Carolyn Rowley, PhD, is the executive director of the Cayenne Wellness Center, which is devoted to supporting people living with 

 in California. Recently, the center launched the California Sickle Cell Disease Mental Health and Wellness Initiative to provide mental health services at no cost to those with the disease. 

Unfortunately, in addition to the various challenges that people with sickle cell disease already face as a direct result of their condition, they often coincide with mental and emotional challenges as well. The initiative focuses on addressing these challenges, like depression and anxiety, which are prevalent in this population.

Rowley emphasized the importance of the initiative because there's been a need for mental health resources, particularly for those living with SCD. The Cayenne Center is known for hosting educational platforms, and according Rowley, the topic of mental health gets discussed in each one.

"We recommended that people seek out mental health, however, that's been challenging," she explained. 

The center's community health workers conducted a focus group last year to get more insight on what clients are looking for and what would motivate them to participate in mental health care.

"They found out that their clients would like to go to a provider that looks like them and also knows about sickle cell disease," Rowley said. "And that's actually quite rare."

People with sickle cell disease, particularly children, may struggle with frequent hospitalizations due to pain crises if their parents or caregivers are unaware of the triggers that precede a crisis. 

"I'm not speaking about the type of depression that is debilitating," Rowley clarified, "but the type of depression that leads to isolation at times, even as a child."

When a patient and their support system are aware of the patient's triggers that lead to a pain criss, that can be the difference between good and poor quality of life. 

Rowley, who also lives with sickle cell disease, said that people have a choice when they realize a pain episode is coming and it's unavoidable, in how they face it. What she does is acknowledge that the episode is coming, but she tells herself "it's not going to shadow everything, it's not going to paint my entire picture."

"I encourage others to do what you can do to manage," Rowley said, "but it's about to come and you're about to be on top of it and so it won't be as bad as it could be, because now, you already know you have tools as to how you can conquer this next pain episode."

Videos

Dr. Carolyn Rowley is leading the California Sickle Cell Disease Mental Health and Wellness Initiative to provide mental health services free to people living with sickle cell disease. 

Carolyn Rowley, PhD, Addresses Mental Health and Wellness in People with Sickle Cell Disease

A new self-guided video-based lifestyle intervention led to improvements in exercise capacity, dyspnea, and weight loss in patients with chronic obstructive pulmonary disease (COPD) who were overweight or obese.

the American Thoracic Society 2022 International Conference

, study author David Au, MD, MS, from the Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, noted the lack of lifestyle interventions associated with COPD.

He spoke of a patient with COPD he treated who, after losing significant weight due to lifestyle changes, no longer experienced shortness of breath and did not rely on medications.

“That made me think about, of studying (COPD) on a systematic basis, and really trying to ask the question about whether or not a lifestyle intervention in and of itself would actually benefit patients who had symptoms, and who were otherwise being fully treated for COPD,” Au said.

As such, Au and colleagues conducted INSIGHT, a pragmatic intervention trial that evaluated whether or not self-directed virtual lifestyle intervention would improve the quality of life and functional outcomes of 684 patients with COPD who were overweight or obese.

They determined whether this intervention improved participant 6-minute walk test distance, dyspnea and participant weight compared to usual care alone, with additional secondary outcomes including cardiovascular risk factors, and generic and condition specific quality of life.

Overall, the intervention appeared to reduce the rate of exercise loss among these patients, with modest improvements in exercise capacity, dyspnea, and weight loss

Au added that, by and large, pulmonologists have focused on medications to improve both quality of life and ameliorate exacerbation risk in patients COPD, in addition to other interventions such as lung transplantation. However, he felt that this data could provide pulmonologists with new possibilities in COPD mitigation.

“This provides an opportunity to think about a patient as a whole and think about how lifestyle intervention that's really kind of focused on weight and moderate exercise improvement can actually have meaningful impacts on patients well-being,” Au said.

Watch the full interview with Dr. Au above, and click 

Dr. Au spoke of how the new data provides an opportunity to think about how lifestyle intervention  focused on weight and moderate exercise can actually have meaningful impacts on patients with COPD.

David Au, MD, MS: Lifestyle Interventions for Weight Loss in Obese Patients with COPD

A new claims-based, machine-learning algorithm model has been shown to be effective in identifying patients with pulmonary arterial hypertension (PAH). This model was responsible for correctly identifying 73% of patients with PAH 6 months prior to a confirmed diagnosis.

The data on this classification model were presented at 

the American Thoracic Society 2020 International Conference

Though early diagnosis and treatment initiation for PAH have always been the objective, PAH symptoms are non-specific, which has resulted in many patients experiencing delays (an average of 2 or more years) in symptom onset and a confirmed diagnosis.

However, investigators led by Katherine Bettencourt, PhD, of Actelion Pharmaceuticals, developed a classification model that could identify PAH prior to diagnosis based on retrospective healthcare claims data.

The machine-learning model analyzed data from the US-based Optum Clinformatics database from January 2015 to December 2019.

Patients from this database with shared early symptomology of PAH including dyspnea, fatigue, and chest pain were divided into 2 cohorts, those with PAG and non-PAH controls with cardiovascular or respiratory disease.

Propensity score matching was controlled for differences such as age, sex, and race, and the matched control cohort was randomly down sampled to create a control to PAH patient ratio of 3:1.

A total of 1724 patients were in the PAH cohort while the control group has 5352 patients. Mean age was similar (69 and 70 years old), and roughly two-thirds of patients were female and White.

Bettencourt and colleagues observed that the model was able to distinguish between patients with PAH and controls at 6 months prior to diagnosis, with a threshold of 0.43.

Additionally, the model was capable of accurately identifying 73% of the patients with PAH, and the precision of the model was 50%.

Regarding the implications of this device, investigators believed the high rate of imaging procedures prior to a confirmed diagnosis of PAH indicated a need to screen sooner. The team also noted that current hospitalization data has shown that shifting diagnosis 6 months sooner could provide an opportunity for earlier treatment and reduce the risk of hospitalization prior to diagnosis.

“The performance of our model indicates the feasibility of identifying patients at a population level who might benefit from PAH-specific screening by using existing data that are routinely collected in a claims database,” the team wrote.

Articles

This model was responsible for correctly identifying 73% of patients with pulmonary arterial hypertension 6 months prior to a confirmed diagnosis.

Claims-Based Algorithm Identifies PAH 6 Months Prior to Diagnosis

A new investigation into inhaled corticosteroids (ICS) found that patients with moderate to very severe chronic obstructive pulmonary disorder (COPD) who withdrew from treatment experienced favorable changes in microbiome composition and improvements in exacerbations.

Though ICS have been shown to reduce exacerbation frequency in patients with COPD and eosinophilic inflammation, they have also been linked to an increased risk of pneumonia.

Additionally, previous research cited an increase in bacterial load in patients who with eosinophilic disease who were treated with ICS.

With the present study, an investigative team led by Holly Keir, PhD, of the University of Dundee, hypothesized that ICS withdrawal would reduce bacterial load and modify the airway microbiome in a study of 80 patients with COPD.

Patients were randomized to receive either Tiotropium and Olodaterol (ICS withdrawal) or Fluticasone Furoate/Vilanterol (ICS continuation) for 6 months.

“Interestingly, we didn't see that reduction in bacterial load that we're expecting to see when we withdrew ICS; however, we did see changes to the microbiome itself,” Keir said. “So, we saw massive changes in beta diversity following ICS withdrawals. When we looked in more detail about what was driving those changes, we found that in patients who had ICS withdrawal had an increase in commensal taxa, which we typically see as beneficial.”

In patients who continued ICS, Keir and colleagues observed higher levels of things like haemophilus and streptococcus, which are known to be pathogenic in those with COPD.

Lugogo added that the results of the study were in line with the ERS international guideline recommendations, which suggest that patients with an eosinophil count of less than 300 cells per microliter, less than two exacerbations, and 2 exacerbations per year, should consider withdrawing ICS.

“That's what we want people to think about- thinking about the ERS guidelines, looking at the blood eosinophil count and thinking if they're on ICS, do we actually need to withdraw? Can we reduce exacerbations? And when can we get patients that more favorable microbiome?”

Watch the full interview with Dr. Keir above, and click 

Dr. Holly Keir cites "massive changes" in beta diversity following ICS withdrawals in patients with moderate to very severe COPD.

Holly Keir, PhD: Changes in Microbiome Observed Following ICS Withdrawal in Patients with COPD

A new investigation suggests that elevated short-acting β-agonist (SABA) use among patients with sub-optimally controlled asthma was much more common than previously believed, including in patients with levels experts believe to be associated with exacerbations and asthma-related death.

 in San Francisco during the late breaking-session, “Application of Modified Delphi Expert Consensus Thresholds on SABA Reliever Use in Asthma to Data Obtained from a 12-Week Study of a Digital Inhaler in Suboptimally Controlled Asthma Patients”.

In an interview with HCPLive, primary investigator Nijira Lucia Lugogo, MD, from the University of Michigan, spoke of the genesis of the study as well as how she and her colleagues collected data on SABA overuse in patients with asthma.

“We started out by polling 100 clinicians around the country to ask them what their thoughts were about what a safe SABA threshold is,” Lugogo said. “Because we know from the guidelines, we're supposed to minimize SABA use as much as possible. But we wanted to know from clinicians (was) do you feel that the guidelines have been clear enough on what an unsafe threshold is?”

Lugogo and colleagues received over 80 responses before convening a panel of experts who concluded that the threshold for harm was roughly 3 inhalers per 12-month period, or 138 inhalations.

These thresholds were retroactively applied to an open-label study that featured 359 patients with ≥1 asthma exacerbation/prior year and suboptimal asthma control, all of whom monitored their SABA use through a digital inhaler called the ProAir Digihaler.

Lugogo and colleagues found that approximately 30% of the study population were using their medication above the suggested threshold, and that 5 patients had to be treated in order to identify 1 potential patient that would be at risk for poor outcomes including asthma exacerbations from SABA overreliance.

At times, patient reports on SABA use can be inaccurate, as can pharmacy fill records. As such, clinicians do not always know if their patients are using their medication appropriately.

With this study, Lugogo believed that the data collected with the Digihaler offers clinicians “a clear line of sight” into how patients are using their medications, giving patients and clinicians better insight into SABA use, which can be utilized to make healthier and appropriate changes to treatment.

“What we were trying to do is really use what the experts believed was important information, apply it to a data set of patients that had been using the digital inhaler with the rescue medication, and then tried to identify how many patients would we need to treat with this device and for how long in order to identify patients that were potentially at risk," Lugogo said. 

Hear the full interview with Dr. Lugogo above, and click 

Dr. Lugogo explains how the ProAir Digihaler was used to accurately monitor SABA use in patients with asthma -many of whom were overusing their medication- which could allow clinicians to make appropriate changes to treatment.

Nijira Lucia Lugogo, MD: Effectively Monitoring SABA Use with Digital Inhaler Technology

Polysomnographic endotypic traits including lower collapsibility, lower loop gain, and more were associated with greater efficacy of AtoOxy - a combination therapy of atomoxetine and oxybutynin- in patients with obstructive sleep apnea (OSA). These traits were also independent of baseline disease severity.

The findings were presented at the American Thoracic Society 2022 International Conference in San Francisco.

Previously, the combination of atomoxetine plus oxybutynin had been shown to significantly reduce the severity of OSA when administered before sleep.

Despite this a recent trial - ComboPlus, NCT03892772- found the response to AtoOxy to be heterogenous.

For the present study, the same investigative team led by Laura Gell, PhD, of the Division of Sleep Medicine at Harvard Medical School, hypothesized that therapeutic efficacy would be associated with “favorable pathophysiology, greater arousal threshold and a greater capacity for pharyngeal muscle compensation”.

A tota of 19 with OSA completed a randomized placebo-controlled crossover study with polysomnographic sleep studies performed at baseline and following 3 nights of AtoOxy therapy including 80/5 mg qhs and half doses that’s were administered on the first night.

An advanced analysis of the baseline study provided endotypic traits including loop gain, arousal threshold, collapsibility, and muscle compensation. 

Meanwhile, multivariable linear regression quantified associations between treatment efficacy and the 4 traits, before adjusting for baseline AHI, and the primary analysis determined if the traits explained unique heterogeneity in efficacy beyond AHI, and subsequent analysis described associations between individual traits and efficacy.

Finally, leave-one-out cross validation provided conservative estimates of predictive value.

AtoOxy efficacy was strongly associated with the four traits according to multivariable regression, independent of baseline AHI (P=0.00025 vs. AHI alone, R2=0.75 vs. 0.05).

Gell and colleagues noted that each of the 4 traits contributed significantly to the model.

As they hypothesized, greater AtoOxy efficacy was associated with lower collapsibility, lower loop gain, higher arousal threshold, and better muscle compensation.

Notably, the model fully separated responders (>50% reduction from baseline, N=10/19) and non- responders (N=9/19).

Predictive value was “promising” following cross validation, as predicted responders lowered AHI from baseline by 74% while predicted non-responders lowered AHI by 31% (P-difference=0.02). 

Meanwhile, the odds ratio for response was 18.7[1.6,223], and prediction accuracy was 79%.

A mixed model analysis confirmed greater AtoOxy efficacy compared to placebo in predicted responders.

“Our results provide new insights into the physiological factors responsible for greater AtoOxy efficacy, and may provide a means to identify patients most suitable for this therapy,” the team wrote.

The new study provides insights into the physiological factors for greater AtoOxy efficacy and can be referenced when identifying patients who are most suited for the therapy.

Polysomnographic Endotypic Traits Associated with AtoOxy Efficacy in OSA

Media and clinic education programs aimed to improve guideline-based aspirin use for preventing 

 (CVD) were not successful, according to new findings from a non-randomized controlled trial. 

Investigators, led by Russell V. Luepker, MD, MS, Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, conducted their trial between 2015 and 2020 to determine if community and clinic education interventions improve guideline-based aspirin use for the prevention of cardiovascular disease. The study authors noted that overuse as well as underuse of low-dose aspirin as a form of primary prevention of cardiovascular disease is common.

The investigators compared Minnesota, the intervention state, to 4 Upper Midwestern adjacent states that served as controls. Minnesota conducted a statewide campaign to distribute billboards, newspaper articles, and other print material, in addition to radio announcements, and the promotion of an Ask About Aspirin website, the study authors said. They also described how primary care clinics identified appropriate aspirin candidates and how those clinicians received continuing education about aspirin.

Investigators conducted 8,342 cross-sectional telephone surveys of men aged 45 - 79 years and women aged 55 - 79 years in 3 phases (baseline, plus 2- and 4-years post-intervention), they said. About half the participants continued through the study and their aspirin use was evaluated using a questionnaire, the study authors said.

Race was self-reported by the participants as mostly white (97%) compared to other races and ethnicities, the study authors reported. However, risk factors for cardiovascular disease – including hypertension, hyperlipidemia, diabetes, and smoking – were similar over the 3 surveys, after adjustments for age.

There were 58 billboards placed throughout Minnesota in the first 6 months of the intervention period, though most were changed at 3 months. Radio announcements were distributed to local stations and articles were distributed to local newspapers and health system newsletters, the study authors detailed.

More than 1 million visitors reached the Ask About Aspirin website, and about 53,000 completed the self-assessment for aspirin candidacy. Of those, about half completed the relevant questions and were advised to consult their physician regarding potential aspirin use. There is no data connecting website visits to physician follow-up due to privacy concerns, investigators noted.

About a quarter of the largest Minnesota health systems participated in the Ask About Aspirin program, which included a 1-credit continuing medical education module. In all, 378 physicians earned the credit, plus a group of 747 physician assistants, nurse practitioners, nurses, and other professionals with direct patient contact, the study authors said.

They additionally noted that google searches for low-dose aspirin benefits showed 7,000 news stories during the study period, in print and digital media.

Participants in Minnesota had reported awareness of the Ask About Aspirin media campaign around 4 to 6%, compared to 2 to 3% of surrounding states throughout the study period, the study authors found. At baseline and year 2 of the survey, the investigators observed that the media messages were predominantly favorable, but didn’t differ significantly between the intervention and control states. 

By year 4, the study authors found the messages not in favor of aspirin use increased significantly and were more often seen or heard in Minnesota. Mixed messages (both positive and negative) increased between years 2 and 4 of the surveys in all states, the study authors said.

The study authors also found that trends in aspirin use discussions with clinicians reportedly increased, but not significantly in Minnesota.

“A 4-year multichannel campaign using professional education, clinic interventions, and analog and digital media did not appear to produce a population-wide improvement in appropriate aspirin use,” Luepker concluded.

Association of a Community Population and Clinic Education Intervention Program With Guideline-Based Aspirin Use for Primary Prevention of Cardiovascular Disease

The media campaign to improve aspirin use included billboards, radio ads and print articles, in addition to a dedicated website. 

Campaign to Inform Low-Dose Aspirin Use for CVD Prevention Found Unsuccessful 

A relatively new method of evaluating would-be 

 may revolutionize the capability of transplant centers helping patients in dire need while on the US waitlist.

At institutions including Massachusetts General Hospital (MGH), it’s already making a difference in vital heart transplant resourcing and strategy.

In a presentation at the International Society for Heart & Lung Transplant (ISHLT) 2022 Meeting this month, MGH Outcomes in Cardiac Surgery Research Fellow Stanley B. Wolfe, MD, presented data and insight into his team’s utility of donation after cardiac death (DCD) heart transplant, on the heels of new advances in postmortem ischemic heart evaluation that allows clinicians to consider previously unwanted donations for waitlist patients.

The DCD heart transplant offering bucks the modern approach of lone donation after brain death practices, offered at most US transplant centers—in which donations occur following the cease of all brain function. MGH is among a few centers to offer DCD heart transplant, which occurs after a donor goes into circulatory arrest.

“As one might imagine, when you have a circulatory arrest, the heart is ischemic, so it’s historically been discouraged to use these donor organs,” Wolfe explained. “Although, every year there has been an increase in donation after circulatory deaths, so it’s something the heart transplant community has been very interested in pursuing.”

 on the brief history of DCD heart transplant, which began after innovations to heart reanimation in 2019 allowed clinicians to evaluate DCD hearts for transplant benefit.

Now, centers like that at MGH are benefitting from a decreased waiting time for its heart transplant-eligible patients—as well as a new confidence in broadening its eligibly for transplantation.

“We’ve always wanted to push the envelope in improving patient care, and every year patients continue to die on the heart transplant waiting list,” Wolfe said. “When presented with opportunity to present a trial where we could expand the use of donation after circulatory deaths, our center hopped on that.”

A Massachusetts General Hospital investigator explains how the innovative DCD practice addresses both waitlist issues and transplant center's capabilities.

How Donation After Cardiac Death Heart Transplants Are Benefitting Care Centers

in late April showed Black and Latinx adults with 

 benefitted from the addition of a patient-directed, quick-reliever provisional inhaled glucocorticoid therapy along with their usual care.

 Introducing Elliot Israel, MD, and Juan Carlos Cardet, MD, MPH


 The strategy and findings of the PREPARE trial


 How to initiate patient-activated reliever-triggered inhaled corticosteroid


 The effect of COVID-19 on real-world asthma trials


 How to lessen the disparities of asthma


The findings contribute to the prospect of implementing simpler care strategies for patients with difficult-to-control asthma, as well as feasible steps toward reducing asthma outcome disparities among people of color.

This May, during Asthma Awareness Month, the concept of PREPARE trial and its leading investigators headline a comprehensive discussion around mitigating key challenges in the chronic respiratory disease.

The newest episode of Lungcast features PREPARE investigators Elliot Israel, MD, of Harvard Medical School and Brigham and Women’s Hospital, and Juan Carlos Cardet, MD, MPH, of the University of South Florida Morsani College of Medicine.

Along with host Albert Rizzo, MD, chief medical officer of the American Lung Association (ALA), the research team discussed guideline-supported SMART strategy, the role of COVID in current asthma risks, and their own research into the disparate medical and financial impacts of asthma on the US patient population.

Lungcast is a monthly respiratory health podcast series from the ALA produced by 

Subscribe or listen to Lungcast on your favorite platforms:

https://open.spotify.com/show/1F3u1hKrwxi9snSQ0q3nti

https://podcasts.apple.com/us/podcast/lungcast/id1524712350

Podcasts

Elliot Israel, MD, and Juan Carlos Cardet, MD, MPH, join Lungcast to discuss their latest research into addressing Black and Latinx asthma outcome disparities.

How PREPARE Data, SMART Recommendations Alter Modern Asthma Strategy

A new investigation found that family history was an important contributor to the pathogenesis of obstructive sleep apnea (OSA), and was responsible for much of its effect on mediated by loop gain and neck size.

Previous research found that first-degree family history of OSA could be a potential risk factor for the sleep disorder, with estimates stating indicating ~40% of the variation in the apnea-hypopnea index (AHI).

However, the mechanisms of this effect have not been fully established.

As such, an investigative team led by Jeremy Orr, MD, Pulmonary and Critical Care Medicine at UC San Diego, tested the hypothesis regarding the effect of family history on AHI and how it is mediated through 1 or more known traits underlying OSA pathogenesis.

Orr and colleagues created a retrospective cohort based on a previous chart review of consecutive patients who were diagnosed with OSA (AHA≥5) based on an in-lab polysomnogram between January 2017 and December 2018. Each patients family history-status was explicitly noted.

The investigative team quantified 4 pathophysiological traits for each subject, including anatomical collapsibility, arousal threshold, loop gain, and pharyngeal dilator recruitment, which were determined via a validated polysomnography-based algorithm.

Following log-transforming of the AHI to increase normality, Orr and colleagues performed simple mediation analyses that included structural equation models. From there, the 4 traits and 2 proxy-markers of anatomical collapsibility functioned as candidate mediators, with age and sex being included as covariates.

A total of 355 patients with OSA were included in the study, all of whom had available data on family history of OSA and OSA traits. Among these patients, 104 (29%) has positive family history of OSA.

Investigators noted that both groups were similar in term of BMI, race and ethnicity. However, patients with a positive history of OSA tended to be younger compared to those without a positive history, with the median ages being 50 and 56, respectively.

Patients with a positive family history also tended to be female (50% versus 41%), and had more severe OSA based on a higher AHI (29 [17-60] vs 23 [12-50]).

Additionally, a positive family history was associated with a 37% (eβ=1.37) (P=0.001) higher AHI, partially mediated by loop gain (P>0.4). As such, this did not mediate its effect on the AHI.

In addition to confirming family history as an “important contributor” of OSA, the investigative team also believed this study suggested that high loop gain be considered as an endotype/phenotype for genome-wide association studies that focus on the genetic underpinnings of OSA.

“However, the majority of family history’s effect on AHI was not explained by traditional traits and markers of an unfavorable anatomy, and residual confounding or reverse causation cannot be excluded,” the team wrote.

Patients with a positive family history of OSA  tended to be female with more severe OSA based on a higher AHI.

Family History of OSA Contributes to Pathogenesis of the Condition

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