diagnose and treat patients, experts said. The goal is to uncover clues that “can help us understand MS a little bit better and reveal insights that could lead to new disease-modifying therapy,” Bruce Bebo, PhD, executive vice president of research with the National MS Society, said in an interview.
 

EBV Boosts MS Risk 32-Fold

EBV was first linked to MS back in 1981. For the 2022 study, researchers at the Harvard T.H. Chan School of Public Health and Harvard Medical School, Boston, analyzed blood serum from 10 million active-duty members of the US military. They focused on 801 recruits with MS and matched them with more than 1500 controls. All but one of those with MS had been infected with EBV; infection appeared to boost the risk for MS 32-fold (95% CI, 4.3-245.3; P < .001).

Neurologist and associate professor Michael Levy, MD, PhD, of Harvard Medical School and Massachusetts General Hospital, said in an interview that the findings are “groundbreaking” and confirm that EBV is “likely the primary cause of MS.”

According to Dr. Levy, there are two main theories about why EBV causes MS. The first hypothesis, known as the “molecular mimicry” theory, suggests that “EBV is a trigger of MS, possibly when the immune system mistakes a viral protein for a myelin protein and then attacks myelin,” Dr. Levy said. In MS, the immune system attacks the protective myelin sheath and the axons it insulates.

“After that point, the virus is not necessary to maintain the disease state and eradicating the virus likely won’t have much effect since the immune response is already triggered,” he said.

The second theory is that “EBV is a driver of MS where there is an ongoing, lifelong immunological response to EBV that continuously causes damage in the central nervous system [CNS]. In theory, if we could eradicate the virus, the destructive immune response could also resolve. Thus, an EBV antiviral treatment could potentially treat and maybe cure MS,” Dr. Levy explained, noting that “removing the pathogenic antigen may be a more effective strategy than removing the immune response.”

However, “we don’t yet know which hypothesis is correct,” he said. But “there is preliminary evidence in favor of each one.”
 

‘Additional Fuses Must Be Ignited’

It’s also unclear why most people infected with EBV do not develop MS. It appears that “additional fuses must be ignited,” for MS to take hold, according to a commentary accompanying the landmark 2022 study.

“As far as clinical implications, knowing whether a patient has a medical or family history of mononucleosis may be a small clue, a small piece of evidence, to help with diagnosis,” Dr. Bebo said.

He agreed with Dr. Levy that an antiviral could be a promising approach “If the problem in MS is a dysfunctional immune response to EBV.”

Natalia Drosu, MD, PhD, a postdoctoral fellow at Harvard-MIT Biomedical Engineering Center, said that a clinical trial of a non-immunosuppressive antiviral targeting EBV in patients with MS would be a crucial step toward better understanding the MS-EBV connection. “If we learn that antivirals are effective in MS, we should develop non-immunosuppressive therapies for patients with MS as soon as possible,” she said.

Stanford University’s Lawrence Steinman, MD, professor of neurology and neurological sciences, pediatrics, and genetics, who coauthored the commentary on the original Science paper, agreed that it’s worth investigating whether antiviral therapies targeting EBV will benefit patients who already have MS. But he cautioned against clinicians experimenting on their own outside of a research study. “You’d want to use the right antiviral and a properly designed trial,” he said.
 

Antivirals May Place a Crucial Role in MS Control

While there are no approved therapies for EBV, several MS disease-modifying therapies have anti-EBV effects, Dr. Levy said, citing anti-CD20 therapy as a clear example. It depletes B cells from the circulation, and it depletes EBV because the virus lives in the B-cell compartment. “Some MS treatments may be inadvertent EBV antivirals,” he said.

Researchers are also thinking about how they might exploit the MS-EBV link to prevent MS from developing in the first place, but there are uncertainties on that front too.

Conceivably, there may be some way to intervene in patients to treat EBV and prevent MS, such as a unique treatment for infectious mononucleosis (IM), Dr. Levy said.

Researchers are especially intrigued by signs that the timing of infection may play a role, with people infected with EBV via IM after early childhood at especially a high risk of developing MS. A 2022 German study calculated that people who developed IM were almost twice as likely as those who didn’t to develop MS within 10 years, although the risks in both groups were very small. Subgroup analysis revealed the strongest association between IM and MS was in the group infected between age 14 and 20 years (hazard ratio, 3.52; 95% CI, 1.00-12.37). They also saw a stronger association in men than in women.

The authors of a 2023 review in Clinical & Translational Immunology wrote that “further understanding of IM may be critical in solving the mystery” of EBV’s role in MS.

Dr. Levy said this line of questioning is important. “In theory, if we can tell who is prone to develop MS or whose immune system might be reacting to EBV to cause MS, we can intervene early to prevent neurological manifestations.”

However, “remember that while most of the world gets EBV infections, only 1 in 1000 will get MS. So, it might not be feasible to test everyone before neurological manifestations occur,” he said.
 

More Questions to Answer About EBV and MS

Researchers hope to answer several questions moving forward. For one, why is EBV uniquely connected to MS? “You would think that if there were cross-reactivity to myelin, there are many viruses that could cause MS. But the association seems to be very restricted to EBV,” Dr. Levy said. “It is probably due to the fact that EBV is one of the only human viruses that can infect B cells, which play important roles in controlling immune responses.”

The molecular mimicry theory also opens up a potential treatment pathway.

A 2022 study reported “high-affinity molecular mimicry between the EBV transcription factor EBV nuclear antigen 1 (EBNA1) and the central nervous system protein glial cell adhesion molecule (GlialCAM)”. Antibodies against EBNA1 and GlialCAM are prevalent in patients with MS. In a mouse model of MS, the researchers showed that EBNA1 immunization exacerbates disease. The authors wrote that “Our results provide a mechanistic link for the association between MS and EBV and could guide the development of new MS therapies.”
 

Could an EBV Vaccine Be the Answer?

On the prevention front, perhaps the most obvious question is whether an EBV vaccine could eliminate MS for good?

Dr. Bebo, from the National MS Society, said it will be important to determine which kind of vaccine is best. Is it one that neutralizes infection with EBV? Or is it enough to simply prevent clinical manifestations?

Both types of vaccines are in development, and at least two clinical trials are now in the works. The National Institute of Allergy and Infectious Diseases is sponsoring a phase 1 study of an adjuvanted EBV gp350-Ferritin nanoparticle vaccine. Forty subjects aged 18-29 years will take part: 20 with EBV and 20 who are not infected. The study is expected to end in 2025.

There is also a phase 1 placebo-controlled study in progress testing an EBV vaccine based on mRNA-1189 in 422 subjects aged 12-30 years. This trial is also due to end in 2025.

“This is very exciting, but it may take a decade or two to determine whether a vaccine is effective at preventing MS,” Dr. Levy said.

Dr. Levy, Dr. Steinman, Dr. Drosu, and Dr. Bebo had no disclosures.
 

A version of this article appeared on Medscape.com.

The Epstein-Barr virus (EBV) is our constant companion, infecting an estimated 90%-95% of adults. Many of us are first infected as children, when the germ may trigger cold and flu symptoms. EBV also causes mononucleosis, or kissing disease, a glandular fever that has afflicted generations of amorous young people.

Post infection, EBV settles in for the long haul and remains in the body until death. It’s thought to be largely innocuous, but EBV is now implicated as a cause of several types of cancer — including lymphoma and nasopharyngeal tumors – and multiple sclerosis (MS). In 2022, a landmark study in Science suggested that previous EBV infection is the primary cause of MS.

While there aren’t many implications for current treatment, greater insight into the origin story of MS may eventually help neurologists better diagnose and treat patients, experts said. The goal is to uncover clues that “can help us understand MS a little bit better and reveal insights that could lead to new disease-modifying therapy,” Bruce Bebo, PhD, executive vice president of research with the National MS Society, said in an interview.
 

EBV Boosts MS Risk 32-Fold

EBV was first linked to MS back in 1981. For the 2022 study, researchers at the Harvard T.H. Chan School of Public Health and Harvard Medical School, Boston, analyzed blood serum from 10 million active-duty members of the US military. They focused on 801 recruits with MS and matched them with more than 1500 controls. All but one of those with MS had been infected with EBV; infection appeared to boost the risk for MS 32-fold (95% CI, 4.3-245.3; P < .001).

Neurologist and associate professor Michael Levy, MD, PhD, of Harvard Medical School and Massachusetts General Hospital, said in an interview that the findings are “groundbreaking” and confirm that EBV is “likely the primary cause of MS.”

According to Dr. Levy, there are two main theories about why EBV causes MS. The first hypothesis, known as the “molecular mimicry” theory, suggests that “EBV is a trigger of MS, possibly when the immune system mistakes a viral protein for a myelin protein and then attacks myelin,” Dr. Levy said. In MS, the immune system attacks the protective myelin sheath and the axons it insulates.

“After that point, the virus is not necessary to maintain the disease state and eradicating the virus likely won’t have much effect since the immune response is already triggered,” he said.

The second theory is that “EBV is a driver of MS where there is an ongoing, lifelong immunological response to EBV that continuously causes damage in the central nervous system [CNS]. In theory, if we could eradicate the virus, the destructive immune response could also resolve. Thus, an EBV antiviral treatment could potentially treat and maybe cure MS,” Dr. Levy explained, noting that “removing the pathogenic antigen may be a more effective strategy than removing the immune response.”

However, “we don’t yet know which hypothesis is correct,” he said. But “there is preliminary evidence in favor of each one.”
 

‘Additional Fuses Must Be Ignited’

It’s also unclear why most people infected with EBV do not develop MS. It appears that “additional fuses must be ignited,” for MS to take hold, according to a commentary accompanying the landmark 2022 study.

“As far as clinical implications, knowing whether a patient has a medical or family history of mononucleosis may be a small clue, a small piece of evidence, to help with diagnosis,” Dr. Bebo said.

He agreed with Dr. Levy that an antiviral could be a promising approach “If the problem in MS is a dysfunctional immune response to EBV.”

Natalia Drosu, MD, PhD, a postdoctoral fellow at Harvard-MIT Biomedical Engineering Center, said that a clinical trial of a non-immunosuppressive antiviral targeting EBV in patients with MS would be a crucial step toward better understanding the MS-EBV connection. “If we learn that antivirals are effective in MS, we should develop non-immunosuppressive therapies for patients with MS as soon as possible,” she said.

Stanford University’s Lawrence Steinman, MD, professor of neurology and neurological sciences, pediatrics, and genetics, who coauthored the commentary on the original Science paper, agreed that it’s worth investigating whether antiviral therapies targeting EBV will benefit patients who already have MS. But he cautioned against clinicians experimenting on their own outside of a research study. “You’d want to use the right antiviral and a properly designed trial,” he said.
 

Antivirals May Place a Crucial Role in MS Control

While there are no approved therapies for EBV, several MS disease-modifying therapies have anti-EBV effects, Dr. Levy said, citing anti-CD20 therapy as a clear example. It depletes B cells from the circulation, and it depletes EBV because the virus lives in the B-cell compartment. “Some MS treatments may be inadvertent EBV antivirals,” he said.

Researchers are also thinking about how they might exploit the MS-EBV link to prevent MS from developing in the first place, but there are uncertainties on that front too.

Conceivably, there may be some way to intervene in patients to treat EBV and prevent MS, such as a unique treatment for infectious mononucleosis (IM), Dr. Levy said.

Researchers are especially intrigued by signs that the timing of infection may play a role, with people infected with EBV via IM after early childhood at especially a high risk of developing MS. A 2022 German study calculated that people who developed IM were almost twice as likely as those who didn’t to develop MS within 10 years, although the risks in both groups were very small. Subgroup analysis revealed the strongest association between IM and MS was in the group infected between age 14 and 20 years (hazard ratio, 3.52; 95% CI, 1.00-12.37). They also saw a stronger association in men than in women.

The authors of a 2023 review in Clinical & Translational Immunology wrote that “further understanding of IM may be critical in solving the mystery” of EBV’s role in MS.

Dr. Levy said this line of questioning is important. “In theory, if we can tell who is prone to develop MS or whose immune system might be reacting to EBV to cause MS, we can intervene early to prevent neurological manifestations.”

However, “remember that while most of the world gets EBV infections, only 1 in 1000 will get MS. So, it might not be feasible to test everyone before neurological manifestations occur,” he said.
 

More Questions to Answer About EBV and MS

Researchers hope to answer several questions moving forward. For one, why is EBV uniquely connected to MS? “You would think that if there were cross-reactivity to myelin, there are many viruses that could cause MS. But the association seems to be very restricted to EBV,” Dr. Levy said. “It is probably due to the fact that EBV is one of the only human viruses that can infect B cells, which play important roles in controlling immune responses.”

The molecular mimicry theory also opens up a potential treatment pathway.

A 2022 study reported “high-affinity molecular mimicry between the EBV transcription factor EBV nuclear antigen 1 (EBNA1) and the central nervous system protein glial cell adhesion molecule (GlialCAM)”. Antibodies against EBNA1 and GlialCAM are prevalent in patients with MS. In a mouse model of MS, the researchers showed that EBNA1 immunization exacerbates disease. The authors wrote that “Our results provide a mechanistic link for the association between MS and EBV and could guide the development of new MS therapies.”
 

Could an EBV Vaccine Be the Answer?

On the prevention front, perhaps the most obvious question is whether an EBV vaccine could eliminate MS for good?

Dr. Bebo, from the National MS Society, said it will be important to determine which kind of vaccine is best. Is it one that neutralizes infection with EBV? Or is it enough to simply prevent clinical manifestations?

Both types of vaccines are in development, and at least two clinical trials are now in the works. The National Institute of Allergy and Infectious Diseases is sponsoring a phase 1 study of an adjuvanted EBV gp350-Ferritin nanoparticle vaccine. Forty subjects aged 18-29 years will take part: 20 with EBV and 20 who are not infected. The study is expected to end in 2025.

There is also a phase 1 placebo-controlled study in progress testing an EBV vaccine based on mRNA-1189 in 422 subjects aged 12-30 years. This trial is also due to end in 2025.

“This is very exciting, but it may take a decade or two to determine whether a vaccine is effective at preventing MS,” Dr. Levy said.

Dr. Levy, Dr. Steinman, Dr. Drosu, and Dr. Bebo had no disclosures.
 

A version of this article appeared on Medscape.com.

The Epstein-Barr virus (EBV) is our constant companion, infecting an estimated 90%-95% of adults. Many of us are first infected as children, when the germ may trigger cold and flu symptoms. EBV also causes mononucleosis, or kissing disease, a glandular fever that has afflicted generations of amorous young people.

Post infection, EBV settles in for the long haul and remains in the body until death. It’s thought to be largely innocuous, but EBV is now implicated as a cause of several types of cancer — including lymphoma and nasopharyngeal tumors – and multiple sclerosis (MS). In 2022, a landmark study in Science suggested that previous EBV infection is the primary cause of MS.

While there aren’t many implications for current treatment, greater insight into the origin story of MS may eventually help neurologists better diagnose and treat patients, experts said. The goal is to uncover clues that “can help us understand MS a little bit better and reveal insights that could lead to new disease-modifying therapy,” Bruce Bebo, PhD, executive vice president of research with the National MS Society, said in an interview.
 

EBV Boosts MS Risk 32-Fold

EBV was first linked to MS back in 1981. For the 2022 study, researchers at the Harvard T.H. Chan School of Public Health and Harvard Medical School, Boston, analyzed blood serum from 10 million active-duty members of the US military. They focused on 801 recruits with MS and matched them with more than 1500 controls. All but one of those with MS had been infected with EBV; infection appeared to boost the risk for MS 32-fold (95% CI, 4.3-245.3; P < .001).

Neurologist and associate professor Michael Levy, MD, PhD, of Harvard Medical School and Massachusetts General Hospital, said in an interview that the findings are “groundbreaking” and confirm that EBV is “likely the primary cause of MS.”

According to Dr. Levy, there are two main theories about why EBV causes MS. The first hypothesis, known as the “molecular mimicry” theory, suggests that “EBV is a trigger of MS, possibly when the immune system mistakes a viral protein for a myelin protein and then attacks myelin,” Dr. Levy said. In MS, the immune system attacks the protective myelin sheath and the axons it insulates.

“After that point, the virus is not necessary to maintain the disease state and eradicating the virus likely won’t have much effect since the immune response is already triggered,” he said.

The second theory is that “EBV is a driver of MS where there is an ongoing, lifelong immunological response to EBV that continuously causes damage in the central nervous system [CNS]. In theory, if we could eradicate the virus, the destructive immune response could also resolve. Thus, an EBV antiviral treatment could potentially treat and maybe cure MS,” Dr. Levy explained, noting that “removing the pathogenic antigen may be a more effective strategy than removing the immune response.”

However, “we don’t yet know which hypothesis is correct,” he said. But “there is preliminary evidence in favor of each one.”
 

‘Additional Fuses Must Be Ignited’

It’s also unclear why most people infected with EBV do not develop MS. It appears that “additional fuses must be ignited,” for MS to take hold, according to a commentary accompanying the landmark 2022 study.

“As far as clinical implications, knowing whether a patient has a medical or family history of mononucleosis may be a small clue, a small piece of evidence, to help with diagnosis,” Dr. Bebo said.

He agreed with Dr. Levy that an antiviral could be a promising approach “If the problem in MS is a dysfunctional immune response to EBV.”

Natalia Drosu, MD, PhD, a postdoctoral fellow at Harvard-MIT Biomedical Engineering Center, said that a clinical trial of a non-immunosuppressive antiviral targeting EBV in patients with MS would be a crucial step toward better understanding the MS-EBV connection. “If we learn that antivirals are effective in MS, we should develop non-immunosuppressive therapies for patients with MS as soon as possible,” she said.

Stanford University’s Lawrence Steinman, MD, professor of neurology and neurological sciences, pediatrics, and genetics, who coauthored the commentary on the original Science paper, agreed that it’s worth investigating whether antiviral therapies targeting EBV will benefit patients who already have MS. But he cautioned against clinicians experimenting on their own outside of a research study. “You’d want to use the right antiviral and a properly designed trial,” he said.
 

Antivirals May Place a Crucial Role in MS Control

While there are no approved therapies for EBV, several MS disease-modifying therapies have anti-EBV effects, Dr. Levy said, citing anti-CD20 therapy as a clear example. It depletes B cells from the circulation, and it depletes EBV because the virus lives in the B-cell compartment. “Some MS treatments may be inadvertent EBV antivirals,” he said.

Researchers are also thinking about how they might exploit the MS-EBV link to prevent MS from developing in the first place, but there are uncertainties on that front too.

Conceivably, there may be some way to intervene in patients to treat EBV and prevent MS, such as a unique treatment for infectious mononucleosis (IM), Dr. Levy said.

Researchers are especially intrigued by signs that the timing of infection may play a role, with people infected with EBV via IM after early childhood at especially a high risk of developing MS. A 2022 German study calculated that people who developed IM were almost twice as likely as those who didn’t to develop MS within 10 years, although the risks in both groups were very small. Subgroup analysis revealed the strongest association between IM and MS was in the group infected between age 14 and 20 years (hazard ratio, 3.52; 95% CI, 1.00-12.37). They also saw a stronger association in men than in women.

The authors of a 2023 review in Clinical & Translational Immunology wrote that “further understanding of IM may be critical in solving the mystery” of EBV’s role in MS.

Dr. Levy said this line of questioning is important. “In theory, if we can tell who is prone to develop MS or whose immune system might be reacting to EBV to cause MS, we can intervene early to prevent neurological manifestations.”

However, “remember that while most of the world gets EBV infections, only 1 in 1000 will get MS. So, it might not be feasible to test everyone before neurological manifestations occur,” he said.
 

More Questions to Answer About EBV and MS

Researchers hope to answer several questions moving forward. For one, why is EBV uniquely connected to MS? “You would think that if there were cross-reactivity to myelin, there are many viruses that could cause MS. But the association seems to be very restricted to EBV,” Dr. Levy said. “It is probably due to the fact that EBV is one of the only human viruses that can infect B cells, which play important roles in controlling immune responses.”

The molecular mimicry theory also opens up a potential treatment pathway.

A 2022 study reported “high-affinity molecular mimicry between the EBV transcription factor EBV nuclear antigen 1 (EBNA1) and the central nervous system protein glial cell adhesion molecule (GlialCAM)”. Antibodies against EBNA1 and GlialCAM are prevalent in patients with MS. In a mouse model of MS, the researchers showed that EBNA1 immunization exacerbates disease. The authors wrote that “Our results provide a mechanistic link for the association between MS and EBV and could guide the development of new MS therapies.”
 

Could an EBV Vaccine Be the Answer?

On the prevention front, perhaps the most obvious question is whether an EBV vaccine could eliminate MS for good?

Dr. Bebo, from the National MS Society, said it will be important to determine which kind of vaccine is best. Is it one that neutralizes infection with EBV? Or is it enough to simply prevent clinical manifestations?

Both types of vaccines are in development, and at least two clinical trials are now in the works. The National Institute of Allergy and Infectious Diseases is sponsoring a phase 1 study of an adjuvanted EBV gp350-Ferritin nanoparticle vaccine. Forty subjects aged 18-29 years will take part: 20 with EBV and 20 who are not infected. The study is expected to end in 2025.

There is also a phase 1 placebo-controlled study in progress testing an EBV vaccine based on mRNA-1189 in 422 subjects aged 12-30 years. This trial is also due to end in 2025.

“This is very exciting, but it may take a decade or two to determine whether a vaccine is effective at preventing MS,” Dr. Levy said.

Dr. Levy, Dr. Steinman, Dr. Drosu, and Dr. Bebo had no disclosures.
 

A version of this article appeared on Medscape.com.

At first glance, hematologists may not seem like they’d be likely to get urgent calls from the emergency department at 3 a.m. After all, they typically work during normal business hours. However, severe medical crises in blood-cancer patients can occur, and drowsy hematologists may find themselves providing guidance to emergency physicians about how to deal with rapidly deteriorating patients.

When a patient with a blood-cancer crisis comes in, “I can recognize what’s going on, and I can initiate treatment. But if you do have a true hematologic emergency, then you need a hematologist to be able to contribute to your care,” Molly Estes, MD, an emergency physician with California’s Loma Linda University, said in an interview.

In situations such as a patient with an extraordinarily high white blood count, “you’ll be calling your hematologist for treatment recommendations and calling your nephrologist for assistance managing electrolyte disorders,” Megan Boysen-Osborn, MD, an emergency physician with the University of California at Irvine, said in an interview.

Here’s a look at three emergency hematologic conditions that lead to late-night phone calls:
 

Leukocytosis

Blood cancers can cause white blood cell counts to skyrocket, a condition known as leukocytosis, but a high count is not necessarily an emergency. The key is to figure out whether the high count is normal for the patient — perhaps due to the disease or the medical treatment — or a sign of an internal medical crisis, Dr. Estes said.

“Let’s say you stubbed your toe in the night, and I happened to get blood work on you and incidentally notice that your white blood cells are high. But they’re the same high level that they always are,” Dr. Estes said. “That’s a completely different scenario than if I’m seeing you for fever, vomiting, and stomach pain.”

Indeed, there’s no cut-off that differentiates a dangerously high white blood count from one that’s acceptable, Mikkael A. Sekeres, MD, MS, chief of hematology at Sylvester Comprehensive Cancer Center at the University of Miami Health System, said in an interview.

“In the past, I’ve taken care of a couple of patients who had chronic lymphocytic leukemia and white blood cell counts that were 200,000 or 300,000 [white blood cells per microliter] and worked out in the gym every day,” he said. “It didn’t negatively affect them. On the flip side, I have also taken care of patients with acute myeloid leukemia with a white blood cell count of 50,000. That landed them in the intensive care unit.”

Dr. Estes said that her first impulse in cases of high white blood cell count is to give IV fluids to dilute the blood and prevent the cells from turning blood into sludge via hyperviscosity syndrome. Dr. Sekeres said this makes sense, since the condition can lead to blockages in vessels and cause heart attacks and strokes.

There are other options, depending on the severity of the case. Hydroxyurea can be administered to lower white blood cell counts along with allopurinol to protect the kidneys, Dr. Sekeres said. In some situations, he said, “we’ll consider initiating chemotherapy immediately to reduce the level of the white blood cells. Or we will consider placing a patient on dialysis to take off some of those white blood cells.”
 

Tumor lysis syndrome

While it’s rare, tumor lysis syndrome can occur when tumors release their content into blood stream. According to Dr. Sekeres, this can happen when “cancers that grow so quickly that they can start to outgrow their own blood supply and start dying before we even treat patients. When this happens, it causes electrolyte disarray.”

It’s crucial to understand the potential for patients to quickly get worse, he said. He advises clinicians to aggressively check lab values for electrolyte abnormalities and aggressively administer IV fluids and electrolyte replacement when needed. “It’s also important to let the intensive care unit know that they may need to be activated,” he said. Fortunately, he noted, patients can often be stabilized.
 

Differentiation syndrome

According to the Cleveland Clinic, medications used to treat acute myeloid leukemia and acute promyelocytic leukemia cause cancer cells to differentiate from immature states to mature normal states. But the process can go awry when fluid leaks out of blood vessels in a condition called differentiation syndrome. This can cause multiple problems, Dr. Sekeres said.

A 2020 report noted the potential for “acute end-organ damage with peripheral edema, hypotension, acute renal failure, and interstitial pulmonary infiltrates.”

In these cases, aggressive supportive management is key, Dr. Sekeres said. If a patient is having difficulty breathing, for example, they’ll need electrolyte management and perhaps support via a respirator, he said.

“Most people with acute promyelocytic leukemia can fully recover from differentiation syndrome with prompt, effective treatment,” the Cleveland Clinic notes. It adds that the disease is “highly curable.”

In all of these emergent crises, Dr. Sekeres said, it’s important for hematologists understand that “patients can get very sick very quickly,” and it’s important to intervene early and often.

Dr. Sekeres serves on advisory boards for BMS and Curium Pharma. Dr. Estes and Dr. Boysen-Osborn have no disclosures.

At first glance, hematologists may not seem like they’d be likely to get urgent calls from the emergency department at 3 a.m. After all, they typically work during normal business hours. However, severe medical crises in blood-cancer patients can occur, and drowsy hematologists may find themselves providing guidance to emergency physicians about how to deal with rapidly deteriorating patients.

When a patient with a blood-cancer crisis comes in, “I can recognize what’s going on, and I can initiate treatment. But if you do have a true hematologic emergency, then you need a hematologist to be able to contribute to your care,” Molly Estes, MD, an emergency physician with California’s Loma Linda University, said in an interview.

In situations such as a patient with an extraordinarily high white blood count, “you’ll be calling your hematologist for treatment recommendations and calling your nephrologist for assistance managing electrolyte disorders,” Megan Boysen-Osborn, MD, an emergency physician with the University of California at Irvine, said in an interview.

Here’s a look at three emergency hematologic conditions that lead to late-night phone calls:
 

Leukocytosis

Blood cancers can cause white blood cell counts to skyrocket, a condition known as leukocytosis, but a high count is not necessarily an emergency. The key is to figure out whether the high count is normal for the patient — perhaps due to the disease or the medical treatment — or a sign of an internal medical crisis, Dr. Estes said.

“Let’s say you stubbed your toe in the night, and I happened to get blood work on you and incidentally notice that your white blood cells are high. But they’re the same high level that they always are,” Dr. Estes said. “That’s a completely different scenario than if I’m seeing you for fever, vomiting, and stomach pain.”

Indeed, there’s no cut-off that differentiates a dangerously high white blood count from one that’s acceptable, Mikkael A. Sekeres, MD, MS, chief of hematology at Sylvester Comprehensive Cancer Center at the University of Miami Health System, said in an interview.

“In the past, I’ve taken care of a couple of patients who had chronic lymphocytic leukemia and white blood cell counts that were 200,000 or 300,000 [white blood cells per microliter] and worked out in the gym every day,” he said. “It didn’t negatively affect them. On the flip side, I have also taken care of patients with acute myeloid leukemia with a white blood cell count of 50,000. That landed them in the intensive care unit.”

Dr. Estes said that her first impulse in cases of high white blood cell count is to give IV fluids to dilute the blood and prevent the cells from turning blood into sludge via hyperviscosity syndrome. Dr. Sekeres said this makes sense, since the condition can lead to blockages in vessels and cause heart attacks and strokes.

There are other options, depending on the severity of the case. Hydroxyurea can be administered to lower white blood cell counts along with allopurinol to protect the kidneys, Dr. Sekeres said. In some situations, he said, “we’ll consider initiating chemotherapy immediately to reduce the level of the white blood cells. Or we will consider placing a patient on dialysis to take off some of those white blood cells.”
 

Tumor lysis syndrome

While it’s rare, tumor lysis syndrome can occur when tumors release their content into blood stream. According to Dr. Sekeres, this can happen when “cancers that grow so quickly that they can start to outgrow their own blood supply and start dying before we even treat patients. When this happens, it causes electrolyte disarray.”

It’s crucial to understand the potential for patients to quickly get worse, he said. He advises clinicians to aggressively check lab values for electrolyte abnormalities and aggressively administer IV fluids and electrolyte replacement when needed. “It’s also important to let the intensive care unit know that they may need to be activated,” he said. Fortunately, he noted, patients can often be stabilized.
 

Differentiation syndrome

According to the Cleveland Clinic, medications used to treat acute myeloid leukemia and acute promyelocytic leukemia cause cancer cells to differentiate from immature states to mature normal states. But the process can go awry when fluid leaks out of blood vessels in a condition called differentiation syndrome. This can cause multiple problems, Dr. Sekeres said.

A 2020 report noted the potential for “acute end-organ damage with peripheral edema, hypotension, acute renal failure, and interstitial pulmonary infiltrates.”

In these cases, aggressive supportive management is key, Dr. Sekeres said. If a patient is having difficulty breathing, for example, they’ll need electrolyte management and perhaps support via a respirator, he said.

“Most people with acute promyelocytic leukemia can fully recover from differentiation syndrome with prompt, effective treatment,” the Cleveland Clinic notes. It adds that the disease is “highly curable.”

In all of these emergent crises, Dr. Sekeres said, it’s important for hematologists understand that “patients can get very sick very quickly,” and it’s important to intervene early and often.

Dr. Sekeres serves on advisory boards for BMS and Curium Pharma. Dr. Estes and Dr. Boysen-Osborn have no disclosures.

At first glance, hematologists may not seem like they’d be likely to get urgent calls from the emergency department at 3 a.m. After all, they typically work during normal business hours. However, severe medical crises in blood-cancer patients can occur, and drowsy hematologists may find themselves providing guidance to emergency physicians about how to deal with rapidly deteriorating patients.

When a patient with a blood-cancer crisis comes in, “I can recognize what’s going on, and I can initiate treatment. But if you do have a true hematologic emergency, then you need a hematologist to be able to contribute to your care,” Molly Estes, MD, an emergency physician with California’s Loma Linda University, said in an interview.

In situations such as a patient with an extraordinarily high white blood count, “you’ll be calling your hematologist for treatment recommendations and calling your nephrologist for assistance managing electrolyte disorders,” Megan Boysen-Osborn, MD, an emergency physician with the University of California at Irvine, said in an interview.

Here’s a look at three emergency hematologic conditions that lead to late-night phone calls:
 

Leukocytosis

Blood cancers can cause white blood cell counts to skyrocket, a condition known as leukocytosis, but a high count is not necessarily an emergency. The key is to figure out whether the high count is normal for the patient — perhaps due to the disease or the medical treatment — or a sign of an internal medical crisis, Dr. Estes said.

“Let’s say you stubbed your toe in the night, and I happened to get blood work on you and incidentally notice that your white blood cells are high. But they’re the same high level that they always are,” Dr. Estes said. “That’s a completely different scenario than if I’m seeing you for fever, vomiting, and stomach pain.”

Indeed, there’s no cut-off that differentiates a dangerously high white blood count from one that’s acceptable, Mikkael A. Sekeres, MD, MS, chief of hematology at Sylvester Comprehensive Cancer Center at the University of Miami Health System, said in an interview.

“In the past, I’ve taken care of a couple of patients who had chronic lymphocytic leukemia and white blood cell counts that were 200,000 or 300,000 [white blood cells per microliter] and worked out in the gym every day,” he said. “It didn’t negatively affect them. On the flip side, I have also taken care of patients with acute myeloid leukemia with a white blood cell count of 50,000. That landed them in the intensive care unit.”

Dr. Estes said that her first impulse in cases of high white blood cell count is to give IV fluids to dilute the blood and prevent the cells from turning blood into sludge via hyperviscosity syndrome. Dr. Sekeres said this makes sense, since the condition can lead to blockages in vessels and cause heart attacks and strokes.

There are other options, depending on the severity of the case. Hydroxyurea can be administered to lower white blood cell counts along with allopurinol to protect the kidneys, Dr. Sekeres said. In some situations, he said, “we’ll consider initiating chemotherapy immediately to reduce the level of the white blood cells. Or we will consider placing a patient on dialysis to take off some of those white blood cells.”
 

Tumor lysis syndrome

While it’s rare, tumor lysis syndrome can occur when tumors release their content into blood stream. According to Dr. Sekeres, this can happen when “cancers that grow so quickly that they can start to outgrow their own blood supply and start dying before we even treat patients. When this happens, it causes electrolyte disarray.”

It’s crucial to understand the potential for patients to quickly get worse, he said. He advises clinicians to aggressively check lab values for electrolyte abnormalities and aggressively administer IV fluids and electrolyte replacement when needed. “It’s also important to let the intensive care unit know that they may need to be activated,” he said. Fortunately, he noted, patients can often be stabilized.
 

Differentiation syndrome

According to the Cleveland Clinic, medications used to treat acute myeloid leukemia and acute promyelocytic leukemia cause cancer cells to differentiate from immature states to mature normal states. But the process can go awry when fluid leaks out of blood vessels in a condition called differentiation syndrome. This can cause multiple problems, Dr. Sekeres said.

A 2020 report noted the potential for “acute end-organ damage with peripheral edema, hypotension, acute renal failure, and interstitial pulmonary infiltrates.”

In these cases, aggressive supportive management is key, Dr. Sekeres said. If a patient is having difficulty breathing, for example, they’ll need electrolyte management and perhaps support via a respirator, he said.

“Most people with acute promyelocytic leukemia can fully recover from differentiation syndrome with prompt, effective treatment,” the Cleveland Clinic notes. It adds that the disease is “highly curable.”

In all of these emergent crises, Dr. Sekeres said, it’s important for hematologists understand that “patients can get very sick very quickly,” and it’s important to intervene early and often.

Dr. Sekeres serves on advisory boards for BMS and Curium Pharma. Dr. Estes and Dr. Boysen-Osborn have no disclosures.

This transcript has been edited for clarity.

I think we’re all aware that Alabama has put itself and the rest of the country into a moral bind when it comes to abortion and the status of human embryos. Back on February 16, 2024, the Alabama Supreme Court rendered a decision in a case called LePage v. Center for Reproductive Medicine, in which the court said that cryopreserved embryos in frozen nitrogen were legally equivalent to children.

They basically said they’re granted the same rights, meaning you certainly can’t destroy them. You certainly could not be in a situation where somebody said, “I’m going to not use them,” because once you create them, you seem to have some duty to make sure they end up in an environment where they can become full-fledged adults.

This decision that embryos in frozen nitrogen — but literally embryos anywhere — are the equivalent of full-bore children put Alabama in a terrible situation if you were a person or a couple seeking in vitro fertilization (IVF).

IVF requires the creation of many eggs. Women have to undergo drug treatment so that they superovulate. It’s too expensive to just go one egg at a time, egg procurement costs too much, and a cycle of IVF could cost as much as $15,000. There are some people who don’t make many eggs, so you want to get as many as you can.

When you get them, you freeze them, as happened in this Alabama case. By the way, what triggered the court case was that somebody in the lab dropped the tray with embryos in it, and they were basically accused not just of a mistake but of murder.

It’s pretty serious when you see this decision and you realize that if you make a multitude of embryos and then you had a child after two tries, but you have six more, you can’t destroy them. What are you going to do with them? Will they be under the governance of the utility company? What’s going to happen?

Many women in Alabama were outraged by the court’s opinion because they want to do IVF. In fact, politically, proponents of thinking that life begins at conception — or fetal personhood as it’s called, and the view that human embryos are children from the minute of conception — were stuck. It’s hard to argue that IVF is not pro-life. It’s hard to argue that people who desperately want to have children should find it difficult to use the technique.

The state has tried to pass a law that exempts IVF clinics from liability if they’re trying to use human embryos to make babies. I do not think this will stand. The court decision is fundamentally wrong, in part because human embryos are not children. They are potential children. They are possible children, but outside of implantation in the environment of a woman’s uterus, they’ll never become anything.

In fact, the court decision is a version of what used to be called preformationism, which sees a tiny baby inside a human embryo. That’s not true. We know today that you’ve got sets of genes that need messages from the mom in order to begin the process of division and development. It isn’t just expanding a tiny, miniature baby into a full-bore baby, as the court in Alabama seems to think.

Dr. Caplan, director, division of medical ethics, New York University Langone Medical Center, New York, has served as a director, officer, partner, employee, adviser, consultant, or trustee for Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position). He is a contributing author and adviser for Medscape.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity.

I think we’re all aware that Alabama has put itself and the rest of the country into a moral bind when it comes to abortion and the status of human embryos. Back on February 16, 2024, the Alabama Supreme Court rendered a decision in a case called LePage v. Center for Reproductive Medicine, in which the court said that cryopreserved embryos in frozen nitrogen were legally equivalent to children.

They basically said they’re granted the same rights, meaning you certainly can’t destroy them. You certainly could not be in a situation where somebody said, “I’m going to not use them,” because once you create them, you seem to have some duty to make sure they end up in an environment where they can become full-fledged adults.

This decision that embryos in frozen nitrogen — but literally embryos anywhere — are the equivalent of full-bore children put Alabama in a terrible situation if you were a person or a couple seeking in vitro fertilization (IVF).

IVF requires the creation of many eggs. Women have to undergo drug treatment so that they superovulate. It’s too expensive to just go one egg at a time, egg procurement costs too much, and a cycle of IVF could cost as much as $15,000. There are some people who don’t make many eggs, so you want to get as many as you can.

When you get them, you freeze them, as happened in this Alabama case. By the way, what triggered the court case was that somebody in the lab dropped the tray with embryos in it, and they were basically accused not just of a mistake but of murder.

It’s pretty serious when you see this decision and you realize that if you make a multitude of embryos and then you had a child after two tries, but you have six more, you can’t destroy them. What are you going to do with them? Will they be under the governance of the utility company? What’s going to happen?

Many women in Alabama were outraged by the court’s opinion because they want to do IVF. In fact, politically, proponents of thinking that life begins at conception — or fetal personhood as it’s called, and the view that human embryos are children from the minute of conception — were stuck. It’s hard to argue that IVF is not pro-life. It’s hard to argue that people who desperately want to have children should find it difficult to use the technique.

The state has tried to pass a law that exempts IVF clinics from liability if they’re trying to use human embryos to make babies. I do not think this will stand. The court decision is fundamentally wrong, in part because human embryos are not children. They are potential children. They are possible children, but outside of implantation in the environment of a woman’s uterus, they’ll never become anything.

In fact, the court decision is a version of what used to be called preformationism, which sees a tiny baby inside a human embryo. That’s not true. We know today that you’ve got sets of genes that need messages from the mom in order to begin the process of division and development. It isn’t just expanding a tiny, miniature baby into a full-bore baby, as the court in Alabama seems to think.

Dr. Caplan, director, division of medical ethics, New York University Langone Medical Center, New York, has served as a director, officer, partner, employee, adviser, consultant, or trustee for Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position). He is a contributing author and adviser for Medscape.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity.

I think we’re all aware that Alabama has put itself and the rest of the country into a moral bind when it comes to abortion and the status of human embryos. Back on February 16, 2024, the Alabama Supreme Court rendered a decision in a case called LePage v. Center for Reproductive Medicine, in which the court said that cryopreserved embryos in frozen nitrogen were legally equivalent to children.

They basically said they’re granted the same rights, meaning you certainly can’t destroy them. You certainly could not be in a situation where somebody said, “I’m going to not use them,” because once you create them, you seem to have some duty to make sure they end up in an environment where they can become full-fledged adults.

This decision that embryos in frozen nitrogen — but literally embryos anywhere — are the equivalent of full-bore children put Alabama in a terrible situation if you were a person or a couple seeking in vitro fertilization (IVF).

IVF requires the creation of many eggs. Women have to undergo drug treatment so that they superovulate. It’s too expensive to just go one egg at a time, egg procurement costs too much, and a cycle of IVF could cost as much as $15,000. There are some people who don’t make many eggs, so you want to get as many as you can.

When you get them, you freeze them, as happened in this Alabama case. By the way, what triggered the court case was that somebody in the lab dropped the tray with embryos in it, and they were basically accused not just of a mistake but of murder.

It’s pretty serious when you see this decision and you realize that if you make a multitude of embryos and then you had a child after two tries, but you have six more, you can’t destroy them. What are you going to do with them? Will they be under the governance of the utility company? What’s going to happen?

Many women in Alabama were outraged by the court’s opinion because they want to do IVF. In fact, politically, proponents of thinking that life begins at conception — or fetal personhood as it’s called, and the view that human embryos are children from the minute of conception — were stuck. It’s hard to argue that IVF is not pro-life. It’s hard to argue that people who desperately want to have children should find it difficult to use the technique.

The state has tried to pass a law that exempts IVF clinics from liability if they’re trying to use human embryos to make babies. I do not think this will stand. The court decision is fundamentally wrong, in part because human embryos are not children. They are potential children. They are possible children, but outside of implantation in the environment of a woman’s uterus, they’ll never become anything.

In fact, the court decision is a version of what used to be called preformationism, which sees a tiny baby inside a human embryo. That’s not true. We know today that you’ve got sets of genes that need messages from the mom in order to begin the process of division and development. It isn’t just expanding a tiny, miniature baby into a full-bore baby, as the court in Alabama seems to think.

Dr. Caplan, director, division of medical ethics, New York University Langone Medical Center, New York, has served as a director, officer, partner, employee, adviser, consultant, or trustee for Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position). He is a contributing author and adviser for Medscape.

A version of this article appeared on Medscape.com.

TOPLINE: 

The geriatric emergency medication safety recommendations (GEMS-Rx) is the first expert consensus-based list identifying high-risk medication classes that should not be prescribed to older patients visiting the emergency department (ED).

METHODOLOGY:

• Around half of the geriatric patients presenting to the ED get discharged with new prescriptions. Some of the newly prescribed drugs may not be appropriate for use in individuals aged ≥ 65 years, thereby increasing the risk for unfavorable adverse events.
• The American Geriatrics Society (AGS)  has already established guidelines to identify potentially inappropriate medications in older adults; however, the criteria are centered on chronic conditions and long-term medication use and are unsuitable for managing ED prescriptions.
• In this study, the GEMS-Rx high-risk prescription list was prepared with a panel of 10 ED physicians with expertise in geriatrics and quality measurement and a pharmacist with expertise in geriatric pharmacotherapy and emergency medicine.
• They reviewed over 30 medication classes from the 2019 AGS Beers Criteria that were deemed inappropriate for use in older patients. Despite their not being included in the Beers list, the use of short- and long-acting opioids was also discussed.
• After three rounds of review and discussion, the panelists ranked each class of medication on a 5-point Likert scale, with a score of 1 indicating the lowest and 5 indicating the greatest need for avoiding a drug in an ED prescription.

TAKEAWAY:

• The first round suggested that first-generation antihistamines, metoclopramide, short-acting opioids, antipsychotics, barbiturates, skeletal muscle relaxants, and benzodiazepines should be avoided, with mean Likert scores ranging from 3.7 to 4.6.
• Although nonbenzodiazepine and benzodiazepine receptor agonist hypnotics (“Z-drugs”) were not initially considered owing to their low frequency of prescription in ED settings, the panelists finally included “Z” drugs and sulfonylureas in the GEMS-Rx list after the second and third rounds.
• The final list of high-risk medications to be avoided in ED settings that were prioritized included benzodiazepines, skeletal muscle relaxants, barbiturates, first-generation antipsychotics, first-generation antihistamines, “Z” drugs, metoclopramide, and sulfonylureas.
• However, seizure disorders, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, end-of-life care, allergic reactions, and ED visits for prescription refilling were deemed exceptional cases in which these high-risk medications could be prescribed.

IN PRACTICE:

“By combining expert consensus and evidence-based criteria, this list can serve as a resource to guide prescribing decisions and mitigate potential risks associated with medications at this crucial care transition. The incorporation of this emergency medicine-specific geriatric prescription list in a national quality measure has the potential to improve patient safety and enhance the quality of care for the millions of older adults who seek care in EDs each year,” the authors said.

SOURCE:

This study was led by Rachel M. Skains, MD, MSPH, Department of Emergency Medicine, University of Alabama at Birmingham, and published online in Annals of Emergency Medicine.

LIMITATIONS:

The GEMS-Rx list was prepared by physicians and pharmacists and may not have fully captured data regarding individual patient preferences, comorbidities, or other contextual factors. During the meetings, the panelists’ identities were not concealed from one another, which may have affected the conversations owing to response and social desirability bias. Furthermore, this list may not be generalizable to other settings because it was produced and intended for usage in US EDs.

DISCLOSURES:

This work was supported by the American College of Emergency Physicians. Some of the authors, including the lead author, declared being supported by various funding agencies. Few authors also declared serving in leadership positions for several sources.

A version of this article appeared on Medscape.com.

TOPLINE: 

The geriatric emergency medication safety recommendations (GEMS-Rx) is the first expert consensus-based list identifying high-risk medication classes that should not be prescribed to older patients visiting the emergency department (ED).

METHODOLOGY:

• Around half of the geriatric patients presenting to the ED get discharged with new prescriptions. Some of the newly prescribed drugs may not be appropriate for use in individuals aged ≥ 65 years, thereby increasing the risk for unfavorable adverse events.
• The American Geriatrics Society (AGS)  has already established guidelines to identify potentially inappropriate medications in older adults; however, the criteria are centered on chronic conditions and long-term medication use and are unsuitable for managing ED prescriptions.
• In this study, the GEMS-Rx high-risk prescription list was prepared with a panel of 10 ED physicians with expertise in geriatrics and quality measurement and a pharmacist with expertise in geriatric pharmacotherapy and emergency medicine.
• They reviewed over 30 medication classes from the 2019 AGS Beers Criteria that were deemed inappropriate for use in older patients. Despite their not being included in the Beers list, the use of short- and long-acting opioids was also discussed.
• After three rounds of review and discussion, the panelists ranked each class of medication on a 5-point Likert scale, with a score of 1 indicating the lowest and 5 indicating the greatest need for avoiding a drug in an ED prescription.

TAKEAWAY:

• The first round suggested that first-generation antihistamines, metoclopramide, short-acting opioids, antipsychotics, barbiturates, skeletal muscle relaxants, and benzodiazepines should be avoided, with mean Likert scores ranging from 3.7 to 4.6.
• Although nonbenzodiazepine and benzodiazepine receptor agonist hypnotics (“Z-drugs”) were not initially considered owing to their low frequency of prescription in ED settings, the panelists finally included “Z” drugs and sulfonylureas in the GEMS-Rx list after the second and third rounds.
• The final list of high-risk medications to be avoided in ED settings that were prioritized included benzodiazepines, skeletal muscle relaxants, barbiturates, first-generation antipsychotics, first-generation antihistamines, “Z” drugs, metoclopramide, and sulfonylureas.
• However, seizure disorders, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, end-of-life care, allergic reactions, and ED visits for prescription refilling were deemed exceptional cases in which these high-risk medications could be prescribed.

IN PRACTICE:

“By combining expert consensus and evidence-based criteria, this list can serve as a resource to guide prescribing decisions and mitigate potential risks associated with medications at this crucial care transition. The incorporation of this emergency medicine-specific geriatric prescription list in a national quality measure has the potential to improve patient safety and enhance the quality of care for the millions of older adults who seek care in EDs each year,” the authors said.

SOURCE:

This study was led by Rachel M. Skains, MD, MSPH, Department of Emergency Medicine, University of Alabama at Birmingham, and published online in Annals of Emergency Medicine.

LIMITATIONS:

The GEMS-Rx list was prepared by physicians and pharmacists and may not have fully captured data regarding individual patient preferences, comorbidities, or other contextual factors. During the meetings, the panelists’ identities were not concealed from one another, which may have affected the conversations owing to response and social desirability bias. Furthermore, this list may not be generalizable to other settings because it was produced and intended for usage in US EDs.

DISCLOSURES:

This work was supported by the American College of Emergency Physicians. Some of the authors, including the lead author, declared being supported by various funding agencies. Few authors also declared serving in leadership positions for several sources.

A version of this article appeared on Medscape.com.

TOPLINE: 

The geriatric emergency medication safety recommendations (GEMS-Rx) is the first expert consensus-based list identifying high-risk medication classes that should not be prescribed to older patients visiting the emergency department (ED).

METHODOLOGY:

• Around half of the geriatric patients presenting to the ED get discharged with new prescriptions. Some of the newly prescribed drugs may not be appropriate for use in individuals aged ≥ 65 years, thereby increasing the risk for unfavorable adverse events.
• The American Geriatrics Society (AGS)  has already established guidelines to identify potentially inappropriate medications in older adults; however, the criteria are centered on chronic conditions and long-term medication use and are unsuitable for managing ED prescriptions.
• In this study, the GEMS-Rx high-risk prescription list was prepared with a panel of 10 ED physicians with expertise in geriatrics and quality measurement and a pharmacist with expertise in geriatric pharmacotherapy and emergency medicine.
• They reviewed over 30 medication classes from the 2019 AGS Beers Criteria that were deemed inappropriate for use in older patients. Despite their not being included in the Beers list, the use of short- and long-acting opioids was also discussed.
• After three rounds of review and discussion, the panelists ranked each class of medication on a 5-point Likert scale, with a score of 1 indicating the lowest and 5 indicating the greatest need for avoiding a drug in an ED prescription.

TAKEAWAY:

• The first round suggested that first-generation antihistamines, metoclopramide, short-acting opioids, antipsychotics, barbiturates, skeletal muscle relaxants, and benzodiazepines should be avoided, with mean Likert scores ranging from 3.7 to 4.6.
• Although nonbenzodiazepine and benzodiazepine receptor agonist hypnotics (“Z-drugs”) were not initially considered owing to their low frequency of prescription in ED settings, the panelists finally included “Z” drugs and sulfonylureas in the GEMS-Rx list after the second and third rounds.
• The final list of high-risk medications to be avoided in ED settings that were prioritized included benzodiazepines, skeletal muscle relaxants, barbiturates, first-generation antipsychotics, first-generation antihistamines, “Z” drugs, metoclopramide, and sulfonylureas.
• However, seizure disorders, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, end-of-life care, allergic reactions, and ED visits for prescription refilling were deemed exceptional cases in which these high-risk medications could be prescribed.

IN PRACTICE:

“By combining expert consensus and evidence-based criteria, this list can serve as a resource to guide prescribing decisions and mitigate potential risks associated with medications at this crucial care transition. The incorporation of this emergency medicine-specific geriatric prescription list in a national quality measure has the potential to improve patient safety and enhance the quality of care for the millions of older adults who seek care in EDs each year,” the authors said.

SOURCE:

This study was led by Rachel M. Skains, MD, MSPH, Department of Emergency Medicine, University of Alabama at Birmingham, and published online in Annals of Emergency Medicine.

LIMITATIONS:

The GEMS-Rx list was prepared by physicians and pharmacists and may not have fully captured data regarding individual patient preferences, comorbidities, or other contextual factors. During the meetings, the panelists’ identities were not concealed from one another, which may have affected the conversations owing to response and social desirability bias. Furthermore, this list may not be generalizable to other settings because it was produced and intended for usage in US EDs.

DISCLOSURES:

This work was supported by the American College of Emergency Physicians. Some of the authors, including the lead author, declared being supported by various funding agencies. Few authors also declared serving in leadership positions for several sources.

A version of this article appeared on Medscape.com.