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Medscape
22-07-2025
- Health
- Medscape
Supplemental Oxygen Therapy: Tailor to Your Patient's Needs
Nothing captivates patient (or physician) imagination quite like oxygen. Its power and necessity are considered self-evident. Also a given is the need for saturation to be 90% or above. It's a nice round number, and we're taught early on it's the tipping point on the sigmoidal hemoglobin curve. No one wants to be caught on the steep portion. So, the floor nurse sneaks a nasal cannula onto your patient at night, and the intern walks them wearing a pulse-ox before discharge. At $2 billion per year for oxygen, we have a problem. JAMA recently published a 'patient-centered' oxygen review. It's excellent reading. Table 1 summarizes studies of patient and caregiver feedback on oxygen use, and Box 1 provides an individual patient narrative. The described experience and related complaints are painfully familiar to anyone caring for a patient on oxygen. There isn't any 'news' here, and others have called for oxygen reform. The review highlights the evidence — or lack thereof — and is notable for its practical depiction of oxygen devices, durable medical equipment (DME) companies, and overall oxygen logistics. I regularly receive emails from the American Thoracic Society (ATS) oxygen interest group asking for feedback to help support passage of the Supplemental Oxygen Access Reform Act. I can't speak to the substance of the act, but — per its proponents — it's designed to achieve what the JAMA review advocates: oxygen reimbursement and supply tailored to individual patient needs. Great. There are things we healthcare providers can do now, though. De-implementation (or deprescribing) is critical to cost efficiency, but it's a distant second to not ordering oxygen at all. Outside of the mortality benefit for those with resting hypoxia, outcomes from oxygen prescriptions range from inconsistent to nonexistent. So, to start, if your patient does not have resting hypoxia, think twice (or perhaps three times) before walking them or doing an exercise test. This brings us to the walk-of-life prior to hospital discharge. The resulting ambulatory oxygen prescription is meant to be 'short-term,' but it is rarely so. More often, it's a gateway drug, driving long-term prescriptions and patient dependence. This is well recognized, and both the ATS and CHEST College list deprescription as part of the their 'Choosing Wisely' campaign. Therapeutic overconfidence and time constraints, along with psychological patient dependence, conspire to prevent it. Discharge is typically handled by general medicine clinicians, house staff, or advanced practice healthcare providers, none of whom are comfortable withholding therapy from someone who desaturates with ambulation. However, to quote an old adage from The House of God , 'if you don't take a temperature, you can't find a fever.' If you don't walk your patient before discharge… I'd take the same approach to nocturnal hypoxia. The Centers for Medicare & Medicaid Services (CMS) reimbursement for desaturation at night is a modern-day medical mystery. The data isn't there and there aren't guidelines recommending it. Past reviews have argued against screening or prescribing. Anecdotally, I see this less now; but again, if you eliminate reimbursement. I'm confident it won't be seen at all. Lastly, there's oxygen education to improve health literacy. This is critical but it's a heavy lift. It takes time and resources, and both are in short supply. The JAMA review recommends an oxygen specialist to shepherd the anaerobe through the DME gauntlet. If only the authors could help me pay for one. Maybe I can negotiate with CMS myself. I'll stop ordering nocturnal and ambulatory oxygen supplementation. With the savings generated, CMS will pay for a respiratory therapist to do deprescription and DME navigation. Now that's choosing wisely.
Medscape
12-06-2025
- Health
- Medscape
Women With ILD Fare Better After ICU Care
Women admitted to ICU for interstitial lung disease (ILD) had shorter hospital stays and a lower risk for death than men, based on a new analysis of more than 800,000 individuals. Although previous studies have shown gender-based disparities in disease progression and severity for ILD based on subtype, data on the effect of gender on ICU outcomes in these patients are limited, according to Matthew Viggiano, MD, an internal medicine resident at Temple University Hospital, Philadelphia, and colleagues. In a study presented at the American Thoracic Society (ATS) 2025 International Conference, the researchers analyzed data from the National Inpatient Sample (NIS), part of the Healthcare Cost and Utilization Project for the period from 2016 to 2018. They identified 810,295 adults aged 18 years or older hospitalized with ILD, of whom 42,080 received ICU care. Of these, 46.7% were women. Female patients were significantly younger than male patients (mean age, 66.9 vs 69.1 years), more likely to be African American (17.0% vs 10.9%), and less likely to be Caucasian (63.7% vs 69.2%; P < .001 for all). Mortality was significantly lower in women than in men (40.5% vs 48.1%) even after adjusting for confounders including age, race, and comorbidities, and this difference was the most striking finding, Viggiano said in an interview. 'It also surprised us that these women tended to have a shorter length of hospital stay, given many came from lower-income areas,' he said. ICU stays were defined using International Classification of Diseases (ICD) codes for central line placement and mechanical ventilation. Overall, hospital stays for female patients lasted 1.15 days less than hospital stays for male patients. Female patients also were significantly more likely than male patients to come from lower-income ZIP codes (38.3% vs 33.2%) and less likely to have a history of tobacco use disorder (35.0% vs 43.9%; P < .001 for both). The reasons for the disparities remain unclear, but new studies suggest that hormones may play a role in disease progression and severity, Viggiano told Medscape Medical News . 'For example, estrogen has been implicated in modulating immune responses and fibrotic processes in the lungs via downregulating profibrotic pathways,' he said. 'Additionally, women may have lower threshold to seek medical attention or follow-up, leading to earlier intervention and management of ILD,' he noted. Other comorbidities unrelated to ILD also may contribute to morbidity and hospital length of stay, he added. 'Overall, recognizing these disparities is a key step toward more personalized treatment strategies, and our hope is that this research will prompt further studies to fully understand and address the underlying causes,' said Viggiano. Not Time for Gender Neutral Treatments Although the results suggest that clinicians should be aware that gender could influence ILD prognosis, the data do not suggest a need to advocate for entirely separate protocols as yet, Viggiano said. 'Instead, we encourage clinicians to recognize that men may have unique risk factors and might require more aggressive monitoring or early interventions; further studies will help refine specific management strategies,' he said. 'We believe evaluating for mortality and hospital stay in different subtypes of ILD would be an immediate future direction for the project,' said Viggiano. The investigation of specific biological, immunologic, and social factors also must be an area of focus, he said. 'Understanding why women fare better could lead to targeted therapies, especially for men who are at higher risk of poor outcomes, and ultimately to more personalized approaches to ILD care,' he added. To that end, Viggiano and colleagues intend to conduct prospective studies to explore specific biological markers and social determinants in men and women with ILD. 'We'll also look at the influence of treatment interventions, medication use, and rehabilitation services on outcomes. Ultimately, we'd like to identify targeted strategies to reduce the mortality gap and enhance care for both genders,' he told Medscape Medical News . Data Reinforce Differences 'As more treatments for interstitial lung diseases emerge, it is important that we now start focusing on which populations get the greatest benefit for specific treatments,' said Anthony Faugno, MD, a pulmonologist at Tufts Medicine, Boston, in an interview. To that end, the authors of the current study used data from the NIS to ask important questions about how sex, demographics, and socioeconomic factors affect patient outcomes, said Faugno, who was not involved in the study. Were You Surprised by Any of the Findings? Why or Why Not? Biologically important differences in hormones between men and women are known to affect the way a given disease behaves; therefore, it is important to have representative samples of diverse sex and race in clinical trials to ensure the generalizability of therapy, Faugno told Medscape Medical News . The current study findings were not surprisingbut reinforce the value of a diverse population using a large, nationally representative sample, he said. The current study findings may not directly affect clinical practice, as the results were based on ICD codes that cover many different diagnoses, Faugno noted. However, as the authors suggest, 'I do think it informs additional research directions, such as doing a similar analysis in specific interstitial diseases,' he said. The current study addresses a global catch-all term of ILD, which may include many different pathologies that respond to different treatments, said Faugno. 'A future analysis that addressed the gender disparities in more specific diagnoses would add to our understanding and help patients better understand how they may respond to a specific therapy,' he said.
Time of India
26-05-2025
- Health
- Time of India
Dr Sameer Arbat presents two research papers at ATS 2025 in San Francisco, USA
1 2 Nagpur: Dr Sameer Arbat, a renowned interventional pulmonologist in Central India, added another significant milestone to his career by presenting two original research papers at the prestigious American Thoracic Society (ATS) International Conference 2025 held in San Francisco, USA from May 16 to May 25. Dr Arbat presented two research papers including one on allergy testing and a rare case of airway stenting and removal conducted at One Healthcare. Both research papers were presented in collaboration with Dr Irfan Rahman, associate dean, Rochester University, New York. His research presentations were based on clinical advancements and innovations in interventional pulmonology, reflecting the growing capabilities of Indian medical research on the global stage. Dr Arbat showcased his contributions to cutting-edge pulmonary research on a global platform that draws thousands of clinicians, researchers, and thought leaders from around the world. Recognising his outstanding contributions and potential for international collaboration, Dr Arbat was selected as the Social Media Ambassador for this event by the Asia-Pacific Society of Respirology (APSR) and awarded a Registration Grant of $750 USD. by Taboola by Taboola Sponsored Links Sponsored Links Promoted Links Promoted Links You May Like ¡Desbloquea tus venas y gana años de vida! Beauty Ideas Leer más Undo The grant is awarded to a select few young researchers and clinicians from the Asia-Pacific region who show promise in advancing respiratory medicine. Dr Arbat, currently the president of Media Committee of World Association for Bronchology and Interventional Pulmonology (WABIP) became a member of the Society for Advanced Bronchoscopy (SAB) USA. Commenting on the honour, Dr Arbat said, "It is a privilege to represent India and the Asia-Pacific region at such a prestigious scientific forum. The American Thoracic Society Conference is one of the largest gathering of respiratory clinicians and researchers. Being able to present my work and exchange ideas with some of the best minds in the field is truly inspiring." Dr Arbat's achievements mark yet another proud moment for Nagpur and the Indian pulmonary fraternity, reinforcing the importance of global engagement and innovation in healthcare. Dr Sameer Arbat has performed more than 1,000 interventional pulmonology procedures including EBUS, Cryobiopsy, Rigid Bronchoscopy, Airway Stenting and Thoracoscopy.
Medscape
22-05-2025
- Health
- Medscape
Frailty in the ICU: Many Definitions, No Easy Solutions
SAN FRANCISCO — Frailty is hard to define and hard to distinguish from the effects of illness, injury, and medical interventions, but the frailty of patients in the intensive care unit (ICU) can have profound effects on outcomes, including the risk for mortality. In a scientific symposium on frailty in the ICU, presented during the American Thoracic Society (ATS) 2025 International Conference, researchers outlined both the challenges of assessing frailty in the ICU and the effects of frailty on patients in the ICU and after discharge. 'I think the ICU is a unique rubric to understand the role of frailty, stress, and maladaptive physiologic responses in mediating short- and long-term outcomes,' said Aluko Akini Hope, MD, from Oregon Health Sciences University in Portland, Oregon. Despite some unique challenges in the ICU setting, frailty can be measured using approaches that consider both frailty phenotype and cumulative deficits, Hope said. He defined physical frailty as 'a clinical state in which the patient has reduced functional reserve and increased vulnerability to stressors due to maladaptive changes across multiple physiologic systems.' Although definitions and means of assessing frailty vary, they can be roughly grouped into two main conceptual models. The phenotypic model relies on physical factors such as recent weight loss > 10 lbs, low grip strength, exhaustion, slow gait, and low physical activity. The cumulative health deficit model can be summed up as 'the more individuals have wrong, the more likely they are to be frail,' Hope said. Multiple Assessment Tools Frailty can be assessed with a variety of approaches, including the frailty index, which generates a score calculated by dividing the number of deficits a patient has by the total number of health variables considered. The assessment using this index can be reduced to approximately 30 items with good predictive validity, Hope said. The predictive power of this model relies, however, on clinical documentation in the electronic health record and is subject to residual confounding. In contrast to the frailty index, the Clinical Frailty Scales is based on clinical judgment of experienced clinicians to summarize the overall frailty or fitness level of older patients. The 9-point scale ranks patients from being 'very fit' to terminally ill and is associated with both morbidity and mortality outcomes in ICUs. This scale, widely used in ICUs in Canada for research purposes, has strong interrater reliability in ICU multidisciplinary teams, Hope commented. The phenotypic approach may be more difficult than other measures to use in a critical care setting because it relies on physical aspects such as ability to rise from a chair, slow walking speed, low physical activity, and exhaustion. These measures all rely on patient or caregiver recall. Performance measures to identify frailty include a sit-to-stand test, balance test, gait speed, and mobility stress testing, which may be appropriate in the post-ICU setting but can be hard to apply in a critical care unit. Impact on Outcomes Lauren Ferrante, MD, MHS, from the Yale School of Medicine in New Haven, Connecticut, noted that although the prevalence of frailty increases with age, from 3.2% in 65- to 70-year-olds to 25.7% in 85- to 89-year-olds in one study, many older adults are not frail, and making assumptions about frailty based only on appearance or immediate circumstances can result in either over- or undertreatment of patients. However, it is identified 'frailty is strongly associated with adverse ICU and hospital outcomes, including mortality,' she said. In addition, frailty 'is associated with worse patient-centered outcomes, including health-related quality-of-life and functional outcomes,' Ferrante said. She summarized findings from the literature on the effects of frailty on outcomes. For example, in a study published this year in the Annals of Intensive Care , investigators looked at the impact of frailty and older age on weaning patients from invasive mechanical ventilation and found that the highest proportion of patients for whom weaning failed was in those patients who were deemed to be frail, and that frailty had more consistent effect on weaning duration and success rates than older age. A separate study from the Canadian Critical Care Trials group, published in Intensive Care Medicine in 2024, found that frail patients were more likely than non-frail patients to experience ICU delirium and had higher in-hospital and 6-month mortality rates. Ferrante and colleagues, Hope and colleagues, and others have also looked at frail patients in longitudinal and cohort studies and found that frailty is associated with post-ICU disabilities and poor functional outcomes. In addition, patients who are frail have a 3.5-fold higher likelihood of new admissions to a nursing home after a critical illness than non-frail patients. And as John Muscedere, MD, Queen's University in Kingston, Ontario, Canada, and colleagues reported in a systematic review and meta-analysis, also presented at ATS 2025 International Conference, compared with non-frail patients, those who were frail had a more than twofold relative risk for in-hospital death, had a more than 2.5-fold relative risk for long-term mortality, and were significantly less likely to be discharged home. 'We should be thinking more about augmenting processes of care for frail ICU across the continuum to post-discharge care,' Ferrante said. She recommend considering automated methods of ascertaining frailty such as the eFrailty Index in the Epic medical record system, which automatically generates a frailty index score from chart data and has the potential to be adapted for use in the ICU. Clinicians should be cautioned, however, not to conflate automated measurements with severity of illness, which could yield false positive results, she emphasized. A Confusing Entity An ICU specialist who attended the session told Medscape Medical News that he wasn't convinced that the research presented during the session fully addressed the problem of frailty in the ICU. 'I really worry when we think about frailty as a construct in the ICU that we end up putting the cart before the horse. It's something that we know when we see it, but it's very difficult to measure, and we're talking about different things. When we say the word 'frailty' we're not always talking about the same thing, and I definitely worry when we think about developing specific interventions, particularly around ICU patients,' said Jeremy Kahn, MD, MS, professor of critical care medicine and health policy and management at the University of Pittsburgh, Pittsburgh. 'If we don't really understand what frailty is then we're going to end up with a lot of negative studies that may be several different diseases that we're conflating as one,' he said. Asked by Medscape Medical News whether the idea of an automated frailty index had merit, he replied that 'it's definitely more objective, but then it does raise the question whether you're measuring something new. We have lots of measures around comorbidities, we have age, which is very predictive, and not to say that frailty isn't a real thing, but if we can't measure it in a way differently from age or comorbidities, we're just using the electronic health record.' In the absence of an accurate objective measure of frailty, clinicians may be measuring things that they already know, such as comorbidities, or may be identifying patient populations that are diverse and may not be amenable to a single intervention, Kahn told Medscape Medical News . Hope, Ferrante, and Kahn reported having no relevant financial disclosures.
Miami Herald
21-05-2025
- Health
- Miami Herald
Lung cancer risk in never-smokers predicted by AI tool ‘Sybil'
ST. PAUL, Minn., May 19 (UPI) -- With lung cancer rates among non-smokers rising, especially young East Asian women, a new study released Monday is touting the promise of an artificial intelligence tool to "strongly" predict who's most at risk. Lung cancer has long been associated with smoking. But even as overall rates steadily drop and smoking decreases around the world, a unique population of young East Asians are seeing a 2% annual increase in lung cancer cases -- even though half of them have never smoked. The cause of this remains unknown, but suspicion is centered on genetic mutations developed during a person's lifetime rather than inherited, such as damage to a gene that codes for a protein known as EGFR, which prevents cells from growing too quickly. This genetic damage is believed to be caused by environmental toxins including second-hand smoke and even fumes produced by high-temperature stir-fry cooking in rooms that lack proper ventilation. Globally, more than 50% of women diagnosed with lung cancer are non-smokers, compared to 15% to 20% of men. Meanwhile, an estimated 57% of Asian-American women diagnosed with lung cancer have never smoked, compared to only about 15% of all other women, according to a recent University of California-San Francisco study. Against this backdrop of rising cancer cases among seemingly low-risk women, the potential of AI to accurately predict who may be most suspectable to a surprise lung cancer diagnosis has generated considerable interest around the world. In a paper presented Monday at the American Thoracic Society's medical conference in San Francisco, Dr. Yeon Wook Kim of the Seoul National University Bundang Hospital reported a new AI tool dubbed "Sybil" has proven to be accurate in identifying which "true low-risk individuals" are more likely to develop lung cancer -- all foretold from a single low-dose chest CT scan, or LDCT. Sybil, named after the female seers of ancient Greek mythology, was developed in 2023 by researchers at the Massachusetts Institute of Technology's Abdul Latif Jameel Clinic for Machine Learning in Health, the Mass General Cancer Center and Chang Gung Memorial Hospital in Taiwan. It was trained first by feeding it LDCT images largely absent of any signs of cancer, since early-stage lung cancer occupies only tiny portions of the lung and is invisible to the human eye. Then, researchers gave Sybil hundreds of scans with visible cancerous tumors. In its first run, Sybil was able to deliver "C-indices" of up to 0.81 in predicted future occurrences of lung cancer from analyzing one LDCT. Models achieving predictive C-index scores of over 0.7 are considered "good" and those over 0.8 are "strong." This week's Korean study validated those results. Kim and his colleagues evaluated 21,087 people ages 50 to 80 who underwent self-initiated LDCT screening between January 2009 and December 2021 in a tertiary hospital-affiliated screening center in South Korea. These subjects were followed up until June 2024. Baseline LDCTs were analyzed with Sybil to calculate the risk of lung cancer diagnosis within one to six years. Analyses were performed for individuals with various smoking histories, ranging from more than 20 "pack-years" to never-smokers, who comprised 11,098 of the participants. Among all participants, 257 (including 115 never-smokers) were diagnosed with lung cancer within six years from the baseline LDCT. Sybil achieved a C-index for lung cancer prediction at one year of 0.86 and 6 years of 0.74 for all the participants, while among never-smokers, one-year and six-year C-indices were 0.86 and 0.79, respectively. Kim told UPI the results hold the promise of helping to regularize lung cancer screening in Asia, where those efforts are inconsistent and, due to differing demographics, sometimes are at a "disconnect" with international screening criteria. "Asia bears the highest burden of lung cancer, accounting for over 60% of new cases and related deaths worldwide," he said in emailed comments. "A growing proportion of this burden is observed among individuals who have never smoked, particularly among women. "In Korea, more than 85% of female lung cancer patients are non-smokers. As a result, increasing attention has been given to evaluating the effectiveness of lung cancer screening, or LCS, in traditionally low-risk populations in Asia." Government-led programs and initiatives have expanded to include never-smokers into their LCS efforts, while other efforts varying from international guidelines due to their inclusion of such never-smokers have "gained traction in East Asian countries, including South Korea, Taiwan and China," Kim said. AI tools like Sybil could be used to develop "personalized strategies" for patients who have already undergone LDCT screening, but have not yet had follow-ups, he added, while cautioning that further validation will be needed "to confirm the model's potential for clinical use. "While the need for screening low-risk groups may be justified in certain settings, the lack of evidence from randomized trials limits the development of long-term LCS strategies for these populations." Researchers, meanwhile, are "actively" working on expanding Sybil's uses into other personalized health applications, said Adam Yala, an assistant professor at the UCSF/UC-Berkeley Joint Program in Computational Precision Health and one of the AI model's developers. "One, this is broadly applicable across many different types of cancers," he told UPI. "We've got processes ongoing for breast cancer, and we're also working on prostate and pancreas cancers. "And there's also evidence that from CT scans you could predict sudden deaths from cardiovascular disease. This would provide early detection, giving you a better opportunity for early intervention to provide better outcomes. So it's not uniquely about cancer. ... There's a version of this for cardiovascular health, and there could be other areas of medicine, as well." AI's potential to provide health benefits, Yala added, "is totally untapped. For instance, now we're only looking at a patient's CT scan once, but over time, you could look at multiple CTs. Mammograms, as well. There's a lot of data available there. It's a field at its infancy." Copyright 2025 UPI News Corporation. All Rights Reserved.
