Mixed Topics

Dear colleagues,

This November issue of The New Gastroenterologist marks my official transition as the new Editor in Chief! I am humbled with this opportunity to be a part of such a unique publication and have received immense support from Dr. Vijaya Rao, the TNG staff, as well as my mentors and colleagues. With its foundation built by Dr. Bryson Katona and then taken to the next level by Dr. Rao, TNG has grown over the years, and I hope that I can continue to extend its reach to more trainees and early faculty.

In this issue’s In Focus, Dr. Wenfei Wang and Dr. Neil Sengupta (both from University of Chicago) review the management of antithrombotic medications in elective endoscopic procedures and emphasize individualizing the approach while providing guideline recommendations on how to navigate the gastrointestinal bleeding risk and cardiovascular disease in this day and age.

With endoscopic bariatric therapy and antiobesity medications burgeoning within gastroenterology, Dr. Singrid Young (New York University), Dr. Cameron Zenger (New York University), Dr. Erik Holzwanger (Harvard Medical School in Boston), and Dr. Violeta Popov (New York University) review how their multidisciplinary approach has made their endoscopic bariatric program successful in treating patients struggling with obesity. In our Ethics section, Dr. David Ney (Thomas Jefferson University Hospital, Philadelphia) and Dr. Jason Karlawish (University of Pennsylvania, Philadelphia) delve into patient capacity, particularly when consenting for procedures.

Being involved with national society committees may seem daunting to a lot of trainees and early faculty, but Dr. Peter S. Liang (New York University Langone Health) and Dr. Stephanie D. Pointer (Tristar Hendersonville Medical Center in Tennessee) describe their journeys to becoming AGA committee chairs as early-career physicians. While you ponder whether to join a committee, it may be a good time to learn new ways to increase your financial portfolio through passive income, detailed by Dr. Latifat Alli-Akintade (Kaiser Permanente South Sacramento Medical Center in California).

Last but not least, I am excited to introduce a personal favorite in this newsletter – a piece on females supporting female gastroenterologists in career development and more. Dr. Tonya Adams outlines action items on how to create a culture that fosters professional and leadership development among females, using the Gastro Health Women’s Network as an example of how this network has succeeded in cultivating such an environment.

If you are interested in contributing or have ideas for future TNG topics, please contact me (jtrieu23@gmail.com), or Jillian Schweitzer (jschweitzer@gastro.org), managing editor of TNG.

Until next time, I leave you with an interesting historical fact: William Beaumont, the father of Gastroenterology, published the first findings on the digestive system after performing experiments on Alexis St. Martin when he developed a large gastrocutaneous fistula from an abdominal gunshot wound.



Yours truly,

Judy A. Trieu, MD, MPH
Editor in Chief
Advanced Endoscopy Fellow, University of North Carolina at Chapel Hill, Division of Gastroenterology & Hepatology
 

Dear colleagues,

This November issue of The New Gastroenterologist marks my official transition as the new Editor in Chief! I am humbled with this opportunity to be a part of such a unique publication and have received immense support from Dr. Vijaya Rao, the TNG staff, as well as my mentors and colleagues. With its foundation built by Dr. Bryson Katona and then taken to the next level by Dr. Rao, TNG has grown over the years, and I hope that I can continue to extend its reach to more trainees and early faculty.

In this issue’s In Focus, Dr. Wenfei Wang and Dr. Neil Sengupta (both from University of Chicago) review the management of antithrombotic medications in elective endoscopic procedures and emphasize individualizing the approach while providing guideline recommendations on how to navigate the gastrointestinal bleeding risk and cardiovascular disease in this day and age.

With endoscopic bariatric therapy and antiobesity medications burgeoning within gastroenterology, Dr. Singrid Young (New York University), Dr. Cameron Zenger (New York University), Dr. Erik Holzwanger (Harvard Medical School in Boston), and Dr. Violeta Popov (New York University) review how their multidisciplinary approach has made their endoscopic bariatric program successful in treating patients struggling with obesity. In our Ethics section, Dr. David Ney (Thomas Jefferson University Hospital, Philadelphia) and Dr. Jason Karlawish (University of Pennsylvania, Philadelphia) delve into patient capacity, particularly when consenting for procedures.

Being involved with national society committees may seem daunting to a lot of trainees and early faculty, but Dr. Peter S. Liang (New York University Langone Health) and Dr. Stephanie D. Pointer (Tristar Hendersonville Medical Center in Tennessee) describe their journeys to becoming AGA committee chairs as early-career physicians. While you ponder whether to join a committee, it may be a good time to learn new ways to increase your financial portfolio through passive income, detailed by Dr. Latifat Alli-Akintade (Kaiser Permanente South Sacramento Medical Center in California).

Last but not least, I am excited to introduce a personal favorite in this newsletter – a piece on females supporting female gastroenterologists in career development and more. Dr. Tonya Adams outlines action items on how to create a culture that fosters professional and leadership development among females, using the Gastro Health Women’s Network as an example of how this network has succeeded in cultivating such an environment.

If you are interested in contributing or have ideas for future TNG topics, please contact me (jtrieu23@gmail.com), or Jillian Schweitzer (jschweitzer@gastro.org), managing editor of TNG.

Until next time, I leave you with an interesting historical fact: William Beaumont, the father of Gastroenterology, published the first findings on the digestive system after performing experiments on Alexis St. Martin when he developed a large gastrocutaneous fistula from an abdominal gunshot wound.



Yours truly,

Judy A. Trieu, MD, MPH
Editor in Chief
Advanced Endoscopy Fellow, University of North Carolina at Chapel Hill, Division of Gastroenterology & Hepatology
 

Dear colleagues,

This November issue of The New Gastroenterologist marks my official transition as the new Editor in Chief! I am humbled with this opportunity to be a part of such a unique publication and have received immense support from Dr. Vijaya Rao, the TNG staff, as well as my mentors and colleagues. With its foundation built by Dr. Bryson Katona and then taken to the next level by Dr. Rao, TNG has grown over the years, and I hope that I can continue to extend its reach to more trainees and early faculty.

In this issue’s In Focus, Dr. Wenfei Wang and Dr. Neil Sengupta (both from University of Chicago) review the management of antithrombotic medications in elective endoscopic procedures and emphasize individualizing the approach while providing guideline recommendations on how to navigate the gastrointestinal bleeding risk and cardiovascular disease in this day and age.

With endoscopic bariatric therapy and antiobesity medications burgeoning within gastroenterology, Dr. Singrid Young (New York University), Dr. Cameron Zenger (New York University), Dr. Erik Holzwanger (Harvard Medical School in Boston), and Dr. Violeta Popov (New York University) review how their multidisciplinary approach has made their endoscopic bariatric program successful in treating patients struggling with obesity. In our Ethics section, Dr. David Ney (Thomas Jefferson University Hospital, Philadelphia) and Dr. Jason Karlawish (University of Pennsylvania, Philadelphia) delve into patient capacity, particularly when consenting for procedures.

Being involved with national society committees may seem daunting to a lot of trainees and early faculty, but Dr. Peter S. Liang (New York University Langone Health) and Dr. Stephanie D. Pointer (Tristar Hendersonville Medical Center in Tennessee) describe their journeys to becoming AGA committee chairs as early-career physicians. While you ponder whether to join a committee, it may be a good time to learn new ways to increase your financial portfolio through passive income, detailed by Dr. Latifat Alli-Akintade (Kaiser Permanente South Sacramento Medical Center in California).

Last but not least, I am excited to introduce a personal favorite in this newsletter – a piece on females supporting female gastroenterologists in career development and more. Dr. Tonya Adams outlines action items on how to create a culture that fosters professional and leadership development among females, using the Gastro Health Women’s Network as an example of how this network has succeeded in cultivating such an environment.

If you are interested in contributing or have ideas for future TNG topics, please contact me (jtrieu23@gmail.com), or Jillian Schweitzer (jschweitzer@gastro.org), managing editor of TNG.

Until next time, I leave you with an interesting historical fact: William Beaumont, the father of Gastroenterology, published the first findings on the digestive system after performing experiments on Alexis St. Martin when he developed a large gastrocutaneous fistula from an abdominal gunshot wound.



Yours truly,

Judy A. Trieu, MD, MPH
Editor in Chief
Advanced Endoscopy Fellow, University of North Carolina at Chapel Hill, Division of Gastroenterology & Hepatology
 

Dear colleagues,

Innovation is the livelihood of our field, driving major advances in endoscopy and attracting many of us to Gastroenterology. From the development of endoscopic retrograde cholangiopancreatography to the wide-spread adoption of third space endoscopy, we continue to push the boundaries of our practice. But what is the next big disruption in GI, and how will it impact us? In this issue of Perspectives, two experts present their thoughts on current hot topics in GI. Dr. Jeremy Glissen Brown discusses the application of artificial intelligence in GI highlighting its promise but also raising important questions. Dr. Raman Muthusamy elaborates on single-use endoscopes – are they the wave of the future in preventing infection and meeting patient preference? Or will their long-term cost and environmental impact limit their use? I welcome your own thoughts on disruptive innovation in Gastroenterology – share with us on Twitter @AGA_GIHN and by email at ginews@gastro.org.

Gyanprakash A. Ketwaroo, MD, MSc, is an associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.

The AI revolution, with some important caveats

BY JEREMY R. GLISSEN BROWN, MD, MSC

In 2018, Japan’s Pharmaceutical and Medical Device Agency approved the first artificial intelligence (AI)–based tool, a computer-aided diagnosis system (CADx) for use in clinical practice.¹ Since that time, we have seen regulatory approval for a variety of deep learning and AI-based tools in endoscopy and beyond. In addition, there has been an enormous amount of commercial and research interest in AI-based tools in clinical medicine and gastroenterology, and it is almost impossible to open a major gastroenterology journal or go to an academic conference without encountering a slew of AI-based projects.

Many thought and industry leaders say that we are in the midst of an AI revolution in gastroenterology. Indeed, we are at a period of unprecedented growth for deep learning and AI for several reasons, including a recent shift toward data-driven approaches, advancement of machine-learning techniques, and increased computing power. There is, however, also an unprecedented amount of scrutiny and thoughtful conversation about the role AI might play in clinical practice and how we use and regulate these tools in the clinical setting. We are thus in a unique position to ask ourselves the essential question: “Are we on the cusp of an AI revolution in gastroenterology, or are we seeing the release of medical software that is perhaps at best useful in a niche environment and at worse a hype-driven novelty without much clinical benefit?” We will use the most popular use-case, computer aided detection (CADe) of polyps in the colon, to explore this question. In the end, I believe that deep-learning technology will fundamentally change the way we practice gastroenterology. However, this is the perfect time to explore what this means now, and what we can do to shape what it will mean for the future.

CADe: Promise and questions

CADe is a computer vision task that involves localization, such as finding a polyp during colonoscopy and highlighting it with a hollow box. CADe in colonoscopy is perhaps the most well-studied application of deep learning in GI endoscopy to date and is furthest along in the development-implementation pipeline. Because of this, it is an ideal use-case for examining both the evidence that currently supports its use as well as the questions that have come up as we are starting to see CADe algorithms deployed in clinical practice. It is honestly astounding to think that, just 5 years ago, we were talking about CADe as a research concept. While early efforts applying traditional machine learning date back at least to the 1990s, we started to see prospective studies of CADe systems with undetectable or nearly undetectable latency in 2019.² Since that time we have seen the publication of at least 10 randomized clinical trials involving CADe.

CADe clearly has an impact on some of the conventional quality metrics we use for colonoscopy. While there is considerable heterogeneity in region and design among these trials, most show a significant increase in adenoma detection rate (ADR) and adenomas per colonoscopy. Tandem studies show decreases in adenoma miss rate, and at least one study showed a decrease in sessile serrated lesion miss rate as well. In one of the first randomized, controlled trials across multiple endoscopy centers in Italy, Repici and colleagues showed an increase in ADR from 40.4% in the control group to 54.8% in the CADe group (RR, 1.30; 95% confidence interval, 1.14-1.45).3 Because of pioneering trials such as this one, there are currently several CADe systems that have received regulatory approval in Europe, Asia, and the United States and are being deployed commercially.

It is also clear that the technology is there. In clinical practice, the Food and Drug Administration–approved systems work smoothly, with little to no detectable latency and generally low false-positive and false-negative rates. With clinical deployment, however, we have seen the emergence of healthy debate surrounding every aspect of this task-specific AI. On the development side, important questions include transparency of development data, ensuring that algorithm development is ethical and equitable (as deep learning is susceptible to exacerbating human biases) and methods of data labeling. On the deployment level, important concerns include proper regulation of locked versus “open” algorithms and downstream effects on cost.

In addition, with CADe we have seen a variety of clinical questions crop up because of the novelty of the technology. These include the concern that the increase in ADR we have seen thus far is driven in large part by diminutive and small adenomas (with healthy debate in turn as to these entities’ influence on interval colorectal cancer rates), the effect CADe might have on fellowship training to detect polyps with the human eye, and whether the technology affects sessile serrated lesion detection rates or not. The great thing about such questions is that they have inspired novel research related to CADe in the clinical setting, including how CADe affects trainee ADR, how CADe affects gaze patterns, and how CADe affects recommended surveillance intervals.

CADx, novel applications, and the future

Though there is not space to expand in this particular forum, it is safe to say that with the advancement of CADx in endoscopy and colonoscopy, we have seen similar and novel questions come up. The beautiful thing about all of this is that we are just scratching the surface of what is achievable with deep learning. We have started to see novel projects utilizing deep-learning algorithms, from detecting cirrhosis on ECG to automatically classifying stool consistency on the Bristol Stool Scale from pictures of stool. I ultimately do think that the deployment of AI tools will fundamentally change the way we practice and think about gastroenterology. We are at an incredibly exciting time where we as physicians have the power to shape what that looks like, how we think about AI deployment and regulation and where we go from here.

Dr. Glissen Brown is with the division of gastroenterology and hepatology at Duke University Medical Center, Durham, N.C. He has served as a consultant for Medtronic.

References

1. Aisu N et al. PLOS Digital Health. 2021 Jan 18. doi: 10.1371/journal.pdig.0000001.

2. Wang P et al. Gut. 2019 Oct;68(10):1813-9.

3. Repici A et al. Gastroenterology. 2020 Aug;159(2):512-20.e7.

What’s the future of single-use endoscopes?

BY V. RAMAN MUTHUSAMY, MD, MAS

Single-use endoscopes have been proposed as a definitive solution to the risk of endoscope-transmitted infections. While these infections have been reported for several decades, they have traditionally been associated with identified breaches in the reprocessing protocol. In 2015, numerous cases of duodenoscope-transmitted infections were reported after endoscopic retrograde cholangiopancreatography (ERCP) procedures. Many, if not most, of these cases were not associated with identified deviations from standard high-level disinfection protocols and occurred at high-volume experienced facilities. A subsequent FDA postmarket surveillance study found contamination rates were linked with potentially pathogenic bacteria in approximately 5% of duodenoscopes. Thus, amid growing concerns about the ability to adequately clean these complex devices, these events prompted the development of single-use duodenoscopes. Given the multifactorial causes leading to contaminated duodenoscopes, the advantages of such single-use devices are their ability to ensure the elimination of the potential of infection transmission as these devices are never reused. In addition to this primary benefit, the ability to create single-use devices could lead to more easily available specialty scopes and allow variations in endoscope design that could improve ergonomics. Single-use devices may also expand the ability to provide endoscopic services by eliminating the need for device reprocessing equipment at low-volume sites. However, several concerns have been raised regarding their use, especially if it were to become widespread. These include issues of device quality and performance (potentially leading to more failed cases or adverse events), cost, their environmental impact and current uncertainty regarding their indications for use. Furthermore, new alternatives such as reusable devices with partially disposable components or future low-temperature sterilization options may minimize the need for such devices. We will briefly discuss these issues in more detail below.

Given that nearly all cases of GI device–transmitted infections where standard reprocessing protocols were followed have occurred in duodenoscopes, I will focus on single-use duodenoscopes in this article. It is important that we reassure our patients and colleagues that standard reprocessing appears to be extremely effective with all other types of devices, including elevator containing linear echoendoscopes. Studies investigating the causes of why duodenoscopes have primarily been associated with device-transmitted outbreaks have focused on the complexity of the elevator including its recesses, fixed end-cap and wire channels. However, culturing has shown that up to one-third of contamination may occur in the instrument channels or in the region of the biopsy cap, leading to some potential residual sites of infection even when newly developed reusable devices with disposable elevators/end-caps are utilized.¹ Another challenge with reprocessing is the ability to prove residual contamination does not exist. While culturing the devices after reprocessing is most used, it should be noted many sites with outbreaks failed to culture the culprit bacteria from the devices as accessing the sites of contamination can be challenging. The use of other markers of residual contamination such as ATP and tests for residual blood/protein have yielded variable results. Specifically, ATP testing has not correlated well with culture results but may be helpful in assessing the quality of manual cleaning.²

These challenges have made the concept of single-use devices more appealing given the lack of a need reprocess devices or validate cleaning efficacy. Currently, there are two FDA-approved devices on the market, but the published literature to date has largely involved one of these devices. To date, in four published studies that have assessed the clinical performance of single-use duodenoscopes in over 400 patients, procedural success rates have ranged from 91% to 97% with adverse event rates and endoscopist satisfaction scores comparable to reusable devices. Most of these users were expert biliary endoscopists and more data are needed regarding the performance of the device in lower-volume and nonexpert users. While indications for use in these studies have varied, I feel that there are four potential scenarios to utilize these devices: in patients with known multidrug-resistant organisms undergoing ERCP; to facilitate logistics/operations when a reusable device is not available; in critically ill patients who would not tolerate a scope-acquired infection; and in procedures associated with a risk of bacteremia.

While preliminary data suggest single-use duodenoscopes are safe and effective in expert hands, concerns exist regarding their implementation more broadly into clinical practice. First, the devices cost between $1,500-3,000, making them impractical for many health systems. One study estimated the break-even cost of the device to be $800-1,300 based on variation in site volume and device contamination rates.³ However, it should be noted that current enhanced reprocessing protocols for reusable devices may add an additional $75,000-$400,000 per year based on center volume.⁴ In the United States, there is currently payment by federal and some commercial payors that cover part or all of the device cost, but whether this will continue long-term is unclear. In addition, there is significant concern regarding the environmental impact of a broader mover to single-use devices. Reprocessing programs do exist for these devices, but detailed analyses regarding the environmental effects of a strategy using single-use versus reusable devices and the waste generated from each are needed.

Finally, while primarily created to avoid device-related infection transmission, other benefits can be realized with single-use devices. The potential for ergonomic enhancements (variable handle sizes or shaft stiffness, R- and L-handed scopes) as well as the creation of specialty devices (extra-long or thin devices, devices with special optical or rotational capabilities) may become more feasible with a single-use platform. Finally, the pace of endoscopic innovation and refinement is likely to quicken with a single use platform, and new advancements can be incorporated in a timelier manner.

Conclusion

In summary, I believe single-use devices offer the potential to improve the safety of endoscopic procedures as well as improve procedural access, enhance ergonomics, and foster and expedite device innovation. However, reductions in cost, refining their indications, and developing recycling programs to minimize their environmental impact will be essential before more widespread adoption is achieved.

Dr. Muthusamy is a professor of clinical medicine at the University of California, Los Angeles, and the medical director of endoscopy at the UCLA Health System. He reported relationships with Medtronic, Boston Scientific, Motus GI, Endogastric Solutions, and Capsovision.

References

1. Bartles RL et al. Gastrointest Endosc. 2018 Aug;88(2):306-13.e2.

2. Day LW et al. Gastrointest Endosc. 2021 Jan;93(1):11-33.e6.

3. Bang JY et al. Gut. 2019 Nov;68(11):1915-7.

4. Bomman S et al. Endosc Int Open. 2021 Aug 23;9(9):E1404-12.

Dear colleagues,

Innovation is the livelihood of our field, driving major advances in endoscopy and attracting many of us to Gastroenterology. From the development of endoscopic retrograde cholangiopancreatography to the wide-spread adoption of third space endoscopy, we continue to push the boundaries of our practice. But what is the next big disruption in GI, and how will it impact us? In this issue of Perspectives, two experts present their thoughts on current hot topics in GI. Dr. Jeremy Glissen Brown discusses the application of artificial intelligence in GI highlighting its promise but also raising important questions. Dr. Raman Muthusamy elaborates on single-use endoscopes – are they the wave of the future in preventing infection and meeting patient preference? Or will their long-term cost and environmental impact limit their use? I welcome your own thoughts on disruptive innovation in Gastroenterology – share with us on Twitter @AGA_GIHN and by email at ginews@gastro.org.

Gyanprakash A. Ketwaroo, MD, MSc, is an associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.

The AI revolution, with some important caveats

BY JEREMY R. GLISSEN BROWN, MD, MSC

In 2018, Japan’s Pharmaceutical and Medical Device Agency approved the first artificial intelligence (AI)–based tool, a computer-aided diagnosis system (CADx) for use in clinical practice.¹ Since that time, we have seen regulatory approval for a variety of deep learning and AI-based tools in endoscopy and beyond. In addition, there has been an enormous amount of commercial and research interest in AI-based tools in clinical medicine and gastroenterology, and it is almost impossible to open a major gastroenterology journal or go to an academic conference without encountering a slew of AI-based projects.

Many thought and industry leaders say that we are in the midst of an AI revolution in gastroenterology. Indeed, we are at a period of unprecedented growth for deep learning and AI for several reasons, including a recent shift toward data-driven approaches, advancement of machine-learning techniques, and increased computing power. There is, however, also an unprecedented amount of scrutiny and thoughtful conversation about the role AI might play in clinical practice and how we use and regulate these tools in the clinical setting. We are thus in a unique position to ask ourselves the essential question: “Are we on the cusp of an AI revolution in gastroenterology, or are we seeing the release of medical software that is perhaps at best useful in a niche environment and at worse a hype-driven novelty without much clinical benefit?” We will use the most popular use-case, computer aided detection (CADe) of polyps in the colon, to explore this question. In the end, I believe that deep-learning technology will fundamentally change the way we practice gastroenterology. However, this is the perfect time to explore what this means now, and what we can do to shape what it will mean for the future.

CADe: Promise and questions

CADe is a computer vision task that involves localization, such as finding a polyp during colonoscopy and highlighting it with a hollow box. CADe in colonoscopy is perhaps the most well-studied application of deep learning in GI endoscopy to date and is furthest along in the development-implementation pipeline. Because of this, it is an ideal use-case for examining both the evidence that currently supports its use as well as the questions that have come up as we are starting to see CADe algorithms deployed in clinical practice. It is honestly astounding to think that, just 5 years ago, we were talking about CADe as a research concept. While early efforts applying traditional machine learning date back at least to the 1990s, we started to see prospective studies of CADe systems with undetectable or nearly undetectable latency in 2019.² Since that time we have seen the publication of at least 10 randomized clinical trials involving CADe.

CADe clearly has an impact on some of the conventional quality metrics we use for colonoscopy. While there is considerable heterogeneity in region and design among these trials, most show a significant increase in adenoma detection rate (ADR) and adenomas per colonoscopy. Tandem studies show decreases in adenoma miss rate, and at least one study showed a decrease in sessile serrated lesion miss rate as well. In one of the first randomized, controlled trials across multiple endoscopy centers in Italy, Repici and colleagues showed an increase in ADR from 40.4% in the control group to 54.8% in the CADe group (RR, 1.30; 95% confidence interval, 1.14-1.45).3 Because of pioneering trials such as this one, there are currently several CADe systems that have received regulatory approval in Europe, Asia, and the United States and are being deployed commercially.

It is also clear that the technology is there. In clinical practice, the Food and Drug Administration–approved systems work smoothly, with little to no detectable latency and generally low false-positive and false-negative rates. With clinical deployment, however, we have seen the emergence of healthy debate surrounding every aspect of this task-specific AI. On the development side, important questions include transparency of development data, ensuring that algorithm development is ethical and equitable (as deep learning is susceptible to exacerbating human biases) and methods of data labeling. On the deployment level, important concerns include proper regulation of locked versus “open” algorithms and downstream effects on cost.

In addition, with CADe we have seen a variety of clinical questions crop up because of the novelty of the technology. These include the concern that the increase in ADR we have seen thus far is driven in large part by diminutive and small adenomas (with healthy debate in turn as to these entities’ influence on interval colorectal cancer rates), the effect CADe might have on fellowship training to detect polyps with the human eye, and whether the technology affects sessile serrated lesion detection rates or not. The great thing about such questions is that they have inspired novel research related to CADe in the clinical setting, including how CADe affects trainee ADR, how CADe affects gaze patterns, and how CADe affects recommended surveillance intervals.

CADx, novel applications, and the future

Though there is not space to expand in this particular forum, it is safe to say that with the advancement of CADx in endoscopy and colonoscopy, we have seen similar and novel questions come up. The beautiful thing about all of this is that we are just scratching the surface of what is achievable with deep learning. We have started to see novel projects utilizing deep-learning algorithms, from detecting cirrhosis on ECG to automatically classifying stool consistency on the Bristol Stool Scale from pictures of stool. I ultimately do think that the deployment of AI tools will fundamentally change the way we practice and think about gastroenterology. We are at an incredibly exciting time where we as physicians have the power to shape what that looks like, how we think about AI deployment and regulation and where we go from here.

Dr. Glissen Brown is with the division of gastroenterology and hepatology at Duke University Medical Center, Durham, N.C. He has served as a consultant for Medtronic.

References

1. Aisu N et al. PLOS Digital Health. 2021 Jan 18. doi: 10.1371/journal.pdig.0000001.

2. Wang P et al. Gut. 2019 Oct;68(10):1813-9.

3. Repici A et al. Gastroenterology. 2020 Aug;159(2):512-20.e7.

What’s the future of single-use endoscopes?

BY V. RAMAN MUTHUSAMY, MD, MAS

Single-use endoscopes have been proposed as a definitive solution to the risk of endoscope-transmitted infections. While these infections have been reported for several decades, they have traditionally been associated with identified breaches in the reprocessing protocol. In 2015, numerous cases of duodenoscope-transmitted infections were reported after endoscopic retrograde cholangiopancreatography (ERCP) procedures. Many, if not most, of these cases were not associated with identified deviations from standard high-level disinfection protocols and occurred at high-volume experienced facilities. A subsequent FDA postmarket surveillance study found contamination rates were linked with potentially pathogenic bacteria in approximately 5% of duodenoscopes. Thus, amid growing concerns about the ability to adequately clean these complex devices, these events prompted the development of single-use duodenoscopes. Given the multifactorial causes leading to contaminated duodenoscopes, the advantages of such single-use devices are their ability to ensure the elimination of the potential of infection transmission as these devices are never reused. In addition to this primary benefit, the ability to create single-use devices could lead to more easily available specialty scopes and allow variations in endoscope design that could improve ergonomics. Single-use devices may also expand the ability to provide endoscopic services by eliminating the need for device reprocessing equipment at low-volume sites. However, several concerns have been raised regarding their use, especially if it were to become widespread. These include issues of device quality and performance (potentially leading to more failed cases or adverse events), cost, their environmental impact and current uncertainty regarding their indications for use. Furthermore, new alternatives such as reusable devices with partially disposable components or future low-temperature sterilization options may minimize the need for such devices. We will briefly discuss these issues in more detail below.

Given that nearly all cases of GI device–transmitted infections where standard reprocessing protocols were followed have occurred in duodenoscopes, I will focus on single-use duodenoscopes in this article. It is important that we reassure our patients and colleagues that standard reprocessing appears to be extremely effective with all other types of devices, including elevator containing linear echoendoscopes. Studies investigating the causes of why duodenoscopes have primarily been associated with device-transmitted outbreaks have focused on the complexity of the elevator including its recesses, fixed end-cap and wire channels. However, culturing has shown that up to one-third of contamination may occur in the instrument channels or in the region of the biopsy cap, leading to some potential residual sites of infection even when newly developed reusable devices with disposable elevators/end-caps are utilized.¹ Another challenge with reprocessing is the ability to prove residual contamination does not exist. While culturing the devices after reprocessing is most used, it should be noted many sites with outbreaks failed to culture the culprit bacteria from the devices as accessing the sites of contamination can be challenging. The use of other markers of residual contamination such as ATP and tests for residual blood/protein have yielded variable results. Specifically, ATP testing has not correlated well with culture results but may be helpful in assessing the quality of manual cleaning.²

These challenges have made the concept of single-use devices more appealing given the lack of a need reprocess devices or validate cleaning efficacy. Currently, there are two FDA-approved devices on the market, but the published literature to date has largely involved one of these devices. To date, in four published studies that have assessed the clinical performance of single-use duodenoscopes in over 400 patients, procedural success rates have ranged from 91% to 97% with adverse event rates and endoscopist satisfaction scores comparable to reusable devices. Most of these users were expert biliary endoscopists and more data are needed regarding the performance of the device in lower-volume and nonexpert users. While indications for use in these studies have varied, I feel that there are four potential scenarios to utilize these devices: in patients with known multidrug-resistant organisms undergoing ERCP; to facilitate logistics/operations when a reusable device is not available; in critically ill patients who would not tolerate a scope-acquired infection; and in procedures associated with a risk of bacteremia.

While preliminary data suggest single-use duodenoscopes are safe and effective in expert hands, concerns exist regarding their implementation more broadly into clinical practice. First, the devices cost between $1,500-3,000, making them impractical for many health systems. One study estimated the break-even cost of the device to be $800-1,300 based on variation in site volume and device contamination rates.³ However, it should be noted that current enhanced reprocessing protocols for reusable devices may add an additional $75,000-$400,000 per year based on center volume.⁴ In the United States, there is currently payment by federal and some commercial payors that cover part or all of the device cost, but whether this will continue long-term is unclear. In addition, there is significant concern regarding the environmental impact of a broader mover to single-use devices. Reprocessing programs do exist for these devices, but detailed analyses regarding the environmental effects of a strategy using single-use versus reusable devices and the waste generated from each are needed.

Finally, while primarily created to avoid device-related infection transmission, other benefits can be realized with single-use devices. The potential for ergonomic enhancements (variable handle sizes or shaft stiffness, R- and L-handed scopes) as well as the creation of specialty devices (extra-long or thin devices, devices with special optical or rotational capabilities) may become more feasible with a single-use platform. Finally, the pace of endoscopic innovation and refinement is likely to quicken with a single use platform, and new advancements can be incorporated in a timelier manner.

Conclusion

In summary, I believe single-use devices offer the potential to improve the safety of endoscopic procedures as well as improve procedural access, enhance ergonomics, and foster and expedite device innovation. However, reductions in cost, refining their indications, and developing recycling programs to minimize their environmental impact will be essential before more widespread adoption is achieved.

Dr. Muthusamy is a professor of clinical medicine at the University of California, Los Angeles, and the medical director of endoscopy at the UCLA Health System. He reported relationships with Medtronic, Boston Scientific, Motus GI, Endogastric Solutions, and Capsovision.

References

1. Bartles RL et al. Gastrointest Endosc. 2018 Aug;88(2):306-13.e2.

2. Day LW et al. Gastrointest Endosc. 2021 Jan;93(1):11-33.e6.

3. Bang JY et al. Gut. 2019 Nov;68(11):1915-7.

4. Bomman S et al. Endosc Int Open. 2021 Aug 23;9(9):E1404-12.

Dear colleagues,

Innovation is the livelihood of our field, driving major advances in endoscopy and attracting many of us to Gastroenterology. From the development of endoscopic retrograde cholangiopancreatography to the wide-spread adoption of third space endoscopy, we continue to push the boundaries of our practice. But what is the next big disruption in GI, and how will it impact us? In this issue of Perspectives, two experts present their thoughts on current hot topics in GI. Dr. Jeremy Glissen Brown discusses the application of artificial intelligence in GI highlighting its promise but also raising important questions. Dr. Raman Muthusamy elaborates on single-use endoscopes – are they the wave of the future in preventing infection and meeting patient preference? Or will their long-term cost and environmental impact limit their use? I welcome your own thoughts on disruptive innovation in Gastroenterology – share with us on Twitter @AGA_GIHN and by email at ginews@gastro.org.

Gyanprakash A. Ketwaroo, MD, MSc, is an associate professor of medicine, Yale University, New Haven, Conn., and chief of endoscopy at West Haven (Conn.) VA Medical Center. He is an associate editor for GI & Hepatology News.

The AI revolution, with some important caveats

BY JEREMY R. GLISSEN BROWN, MD, MSC

In 2018, Japan’s Pharmaceutical and Medical Device Agency approved the first artificial intelligence (AI)–based tool, a computer-aided diagnosis system (CADx) for use in clinical practice.¹ Since that time, we have seen regulatory approval for a variety of deep learning and AI-based tools in endoscopy and beyond. In addition, there has been an enormous amount of commercial and research interest in AI-based tools in clinical medicine and gastroenterology, and it is almost impossible to open a major gastroenterology journal or go to an academic conference without encountering a slew of AI-based projects.

Many thought and industry leaders say that we are in the midst of an AI revolution in gastroenterology. Indeed, we are at a period of unprecedented growth for deep learning and AI for several reasons, including a recent shift toward data-driven approaches, advancement of machine-learning techniques, and increased computing power. There is, however, also an unprecedented amount of scrutiny and thoughtful conversation about the role AI might play in clinical practice and how we use and regulate these tools in the clinical setting. We are thus in a unique position to ask ourselves the essential question: “Are we on the cusp of an AI revolution in gastroenterology, or are we seeing the release of medical software that is perhaps at best useful in a niche environment and at worse a hype-driven novelty without much clinical benefit?” We will use the most popular use-case, computer aided detection (CADe) of polyps in the colon, to explore this question. In the end, I believe that deep-learning technology will fundamentally change the way we practice gastroenterology. However, this is the perfect time to explore what this means now, and what we can do to shape what it will mean for the future.

CADe: Promise and questions

CADe is a computer vision task that involves localization, such as finding a polyp during colonoscopy and highlighting it with a hollow box. CADe in colonoscopy is perhaps the most well-studied application of deep learning in GI endoscopy to date and is furthest along in the development-implementation pipeline. Because of this, it is an ideal use-case for examining both the evidence that currently supports its use as well as the questions that have come up as we are starting to see CADe algorithms deployed in clinical practice. It is honestly astounding to think that, just 5 years ago, we were talking about CADe as a research concept. While early efforts applying traditional machine learning date back at least to the 1990s, we started to see prospective studies of CADe systems with undetectable or nearly undetectable latency in 2019.² Since that time we have seen the publication of at least 10 randomized clinical trials involving CADe.

CADe clearly has an impact on some of the conventional quality metrics we use for colonoscopy. While there is considerable heterogeneity in region and design among these trials, most show a significant increase in adenoma detection rate (ADR) and adenomas per colonoscopy. Tandem studies show decreases in adenoma miss rate, and at least one study showed a decrease in sessile serrated lesion miss rate as well. In one of the first randomized, controlled trials across multiple endoscopy centers in Italy, Repici and colleagues showed an increase in ADR from 40.4% in the control group to 54.8% in the CADe group (RR, 1.30; 95% confidence interval, 1.14-1.45).3 Because of pioneering trials such as this one, there are currently several CADe systems that have received regulatory approval in Europe, Asia, and the United States and are being deployed commercially.

It is also clear that the technology is there. In clinical practice, the Food and Drug Administration–approved systems work smoothly, with little to no detectable latency and generally low false-positive and false-negative rates. With clinical deployment, however, we have seen the emergence of healthy debate surrounding every aspect of this task-specific AI. On the development side, important questions include transparency of development data, ensuring that algorithm development is ethical and equitable (as deep learning is susceptible to exacerbating human biases) and methods of data labeling. On the deployment level, important concerns include proper regulation of locked versus “open” algorithms and downstream effects on cost.

In addition, with CADe we have seen a variety of clinical questions crop up because of the novelty of the technology. These include the concern that the increase in ADR we have seen thus far is driven in large part by diminutive and small adenomas (with healthy debate in turn as to these entities’ influence on interval colorectal cancer rates), the effect CADe might have on fellowship training to detect polyps with the human eye, and whether the technology affects sessile serrated lesion detection rates or not. The great thing about such questions is that they have inspired novel research related to CADe in the clinical setting, including how CADe affects trainee ADR, how CADe affects gaze patterns, and how CADe affects recommended surveillance intervals.

CADx, novel applications, and the future

Though there is not space to expand in this particular forum, it is safe to say that with the advancement of CADx in endoscopy and colonoscopy, we have seen similar and novel questions come up. The beautiful thing about all of this is that we are just scratching the surface of what is achievable with deep learning. We have started to see novel projects utilizing deep-learning algorithms, from detecting cirrhosis on ECG to automatically classifying stool consistency on the Bristol Stool Scale from pictures of stool. I ultimately do think that the deployment of AI tools will fundamentally change the way we practice and think about gastroenterology. We are at an incredibly exciting time where we as physicians have the power to shape what that looks like, how we think about AI deployment and regulation and where we go from here.

Dr. Glissen Brown is with the division of gastroenterology and hepatology at Duke University Medical Center, Durham, N.C. He has served as a consultant for Medtronic.

References

1. Aisu N et al. PLOS Digital Health. 2021 Jan 18. doi: 10.1371/journal.pdig.0000001.

2. Wang P et al. Gut. 2019 Oct;68(10):1813-9.

3. Repici A et al. Gastroenterology. 2020 Aug;159(2):512-20.e7.

What’s the future of single-use endoscopes?

BY V. RAMAN MUTHUSAMY, MD, MAS

Single-use endoscopes have been proposed as a definitive solution to the risk of endoscope-transmitted infections. While these infections have been reported for several decades, they have traditionally been associated with identified breaches in the reprocessing protocol. In 2015, numerous cases of duodenoscope-transmitted infections were reported after endoscopic retrograde cholangiopancreatography (ERCP) procedures. Many, if not most, of these cases were not associated with identified deviations from standard high-level disinfection protocols and occurred at high-volume experienced facilities. A subsequent FDA postmarket surveillance study found contamination rates were linked with potentially pathogenic bacteria in approximately 5% of duodenoscopes. Thus, amid growing concerns about the ability to adequately clean these complex devices, these events prompted the development of single-use duodenoscopes. Given the multifactorial causes leading to contaminated duodenoscopes, the advantages of such single-use devices are their ability to ensure the elimination of the potential of infection transmission as these devices are never reused. In addition to this primary benefit, the ability to create single-use devices could lead to more easily available specialty scopes and allow variations in endoscope design that could improve ergonomics. Single-use devices may also expand the ability to provide endoscopic services by eliminating the need for device reprocessing equipment at low-volume sites. However, several concerns have been raised regarding their use, especially if it were to become widespread. These include issues of device quality and performance (potentially leading to more failed cases or adverse events), cost, their environmental impact and current uncertainty regarding their indications for use. Furthermore, new alternatives such as reusable devices with partially disposable components or future low-temperature sterilization options may minimize the need for such devices. We will briefly discuss these issues in more detail below.

Given that nearly all cases of GI device–transmitted infections where standard reprocessing protocols were followed have occurred in duodenoscopes, I will focus on single-use duodenoscopes in this article. It is important that we reassure our patients and colleagues that standard reprocessing appears to be extremely effective with all other types of devices, including elevator containing linear echoendoscopes. Studies investigating the causes of why duodenoscopes have primarily been associated with device-transmitted outbreaks have focused on the complexity of the elevator including its recesses, fixed end-cap and wire channels. However, culturing has shown that up to one-third of contamination may occur in the instrument channels or in the region of the biopsy cap, leading to some potential residual sites of infection even when newly developed reusable devices with disposable elevators/end-caps are utilized.¹ Another challenge with reprocessing is the ability to prove residual contamination does not exist. While culturing the devices after reprocessing is most used, it should be noted many sites with outbreaks failed to culture the culprit bacteria from the devices as accessing the sites of contamination can be challenging. The use of other markers of residual contamination such as ATP and tests for residual blood/protein have yielded variable results. Specifically, ATP testing has not correlated well with culture results but may be helpful in assessing the quality of manual cleaning.²

These challenges have made the concept of single-use devices more appealing given the lack of a need reprocess devices or validate cleaning efficacy. Currently, there are two FDA-approved devices on the market, but the published literature to date has largely involved one of these devices. To date, in four published studies that have assessed the clinical performance of single-use duodenoscopes in over 400 patients, procedural success rates have ranged from 91% to 97% with adverse event rates and endoscopist satisfaction scores comparable to reusable devices. Most of these users were expert biliary endoscopists and more data are needed regarding the performance of the device in lower-volume and nonexpert users. While indications for use in these studies have varied, I feel that there are four potential scenarios to utilize these devices: in patients with known multidrug-resistant organisms undergoing ERCP; to facilitate logistics/operations when a reusable device is not available; in critically ill patients who would not tolerate a scope-acquired infection; and in procedures associated with a risk of bacteremia.

While preliminary data suggest single-use duodenoscopes are safe and effective in expert hands, concerns exist regarding their implementation more broadly into clinical practice. First, the devices cost between $1,500-3,000, making them impractical for many health systems. One study estimated the break-even cost of the device to be $800-1,300 based on variation in site volume and device contamination rates.³ However, it should be noted that current enhanced reprocessing protocols for reusable devices may add an additional $75,000-$400,000 per year based on center volume.⁴ In the United States, there is currently payment by federal and some commercial payors that cover part or all of the device cost, but whether this will continue long-term is unclear. In addition, there is significant concern regarding the environmental impact of a broader mover to single-use devices. Reprocessing programs do exist for these devices, but detailed analyses regarding the environmental effects of a strategy using single-use versus reusable devices and the waste generated from each are needed.

Finally, while primarily created to avoid device-related infection transmission, other benefits can be realized with single-use devices. The potential for ergonomic enhancements (variable handle sizes or shaft stiffness, R- and L-handed scopes) as well as the creation of specialty devices (extra-long or thin devices, devices with special optical or rotational capabilities) may become more feasible with a single-use platform. Finally, the pace of endoscopic innovation and refinement is likely to quicken with a single use platform, and new advancements can be incorporated in a timelier manner.

Conclusion

In summary, I believe single-use devices offer the potential to improve the safety of endoscopic procedures as well as improve procedural access, enhance ergonomics, and foster and expedite device innovation. However, reductions in cost, refining their indications, and developing recycling programs to minimize their environmental impact will be essential before more widespread adoption is achieved.

Dr. Muthusamy is a professor of clinical medicine at the University of California, Los Angeles, and the medical director of endoscopy at the UCLA Health System. He reported relationships with Medtronic, Boston Scientific, Motus GI, Endogastric Solutions, and Capsovision.

References

1. Bartles RL et al. Gastrointest Endosc. 2018 Aug;88(2):306-13.e2.

2. Day LW et al. Gastrointest Endosc. 2021 Jan;93(1):11-33.e6.

3. Bang JY et al. Gut. 2019 Nov;68(11):1915-7.

4. Bomman S et al. Endosc Int Open. 2021 Aug 23;9(9):E1404-12.

Correct answer: B. Selenium exposure. 
 
Rationale 
Helicobacter pylori infection is by far the most important risk factor for gastric cancer worldwide. Less common risk factors for gastric cancer include Lynch syndrome, Peutz-Jeghers syndrome, Menetrier's disease, and germline mutations in the CDH gene (encoding E-cadherin). However, there is some evidence that selenium, as well as high consumption of fruits and vegetables, may have protective effects against gastric cancer.  
 
References  
de Martel C et al. Gastroenterol Clin North Am. 2013 Jun;42(2):219-40.  
Giardiello FM et al. N Engl J Med. 1987 Jun 11;316(24):1511-4.  
Qiao YL et al. J Natl Cancer Inst. 2009 Apr 1;101(7):507-18. 

Correct answer: B. Selenium exposure. 
 
Rationale 
Helicobacter pylori infection is by far the most important risk factor for gastric cancer worldwide. Less common risk factors for gastric cancer include Lynch syndrome, Peutz-Jeghers syndrome, Menetrier's disease, and germline mutations in the CDH gene (encoding E-cadherin). However, there is some evidence that selenium, as well as high consumption of fruits and vegetables, may have protective effects against gastric cancer.  
 
References  
de Martel C et al. Gastroenterol Clin North Am. 2013 Jun;42(2):219-40.  
Giardiello FM et al. N Engl J Med. 1987 Jun 11;316(24):1511-4.  
Qiao YL et al. J Natl Cancer Inst. 2009 Apr 1;101(7):507-18. 

Correct answer: B. Selenium exposure. 
 
Rationale 
Helicobacter pylori infection is by far the most important risk factor for gastric cancer worldwide. Less common risk factors for gastric cancer include Lynch syndrome, Peutz-Jeghers syndrome, Menetrier's disease, and germline mutations in the CDH gene (encoding E-cadherin). However, there is some evidence that selenium, as well as high consumption of fruits and vegetables, may have protective effects against gastric cancer.  
 
References  
de Martel C et al. Gastroenterol Clin North Am. 2013 Jun;42(2):219-40.  
Giardiello FM et al. N Engl J Med. 1987 Jun 11;316(24):1511-4.  
Qiao YL et al. J Natl Cancer Inst. 2009 Apr 1;101(7):507-18. 

Correct answer: E. Cervical dysplasia. 
 
Rationale  
In a nationwide cohort study, women with Crohn's disease and ulcerative colitis were found to have an increased risk of cervical dysplasia. Patients with ulcerative colitis had increased risks of low- and high-grade squamous intraepithelial lesions, whereas patients with Crohn's disease also had increased risks of cervical cancer. Age-appropriate screening with pap smears is important for women diagnosed with inflammatory bowel disease regardless of treatment type.  
 
Reference  
Rungoe et al. Clin Gastroenterol Hepatol. 2015 Apr;13(4):693-700.e1.

Correct answer: E. Cervical dysplasia. 
 
Rationale  
In a nationwide cohort study, women with Crohn's disease and ulcerative colitis were found to have an increased risk of cervical dysplasia. Patients with ulcerative colitis had increased risks of low- and high-grade squamous intraepithelial lesions, whereas patients with Crohn's disease also had increased risks of cervical cancer. Age-appropriate screening with pap smears is important for women diagnosed with inflammatory bowel disease regardless of treatment type.  
 
Reference  
Rungoe et al. Clin Gastroenterol Hepatol. 2015 Apr;13(4):693-700.e1.

Correct answer: E. Cervical dysplasia. 
 
Rationale  
In a nationwide cohort study, women with Crohn's disease and ulcerative colitis were found to have an increased risk of cervical dysplasia. Patients with ulcerative colitis had increased risks of low- and high-grade squamous intraepithelial lesions, whereas patients with Crohn's disease also had increased risks of cervical cancer. Age-appropriate screening with pap smears is important for women diagnosed with inflammatory bowel disease regardless of treatment type.  
 
Reference  
Rungoe et al. Clin Gastroenterol Hepatol. 2015 Apr;13(4):693-700.e1.

When maternal-fetal medicine specialist Andra James, MD, MPH, trained as a midwife decades ago, women with sickle cell disease (SCD) were urged to never get pregnant. If they did, termination was considered the best option.

“If they did carry a pregnancy, the baby would not survive to the point of viability,” Dr. James, emeritus professor of obstetrics and gynecology at Duke University, Durham, N.C., recalled in an interview.

The fates of women with SCD have transformed dramatically since those grim days. In general, this blood disorder no longer robs patients of decades of life, and many women with SCD bear healthy children. But their pregnancies are still considered high risk with significant potential for health crises and death. Now, there’s a new complication: The overturning of Roe v. Wade.

Many states imposed tighter restrictions on abortions in the wake of the U.S. Supreme Court’s landmark Dobbs ruling, sparking worry among physicians that women with SCD won’t be able to get proper maternal care in some parts of the United States.

For example, women with SCD may be unable able to seek elective abortions in some states even if their pregnancies pose a danger to their lives. And abortion restrictions are imperiling access to a medication that’s used to treat miscarriages, which are more common in women with SCD.

“The situation with Dobbs is dire, and maternal health care is being compromised,” Johns Hopkins University pediatric hematologist Lydia Pecker, MD, who treats young people with SCD and studies its impact on pregnancy, said in an interview. “Women with sickle cell disease who are pregnant constitute an underserved and understudied population with special health care needs, and the Dobbs decision will only make providing their care even more difficult in many parts of the country.”

For her part, Dr. James described the risk to pregnant women with SCD this way: In the wake of the court ruling, “we increase the opportunity for them to lose their lives and for their babies to die.”
 

SCD’s impact on pregnancy

While physicians no longer advise women with SCD to avoid motherhood, pregnancy is still uniquely dangerous for them. “Most of them have babies and children who are thriving, but it’s not easy for them,” University of North Carolina at Chapel Hill hematologist and SCD specialist Jane Little, MD, said in an interview. And in some cases, she said, pregnancies “do not end well.”

For a 2022 report, Dr. Pecker and colleagues analyzed 2012-2018 data for 6,610 U.S. hospital admissions among women with SCD (87% of whom were Black). These women were more likely than were unaffected women to suffer severe maternal morbidity (odds ratio[OR], 4.63, 95% confidence interval [CI], 4.16-5.16, P < .001). Cerebrovascular event were especially more common in SCD (OR, 13.94, P < .001).

According to a 2019 report, pregnant women with SCD “are more likely to develop a host of complications, particularly hypertensive syndromes (such as preeclampsia), venous thromboembolism (VTE), preterm labor, and fetal loss. Newborns are more likely to have growth problems and prematurity.”

Although data are sparse, experts say it’s also clear that women with SCD face significantly higher risk of death in pregnancy compared to other women. In fact, the maternal mortality rate for females with SCD “is higher than for Black females without SCD, who already suffer from a higher mortality rate than White females during pregnancy and childbirth,” Andrea Roe, MD, MPH, assistant professor of obstetrics and gynecology at the Hospital of the University of Pennsylvania, Philadelphia, said in an interview.

Women with SCD also are more likely to have premature and stillborn births.

Some of the health challenges in pregnant women with SCD stem from the body’s inability to boost blood production in order to supply the placenta, said Dr. James, the Duke University emeritus professor. “Her bone marrow is already turning out red blood cells as fast as it can.”

In addition, she said, these women are more susceptible to infection, blood clots, and damage to the kidneys and lungs.

Still, in most cases of SCD in pregnancy, “we counsel a woman that we can get you safely through it,” Dr. James said. “But there is a subset of patients that will have organ damage from their sickle cell disease and should not become pregnant or stay pregnant if they become pregnant.”
 

Court ruling limits options in some states

The Dobbs ruling affects pregnant women with SCD in two ways: It allows states to restrict or ban abortion to greater extents than were possible over the last 50 years, and it has spawned further limitations on access to mifepristone, which is commonly used to treat early miscarriages.

In some cases, Dr. James said, abortions in this population are elective. “People with sickle cell disease are frequently in pain, they are frequently hospitalized. They may have suffered strokes or subclinical strokes or have some cognitive impairment, and they don’t have the mental and physical fortitude [to tolerate pregnancy and birth].”

In other cases, abortions are medically necessary to preserve the mother’s life. The American Society of Hematology highlighted the risks posed by SCD to maternal health in a June 24 statement that criticized the Dobbs ruling. “In some cases, denying women their right to terminate a pregnancy puts them at risk of serious illness or death,” wrote Jane N. Winter, MD, president of ASH and professor of medicine at Northwestern University, Chicago.

There do not appear to be any statistics about abortion rates among women with SCD in the United States or whether the rates are higher than in other groups.

As for miscarriages in SCD, an analysis of first pregnancies in California women with SCD from 1991 to 2016 found that about 16% were “incomplete,” mainly (59.3%) from miscarriage.

The Dobbs ruling allows states to further restrict the drug combination of mifepristone and misoprostol, which is used to trigger abortions and to treat early pregnancy loss. Access to mifepristone was already limited prior to the ruling due to tight regulation, and advocates say it’s now even harder to get.
 

What now? Physicians urge focus on contraception

As the ramifications of the Dobbs ruling sink in, SCD specialists are emphasizing the importance of providing gynecological and contraceptive care to help women with the condition avoid unwanted pregnancies. At the University of North Carolina, “we’re pretty aggressive about trying to give women the option to see a gynecologist to get the best care they can,” Dr. Little said. “We have a shared gynecology and sickle cell clinic because we really want women to be making the choice [to become pregnant] when they are ready because it’s a strain on their health and their lives.”

Dr. Pecker, the Johns Hopkins University pediatric hematologist, urged colleagues to partner with maternal-fetal medicine specialists so they can quickly get help for pregnant patients when needed. “That way they can get high-quality pregnancy care and help to end pregnancies that need to be ended.”

She recommended “highly effective” progesterone-based birth control as the best first-line contraceptive for women with SCD. And, she said, every woman of child-bearing age with SCD should be assessed annually for their intentions regarding pregnancy. As she put it, “there’s so much that we can do to reduce harms.”

Dr. Pecker disclosed financial relationships with the National Institutes of Health, American Society of Hematology, Doris Duke Charitable Foundation, the Mellon Foundation, Global Blood Therapeutics, and Novo Nordisk. Dr. Little disclosed financial relationships with Global Blood Therapeutics, Bluebird Bio, and Forma Therapeutics. Dr. Roe has no disclosures.

When maternal-fetal medicine specialist Andra James, MD, MPH, trained as a midwife decades ago, women with sickle cell disease (SCD) were urged to never get pregnant. If they did, termination was considered the best option.

“If they did carry a pregnancy, the baby would not survive to the point of viability,” Dr. James, emeritus professor of obstetrics and gynecology at Duke University, Durham, N.C., recalled in an interview.

The fates of women with SCD have transformed dramatically since those grim days. In general, this blood disorder no longer robs patients of decades of life, and many women with SCD bear healthy children. But their pregnancies are still considered high risk with significant potential for health crises and death. Now, there’s a new complication: The overturning of Roe v. Wade.

Many states imposed tighter restrictions on abortions in the wake of the U.S. Supreme Court’s landmark Dobbs ruling, sparking worry among physicians that women with SCD won’t be able to get proper maternal care in some parts of the United States.

For example, women with SCD may be unable able to seek elective abortions in some states even if their pregnancies pose a danger to their lives. And abortion restrictions are imperiling access to a medication that’s used to treat miscarriages, which are more common in women with SCD.

“The situation with Dobbs is dire, and maternal health care is being compromised,” Johns Hopkins University pediatric hematologist Lydia Pecker, MD, who treats young people with SCD and studies its impact on pregnancy, said in an interview. “Women with sickle cell disease who are pregnant constitute an underserved and understudied population with special health care needs, and the Dobbs decision will only make providing their care even more difficult in many parts of the country.”

For her part, Dr. James described the risk to pregnant women with SCD this way: In the wake of the court ruling, “we increase the opportunity for them to lose their lives and for their babies to die.”
 

SCD’s impact on pregnancy

While physicians no longer advise women with SCD to avoid motherhood, pregnancy is still uniquely dangerous for them. “Most of them have babies and children who are thriving, but it’s not easy for them,” University of North Carolina at Chapel Hill hematologist and SCD specialist Jane Little, MD, said in an interview. And in some cases, she said, pregnancies “do not end well.”

For a 2022 report, Dr. Pecker and colleagues analyzed 2012-2018 data for 6,610 U.S. hospital admissions among women with SCD (87% of whom were Black). These women were more likely than were unaffected women to suffer severe maternal morbidity (odds ratio[OR], 4.63, 95% confidence interval [CI], 4.16-5.16, P < .001). Cerebrovascular event were especially more common in SCD (OR, 13.94, P < .001).

According to a 2019 report, pregnant women with SCD “are more likely to develop a host of complications, particularly hypertensive syndromes (such as preeclampsia), venous thromboembolism (VTE), preterm labor, and fetal loss. Newborns are more likely to have growth problems and prematurity.”

Although data are sparse, experts say it’s also clear that women with SCD face significantly higher risk of death in pregnancy compared to other women. In fact, the maternal mortality rate for females with SCD “is higher than for Black females without SCD, who already suffer from a higher mortality rate than White females during pregnancy and childbirth,” Andrea Roe, MD, MPH, assistant professor of obstetrics and gynecology at the Hospital of the University of Pennsylvania, Philadelphia, said in an interview.

Women with SCD also are more likely to have premature and stillborn births.

Some of the health challenges in pregnant women with SCD stem from the body’s inability to boost blood production in order to supply the placenta, said Dr. James, the Duke University emeritus professor. “Her bone marrow is already turning out red blood cells as fast as it can.”

In addition, she said, these women are more susceptible to infection, blood clots, and damage to the kidneys and lungs.

Still, in most cases of SCD in pregnancy, “we counsel a woman that we can get you safely through it,” Dr. James said. “But there is a subset of patients that will have organ damage from their sickle cell disease and should not become pregnant or stay pregnant if they become pregnant.”
 

Court ruling limits options in some states

The Dobbs ruling affects pregnant women with SCD in two ways: It allows states to restrict or ban abortion to greater extents than were possible over the last 50 years, and it has spawned further limitations on access to mifepristone, which is commonly used to treat early miscarriages.

In some cases, Dr. James said, abortions in this population are elective. “People with sickle cell disease are frequently in pain, they are frequently hospitalized. They may have suffered strokes or subclinical strokes or have some cognitive impairment, and they don’t have the mental and physical fortitude [to tolerate pregnancy and birth].”

In other cases, abortions are medically necessary to preserve the mother’s life. The American Society of Hematology highlighted the risks posed by SCD to maternal health in a June 24 statement that criticized the Dobbs ruling. “In some cases, denying women their right to terminate a pregnancy puts them at risk of serious illness or death,” wrote Jane N. Winter, MD, president of ASH and professor of medicine at Northwestern University, Chicago.

There do not appear to be any statistics about abortion rates among women with SCD in the United States or whether the rates are higher than in other groups.

As for miscarriages in SCD, an analysis of first pregnancies in California women with SCD from 1991 to 2016 found that about 16% were “incomplete,” mainly (59.3%) from miscarriage.

The Dobbs ruling allows states to further restrict the drug combination of mifepristone and misoprostol, which is used to trigger abortions and to treat early pregnancy loss. Access to mifepristone was already limited prior to the ruling due to tight regulation, and advocates say it’s now even harder to get.
 

What now? Physicians urge focus on contraception

As the ramifications of the Dobbs ruling sink in, SCD specialists are emphasizing the importance of providing gynecological and contraceptive care to help women with the condition avoid unwanted pregnancies. At the University of North Carolina, “we’re pretty aggressive about trying to give women the option to see a gynecologist to get the best care they can,” Dr. Little said. “We have a shared gynecology and sickle cell clinic because we really want women to be making the choice [to become pregnant] when they are ready because it’s a strain on their health and their lives.”

Dr. Pecker, the Johns Hopkins University pediatric hematologist, urged colleagues to partner with maternal-fetal medicine specialists so they can quickly get help for pregnant patients when needed. “That way they can get high-quality pregnancy care and help to end pregnancies that need to be ended.”

She recommended “highly effective” progesterone-based birth control as the best first-line contraceptive for women with SCD. And, she said, every woman of child-bearing age with SCD should be assessed annually for their intentions regarding pregnancy. As she put it, “there’s so much that we can do to reduce harms.”

Dr. Pecker disclosed financial relationships with the National Institutes of Health, American Society of Hematology, Doris Duke Charitable Foundation, the Mellon Foundation, Global Blood Therapeutics, and Novo Nordisk. Dr. Little disclosed financial relationships with Global Blood Therapeutics, Bluebird Bio, and Forma Therapeutics. Dr. Roe has no disclosures.

When maternal-fetal medicine specialist Andra James, MD, MPH, trained as a midwife decades ago, women with sickle cell disease (SCD) were urged to never get pregnant. If they did, termination was considered the best option.

“If they did carry a pregnancy, the baby would not survive to the point of viability,” Dr. James, emeritus professor of obstetrics and gynecology at Duke University, Durham, N.C., recalled in an interview.

The fates of women with SCD have transformed dramatically since those grim days. In general, this blood disorder no longer robs patients of decades of life, and many women with SCD bear healthy children. But their pregnancies are still considered high risk with significant potential for health crises and death. Now, there’s a new complication: The overturning of Roe v. Wade.

Many states imposed tighter restrictions on abortions in the wake of the U.S. Supreme Court’s landmark Dobbs ruling, sparking worry among physicians that women with SCD won’t be able to get proper maternal care in some parts of the United States.

For example, women with SCD may be unable able to seek elective abortions in some states even if their pregnancies pose a danger to their lives. And abortion restrictions are imperiling access to a medication that’s used to treat miscarriages, which are more common in women with SCD.

“The situation with Dobbs is dire, and maternal health care is being compromised,” Johns Hopkins University pediatric hematologist Lydia Pecker, MD, who treats young people with SCD and studies its impact on pregnancy, said in an interview. “Women with sickle cell disease who are pregnant constitute an underserved and understudied population with special health care needs, and the Dobbs decision will only make providing their care even more difficult in many parts of the country.”

For her part, Dr. James described the risk to pregnant women with SCD this way: In the wake of the court ruling, “we increase the opportunity for them to lose their lives and for their babies to die.”
 

SCD’s impact on pregnancy

While physicians no longer advise women with SCD to avoid motherhood, pregnancy is still uniquely dangerous for them. “Most of them have babies and children who are thriving, but it’s not easy for them,” University of North Carolina at Chapel Hill hematologist and SCD specialist Jane Little, MD, said in an interview. And in some cases, she said, pregnancies “do not end well.”

For a 2022 report, Dr. Pecker and colleagues analyzed 2012-2018 data for 6,610 U.S. hospital admissions among women with SCD (87% of whom were Black). These women were more likely than were unaffected women to suffer severe maternal morbidity (odds ratio[OR], 4.63, 95% confidence interval [CI], 4.16-5.16, P < .001). Cerebrovascular event were especially more common in SCD (OR, 13.94, P < .001).

According to a 2019 report, pregnant women with SCD “are more likely to develop a host of complications, particularly hypertensive syndromes (such as preeclampsia), venous thromboembolism (VTE), preterm labor, and fetal loss. Newborns are more likely to have growth problems and prematurity.”

Although data are sparse, experts say it’s also clear that women with SCD face significantly higher risk of death in pregnancy compared to other women. In fact, the maternal mortality rate for females with SCD “is higher than for Black females without SCD, who already suffer from a higher mortality rate than White females during pregnancy and childbirth,” Andrea Roe, MD, MPH, assistant professor of obstetrics and gynecology at the Hospital of the University of Pennsylvania, Philadelphia, said in an interview.

Women with SCD also are more likely to have premature and stillborn births.

Some of the health challenges in pregnant women with SCD stem from the body’s inability to boost blood production in order to supply the placenta, said Dr. James, the Duke University emeritus professor. “Her bone marrow is already turning out red blood cells as fast as it can.”

In addition, she said, these women are more susceptible to infection, blood clots, and damage to the kidneys and lungs.

Still, in most cases of SCD in pregnancy, “we counsel a woman that we can get you safely through it,” Dr. James said. “But there is a subset of patients that will have organ damage from their sickle cell disease and should not become pregnant or stay pregnant if they become pregnant.”
 

Court ruling limits options in some states

The Dobbs ruling affects pregnant women with SCD in two ways: It allows states to restrict or ban abortion to greater extents than were possible over the last 50 years, and it has spawned further limitations on access to mifepristone, which is commonly used to treat early miscarriages.

In some cases, Dr. James said, abortions in this population are elective. “People with sickle cell disease are frequently in pain, they are frequently hospitalized. They may have suffered strokes or subclinical strokes or have some cognitive impairment, and they don’t have the mental and physical fortitude [to tolerate pregnancy and birth].”

In other cases, abortions are medically necessary to preserve the mother’s life. The American Society of Hematology highlighted the risks posed by SCD to maternal health in a June 24 statement that criticized the Dobbs ruling. “In some cases, denying women their right to terminate a pregnancy puts them at risk of serious illness or death,” wrote Jane N. Winter, MD, president of ASH and professor of medicine at Northwestern University, Chicago.

There do not appear to be any statistics about abortion rates among women with SCD in the United States or whether the rates are higher than in other groups.

As for miscarriages in SCD, an analysis of first pregnancies in California women with SCD from 1991 to 2016 found that about 16% were “incomplete,” mainly (59.3%) from miscarriage.

The Dobbs ruling allows states to further restrict the drug combination of mifepristone and misoprostol, which is used to trigger abortions and to treat early pregnancy loss. Access to mifepristone was already limited prior to the ruling due to tight regulation, and advocates say it’s now even harder to get.
 

What now? Physicians urge focus on contraception

As the ramifications of the Dobbs ruling sink in, SCD specialists are emphasizing the importance of providing gynecological and contraceptive care to help women with the condition avoid unwanted pregnancies. At the University of North Carolina, “we’re pretty aggressive about trying to give women the option to see a gynecologist to get the best care they can,” Dr. Little said. “We have a shared gynecology and sickle cell clinic because we really want women to be making the choice [to become pregnant] when they are ready because it’s a strain on their health and their lives.”

Dr. Pecker, the Johns Hopkins University pediatric hematologist, urged colleagues to partner with maternal-fetal medicine specialists so they can quickly get help for pregnant patients when needed. “That way they can get high-quality pregnancy care and help to end pregnancies that need to be ended.”

She recommended “highly effective” progesterone-based birth control as the best first-line contraceptive for women with SCD. And, she said, every woman of child-bearing age with SCD should be assessed annually for their intentions regarding pregnancy. As she put it, “there’s so much that we can do to reduce harms.”

Dr. Pecker disclosed financial relationships with the National Institutes of Health, American Society of Hematology, Doris Duke Charitable Foundation, the Mellon Foundation, Global Blood Therapeutics, and Novo Nordisk. Dr. Little disclosed financial relationships with Global Blood Therapeutics, Bluebird Bio, and Forma Therapeutics. Dr. Roe has no disclosures.

As an undergraduate student at Northeastern University in Boston, Meghan Chin spent her summers working for a day program in Rhode Island. Her charges were adults with various forms of intellectual and developmental disabilities (IDD).

“I was very much a caretaker,” Ms. Chin, now 29, said. “It was everything from helping them get dressed in the morning to getting them to medical appointments.”

During one such visit Ms. Chin got a lesson about how health care looks from the viewpoint of someone with an IDD.

The patient was a woman in her 60s and she was having gastrointestinal issues; symptoms she could have articulated, if asked. “She was perfectly capable of telling a clinician where it hurt, how long she had experienced the problem, and what she had done or not done to alleviate it,” Ms. Chin said.

And of comprehending a response. But she was not given the opportunity.

“She would explain what was going on to the clinician,” Ms. Chin recalled. “And the clinician would turn to me and answer. It was this weird three-way conversation – as if she wasn’t even there in the room with us.”

Ms. Chin was incensed at the rude and disrespectful way the patient had been treated. But her charge didn’t seem upset or surprised. Just resigned. “Sadly, she had become used to this,” Ms. Chin said. 

For the young aide, however, the experience was searing. “It didn’t seem right to me,” Ms. Chin said. “That’s why, when I went to medical school, I knew I wanted to do better for this population.”

Serendipity led her to Georgetown University, Washington, where she met Kim Bullock, MD, one of the country’s leading advocates for improved health care delivery to those with IDDs.

Dr. Bullock, an associate professor of family medicine, seeks to create better training and educational opportunities for medical students who will likely encounter patients with these disabilities in their practices.

When Dr. Bullock heard Ms. Chin’s story about the patient being ignored, she was not surprised.

“This is not an unusual or unique situation,” said Dr. Bullock, who is also director of Georgetown’s community health division and a faculty member of the university’s Center for Excellence for Developmental Disabilities. “In fact, it’s quite common and is part of what spurred my own interest in educating pre-med and medical students about effective communication techniques, particularly when addressing neurodiverse patients.”

More than 13% of Americans, or roughly 44 million people, have some form of disability, according to the National Institute on Disability at the University of New Hampshire, a figure that does not include those who are institutionalized. The Centers for Disease Control and Prevention estimates that 17% of children aged 3-17 years have a developmental disability.

Even so, many physicians feel ill-prepared to care for disabled patients. A survey of physicians, published in the journal Health Affairs, found that some lacked the resources and training to properly care for patients with disabilities, or that they struggled to coordinate care for such individuals. Some said they did not know which types of accessible equipment, like adjustable tables and chair scales, were needed or how to use them. And some said they actively try to avoid treating patients with disabilities.
 

Don’t assume

The first step at correcting the problem, Dr. Bullock said, is to not assume that all IDD patients are incapable of communicating. By talking not to the patient but to their caregiver or spouse or child, as the clinician did with Ms. Chin years ago, “we are taking away their agency, their autonomy to speak for and about themselves.”

Change involves altering physicians’ attitudes and assumptions toward this population, through education. But how?

“The medical school curriculum is tight as it is,” Dr. Bullock acknowledged. “There’s a lot of things students have to learn. People wonder: where we will add this?”

Her suggestion: Incorporate IDD all along the way, through programs or experiences that will enable medical students to see such patients “not as something separate, but as people that have special needs just as other populations have.”

Case in point: Operation House Call, a program in Massachusetts designed to support young health care professionals, by building “confidence, interest, and sensitivity” toward individuals with IDD.

Eight medical and allied health schools, including those at Harvard Medical School and Yale School of Nursing, participate in the program, the centerpiece of which is time spent by teams of medical students in the homes of families with neurodiverse members. “It’s transformational,” said Susan Feeney, DNP, NP-C, director of adult gerontology and family nurse practitioner programs at the graduate school of nursing at the University of Massachusetts, Worcester. “They spend a few hours at the homes of these families, have this interaction with them, and journal about their experiences.”

Dr. Feeney described as “transformational” the experience of the students after getting to know these families. “They all come back profoundly changed,” she told this news organization. “As a medical or health care professional, you meet people in an artificial environment of the clinic and hospital. Here, they become human, like you. It takes the stigma away.”

One area of medicine in which this is an exception is pediatrics, where interaction with children with IDD and their families is common – and close. “They’re going to be much more attuned to this,” Dr. Feeney said. “The problem is primary care or internal medicine. Once these children get into their mid and later 20s, and they need a practitioner to talk to about adult concerns.”

And with adulthood come other medical needs, as the physical demands of age fall no less heavily on individuals with IDDs than those without. For example: “Neurodiverse people get pregnant,” Dr. Bullock said. They also can get heart disease as they age; or require the care of a rheumatologist, a neurologist, an orthopedic surgeon, or any other medical specialty.

Generation gap

Fortunately, the next generation of physicians may be more open to this more inclusionary approach toward a widely misunderstood population.

Like Ms. Chin, Sarah Bdeir had experience with this population prior to beginning her training in medicine. She had volunteered at a school for people with IDD.

“It was one of the best experiences I’ve ever had,” Ms. Bdeir, now 23 and a first-year medical student at Wayne State University, Detroit, said. She found that the neurodiverse individuals she worked with had as many abilities as disabilities. “They are capable of learning, but they do it differently,” she said. “You have to adjust to the way they learn. And you have to step out of your own box.”

Ms. Bdeir also heard about Dr. Bullock’s work and is assisting her in a research project on how to better improve nutritional education for people with IDDs. And although she said it may take time for curriculum boards at medical schools to integrate this kind of training into their programs, she believes they will, in part because the rising cohort of medical students today have an eagerness to engage with and learn more about IDD patients.

As does Ms. Chin.

“When I talk to my peers about this, they’re very receptive,” Ms. Chin said. “They want to learn how to better support the IDD population. And they will learn. I believe in my generation of future doctors.”

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

As an undergraduate student at Northeastern University in Boston, Meghan Chin spent her summers working for a day program in Rhode Island. Her charges were adults with various forms of intellectual and developmental disabilities (IDD).

“I was very much a caretaker,” Ms. Chin, now 29, said. “It was everything from helping them get dressed in the morning to getting them to medical appointments.”

During one such visit Ms. Chin got a lesson about how health care looks from the viewpoint of someone with an IDD.

The patient was a woman in her 60s and she was having gastrointestinal issues; symptoms she could have articulated, if asked. “She was perfectly capable of telling a clinician where it hurt, how long she had experienced the problem, and what she had done or not done to alleviate it,” Ms. Chin said.

And of comprehending a response. But she was not given the opportunity.

“She would explain what was going on to the clinician,” Ms. Chin recalled. “And the clinician would turn to me and answer. It was this weird three-way conversation – as if she wasn’t even there in the room with us.”

Ms. Chin was incensed at the rude and disrespectful way the patient had been treated. But her charge didn’t seem upset or surprised. Just resigned. “Sadly, she had become used to this,” Ms. Chin said. 

For the young aide, however, the experience was searing. “It didn’t seem right to me,” Ms. Chin said. “That’s why, when I went to medical school, I knew I wanted to do better for this population.”

Serendipity led her to Georgetown University, Washington, where she met Kim Bullock, MD, one of the country’s leading advocates for improved health care delivery to those with IDDs.

Dr. Bullock, an associate professor of family medicine, seeks to create better training and educational opportunities for medical students who will likely encounter patients with these disabilities in their practices.

When Dr. Bullock heard Ms. Chin’s story about the patient being ignored, she was not surprised.

“This is not an unusual or unique situation,” said Dr. Bullock, who is also director of Georgetown’s community health division and a faculty member of the university’s Center for Excellence for Developmental Disabilities. “In fact, it’s quite common and is part of what spurred my own interest in educating pre-med and medical students about effective communication techniques, particularly when addressing neurodiverse patients.”

More than 13% of Americans, or roughly 44 million people, have some form of disability, according to the National Institute on Disability at the University of New Hampshire, a figure that does not include those who are institutionalized. The Centers for Disease Control and Prevention estimates that 17% of children aged 3-17 years have a developmental disability.

Even so, many physicians feel ill-prepared to care for disabled patients. A survey of physicians, published in the journal Health Affairs, found that some lacked the resources and training to properly care for patients with disabilities, or that they struggled to coordinate care for such individuals. Some said they did not know which types of accessible equipment, like adjustable tables and chair scales, were needed or how to use them. And some said they actively try to avoid treating patients with disabilities.
 

Don’t assume

The first step at correcting the problem, Dr. Bullock said, is to not assume that all IDD patients are incapable of communicating. By talking not to the patient but to their caregiver or spouse or child, as the clinician did with Ms. Chin years ago, “we are taking away their agency, their autonomy to speak for and about themselves.”

Change involves altering physicians’ attitudes and assumptions toward this population, through education. But how?

“The medical school curriculum is tight as it is,” Dr. Bullock acknowledged. “There’s a lot of things students have to learn. People wonder: where we will add this?”

Her suggestion: Incorporate IDD all along the way, through programs or experiences that will enable medical students to see such patients “not as something separate, but as people that have special needs just as other populations have.”

Case in point: Operation House Call, a program in Massachusetts designed to support young health care professionals, by building “confidence, interest, and sensitivity” toward individuals with IDD.

Eight medical and allied health schools, including those at Harvard Medical School and Yale School of Nursing, participate in the program, the centerpiece of which is time spent by teams of medical students in the homes of families with neurodiverse members. “It’s transformational,” said Susan Feeney, DNP, NP-C, director of adult gerontology and family nurse practitioner programs at the graduate school of nursing at the University of Massachusetts, Worcester. “They spend a few hours at the homes of these families, have this interaction with them, and journal about their experiences.”

Dr. Feeney described as “transformational” the experience of the students after getting to know these families. “They all come back profoundly changed,” she told this news organization. “As a medical or health care professional, you meet people in an artificial environment of the clinic and hospital. Here, they become human, like you. It takes the stigma away.”

One area of medicine in which this is an exception is pediatrics, where interaction with children with IDD and their families is common – and close. “They’re going to be much more attuned to this,” Dr. Feeney said. “The problem is primary care or internal medicine. Once these children get into their mid and later 20s, and they need a practitioner to talk to about adult concerns.”

And with adulthood come other medical needs, as the physical demands of age fall no less heavily on individuals with IDDs than those without. For example: “Neurodiverse people get pregnant,” Dr. Bullock said. They also can get heart disease as they age; or require the care of a rheumatologist, a neurologist, an orthopedic surgeon, or any other medical specialty.

Generation gap

Fortunately, the next generation of physicians may be more open to this more inclusionary approach toward a widely misunderstood population.

Like Ms. Chin, Sarah Bdeir had experience with this population prior to beginning her training in medicine. She had volunteered at a school for people with IDD.

“It was one of the best experiences I’ve ever had,” Ms. Bdeir, now 23 and a first-year medical student at Wayne State University, Detroit, said. She found that the neurodiverse individuals she worked with had as many abilities as disabilities. “They are capable of learning, but they do it differently,” she said. “You have to adjust to the way they learn. And you have to step out of your own box.”

Ms. Bdeir also heard about Dr. Bullock’s work and is assisting her in a research project on how to better improve nutritional education for people with IDDs. And although she said it may take time for curriculum boards at medical schools to integrate this kind of training into their programs, she believes they will, in part because the rising cohort of medical students today have an eagerness to engage with and learn more about IDD patients.

As does Ms. Chin.

“When I talk to my peers about this, they’re very receptive,” Ms. Chin said. “They want to learn how to better support the IDD population. And they will learn. I believe in my generation of future doctors.”

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

As an undergraduate student at Northeastern University in Boston, Meghan Chin spent her summers working for a day program in Rhode Island. Her charges were adults with various forms of intellectual and developmental disabilities (IDD).

“I was very much a caretaker,” Ms. Chin, now 29, said. “It was everything from helping them get dressed in the morning to getting them to medical appointments.”

During one such visit Ms. Chin got a lesson about how health care looks from the viewpoint of someone with an IDD.

The patient was a woman in her 60s and she was having gastrointestinal issues; symptoms she could have articulated, if asked. “She was perfectly capable of telling a clinician where it hurt, how long she had experienced the problem, and what she had done or not done to alleviate it,” Ms. Chin said.

And of comprehending a response. But she was not given the opportunity.

“She would explain what was going on to the clinician,” Ms. Chin recalled. “And the clinician would turn to me and answer. It was this weird three-way conversation – as if she wasn’t even there in the room with us.”

Ms. Chin was incensed at the rude and disrespectful way the patient had been treated. But her charge didn’t seem upset or surprised. Just resigned. “Sadly, she had become used to this,” Ms. Chin said. 

For the young aide, however, the experience was searing. “It didn’t seem right to me,” Ms. Chin said. “That’s why, when I went to medical school, I knew I wanted to do better for this population.”

Serendipity led her to Georgetown University, Washington, where she met Kim Bullock, MD, one of the country’s leading advocates for improved health care delivery to those with IDDs.

Dr. Bullock, an associate professor of family medicine, seeks to create better training and educational opportunities for medical students who will likely encounter patients with these disabilities in their practices.

When Dr. Bullock heard Ms. Chin’s story about the patient being ignored, she was not surprised.

“This is not an unusual or unique situation,” said Dr. Bullock, who is also director of Georgetown’s community health division and a faculty member of the university’s Center for Excellence for Developmental Disabilities. “In fact, it’s quite common and is part of what spurred my own interest in educating pre-med and medical students about effective communication techniques, particularly when addressing neurodiverse patients.”

More than 13% of Americans, or roughly 44 million people, have some form of disability, according to the National Institute on Disability at the University of New Hampshire, a figure that does not include those who are institutionalized. The Centers for Disease Control and Prevention estimates that 17% of children aged 3-17 years have a developmental disability.

Even so, many physicians feel ill-prepared to care for disabled patients. A survey of physicians, published in the journal Health Affairs, found that some lacked the resources and training to properly care for patients with disabilities, or that they struggled to coordinate care for such individuals. Some said they did not know which types of accessible equipment, like adjustable tables and chair scales, were needed or how to use them. And some said they actively try to avoid treating patients with disabilities.
 

Don’t assume

The first step at correcting the problem, Dr. Bullock said, is to not assume that all IDD patients are incapable of communicating. By talking not to the patient but to their caregiver or spouse or child, as the clinician did with Ms. Chin years ago, “we are taking away their agency, their autonomy to speak for and about themselves.”

Change involves altering physicians’ attitudes and assumptions toward this population, through education. But how?

“The medical school curriculum is tight as it is,” Dr. Bullock acknowledged. “There’s a lot of things students have to learn. People wonder: where we will add this?”

Her suggestion: Incorporate IDD all along the way, through programs or experiences that will enable medical students to see such patients “not as something separate, but as people that have special needs just as other populations have.”

Case in point: Operation House Call, a program in Massachusetts designed to support young health care professionals, by building “confidence, interest, and sensitivity” toward individuals with IDD.

Eight medical and allied health schools, including those at Harvard Medical School and Yale School of Nursing, participate in the program, the centerpiece of which is time spent by teams of medical students in the homes of families with neurodiverse members. “It’s transformational,” said Susan Feeney, DNP, NP-C, director of adult gerontology and family nurse practitioner programs at the graduate school of nursing at the University of Massachusetts, Worcester. “They spend a few hours at the homes of these families, have this interaction with them, and journal about their experiences.”

Dr. Feeney described as “transformational” the experience of the students after getting to know these families. “They all come back profoundly changed,” she told this news organization. “As a medical or health care professional, you meet people in an artificial environment of the clinic and hospital. Here, they become human, like you. It takes the stigma away.”

One area of medicine in which this is an exception is pediatrics, where interaction with children with IDD and their families is common – and close. “They’re going to be much more attuned to this,” Dr. Feeney said. “The problem is primary care or internal medicine. Once these children get into their mid and later 20s, and they need a practitioner to talk to about adult concerns.”

And with adulthood come other medical needs, as the physical demands of age fall no less heavily on individuals with IDDs than those without. For example: “Neurodiverse people get pregnant,” Dr. Bullock said. They also can get heart disease as they age; or require the care of a rheumatologist, a neurologist, an orthopedic surgeon, or any other medical specialty.

Generation gap

Fortunately, the next generation of physicians may be more open to this more inclusionary approach toward a widely misunderstood population.

Like Ms. Chin, Sarah Bdeir had experience with this population prior to beginning her training in medicine. She had volunteered at a school for people with IDD.

“It was one of the best experiences I’ve ever had,” Ms. Bdeir, now 23 and a first-year medical student at Wayne State University, Detroit, said. She found that the neurodiverse individuals she worked with had as many abilities as disabilities. “They are capable of learning, but they do it differently,” she said. “You have to adjust to the way they learn. And you have to step out of your own box.”

Ms. Bdeir also heard about Dr. Bullock’s work and is assisting her in a research project on how to better improve nutritional education for people with IDDs. And although she said it may take time for curriculum boards at medical schools to integrate this kind of training into their programs, she believes they will, in part because the rising cohort of medical students today have an eagerness to engage with and learn more about IDD patients.

As does Ms. Chin.

“When I talk to my peers about this, they’re very receptive,” Ms. Chin said. “They want to learn how to better support the IDD population. And they will learn. I believe in my generation of future doctors.”

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

Listening to birdsong appears to have a positive and significant impact on mental health and mood, new research suggests.

Investigators found that people who listened to recordings of birds singing experienced a significant reduction in anxiety and paranoia. In contrast, the researchers also found that recordings of traffic noises, including car engines, sirens, and construction, increased depressive states.

“The results suggest that it may be worthwhile to investigate the targeted use of natural sounds such as birdsong in a clinical setting – for example, in hospital waiting rooms or in psychiatric settings,” study investigator Emil Stobbe, MSc, a predoctoral fellow at the Max Planck Institute for Human Development, Berlin, said in an interview.

“If someone is seeking an easily accessible intervention to lower distress, listening to an audio clip of birds singing might be a great option,” he added.

The study was published online in Scientific Reports.
 

Nature’s calming effect

The aim of the research was “to investigate how the physical environment impact brain and mental health,” Mr. Stobbe said.

Mr. Stobbe said that there is significantly more research examining visual properties of the physical environment but that the auditory domain is not as well researched, although, he added, that the beneficial effects of interactions with nature are “well studied.”

He noted that anxiety and paranoia can be experienced by many individuals even though they may be unaware that they are experiencing these states.

“We wanted to investigate if the beneficial effects of nature can also exert their impact on these states. In theory, birds can be representational for natural and vital environment, which, in turn, transfer the positive effects of nature on birdsong listeners,” he said.

A previous study compared nature versus city soundscape conditions and showed that the nature soundscape improved participants’ cognitive performance but did not improve mood. The present study added diversity to the soundscapes and focused not only on cognition and general mood but also on state paranoia, “which can be measured in a change-sensitive manner” and “has been shown to increase in response to traffic noise.”

The researchers hypothesized that birdsong would have a greater beneficial effect on mood and paranoia and on cognitive performance compared with traffic noise. They also investigated whether greater versus lower diversity of bird species or noise sources within the soundscapes “would be a relevant factor modulating the effects.”

The researchers recruited participants (n = 295) from a crowdsourcing platform. Participants’ mean age was late 20s (standard deviations ranged from 6.30 to 7.72), with a greater proportion of male versus female participants.

To be included, participants were required to have no history of mental illness, hearing difficulties, substance/drug intake, or suicidal thoughts/tendencies.

The outcomes of interest (mood, paranoia, cognitive performance) were measured before and after soundscape exposure and each soundscape had a low- versus high-diversity version. This resulted in several analyses that compared two types of sounds (birdsongs vs. traffic noise) x two levels of diversity (low vs. high diversity) and two time points (pre- vs. post exposure).

The exposure to sounds lasted for 6 minutes, after which they were asked to report (on a 0-100 visual scale) how diverse/monotone, beautiful, and pleasant they perceived the soundscape to be.
 

Reduction in depressive symptoms

Participants were divided into four groups: low-diversity traffic noise soundscape (n = 83), high-diversity traffic noise soundscape (n = 60), low-diversity birdsong soundscape (n = 63), and high-diversity birdsong soundscape (n = 80)

In addition to listening to the sounds, participants completed questionnaires measuring mood (depression and anxiety) and paranoia as well as a test of digit span cognitive performance (both the forward and the backward versions).

The type, diversity, and type x diversity all revealed significant effect sizes (F[3, 276] = 78.6; P < .001; eta-squared = 0.461; F[3, 276] = 3.16; P = .025; eta-squared = 0.033; and F[3, 276] = 2.66; P = .028, respectively), “suggesting that all of these factors, as well as their interaction, had a significant impact on the perception of soundscapes (that is, ratings on monotony/diversity, beauty, and pleasantness).”

A post hoc examination showed that depressive symptoms significantly increased within the low- and high-diversity urban soundscapes but decreased significantly in the high-diversity birdsong soundscapes (T[1, 60] = –2.57; P = .012; d = –0.29).

For anxiety, the post hoc within-group analyses found no effects within low- and high-diversity traffic noise conditions (T[1, 82] = –1.37; P = .174; d = –0.15 and T[1, 68] = 0.49; P = .629; d = 0.06, respectively). By contrast, there were significant declines in both birdsong conditions (low diversity: T[1, 62] = –6.13; P < .001; d = –0.77; high diversity: T[1, 60] = –6.32; P < .001; d =  –0.70).

Similarly, there were no changes in participants with paranoia when they listened to either low- or high-diversity traffic noises (T[1, 82] = –0.55; P = .583; d = –0.06 and T[1, 68] = 0.67; P = .507; d = 0.08, respectively). On the other hand, both birdsong conditions yielded reductions in paranoia (low diversity: T[1, 62] = –5.90; P < .001; d = –0.74; high diversity: T[1, 60] =  –4.11; P < .001; d = –0.46).

None of the soundscapes had any effect on cognition.

“In theory, birds can be representational for natural and vital environments which, in turn, transfer the positive effects of nature on birdsong listeners,” said Mr. Stobbe.

“Taken together, the findings of the current study provide another facet of why interactions with nature can be beneficial for our mental health, and it is highly important to preserve nature,” he added.

Mr. Stobbe said that future research should focus on investigating mixed soundscapes including examining whether the presence of natural sounds in urban settings lower stressors such as traffic noise.
 

An understudied area

Commenting for this article, Ken Duckworth, MD, chief medical officer of the National Alliance on Mental Illness called the study “interesting but limited.”

Dr. Duckworth, who was not involved in the research said that the “benefits of nature are understudied” and agreed with the investigators that it is potentially important to study the use of birdsongs in psychiatric facilities. “Future studies could also correlate the role of birdsong with the mental health benefits/aspects of ‘being in nature,’ which has been found to have some effect.”

Open Access funding was enabled and organized by Projekt DEAL. The authors and Dr. Duckworth declared no competing interests.

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

Listening to birdsong appears to have a positive and significant impact on mental health and mood, new research suggests.

Investigators found that people who listened to recordings of birds singing experienced a significant reduction in anxiety and paranoia. In contrast, the researchers also found that recordings of traffic noises, including car engines, sirens, and construction, increased depressive states.

“The results suggest that it may be worthwhile to investigate the targeted use of natural sounds such as birdsong in a clinical setting – for example, in hospital waiting rooms or in psychiatric settings,” study investigator Emil Stobbe, MSc, a predoctoral fellow at the Max Planck Institute for Human Development, Berlin, said in an interview.

“If someone is seeking an easily accessible intervention to lower distress, listening to an audio clip of birds singing might be a great option,” he added.

The study was published online in Scientific Reports.
 

Nature’s calming effect

The aim of the research was “to investigate how the physical environment impact brain and mental health,” Mr. Stobbe said.

Mr. Stobbe said that there is significantly more research examining visual properties of the physical environment but that the auditory domain is not as well researched, although, he added, that the beneficial effects of interactions with nature are “well studied.”

He noted that anxiety and paranoia can be experienced by many individuals even though they may be unaware that they are experiencing these states.

“We wanted to investigate if the beneficial effects of nature can also exert their impact on these states. In theory, birds can be representational for natural and vital environment, which, in turn, transfer the positive effects of nature on birdsong listeners,” he said.

A previous study compared nature versus city soundscape conditions and showed that the nature soundscape improved participants’ cognitive performance but did not improve mood. The present study added diversity to the soundscapes and focused not only on cognition and general mood but also on state paranoia, “which can be measured in a change-sensitive manner” and “has been shown to increase in response to traffic noise.”

The researchers hypothesized that birdsong would have a greater beneficial effect on mood and paranoia and on cognitive performance compared with traffic noise. They also investigated whether greater versus lower diversity of bird species or noise sources within the soundscapes “would be a relevant factor modulating the effects.”

The researchers recruited participants (n = 295) from a crowdsourcing platform. Participants’ mean age was late 20s (standard deviations ranged from 6.30 to 7.72), with a greater proportion of male versus female participants.

To be included, participants were required to have no history of mental illness, hearing difficulties, substance/drug intake, or suicidal thoughts/tendencies.

The outcomes of interest (mood, paranoia, cognitive performance) were measured before and after soundscape exposure and each soundscape had a low- versus high-diversity version. This resulted in several analyses that compared two types of sounds (birdsongs vs. traffic noise) x two levels of diversity (low vs. high diversity) and two time points (pre- vs. post exposure).

The exposure to sounds lasted for 6 minutes, after which they were asked to report (on a 0-100 visual scale) how diverse/monotone, beautiful, and pleasant they perceived the soundscape to be.
 

Reduction in depressive symptoms

Participants were divided into four groups: low-diversity traffic noise soundscape (n = 83), high-diversity traffic noise soundscape (n = 60), low-diversity birdsong soundscape (n = 63), and high-diversity birdsong soundscape (n = 80)

In addition to listening to the sounds, participants completed questionnaires measuring mood (depression and anxiety) and paranoia as well as a test of digit span cognitive performance (both the forward and the backward versions).

The type, diversity, and type x diversity all revealed significant effect sizes (F[3, 276] = 78.6; P < .001; eta-squared = 0.461; F[3, 276] = 3.16; P = .025; eta-squared = 0.033; and F[3, 276] = 2.66; P = .028, respectively), “suggesting that all of these factors, as well as their interaction, had a significant impact on the perception of soundscapes (that is, ratings on monotony/diversity, beauty, and pleasantness).”

A post hoc examination showed that depressive symptoms significantly increased within the low- and high-diversity urban soundscapes but decreased significantly in the high-diversity birdsong soundscapes (T[1, 60] = –2.57; P = .012; d = –0.29).

For anxiety, the post hoc within-group analyses found no effects within low- and high-diversity traffic noise conditions (T[1, 82] = –1.37; P = .174; d = –0.15 and T[1, 68] = 0.49; P = .629; d = 0.06, respectively). By contrast, there were significant declines in both birdsong conditions (low diversity: T[1, 62] = –6.13; P < .001; d = –0.77; high diversity: T[1, 60] = –6.32; P < .001; d =  –0.70).

Similarly, there were no changes in participants with paranoia when they listened to either low- or high-diversity traffic noises (T[1, 82] = –0.55; P = .583; d = –0.06 and T[1, 68] = 0.67; P = .507; d = 0.08, respectively). On the other hand, both birdsong conditions yielded reductions in paranoia (low diversity: T[1, 62] = –5.90; P < .001; d = –0.74; high diversity: T[1, 60] =  –4.11; P < .001; d = –0.46).

None of the soundscapes had any effect on cognition.

“In theory, birds can be representational for natural and vital environments which, in turn, transfer the positive effects of nature on birdsong listeners,” said Mr. Stobbe.

“Taken together, the findings of the current study provide another facet of why interactions with nature can be beneficial for our mental health, and it is highly important to preserve nature,” he added.

Mr. Stobbe said that future research should focus on investigating mixed soundscapes including examining whether the presence of natural sounds in urban settings lower stressors such as traffic noise.
 

An understudied area

Commenting for this article, Ken Duckworth, MD, chief medical officer of the National Alliance on Mental Illness called the study “interesting but limited.”

Dr. Duckworth, who was not involved in the research said that the “benefits of nature are understudied” and agreed with the investigators that it is potentially important to study the use of birdsongs in psychiatric facilities. “Future studies could also correlate the role of birdsong with the mental health benefits/aspects of ‘being in nature,’ which has been found to have some effect.”

Open Access funding was enabled and organized by Projekt DEAL. The authors and Dr. Duckworth declared no competing interests.

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

Listening to birdsong appears to have a positive and significant impact on mental health and mood, new research suggests.

Investigators found that people who listened to recordings of birds singing experienced a significant reduction in anxiety and paranoia. In contrast, the researchers also found that recordings of traffic noises, including car engines, sirens, and construction, increased depressive states.

“The results suggest that it may be worthwhile to investigate the targeted use of natural sounds such as birdsong in a clinical setting – for example, in hospital waiting rooms or in psychiatric settings,” study investigator Emil Stobbe, MSc, a predoctoral fellow at the Max Planck Institute for Human Development, Berlin, said in an interview.

“If someone is seeking an easily accessible intervention to lower distress, listening to an audio clip of birds singing might be a great option,” he added.

The study was published online in Scientific Reports.
 

Nature’s calming effect

The aim of the research was “to investigate how the physical environment impact brain and mental health,” Mr. Stobbe said.

Mr. Stobbe said that there is significantly more research examining visual properties of the physical environment but that the auditory domain is not as well researched, although, he added, that the beneficial effects of interactions with nature are “well studied.”

He noted that anxiety and paranoia can be experienced by many individuals even though they may be unaware that they are experiencing these states.

“We wanted to investigate if the beneficial effects of nature can also exert their impact on these states. In theory, birds can be representational for natural and vital environment, which, in turn, transfer the positive effects of nature on birdsong listeners,” he said.

A previous study compared nature versus city soundscape conditions and showed that the nature soundscape improved participants’ cognitive performance but did not improve mood. The present study added diversity to the soundscapes and focused not only on cognition and general mood but also on state paranoia, “which can be measured in a change-sensitive manner” and “has been shown to increase in response to traffic noise.”

The researchers hypothesized that birdsong would have a greater beneficial effect on mood and paranoia and on cognitive performance compared with traffic noise. They also investigated whether greater versus lower diversity of bird species or noise sources within the soundscapes “would be a relevant factor modulating the effects.”

The researchers recruited participants (n = 295) from a crowdsourcing platform. Participants’ mean age was late 20s (standard deviations ranged from 6.30 to 7.72), with a greater proportion of male versus female participants.

To be included, participants were required to have no history of mental illness, hearing difficulties, substance/drug intake, or suicidal thoughts/tendencies.

The outcomes of interest (mood, paranoia, cognitive performance) were measured before and after soundscape exposure and each soundscape had a low- versus high-diversity version. This resulted in several analyses that compared two types of sounds (birdsongs vs. traffic noise) x two levels of diversity (low vs. high diversity) and two time points (pre- vs. post exposure).

The exposure to sounds lasted for 6 minutes, after which they were asked to report (on a 0-100 visual scale) how diverse/monotone, beautiful, and pleasant they perceived the soundscape to be.
 

Reduction in depressive symptoms

Participants were divided into four groups: low-diversity traffic noise soundscape (n = 83), high-diversity traffic noise soundscape (n = 60), low-diversity birdsong soundscape (n = 63), and high-diversity birdsong soundscape (n = 80)

In addition to listening to the sounds, participants completed questionnaires measuring mood (depression and anxiety) and paranoia as well as a test of digit span cognitive performance (both the forward and the backward versions).

The type, diversity, and type x diversity all revealed significant effect sizes (F[3, 276] = 78.6; P < .001; eta-squared = 0.461; F[3, 276] = 3.16; P = .025; eta-squared = 0.033; and F[3, 276] = 2.66; P = .028, respectively), “suggesting that all of these factors, as well as their interaction, had a significant impact on the perception of soundscapes (that is, ratings on monotony/diversity, beauty, and pleasantness).”

A post hoc examination showed that depressive symptoms significantly increased within the low- and high-diversity urban soundscapes but decreased significantly in the high-diversity birdsong soundscapes (T[1, 60] = –2.57; P = .012; d = –0.29).

For anxiety, the post hoc within-group analyses found no effects within low- and high-diversity traffic noise conditions (T[1, 82] = –1.37; P = .174; d = –0.15 and T[1, 68] = 0.49; P = .629; d = 0.06, respectively). By contrast, there were significant declines in both birdsong conditions (low diversity: T[1, 62] = –6.13; P < .001; d = –0.77; high diversity: T[1, 60] = –6.32; P < .001; d =  –0.70).

Similarly, there were no changes in participants with paranoia when they listened to either low- or high-diversity traffic noises (T[1, 82] = –0.55; P = .583; d = –0.06 and T[1, 68] = 0.67; P = .507; d = 0.08, respectively). On the other hand, both birdsong conditions yielded reductions in paranoia (low diversity: T[1, 62] = –5.90; P < .001; d = –0.74; high diversity: T[1, 60] =  –4.11; P < .001; d = –0.46).

None of the soundscapes had any effect on cognition.

“In theory, birds can be representational for natural and vital environments which, in turn, transfer the positive effects of nature on birdsong listeners,” said Mr. Stobbe.

“Taken together, the findings of the current study provide another facet of why interactions with nature can be beneficial for our mental health, and it is highly important to preserve nature,” he added.

Mr. Stobbe said that future research should focus on investigating mixed soundscapes including examining whether the presence of natural sounds in urban settings lower stressors such as traffic noise.
 

An understudied area

Commenting for this article, Ken Duckworth, MD, chief medical officer of the National Alliance on Mental Illness called the study “interesting but limited.”

Dr. Duckworth, who was not involved in the research said that the “benefits of nature are understudied” and agreed with the investigators that it is potentially important to study the use of birdsongs in psychiatric facilities. “Future studies could also correlate the role of birdsong with the mental health benefits/aspects of ‘being in nature,’ which has been found to have some effect.”

Open Access funding was enabled and organized by Projekt DEAL. The authors and Dr. Duckworth declared no competing interests.

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

Psychiatric patients with impaired communication abilities were significantly more likely to be admitted involuntarily to inpatient care and to experience coercive measures after admission, based on data from more than 1,500 individuals.

Despite improvements in reducing coercive measures in psychiatric inpatient care, both involuntary admission and coercive measures remain in use in many countries worldwide, wrote Celline Cole, MSc, a doctoral candidate at Charité Universitätsmedizin, Berlin, and colleagues. Such measures are considered “severe violations of a person’s rights to self-determination and personal freedom,” they wrote.

Previous studies have identified characteristics that increase the risk of involuntary inpatient admission, but the association between patients’ communication ability and coercive measures has not been explored, they noted.

In a study published in the Journal of Psychiatric Research, the investigators reviewed data from 1,556 adults who were admitted to psychiatric inpatient care at a single center in Germany in 2019. Patients’ communication ability was defined and recorded as one of the following: perfect; limited because of language or other reasons; or impossible because of language or other reasons (no communication).

Overall, 23% of patients were admitted involuntarily; the most common reasons for referral to inpatient care in the study population were physical aggression against individuals (8%) or objects (4%), and verbal aggression (7%). A total of 1,085 patients (70%) were able or willing to communicate.

Patients with limited or no communication ability because of language issues were three to four times more likely to be admitted involuntarily (odds ratios, 3.08 and 4.02, respectively), while those with limited or no communication ability because of nonlanguage issues were even more likely to be admitted involuntarily (ORs, 3.10 and 13.71, respectively), compared with patients without communication problems.

Patients with limited communication ability because of language issues also were significantly more likely than those without communication issues to experience coercive measures (OR, 4.53), as were patients with either limited or no communication ability because of no-language issues (ORs, 1.58 and 3.55, respectively).

Involuntary admission was defined as provisional detention, detention initiated by the patient’s legal guardian followed by a court order, or detention by court order “according to the Mental Health Law of the State of Berlin,” the researchers said. The average length of inpatient stay was 19 days. The age of the patients ranged from 18 to 96 years, with a mean age of 41.5 years, and 63% identified as male. Approximately two-thirds (62%) were unemployed or job-seeking during their treatment period, 38% were living alone, and 17% were homeless.

Although most of the study population (84%) was of German nationality, nearly half (48%) had a first- or second-generation migration background, the researchers noted.

“When thinking about effectively targeting this issue it is crucial to consider the different reasons why patients are limited in their ability to communicate,” the researchers wrote in their discussion. “Considering the rising numbers of refugees and persons with a migration background in Germany and many other countries worldwide, it is likely that more and more individuals with a language barrier will present at psychiatric emergency rooms,” they emphasized.

The findings were limited by several factors including the retrospective design, the relatively small number of patients with limitations or complete inability to communicate, and the use of data from a single hospital, and the incomplete data on nonlanguage reasons for limited or no communication ability, the researchers noted. Future studies should include more complete measures for recording these reasons, and data on forced medication, they added.

However, the results were strengthened by the range of sociodemographic, clinical, and admission-related variables in a large and representative sample, and highlight the need for appropriate interventions for patients with communication challenges, they said.

“Adequate financial and human resources need to be allocated to psychiatric hospitals that allow for high quality, available, and accessible interpretation services as well as mobilization of patients’ support networks during and after admission,” they concluded.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Psychiatric patients with impaired communication abilities were significantly more likely to be admitted involuntarily to inpatient care and to experience coercive measures after admission, based on data from more than 1,500 individuals.

Despite improvements in reducing coercive measures in psychiatric inpatient care, both involuntary admission and coercive measures remain in use in many countries worldwide, wrote Celline Cole, MSc, a doctoral candidate at Charité Universitätsmedizin, Berlin, and colleagues. Such measures are considered “severe violations of a person’s rights to self-determination and personal freedom,” they wrote.

Previous studies have identified characteristics that increase the risk of involuntary inpatient admission, but the association between patients’ communication ability and coercive measures has not been explored, they noted.

In a study published in the Journal of Psychiatric Research, the investigators reviewed data from 1,556 adults who were admitted to psychiatric inpatient care at a single center in Germany in 2019. Patients’ communication ability was defined and recorded as one of the following: perfect; limited because of language or other reasons; or impossible because of language or other reasons (no communication).

Overall, 23% of patients were admitted involuntarily; the most common reasons for referral to inpatient care in the study population were physical aggression against individuals (8%) or objects (4%), and verbal aggression (7%). A total of 1,085 patients (70%) were able or willing to communicate.

Patients with limited or no communication ability because of language issues were three to four times more likely to be admitted involuntarily (odds ratios, 3.08 and 4.02, respectively), while those with limited or no communication ability because of nonlanguage issues were even more likely to be admitted involuntarily (ORs, 3.10 and 13.71, respectively), compared with patients without communication problems.

Patients with limited communication ability because of language issues also were significantly more likely than those without communication issues to experience coercive measures (OR, 4.53), as were patients with either limited or no communication ability because of no-language issues (ORs, 1.58 and 3.55, respectively).

Involuntary admission was defined as provisional detention, detention initiated by the patient’s legal guardian followed by a court order, or detention by court order “according to the Mental Health Law of the State of Berlin,” the researchers said. The average length of inpatient stay was 19 days. The age of the patients ranged from 18 to 96 years, with a mean age of 41.5 years, and 63% identified as male. Approximately two-thirds (62%) were unemployed or job-seeking during their treatment period, 38% were living alone, and 17% were homeless.

Although most of the study population (84%) was of German nationality, nearly half (48%) had a first- or second-generation migration background, the researchers noted.

“When thinking about effectively targeting this issue it is crucial to consider the different reasons why patients are limited in their ability to communicate,” the researchers wrote in their discussion. “Considering the rising numbers of refugees and persons with a migration background in Germany and many other countries worldwide, it is likely that more and more individuals with a language barrier will present at psychiatric emergency rooms,” they emphasized.

The findings were limited by several factors including the retrospective design, the relatively small number of patients with limitations or complete inability to communicate, and the use of data from a single hospital, and the incomplete data on nonlanguage reasons for limited or no communication ability, the researchers noted. Future studies should include more complete measures for recording these reasons, and data on forced medication, they added.

However, the results were strengthened by the range of sociodemographic, clinical, and admission-related variables in a large and representative sample, and highlight the need for appropriate interventions for patients with communication challenges, they said.

“Adequate financial and human resources need to be allocated to psychiatric hospitals that allow for high quality, available, and accessible interpretation services as well as mobilization of patients’ support networks during and after admission,” they concluded.

The study received no outside funding. The researchers had no financial conflicts to disclose.

Psychiatric patients with impaired communication abilities were significantly more likely to be admitted involuntarily to inpatient care and to experience coercive measures after admission, based on data from more than 1,500 individuals.

Despite improvements in reducing coercive measures in psychiatric inpatient care, both involuntary admission and coercive measures remain in use in many countries worldwide, wrote Celline Cole, MSc, a doctoral candidate at Charité Universitätsmedizin, Berlin, and colleagues. Such measures are considered “severe violations of a person’s rights to self-determination and personal freedom,” they wrote.

Previous studies have identified characteristics that increase the risk of involuntary inpatient admission, but the association between patients’ communication ability and coercive measures has not been explored, they noted.

In a study published in the Journal of Psychiatric Research, the investigators reviewed data from 1,556 adults who were admitted to psychiatric inpatient care at a single center in Germany in 2019. Patients’ communication ability was defined and recorded as one of the following: perfect; limited because of language or other reasons; or impossible because of language or other reasons (no communication).

Overall, 23% of patients were admitted involuntarily; the most common reasons for referral to inpatient care in the study population were physical aggression against individuals (8%) or objects (4%), and verbal aggression (7%). A total of 1,085 patients (70%) were able or willing to communicate.

Patients with limited or no communication ability because of language issues were three to four times more likely to be admitted involuntarily (odds ratios, 3.08 and 4.02, respectively), while those with limited or no communication ability because of nonlanguage issues were even more likely to be admitted involuntarily (ORs, 3.10 and 13.71, respectively), compared with patients without communication problems.

Patients with limited communication ability because of language issues also were significantly more likely than those without communication issues to experience coercive measures (OR, 4.53), as were patients with either limited or no communication ability because of no-language issues (ORs, 1.58 and 3.55, respectively).

Involuntary admission was defined as provisional detention, detention initiated by the patient’s legal guardian followed by a court order, or detention by court order “according to the Mental Health Law of the State of Berlin,” the researchers said. The average length of inpatient stay was 19 days. The age of the patients ranged from 18 to 96 years, with a mean age of 41.5 years, and 63% identified as male. Approximately two-thirds (62%) were unemployed or job-seeking during their treatment period, 38% were living alone, and 17% were homeless.

Although most of the study population (84%) was of German nationality, nearly half (48%) had a first- or second-generation migration background, the researchers noted.

“When thinking about effectively targeting this issue it is crucial to consider the different reasons why patients are limited in their ability to communicate,” the researchers wrote in their discussion. “Considering the rising numbers of refugees and persons with a migration background in Germany and many other countries worldwide, it is likely that more and more individuals with a language barrier will present at psychiatric emergency rooms,” they emphasized.

The findings were limited by several factors including the retrospective design, the relatively small number of patients with limitations or complete inability to communicate, and the use of data from a single hospital, and the incomplete data on nonlanguage reasons for limited or no communication ability, the researchers noted. Future studies should include more complete measures for recording these reasons, and data on forced medication, they added.

However, the results were strengthened by the range of sociodemographic, clinical, and admission-related variables in a large and representative sample, and highlight the need for appropriate interventions for patients with communication challenges, they said.

“Adequate financial and human resources need to be allocated to psychiatric hospitals that allow for high quality, available, and accessible interpretation services as well as mobilization of patients’ support networks during and after admission,” they concluded.

The study received no outside funding. The researchers had no financial conflicts to disclose.

DENVER – Patients who continued to undergo routine minimally invasive cosmetic procedures during the COVID-19 Omicron outbreak in 2021 were happier and more satisfied with life overall compared with the general population, according to a study of 42 individuals. However, these treatments did not improve their baseline happiness or life satisfaction scores at follow-up.

Those are key findings from the study that lead author Rishi Chopra, MD, MS, presented during an oral abstract session at the annual meeting of the American Society for Dermatologic Surgery.

“These are interesting and surprising results,” said Dr. Chopra, a dermatologist and laser and cosmetic dermatologic surgery fellow at Harvard Medical School and Massachusetts General Hospital in Boston. “Patients are seeking consultations with us with the hope that the treatments we offer may potentially help them feel happier, but are we really delivering on that?”

In a pivotal 2018 study that examined patient motivations for undergoing cosmetic dermatology procedures, investigators found that 67.2% did so to “feel happier and more confident or improve total quality of life”. Moreover, 38.5% cited the desire to “feel happier, better overall, or improve total quality of life” as the key reason for pursuing cosmetic procedures.

Prior published evidence validates this benefit of procedures, as neuromodulators have repeatedly demonstrated to improve mood and depression, including a 2020 randomized, single-blind crossover study that examined the impact of neuromodulators on mood and appearance during the COVID-19 pandemic. It found that patients who received treatment with neuromodulators prior to the pandemic, stopped during the pandemic, and restarted again, reported increased happiness, self-satisfaction with appearance, and overall treatment satisfaction.

“However, studies evaluating the effect of filler on happiness have failed to demonstrate an impact,” Dr. Chopra said. “Thus, the jury is still out.”

Study evaluated 42 patients

In what he said is the first study of its kind, he and his colleagues evaluated the impact of minimally invasive cosmetic procedures on the happiness of 42 treatment non-naive patients (those who regularly undergo cosmetic procedures) with a mean age of 47 years who were surveyed in November and December of 2021 during the COVID-19 Omicron subvariant outbreak at the cosmetic dermatology practices of Sabrina G. Fabi, MD, in San Diego, and Nicole Kanaris, MBBCh, in Johannesburg, South Africa.

“On average, these patients were undergoing six treatments per year during four visits per year, so these were frequent flyers,” Dr. Chopra said. “We set out to assess: Are patients who seek cosmetic procedures happy at baseline? And, do cosmetic procedures make us happier or more satisfied with life?”

Prior to treatment, patients completed the Subjective Happiness Scale (SHS) and Satisfaction With Life Scale (SWLS). Three weeks later, patients completed the SHS, SWLS, the Global Aesthetic Improvement Scale (GAIS) and a 5-point satisfaction score. The researchers used paired and unpaired t-tests, independent sample t-tests, and Spearman rank correlations to conduct statistical analyses.

The baseline SHS score of study participants was an average of 5.87, which Dr. Chopra said is higher than the worldwide population range between 4.57 and 5.33, and 5.05 in the U.S. population. “The patients in our study were very happy to begin with,” an important point to consider, he said. Following their treatments, respondents felt “improved” or “much improved” on the GAIS (a mean score of 3.64) and “somewhat satisfied” or “very satisfied” based on the SWLS (a mean score of 4.4). “So overall, they viewed their treatments as a success,” Dr. Chopra said.

In terms of happiness, however, the researchers observed no significant differences between pre- and posttreatment scores on the SHS (a mean of 5.87 vs. 6.61, respectively; P = .634) nor on the SWLS (a mean of 29.62 vs. 29.1; P = .709). On stratified analysis, no significant differences in the SHS, SWLS, and the GAIS were observed when the researchers accounted for the aggressiveness of the procedure, the number of treatments, the number of sites treated, the type of treatment, and whether the respondents were happier or sadder at baseline. “Surprisingly, this had no effect whatsoever on happiness,” he said. “Not only that, these factors didn’t improve a patient’s perception of the efficacy or satisfaction with a treatment either.”

“In addition, only two locations were surveyed, so the results could have location bias. I think it would be a great idea to replicate this survey of experienced cosmetic treatment patients with many locations and to include survey responses based on the procedure that was done. That said, it is interesting that overall, investigator satisfaction did not correlate with patient happiness from the treatments.”

Dr. Chopra reported having no financial disclosures. Dr. Green disclosed that he is a speaker, consultant, or investigator for numerous pharmaceutical companies.

DENVER – Patients who continued to undergo routine minimally invasive cosmetic procedures during the COVID-19 Omicron outbreak in 2021 were happier and more satisfied with life overall compared with the general population, according to a study of 42 individuals. However, these treatments did not improve their baseline happiness or life satisfaction scores at follow-up.

Those are key findings from the study that lead author Rishi Chopra, MD, MS, presented during an oral abstract session at the annual meeting of the American Society for Dermatologic Surgery.

“These are interesting and surprising results,” said Dr. Chopra, a dermatologist and laser and cosmetic dermatologic surgery fellow at Harvard Medical School and Massachusetts General Hospital in Boston. “Patients are seeking consultations with us with the hope that the treatments we offer may potentially help them feel happier, but are we really delivering on that?”

In a pivotal 2018 study that examined patient motivations for undergoing cosmetic dermatology procedures, investigators found that 67.2% did so to “feel happier and more confident or improve total quality of life”. Moreover, 38.5% cited the desire to “feel happier, better overall, or improve total quality of life” as the key reason for pursuing cosmetic procedures.

Prior published evidence validates this benefit of procedures, as neuromodulators have repeatedly demonstrated to improve mood and depression, including a 2020 randomized, single-blind crossover study that examined the impact of neuromodulators on mood and appearance during the COVID-19 pandemic. It found that patients who received treatment with neuromodulators prior to the pandemic, stopped during the pandemic, and restarted again, reported increased happiness, self-satisfaction with appearance, and overall treatment satisfaction.

“However, studies evaluating the effect of filler on happiness have failed to demonstrate an impact,” Dr. Chopra said. “Thus, the jury is still out.”

Study evaluated 42 patients

In what he said is the first study of its kind, he and his colleagues evaluated the impact of minimally invasive cosmetic procedures on the happiness of 42 treatment non-naive patients (those who regularly undergo cosmetic procedures) with a mean age of 47 years who were surveyed in November and December of 2021 during the COVID-19 Omicron subvariant outbreak at the cosmetic dermatology practices of Sabrina G. Fabi, MD, in San Diego, and Nicole Kanaris, MBBCh, in Johannesburg, South Africa.

“On average, these patients were undergoing six treatments per year during four visits per year, so these were frequent flyers,” Dr. Chopra said. “We set out to assess: Are patients who seek cosmetic procedures happy at baseline? And, do cosmetic procedures make us happier or more satisfied with life?”

Prior to treatment, patients completed the Subjective Happiness Scale (SHS) and Satisfaction With Life Scale (SWLS). Three weeks later, patients completed the SHS, SWLS, the Global Aesthetic Improvement Scale (GAIS) and a 5-point satisfaction score. The researchers used paired and unpaired t-tests, independent sample t-tests, and Spearman rank correlations to conduct statistical analyses.

The baseline SHS score of study participants was an average of 5.87, which Dr. Chopra said is higher than the worldwide population range between 4.57 and 5.33, and 5.05 in the U.S. population. “The patients in our study were very happy to begin with,” an important point to consider, he said. Following their treatments, respondents felt “improved” or “much improved” on the GAIS (a mean score of 3.64) and “somewhat satisfied” or “very satisfied” based on the SWLS (a mean score of 4.4). “So overall, they viewed their treatments as a success,” Dr. Chopra said.

In terms of happiness, however, the researchers observed no significant differences between pre- and posttreatment scores on the SHS (a mean of 5.87 vs. 6.61, respectively; P = .634) nor on the SWLS (a mean of 29.62 vs. 29.1; P = .709). On stratified analysis, no significant differences in the SHS, SWLS, and the GAIS were observed when the researchers accounted for the aggressiveness of the procedure, the number of treatments, the number of sites treated, the type of treatment, and whether the respondents were happier or sadder at baseline. “Surprisingly, this had no effect whatsoever on happiness,” he said. “Not only that, these factors didn’t improve a patient’s perception of the efficacy or satisfaction with a treatment either.”

“In addition, only two locations were surveyed, so the results could have location bias. I think it would be a great idea to replicate this survey of experienced cosmetic treatment patients with many locations and to include survey responses based on the procedure that was done. That said, it is interesting that overall, investigator satisfaction did not correlate with patient happiness from the treatments.”

Dr. Chopra reported having no financial disclosures. Dr. Green disclosed that he is a speaker, consultant, or investigator for numerous pharmaceutical companies.

DENVER – Patients who continued to undergo routine minimally invasive cosmetic procedures during the COVID-19 Omicron outbreak in 2021 were happier and more satisfied with life overall compared with the general population, according to a study of 42 individuals. However, these treatments did not improve their baseline happiness or life satisfaction scores at follow-up.

Those are key findings from the study that lead author Rishi Chopra, MD, MS, presented during an oral abstract session at the annual meeting of the American Society for Dermatologic Surgery.

“These are interesting and surprising results,” said Dr. Chopra, a dermatologist and laser and cosmetic dermatologic surgery fellow at Harvard Medical School and Massachusetts General Hospital in Boston. “Patients are seeking consultations with us with the hope that the treatments we offer may potentially help them feel happier, but are we really delivering on that?”

In a pivotal 2018 study that examined patient motivations for undergoing cosmetic dermatology procedures, investigators found that 67.2% did so to “feel happier and more confident or improve total quality of life”. Moreover, 38.5% cited the desire to “feel happier, better overall, or improve total quality of life” as the key reason for pursuing cosmetic procedures.

Prior published evidence validates this benefit of procedures, as neuromodulators have repeatedly demonstrated to improve mood and depression, including a 2020 randomized, single-blind crossover study that examined the impact of neuromodulators on mood and appearance during the COVID-19 pandemic. It found that patients who received treatment with neuromodulators prior to the pandemic, stopped during the pandemic, and restarted again, reported increased happiness, self-satisfaction with appearance, and overall treatment satisfaction.

“However, studies evaluating the effect of filler on happiness have failed to demonstrate an impact,” Dr. Chopra said. “Thus, the jury is still out.”

Study evaluated 42 patients

In what he said is the first study of its kind, he and his colleagues evaluated the impact of minimally invasive cosmetic procedures on the happiness of 42 treatment non-naive patients (those who regularly undergo cosmetic procedures) with a mean age of 47 years who were surveyed in November and December of 2021 during the COVID-19 Omicron subvariant outbreak at the cosmetic dermatology practices of Sabrina G. Fabi, MD, in San Diego, and Nicole Kanaris, MBBCh, in Johannesburg, South Africa.

“On average, these patients were undergoing six treatments per year during four visits per year, so these were frequent flyers,” Dr. Chopra said. “We set out to assess: Are patients who seek cosmetic procedures happy at baseline? And, do cosmetic procedures make us happier or more satisfied with life?”

Prior to treatment, patients completed the Subjective Happiness Scale (SHS) and Satisfaction With Life Scale (SWLS). Three weeks later, patients completed the SHS, SWLS, the Global Aesthetic Improvement Scale (GAIS) and a 5-point satisfaction score. The researchers used paired and unpaired t-tests, independent sample t-tests, and Spearman rank correlations to conduct statistical analyses.

The baseline SHS score of study participants was an average of 5.87, which Dr. Chopra said is higher than the worldwide population range between 4.57 and 5.33, and 5.05 in the U.S. population. “The patients in our study were very happy to begin with,” an important point to consider, he said. Following their treatments, respondents felt “improved” or “much improved” on the GAIS (a mean score of 3.64) and “somewhat satisfied” or “very satisfied” based on the SWLS (a mean score of 4.4). “So overall, they viewed their treatments as a success,” Dr. Chopra said.

In terms of happiness, however, the researchers observed no significant differences between pre- and posttreatment scores on the SHS (a mean of 5.87 vs. 6.61, respectively; P = .634) nor on the SWLS (a mean of 29.62 vs. 29.1; P = .709). On stratified analysis, no significant differences in the SHS, SWLS, and the GAIS were observed when the researchers accounted for the aggressiveness of the procedure, the number of treatments, the number of sites treated, the type of treatment, and whether the respondents were happier or sadder at baseline. “Surprisingly, this had no effect whatsoever on happiness,” he said. “Not only that, these factors didn’t improve a patient’s perception of the efficacy or satisfaction with a treatment either.”

“In addition, only two locations were surveyed, so the results could have location bias. I think it would be a great idea to replicate this survey of experienced cosmetic treatment patients with many locations and to include survey responses based on the procedure that was done. That said, it is interesting that overall, investigator satisfaction did not correlate with patient happiness from the treatments.”

Dr. Chopra reported having no financial disclosures. Dr. Green disclosed that he is a speaker, consultant, or investigator for numerous pharmaceutical companies.

Smokers who quit before age 35 showed a "substantial" reduction in risk, compared with people who never smoked, according to a new national study.

Researchers also quantified the benefit of quitting for those older than 35. The added risk of death associated with smoking was reduced by 90% for those who quit before age 45 and 66% for those who quit at ages 45 to 64.

“The distal nature of the health consequences for young smokers is a challenge for professionals trying to motivate quitting in younger age groups. Without a proximal goal, it is tempting for smokers to abandon a quit attempt with cognitions such as ‘I don’t really need to do it just now,’ ” John P. Pierce, PhD, director for Population Sciences at UC-San Diego’s Moores Cancer Center, wrote in a commentary. 

Current smokers were twice as likely to die from any cause during the study, compared with the group researchers called “never smokers,” who were defined as smoking fewer than 100 lifetime cigarettes. 

Published in JAMA Network Open, the study involved 551,388 U.S. participants using information collected by the CDC from 1997 to 2018. Researchers collected data for specific causes of death of participants through the end of 2019.

The results echo past findings but also established whether demographic factors such as a smoker’s race and gender impact the benefits of quitting. (In many areas of health research, a person’s race or gender is associated with varying risks.)

The researchers found that the benefits of quitting smoking in reducing risk of death are comparable across demographic groups.

“Among former smokers in each racial and ethnic group, whether male or female, quitting was associated with reductions of approximately 80% of the excess mortality associated with continued smoking,” the authors stated. “These associations were generally consistent for deaths from cancer, cardiovascular disease, and lower respiratory disease.”

The findings are also important for guiding stop-smoking efforts because while smoking nationwide has decreased, the reduction has varied across demographic groups.

“Monitoring the association of smoking with mortality by race, ethnicity, and sex is critical to understanding how the U.S. tobacco epidemic continues to evolve over time and who is most affected by the changes,” the authors stated. “Despite continued decreases in U.S. smoking prevalence in recent decades, progress has not been equal across demographic groups. Recent progress in raising the quit ratio among U.S. ever-smokers overall has been modest, and the quit ratio has been consistently lower among Black and Hispanic ever-smokers than among non-Hispanic White ever-smokers.”

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

This article was updated 10/27/22.

Smokers who quit before age 35 showed a "substantial" reduction in risk, compared with people who never smoked, according to a new national study.

Researchers also quantified the benefit of quitting for those older than 35. The added risk of death associated with smoking was reduced by 90% for those who quit before age 45 and 66% for those who quit at ages 45 to 64.

“The distal nature of the health consequences for young smokers is a challenge for professionals trying to motivate quitting in younger age groups. Without a proximal goal, it is tempting for smokers to abandon a quit attempt with cognitions such as ‘I don’t really need to do it just now,’ ” John P. Pierce, PhD, director for Population Sciences at UC-San Diego’s Moores Cancer Center, wrote in a commentary. 

Current smokers were twice as likely to die from any cause during the study, compared with the group researchers called “never smokers,” who were defined as smoking fewer than 100 lifetime cigarettes. 

Published in JAMA Network Open, the study involved 551,388 U.S. participants using information collected by the CDC from 1997 to 2018. Researchers collected data for specific causes of death of participants through the end of 2019.

The results echo past findings but also established whether demographic factors such as a smoker’s race and gender impact the benefits of quitting. (In many areas of health research, a person’s race or gender is associated with varying risks.)

The researchers found that the benefits of quitting smoking in reducing risk of death are comparable across demographic groups.

“Among former smokers in each racial and ethnic group, whether male or female, quitting was associated with reductions of approximately 80% of the excess mortality associated with continued smoking,” the authors stated. “These associations were generally consistent for deaths from cancer, cardiovascular disease, and lower respiratory disease.”

The findings are also important for guiding stop-smoking efforts because while smoking nationwide has decreased, the reduction has varied across demographic groups.

“Monitoring the association of smoking with mortality by race, ethnicity, and sex is critical to understanding how the U.S. tobacco epidemic continues to evolve over time and who is most affected by the changes,” the authors stated. “Despite continued decreases in U.S. smoking prevalence in recent decades, progress has not been equal across demographic groups. Recent progress in raising the quit ratio among U.S. ever-smokers overall has been modest, and the quit ratio has been consistently lower among Black and Hispanic ever-smokers than among non-Hispanic White ever-smokers.”

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

This article was updated 10/27/22.

Smokers who quit before age 35 showed a "substantial" reduction in risk, compared with people who never smoked, according to a new national study.

Researchers also quantified the benefit of quitting for those older than 35. The added risk of death associated with smoking was reduced by 90% for those who quit before age 45 and 66% for those who quit at ages 45 to 64.

“The distal nature of the health consequences for young smokers is a challenge for professionals trying to motivate quitting in younger age groups. Without a proximal goal, it is tempting for smokers to abandon a quit attempt with cognitions such as ‘I don’t really need to do it just now,’ ” John P. Pierce, PhD, director for Population Sciences at UC-San Diego’s Moores Cancer Center, wrote in a commentary. 

Current smokers were twice as likely to die from any cause during the study, compared with the group researchers called “never smokers,” who were defined as smoking fewer than 100 lifetime cigarettes. 

Published in JAMA Network Open, the study involved 551,388 U.S. participants using information collected by the CDC from 1997 to 2018. Researchers collected data for specific causes of death of participants through the end of 2019.

The results echo past findings but also established whether demographic factors such as a smoker’s race and gender impact the benefits of quitting. (In many areas of health research, a person’s race or gender is associated with varying risks.)

The researchers found that the benefits of quitting smoking in reducing risk of death are comparable across demographic groups.

“Among former smokers in each racial and ethnic group, whether male or female, quitting was associated with reductions of approximately 80% of the excess mortality associated with continued smoking,” the authors stated. “These associations were generally consistent for deaths from cancer, cardiovascular disease, and lower respiratory disease.”

The findings are also important for guiding stop-smoking efforts because while smoking nationwide has decreased, the reduction has varied across demographic groups.

“Monitoring the association of smoking with mortality by race, ethnicity, and sex is critical to understanding how the U.S. tobacco epidemic continues to evolve over time and who is most affected by the changes,” the authors stated. “Despite continued decreases in U.S. smoking prevalence in recent decades, progress has not been equal across demographic groups. Recent progress in raising the quit ratio among U.S. ever-smokers overall has been modest, and the quit ratio has been consistently lower among Black and Hispanic ever-smokers than among non-Hispanic White ever-smokers.”

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

This article was updated 10/27/22.