CHEST Physician

CHEST works to provide opportunities for members to serve as expert sources for both mainstream and trade media to create a stronger voice for members in pulmonary, critical care, and sleep medicine.

Below are media coverage highlights from the past few months that work to expand awareness of CHEST and to promote the expertise of CHEST members in the media.
 

Improving NIV access for patients with COPD

In December, Pulmonology Advisor covered recommendations from the noninvasive ventilation Technical Expert Panel report published in the journal CHEST^® by The American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society.

The article shares that, in the United States, patients with COPD are often prescribed home mechanical ventilators rather than more appropriate devices, due largely to current Centers for Medicare & Medicaid Services (CMS) policies that do not always take into account unique complexities of patients’ conditions.

In addition to the recommendations covered in Optimal NIV Medicare Access Promotion: Patients With COPD, the Technical Expert Panel also published reports on patients with Obstructive Sleep Apnea, patients with Central Sleep Apnea, patients with Hypoventilation Syndromes, and patients with Thoracic Restrictive Disorders in the journal CHEST.

The full article, Expert Panel Guidelines Promote Access to In-Home NIV for Patients With COPD, can be found on the Pulmonology Advisor website.
 

OSA and cardiovascular mortality

A journal CHEST® article, “A Validation Study of Four Different Cluster Analyses of OSA and the Incidence of Cardiovascular Mortality in a Hispanic Population,” by Gonzalo Labarca, MD, et al. was featured in a Healio Pulmonology article.

The research showed an association between excessive sleepiness and increased risk for cardiovascular mortality in Hispanic adults with moderate to severe Obstructive Sleep Apnea and, in the article, Dr. Labarca says, “The Latino population is underrepresented in the scientific literature. Therefore, validation data regarding novel approaches to better identify a subtype of OSA patients at high risk of CV mortality is strongly needed.”

The full article, Risk for CV Mortality Elevated in Hispanic Adults with OSA, Excessive Sleepiness, can be found on the Healio website.
 

Member in the news:

Chair of the CHEST COVID-19 Task Force, Ryan Maves, MD , joined New York Times podcast, “The Daily” to discuss how the omicron COVID-19 surge was different than previous surges because unvaccinated deaths are skewing younger. During the podcast, Dr. Maves said, “You know, many more [unvaccinated] people in their 40s and 50s are dying. And it’s a grim feeling, watching people who are your own age and maybe not that much older than you die of an entirely preventable illness.” The full podcast, This COVID Surge Feels Different can be found on the New York Times website.

CHEST news

CHEST regularly issues statements and press releases on a variety of topics, including closing the synthetic nicotine loophole and requests for Congress to extend telehealth services.

For all recent CHEST News, including these statements, visit the CHEST Newsroom at chestnet.org, and follow the hashtag #CHESTNews on Twitter.

If you have been included in a recent news article and would like it to be featured, send the coverage to [email protected].

CHEST works to provide opportunities for members to serve as expert sources for both mainstream and trade media to create a stronger voice for members in pulmonary, critical care, and sleep medicine.

Below are media coverage highlights from the past few months that work to expand awareness of CHEST and to promote the expertise of CHEST members in the media.
 

Improving NIV access for patients with COPD

In December, Pulmonology Advisor covered recommendations from the noninvasive ventilation Technical Expert Panel report published in the journal CHEST^® by The American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society.

The article shares that, in the United States, patients with COPD are often prescribed home mechanical ventilators rather than more appropriate devices, due largely to current Centers for Medicare & Medicaid Services (CMS) policies that do not always take into account unique complexities of patients’ conditions.

In addition to the recommendations covered in Optimal NIV Medicare Access Promotion: Patients With COPD, the Technical Expert Panel also published reports on patients with Obstructive Sleep Apnea, patients with Central Sleep Apnea, patients with Hypoventilation Syndromes, and patients with Thoracic Restrictive Disorders in the journal CHEST.

The full article, Expert Panel Guidelines Promote Access to In-Home NIV for Patients With COPD, can be found on the Pulmonology Advisor website.
 

OSA and cardiovascular mortality

A journal CHEST® article, “A Validation Study of Four Different Cluster Analyses of OSA and the Incidence of Cardiovascular Mortality in a Hispanic Population,” by Gonzalo Labarca, MD, et al. was featured in a Healio Pulmonology article.

The research showed an association between excessive sleepiness and increased risk for cardiovascular mortality in Hispanic adults with moderate to severe Obstructive Sleep Apnea and, in the article, Dr. Labarca says, “The Latino population is underrepresented in the scientific literature. Therefore, validation data regarding novel approaches to better identify a subtype of OSA patients at high risk of CV mortality is strongly needed.”

The full article, Risk for CV Mortality Elevated in Hispanic Adults with OSA, Excessive Sleepiness, can be found on the Healio website.
 

Member in the news:

Chair of the CHEST COVID-19 Task Force, Ryan Maves, MD , joined New York Times podcast, “The Daily” to discuss how the omicron COVID-19 surge was different than previous surges because unvaccinated deaths are skewing younger. During the podcast, Dr. Maves said, “You know, many more [unvaccinated] people in their 40s and 50s are dying. And it’s a grim feeling, watching people who are your own age and maybe not that much older than you die of an entirely preventable illness.” The full podcast, This COVID Surge Feels Different can be found on the New York Times website.

CHEST news

CHEST regularly issues statements and press releases on a variety of topics, including closing the synthetic nicotine loophole and requests for Congress to extend telehealth services.

For all recent CHEST News, including these statements, visit the CHEST Newsroom at chestnet.org, and follow the hashtag #CHESTNews on Twitter.

If you have been included in a recent news article and would like it to be featured, send the coverage to [email protected].

CHEST works to provide opportunities for members to serve as expert sources for both mainstream and trade media to create a stronger voice for members in pulmonary, critical care, and sleep medicine.

Below are media coverage highlights from the past few months that work to expand awareness of CHEST and to promote the expertise of CHEST members in the media.
 

Improving NIV access for patients with COPD

In December, Pulmonology Advisor covered recommendations from the noninvasive ventilation Technical Expert Panel report published in the journal CHEST^® by The American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society.

The article shares that, in the United States, patients with COPD are often prescribed home mechanical ventilators rather than more appropriate devices, due largely to current Centers for Medicare & Medicaid Services (CMS) policies that do not always take into account unique complexities of patients’ conditions.

In addition to the recommendations covered in Optimal NIV Medicare Access Promotion: Patients With COPD, the Technical Expert Panel also published reports on patients with Obstructive Sleep Apnea, patients with Central Sleep Apnea, patients with Hypoventilation Syndromes, and patients with Thoracic Restrictive Disorders in the journal CHEST.

The full article, Expert Panel Guidelines Promote Access to In-Home NIV for Patients With COPD, can be found on the Pulmonology Advisor website.
 

OSA and cardiovascular mortality

A journal CHEST® article, “A Validation Study of Four Different Cluster Analyses of OSA and the Incidence of Cardiovascular Mortality in a Hispanic Population,” by Gonzalo Labarca, MD, et al. was featured in a Healio Pulmonology article.

The research showed an association between excessive sleepiness and increased risk for cardiovascular mortality in Hispanic adults with moderate to severe Obstructive Sleep Apnea and, in the article, Dr. Labarca says, “The Latino population is underrepresented in the scientific literature. Therefore, validation data regarding novel approaches to better identify a subtype of OSA patients at high risk of CV mortality is strongly needed.”

The full article, Risk for CV Mortality Elevated in Hispanic Adults with OSA, Excessive Sleepiness, can be found on the Healio website.
 

Member in the news:

Chair of the CHEST COVID-19 Task Force, Ryan Maves, MD , joined New York Times podcast, “The Daily” to discuss how the omicron COVID-19 surge was different than previous surges because unvaccinated deaths are skewing younger. During the podcast, Dr. Maves said, “You know, many more [unvaccinated] people in their 40s and 50s are dying. And it’s a grim feeling, watching people who are your own age and maybe not that much older than you die of an entirely preventable illness.” The full podcast, This COVID Surge Feels Different can be found on the New York Times website.

CHEST news

CHEST regularly issues statements and press releases on a variety of topics, including closing the synthetic nicotine loophole and requests for Congress to extend telehealth services.

For all recent CHEST News, including these statements, visit the CHEST Newsroom at chestnet.org, and follow the hashtag #CHESTNews on Twitter.

If you have been included in a recent news article and would like it to be featured, send the coverage to [email protected].

During the fall of 2020, the CHEST Foundation launched a Listening Tour in areas of the United States that were experiencing disproportionate incidents and mortality from COVID-19. This program was initiated to gain insights in order toand identify solutions to combat lung health inequities among marginalized communities. The COVID-19 pandemic has exacerbated health disparities in America. Underserved communities, communities with higher rates of poverty, and communities of color have suffered disproportionate rates of illness and mortality due to COVID-19.

Even before the COVID-19 pandemic, underserved communities were impacted disproportionately by four of the most common lung diseases: asthma, chronic obstructive pulmonary diseaseCOPD, interstitial lung disease, and lung cancer. Inequities in care and health outcomes are well documented. Inequities are due to a multitude of factors, including socioeconomic status, environmental issues such as air populationpollution, and issues that impact access to care, such as individuals being uninsured or under insured, and a lack of specialists in underserved communities.

The CHEST Foundation selected Listening Tour cities based on a number of criteria, including documented inequities in lung health and prevalence of the predominant lung diseases. Listening Tour events were held virtually in Jackson, MS; New York, NY; Chicago, IL; South Texas; and the US Southwest. In each location, the CHEST Foundation approached community leaders, clinicians, patients, and families to participate. Individual interviews focused on lung health experiences, positive and negative; needs from clinicians, patients, families, and community leaders; and help actually received (or not) based on these needs.

A theme that emerged centered on the importance trust plays in the patient/clinician relationship. Barriers to the establishment of trust as expressed by patients related to:

• Perceived dismissive attitudes among physicians
• Lack of understanding and/or appreciation about social determinants of health
• Overuse of highly technical/medical terminology that can be intimidating to patients
• General cultural and philosophical differences that may contribute to implicit biases

Gaining trust and building rapport among patients is not only limited to key findings from the Listening Tour but also corroborated through peer- reviewed studies. Many studies have documented that trust is the foundation on which patient/clinician relationshipss are built and without it, patients are less likely to maintain adherence to treatment plans, miss appointments, minimize sharing information about their symptoms, and suffer from poorer health and overall quality of life.

In response, the CHEST Foundation is proposing a project with the aim of broader replication based upon key findings. Building trust and developing rapport with patients areis key in creating an environment where they are active participants in their care. An empathetic care training model will provide clinicians with an understanding of the barriers that exist and the tools needed to establish trust with their patients.

The major components of the project include:

1. Development and standardization of a culturally competent toolkit for use during the first five 5 minutes of clinician/patient encounters

2. Creating Creation of education on the tool and training clinicians that who will pilot the tool in health care clinics/medical institutions and collect data on its impact

3. Implementation of the tool use during clinician/patient visits and data collection

4. Data analysis and synthesis of findings for use in refinement and scalability for broader impact

Future plans include scaling the project to additional sites and health care settings; disseminating the culturally competent tool along with education for its utilization to CHEST’s membership and to a larger audience of health care providers; and sharing results and lessons learned. The CHEST Foundation is hoping to build a national, sustainable program that helps achieve health equity, but in order to achieve this, we need your help. Make a donation, and join the CHEST Foundation as we embark on a bold new initiative to build trust, identify and remove barriers, and promote health care access for all in order to help fight lung disease. Together, we will build trust and understanding within communities, specifically between patients, their families, their caregivers, and their clinicians.

During the fall of 2020, the CHEST Foundation launched a Listening Tour in areas of the United States that were experiencing disproportionate incidents and mortality from COVID-19. This program was initiated to gain insights in order toand identify solutions to combat lung health inequities among marginalized communities. The COVID-19 pandemic has exacerbated health disparities in America. Underserved communities, communities with higher rates of poverty, and communities of color have suffered disproportionate rates of illness and mortality due to COVID-19.

Even before the COVID-19 pandemic, underserved communities were impacted disproportionately by four of the most common lung diseases: asthma, chronic obstructive pulmonary diseaseCOPD, interstitial lung disease, and lung cancer. Inequities in care and health outcomes are well documented. Inequities are due to a multitude of factors, including socioeconomic status, environmental issues such as air populationpollution, and issues that impact access to care, such as individuals being uninsured or under insured, and a lack of specialists in underserved communities.

The CHEST Foundation selected Listening Tour cities based on a number of criteria, including documented inequities in lung health and prevalence of the predominant lung diseases. Listening Tour events were held virtually in Jackson, MS; New York, NY; Chicago, IL; South Texas; and the US Southwest. In each location, the CHEST Foundation approached community leaders, clinicians, patients, and families to participate. Individual interviews focused on lung health experiences, positive and negative; needs from clinicians, patients, families, and community leaders; and help actually received (or not) based on these needs.

A theme that emerged centered on the importance trust plays in the patient/clinician relationship. Barriers to the establishment of trust as expressed by patients related to:

• Perceived dismissive attitudes among physicians
• Lack of understanding and/or appreciation about social determinants of health
• Overuse of highly technical/medical terminology that can be intimidating to patients
• General cultural and philosophical differences that may contribute to implicit biases

Gaining trust and building rapport among patients is not only limited to key findings from the Listening Tour but also corroborated through peer- reviewed studies. Many studies have documented that trust is the foundation on which patient/clinician relationshipss are built and without it, patients are less likely to maintain adherence to treatment plans, miss appointments, minimize sharing information about their symptoms, and suffer from poorer health and overall quality of life.

In response, the CHEST Foundation is proposing a project with the aim of broader replication based upon key findings. Building trust and developing rapport with patients areis key in creating an environment where they are active participants in their care. An empathetic care training model will provide clinicians with an understanding of the barriers that exist and the tools needed to establish trust with their patients.

The major components of the project include:

1. Development and standardization of a culturally competent toolkit for use during the first five 5 minutes of clinician/patient encounters

2. Creating Creation of education on the tool and training clinicians that who will pilot the tool in health care clinics/medical institutions and collect data on its impact

3. Implementation of the tool use during clinician/patient visits and data collection

4. Data analysis and synthesis of findings for use in refinement and scalability for broader impact

Future plans include scaling the project to additional sites and health care settings; disseminating the culturally competent tool along with education for its utilization to CHEST’s membership and to a larger audience of health care providers; and sharing results and lessons learned. The CHEST Foundation is hoping to build a national, sustainable program that helps achieve health equity, but in order to achieve this, we need your help. Make a donation, and join the CHEST Foundation as we embark on a bold new initiative to build trust, identify and remove barriers, and promote health care access for all in order to help fight lung disease. Together, we will build trust and understanding within communities, specifically between patients, their families, their caregivers, and their clinicians.

During the fall of 2020, the CHEST Foundation launched a Listening Tour in areas of the United States that were experiencing disproportionate incidents and mortality from COVID-19. This program was initiated to gain insights in order toand identify solutions to combat lung health inequities among marginalized communities. The COVID-19 pandemic has exacerbated health disparities in America. Underserved communities, communities with higher rates of poverty, and communities of color have suffered disproportionate rates of illness and mortality due to COVID-19.

Even before the COVID-19 pandemic, underserved communities were impacted disproportionately by four of the most common lung diseases: asthma, chronic obstructive pulmonary diseaseCOPD, interstitial lung disease, and lung cancer. Inequities in care and health outcomes are well documented. Inequities are due to a multitude of factors, including socioeconomic status, environmental issues such as air populationpollution, and issues that impact access to care, such as individuals being uninsured or under insured, and a lack of specialists in underserved communities.

The CHEST Foundation selected Listening Tour cities based on a number of criteria, including documented inequities in lung health and prevalence of the predominant lung diseases. Listening Tour events were held virtually in Jackson, MS; New York, NY; Chicago, IL; South Texas; and the US Southwest. In each location, the CHEST Foundation approached community leaders, clinicians, patients, and families to participate. Individual interviews focused on lung health experiences, positive and negative; needs from clinicians, patients, families, and community leaders; and help actually received (or not) based on these needs.

A theme that emerged centered on the importance trust plays in the patient/clinician relationship. Barriers to the establishment of trust as expressed by patients related to:

• Perceived dismissive attitudes among physicians
• Lack of understanding and/or appreciation about social determinants of health
• Overuse of highly technical/medical terminology that can be intimidating to patients
• General cultural and philosophical differences that may contribute to implicit biases

Gaining trust and building rapport among patients is not only limited to key findings from the Listening Tour but also corroborated through peer- reviewed studies. Many studies have documented that trust is the foundation on which patient/clinician relationshipss are built and without it, patients are less likely to maintain adherence to treatment plans, miss appointments, minimize sharing information about their symptoms, and suffer from poorer health and overall quality of life.

In response, the CHEST Foundation is proposing a project with the aim of broader replication based upon key findings. Building trust and developing rapport with patients areis key in creating an environment where they are active participants in their care. An empathetic care training model will provide clinicians with an understanding of the barriers that exist and the tools needed to establish trust with their patients.

The major components of the project include:

1. Development and standardization of a culturally competent toolkit for use during the first five 5 minutes of clinician/patient encounters

2. Creating Creation of education on the tool and training clinicians that who will pilot the tool in health care clinics/medical institutions and collect data on its impact

3. Implementation of the tool use during clinician/patient visits and data collection

4. Data analysis and synthesis of findings for use in refinement and scalability for broader impact

Future plans include scaling the project to additional sites and health care settings; disseminating the culturally competent tool along with education for its utilization to CHEST’s membership and to a larger audience of health care providers; and sharing results and lessons learned. The CHEST Foundation is hoping to build a national, sustainable program that helps achieve health equity, but in order to achieve this, we need your help. Make a donation, and join the CHEST Foundation as we embark on a bold new initiative to build trust, identify and remove barriers, and promote health care access for all in order to help fight lung disease. Together, we will build trust and understanding within communities, specifically between patients, their families, their caregivers, and their clinicians.

Airway disorders network: Asthma and COPD section

Betting on asthma: The over and under of diagnosis

Asthma is one of the major chronic respiratory diseases worldwide (WHO 2020), yet it is a clinical syndrome that lacks a consensus on its definition, is comprised of nonspecific respiratory symptoms, and is without a gold standard diagnostic test or a set guideline on confirmation of bronchial hyperresponsiveness (Sá-Sousa A et al. Clin Transl Allergy. 2014 Aug 4;4:24). In addition, once adequately treated, there is an absence of an algorithm to diagnose disease remission (Aaron SD et al. Am J Respir Crit Care Med. 2018 Oct 15;198[8]:1012-20). It is estimated that 20%-70% of people with asthma worldwide across the spectrum of all ages remain undiagnosed.

Spirometry and bronchoprovocation challenges with fixed cut-off values demonstrate reduced sensitivity with day-to-day, diurnal, and long-term variation in airflow obstruction, inflammation, and bronchial hyperresponsiveness (Wang R et al. Thorax. 2021 Jun;76[6]:624-31). Inflammatory biomarkers like fractional exhaled nitric oxide (FeNO) have higher specificity but are subject to diurnal variation and confounding diagnoses.

Overdiagnosis of asthma can result in lost opportunity to diagnose significant cardiopulmonary diseases, unnecessary escalation of the asthma treatment regimen for poorly controlled respiratory symptoms, potential for medication adverse effects, and, increased cost burden to the patient and to the health care system (Aaron SD et al. JAMA. 2017;317:269-79; Shaw D et al. Prim Care Respir J. 2012;21:283-7). Among the newly physician-diagnosed asthmatics, <50% have spirometry performed within 1 year of diagnosis (Sokol KC et al. Am J Med. 2015 May;128[5]:502-8). Spirometry was further underutilized with limit on aerosol-generating procedures during COVID-19 pandemic (Kankaanranta H et al. J Allergy Clin Immunol Pract. 2021 Dec;9[12]:4252-3); 30%-35% obese and nonobese patients with physician-diagnosed asthma did not have current asthma when objectively assessed for airflow limitation (Aaron SD et al. JAMA. 2017;317:269-79; van Huisstede A, et al. Respir Med. 2013;107:1356-64).

Clinical remission is greater in early-onset asthma as compared with late-onset asthma (De Marco R et al. J Allergy Clin Immunol. 2002;110:228-35). If asthma is well controlled, a stepping down treatment regimen is suggested (Global Initiative for Asthma 2021;Usmani  et al. J Allergy Clin Immunol Pract. 2017 Sep-Oct;5[5]:1378-87.e5; Hagan JB et al. Allergy. 2014 Apr;69[4]:510-6), and although a randomized trial is lacking, it may be feasible to “undiagnose” patients who don’t experience clinical worsening, airflow obstruction, or bronchial hyperresponsiveness after being tapered off all asthma medications with a low relapse rate (Aaron SD et al. JAMA. 2017;317:269-79; J Fam Pract. 2018;67(11):704-7).

Asthma over- and underdiagnosis is prevalent and has clinical and global health consequences. New standardized algorithms with improved biomarkers may help alter this oversight.

Richa Nahar, MD 

Network Member-at-Large

Allen J. Blaivas, DO, FCCP 

Network Steering Committee Chair

Diffuse lung disease and lung transplant network: Interstitial lung disease section

Future therapies for IPF

Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease characterized by progressive fibrosis, respiratory failure, and a mortality rate of 80% at 5 years. Only two drugs are currently FDA-approved for IPF treatment.

The antifibrotics pirfenidone and nintedanib reduce the rate of forced vital capacity (FVC) decline and improve progression free survival (King TE et al. N Engl J Med. 2014;370:2083-92; King TE et al. N Engl J Med. 2014;370:2071-82). While considered revolutionary when introduced, these medications neither reverse disease progression nor improve symptoms. More recently, the Galapagos ISABELA Phase III clinical trial of ziritaxestat in IPF was discontinued due to an unfavorable risk-benefit profile. Despite this, several prospects for IPF therapy exist.

Post hoc analysis of the INCREASE Trial demonstrated a positive effect of inhaled treprostinil on FVC in patients with IPF and group 3 pulmonary hypertension (Waxman A et al. N Engl J Med. 2021;384:325-34). Consequently, a phase 3 randomized trial investigating its safety and efficacy in patients with IPF alone is ongoing. Additional targeted therapies for IPF are also emerging. Recombinant human pentraxin-2, an inhibitor of monocyte differentiation into proinflammatory macrophages, and pamrevlumab, a recombinant human monoclonal antibody against connective tissue growth factor, both demonstrated attenuation of FVC decline compared with placebo in phase 2 trials. Both are currently in phase 3 studies (Raghu G et al. JAMA. 2018 Jun 12;319[22]:2299-307; Sgalla G et al. Expert Opin Investig Drugs. 2020 Aug;29[8]:771-7) Lastly, in February the Food and Drug Administration granted breakthrough therapy designation to BI 1015550 for treatment of IPF based on a 12-week phase 2 randomized, double-blind, placebo-controlled trial. (Data will be presented at ATS). BI 1015550 is an oral, phosphodiesterase 4B (PDE4B) inhibitor with both antifibrotic and anti-inflammatory properties. These advances in drug development provide hope for a future where IPF is transformed from a fatal disease to one manageable over many years.

Adrian Shifren, MD

Network Member-at-Large

Gabriel Schroeder, MD

Network Member-at-Large

Sleep medicine network: Home-based mechanical ventilation and neuromuscular section

Role of airway clearance therapies in neuromuscular disease

Individuals with neuromuscular weakness have an impaired ability to cough and clear secretions from the airway, which can result in atelectasis and pneumonia. Proximal airway clearance therapies (ACT), including manual lung volume recruitment (LVR) and mechanical in-exsufflation (MI-E), mobilize secretions, improve cough efficacy, maintain chest wall compliance, and slow progression of restrictive lung impairment (Chatwin et al. Respir Med. 2018;136:98-110; Sheers et al. Respirology. 2019;24:512-520).

ACT are recommended in international care guidelines for respiratory management of individuals with neuromuscular disease. At a recent Home-based Mechanical Ventilation and Neuromuscular Disease Section “PEEPS Talking PAP” rounds, participants discussed their approach to ACT. Practices varied by country and between adult/pediatric care providers. MI-E is most often used in the United States, but elsewhere in the world, LVR with a self-inflating bag and one-way valve is first-line therapy. Clinical care guidelines suggest initiation of regular ACT when cough peak flow is < 270 L/minute, forced vital capacity < 40%-60% predicted, or with subjectively weak cough (Hull et al. Thorax. 2012;67(7):654-655; Amin et al. Can J Resp Crit Care Sleep Med. 2017;1(1):7-36; McKim et al. Can Resp J. 2011;18(4):197-215; Birnkrant et al. Lancet Neurol. 2018;17(4):347-361; Sheehan et al. Pediatrics. 2018;142(Suppl 2):S62-s71).

Optimal timing for initiation of routine ACT, however, is not clear. A newly published randomized controlled trial of twice daily LVR in boys with Duchenne muscular dystrophy with relatively normal baseline lung function did not demonstrate a significant slowing of decline in forced vital capacity over 2 years. In individuals with preserved lung function, the burden of regular therapy may outweigh benefit (Katz et al. Thorax. 2022; doi: 10.1136/thoraxjnl-2021-218196). (While we are still learning about how best to apply this therapy in less advanced neuromuscular disease, ACT has demonstrated benefits during respiratory exacerbations, and routine use plays a role in preservation of lung function in more advanced disease (Katz et al. Ann Am Thorac Soc. 2016;13(2):217-222; McKim et al. Arch Phys Med Rehab. 2012;93(7):1117-1122; O’Sullivan et al. Arch Phys Med Rehabil. 2021;102(5):976-983; Bach et al. Am J Phys Med Rehab. 2008;87(9):720-725).

Sherri Katz, MD, FCCP

Section Steering Committee Chair

Critical care network: Mechanical ventilation and airways management section

NIV following extubation: Which devices and which patients?

For those of us interested in studying mechanical ventilation, an interesting paradox exists: despite our interest and enthusiasm in studying it, our patients benefit from avoiding it! Patients who require re-intubation are at high risk of in-hospital mortality (Frutos-Vivar et al. J Crit Care. 2011;26:502-9). 

Studies in high-risk patients receiving mechanical ventilation have demonstrated that patients treated with immediate noninvasive ventilation (NIV) following extubation had reduced risk of re-intubation. CHEST guidelines focused on ventilator liberation considered these studies in a metanalysis which led to recommendations to employ NIV immediately after extubation in high-risk patients to reduce re-intubation rates (Ouellette D et al. Chest. 2017;151:166-80). 

In the years since the publication of the CHEST guidelines, more information has been forthcoming. Evidence has emerged that treatment with high-flow nasal cannula devices following extubation may mitigate against re-intubation. An interesting strategy from the High-Wean Study Group suggested that postextubation combination therapy with both a high-flow cannula and NIV leads to improved outcomes compared with high-flow alone (Thille AW et al. JAMA. 2019;322:1465-75).   

Thille and coworkers recently broadened our concept of patients who may benefit from NIV post extubation. They examined a cohort of obese patients requiring mechanical ventilation, finding that when patients were treated with NIV and high-flow nasal cannula post extubation, that they had a reduced risk of re-intubation compared with a group receiving high flow alone (Thille AW, et al. Am J Respir Crit Care Med. 2022;205:440-9). 

As the incoming chair of the Mechanical Ventilation and Airways Management Section of the CHEST Critical Care Network, I look forward during the next 2 years to having interesting conversations about topics like this one and working with section members to develop exciting new projects concerning mechanical ventilation. 

Daniel Ouellette, MD, MS, FCCP

Section Steering Committee Chair
 

Thoracic oncology and chest procedures network: Pleural disease section

Management of recurrent transudative pleural effusions (REDUCE trial)

Nonmalignant pleural effusions contribute significantly to health care costs and mortality (Mummadi SR et al. CHEST. 2021 Oct;160[4]:1534-51; Walker SP et al. CHEST. 2017 May;151[5]:1099-105). Management of transudative effusions has traditionally been to treat the underlying etiology. However, despite maximal medical therapies, these recurrent effusions may add to patients’ symptom burden and often create a challenge for the clinician. In 2017, the FDA approved the use of indwelling pleural catheters (IPC) in patients with recurrent transudative effusions, but data are limited.

In a recent prospective multicenter randomized control trial, Walker and colleagues (Eur Respir J. 2022 Feb;59:2101362) aimed to compare IPCs to repeated therapeutic thoracentesis (TT) in the management of transudative effusions. Pleural fluid etiologies included heart (68%), liver (24%), and renal failure (8%). The primary outcome was mean dyspnea score (daily visual analog scales) over 12 weeks, and there was no significant difference noted (39.7 vs. 45.0, mean difference –2.9 mm, 95% confidence interval [CI] –16.1 to 10.3; P = .67). Secondary outcomes demonstrated increased overall drainage in the IPC vs. TT group (17,412 mL vs. 2,901 mL, difference 13,892 mL, 95% CI, 7,669-20,116 mL; P < .001) and fewer invasive procedures required in the IPC group. Adverse events were noted in 59% of the IPC group compared with 37% managed with TT (OR, 3.13, 95% CI, 1.07-9.13, P = .04).

The REDUCE trial offers valuable data, but failure to meet primary outcome, study size, and adverse events highlight limitations to a definitive change in practice. Further study with specific-disease processes (ie, cardiac) may be helpful in the future. As in malignant pleural effusions, the selection of definitive pleural intervention should be tailored for each patient.

Maria Azhar, MD

Network Member-at-Large

Saadia A. Faiz, MD FCCP

Section Steering Committee Chair

Airway disorders network: Asthma and COPD section

Betting on asthma: The over and under of diagnosis

Asthma is one of the major chronic respiratory diseases worldwide (WHO 2020), yet it is a clinical syndrome that lacks a consensus on its definition, is comprised of nonspecific respiratory symptoms, and is without a gold standard diagnostic test or a set guideline on confirmation of bronchial hyperresponsiveness (Sá-Sousa A et al. Clin Transl Allergy. 2014 Aug 4;4:24). In addition, once adequately treated, there is an absence of an algorithm to diagnose disease remission (Aaron SD et al. Am J Respir Crit Care Med. 2018 Oct 15;198[8]:1012-20). It is estimated that 20%-70% of people with asthma worldwide across the spectrum of all ages remain undiagnosed.

Spirometry and bronchoprovocation challenges with fixed cut-off values demonstrate reduced sensitivity with day-to-day, diurnal, and long-term variation in airflow obstruction, inflammation, and bronchial hyperresponsiveness (Wang R et al. Thorax. 2021 Jun;76[6]:624-31). Inflammatory biomarkers like fractional exhaled nitric oxide (FeNO) have higher specificity but are subject to diurnal variation and confounding diagnoses.

Overdiagnosis of asthma can result in lost opportunity to diagnose significant cardiopulmonary diseases, unnecessary escalation of the asthma treatment regimen for poorly controlled respiratory symptoms, potential for medication adverse effects, and, increased cost burden to the patient and to the health care system (Aaron SD et al. JAMA. 2017;317:269-79; Shaw D et al. Prim Care Respir J. 2012;21:283-7). Among the newly physician-diagnosed asthmatics, <50% have spirometry performed within 1 year of diagnosis (Sokol KC et al. Am J Med. 2015 May;128[5]:502-8). Spirometry was further underutilized with limit on aerosol-generating procedures during COVID-19 pandemic (Kankaanranta H et al. J Allergy Clin Immunol Pract. 2021 Dec;9[12]:4252-3); 30%-35% obese and nonobese patients with physician-diagnosed asthma did not have current asthma when objectively assessed for airflow limitation (Aaron SD et al. JAMA. 2017;317:269-79; van Huisstede A, et al. Respir Med. 2013;107:1356-64).

Clinical remission is greater in early-onset asthma as compared with late-onset asthma (De Marco R et al. J Allergy Clin Immunol. 2002;110:228-35). If asthma is well controlled, a stepping down treatment regimen is suggested (Global Initiative for Asthma 2021;Usmani  et al. J Allergy Clin Immunol Pract. 2017 Sep-Oct;5[5]:1378-87.e5; Hagan JB et al. Allergy. 2014 Apr;69[4]:510-6), and although a randomized trial is lacking, it may be feasible to “undiagnose” patients who don’t experience clinical worsening, airflow obstruction, or bronchial hyperresponsiveness after being tapered off all asthma medications with a low relapse rate (Aaron SD et al. JAMA. 2017;317:269-79; J Fam Pract. 2018;67(11):704-7).

Asthma over- and underdiagnosis is prevalent and has clinical and global health consequences. New standardized algorithms with improved biomarkers may help alter this oversight.

Richa Nahar, MD 

Network Member-at-Large

Allen J. Blaivas, DO, FCCP 

Network Steering Committee Chair

Diffuse lung disease and lung transplant network: Interstitial lung disease section

Future therapies for IPF

Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease characterized by progressive fibrosis, respiratory failure, and a mortality rate of 80% at 5 years. Only two drugs are currently FDA-approved for IPF treatment.

The antifibrotics pirfenidone and nintedanib reduce the rate of forced vital capacity (FVC) decline and improve progression free survival (King TE et al. N Engl J Med. 2014;370:2083-92; King TE et al. N Engl J Med. 2014;370:2071-82). While considered revolutionary when introduced, these medications neither reverse disease progression nor improve symptoms. More recently, the Galapagos ISABELA Phase III clinical trial of ziritaxestat in IPF was discontinued due to an unfavorable risk-benefit profile. Despite this, several prospects for IPF therapy exist.

Post hoc analysis of the INCREASE Trial demonstrated a positive effect of inhaled treprostinil on FVC in patients with IPF and group 3 pulmonary hypertension (Waxman A et al. N Engl J Med. 2021;384:325-34). Consequently, a phase 3 randomized trial investigating its safety and efficacy in patients with IPF alone is ongoing. Additional targeted therapies for IPF are also emerging. Recombinant human pentraxin-2, an inhibitor of monocyte differentiation into proinflammatory macrophages, and pamrevlumab, a recombinant human monoclonal antibody against connective tissue growth factor, both demonstrated attenuation of FVC decline compared with placebo in phase 2 trials. Both are currently in phase 3 studies (Raghu G et al. JAMA. 2018 Jun 12;319[22]:2299-307; Sgalla G et al. Expert Opin Investig Drugs. 2020 Aug;29[8]:771-7) Lastly, in February the Food and Drug Administration granted breakthrough therapy designation to BI 1015550 for treatment of IPF based on a 12-week phase 2 randomized, double-blind, placebo-controlled trial. (Data will be presented at ATS). BI 1015550 is an oral, phosphodiesterase 4B (PDE4B) inhibitor with both antifibrotic and anti-inflammatory properties. These advances in drug development provide hope for a future where IPF is transformed from a fatal disease to one manageable over many years.

Adrian Shifren, MD

Network Member-at-Large

Gabriel Schroeder, MD

Network Member-at-Large

Sleep medicine network: Home-based mechanical ventilation and neuromuscular section

Role of airway clearance therapies in neuromuscular disease

Individuals with neuromuscular weakness have an impaired ability to cough and clear secretions from the airway, which can result in atelectasis and pneumonia. Proximal airway clearance therapies (ACT), including manual lung volume recruitment (LVR) and mechanical in-exsufflation (MI-E), mobilize secretions, improve cough efficacy, maintain chest wall compliance, and slow progression of restrictive lung impairment (Chatwin et al. Respir Med. 2018;136:98-110; Sheers et al. Respirology. 2019;24:512-520).

ACT are recommended in international care guidelines for respiratory management of individuals with neuromuscular disease. At a recent Home-based Mechanical Ventilation and Neuromuscular Disease Section “PEEPS Talking PAP” rounds, participants discussed their approach to ACT. Practices varied by country and between adult/pediatric care providers. MI-E is most often used in the United States, but elsewhere in the world, LVR with a self-inflating bag and one-way valve is first-line therapy. Clinical care guidelines suggest initiation of regular ACT when cough peak flow is < 270 L/minute, forced vital capacity < 40%-60% predicted, or with subjectively weak cough (Hull et al. Thorax. 2012;67(7):654-655; Amin et al. Can J Resp Crit Care Sleep Med. 2017;1(1):7-36; McKim et al. Can Resp J. 2011;18(4):197-215; Birnkrant et al. Lancet Neurol. 2018;17(4):347-361; Sheehan et al. Pediatrics. 2018;142(Suppl 2):S62-s71).

Optimal timing for initiation of routine ACT, however, is not clear. A newly published randomized controlled trial of twice daily LVR in boys with Duchenne muscular dystrophy with relatively normal baseline lung function did not demonstrate a significant slowing of decline in forced vital capacity over 2 years. In individuals with preserved lung function, the burden of regular therapy may outweigh benefit (Katz et al. Thorax. 2022; doi: 10.1136/thoraxjnl-2021-218196). (While we are still learning about how best to apply this therapy in less advanced neuromuscular disease, ACT has demonstrated benefits during respiratory exacerbations, and routine use plays a role in preservation of lung function in more advanced disease (Katz et al. Ann Am Thorac Soc. 2016;13(2):217-222; McKim et al. Arch Phys Med Rehab. 2012;93(7):1117-1122; O’Sullivan et al. Arch Phys Med Rehabil. 2021;102(5):976-983; Bach et al. Am J Phys Med Rehab. 2008;87(9):720-725).

Sherri Katz, MD, FCCP

Section Steering Committee Chair

Critical care network: Mechanical ventilation and airways management section

NIV following extubation: Which devices and which patients?

For those of us interested in studying mechanical ventilation, an interesting paradox exists: despite our interest and enthusiasm in studying it, our patients benefit from avoiding it! Patients who require re-intubation are at high risk of in-hospital mortality (Frutos-Vivar et al. J Crit Care. 2011;26:502-9). 

Studies in high-risk patients receiving mechanical ventilation have demonstrated that patients treated with immediate noninvasive ventilation (NIV) following extubation had reduced risk of re-intubation. CHEST guidelines focused on ventilator liberation considered these studies in a metanalysis which led to recommendations to employ NIV immediately after extubation in high-risk patients to reduce re-intubation rates (Ouellette D et al. Chest. 2017;151:166-80). 

In the years since the publication of the CHEST guidelines, more information has been forthcoming. Evidence has emerged that treatment with high-flow nasal cannula devices following extubation may mitigate against re-intubation. An interesting strategy from the High-Wean Study Group suggested that postextubation combination therapy with both a high-flow cannula and NIV leads to improved outcomes compared with high-flow alone (Thille AW et al. JAMA. 2019;322:1465-75).   

Thille and coworkers recently broadened our concept of patients who may benefit from NIV post extubation. They examined a cohort of obese patients requiring mechanical ventilation, finding that when patients were treated with NIV and high-flow nasal cannula post extubation, that they had a reduced risk of re-intubation compared with a group receiving high flow alone (Thille AW, et al. Am J Respir Crit Care Med. 2022;205:440-9). 

As the incoming chair of the Mechanical Ventilation and Airways Management Section of the CHEST Critical Care Network, I look forward during the next 2 years to having interesting conversations about topics like this one and working with section members to develop exciting new projects concerning mechanical ventilation. 

Daniel Ouellette, MD, MS, FCCP

Section Steering Committee Chair
 

Thoracic oncology and chest procedures network: Pleural disease section

Management of recurrent transudative pleural effusions (REDUCE trial)

Nonmalignant pleural effusions contribute significantly to health care costs and mortality (Mummadi SR et al. CHEST. 2021 Oct;160[4]:1534-51; Walker SP et al. CHEST. 2017 May;151[5]:1099-105). Management of transudative effusions has traditionally been to treat the underlying etiology. However, despite maximal medical therapies, these recurrent effusions may add to patients’ symptom burden and often create a challenge for the clinician. In 2017, the FDA approved the use of indwelling pleural catheters (IPC) in patients with recurrent transudative effusions, but data are limited.

In a recent prospective multicenter randomized control trial, Walker and colleagues (Eur Respir J. 2022 Feb;59:2101362) aimed to compare IPCs to repeated therapeutic thoracentesis (TT) in the management of transudative effusions. Pleural fluid etiologies included heart (68%), liver (24%), and renal failure (8%). The primary outcome was mean dyspnea score (daily visual analog scales) over 12 weeks, and there was no significant difference noted (39.7 vs. 45.0, mean difference –2.9 mm, 95% confidence interval [CI] –16.1 to 10.3; P = .67). Secondary outcomes demonstrated increased overall drainage in the IPC vs. TT group (17,412 mL vs. 2,901 mL, difference 13,892 mL, 95% CI, 7,669-20,116 mL; P < .001) and fewer invasive procedures required in the IPC group. Adverse events were noted in 59% of the IPC group compared with 37% managed with TT (OR, 3.13, 95% CI, 1.07-9.13, P = .04).

The REDUCE trial offers valuable data, but failure to meet primary outcome, study size, and adverse events highlight limitations to a definitive change in practice. Further study with specific-disease processes (ie, cardiac) may be helpful in the future. As in malignant pleural effusions, the selection of definitive pleural intervention should be tailored for each patient.

Maria Azhar, MD

Network Member-at-Large

Saadia A. Faiz, MD FCCP

Section Steering Committee Chair

Airway disorders network: Asthma and COPD section

Betting on asthma: The over and under of diagnosis

Asthma is one of the major chronic respiratory diseases worldwide (WHO 2020), yet it is a clinical syndrome that lacks a consensus on its definition, is comprised of nonspecific respiratory symptoms, and is without a gold standard diagnostic test or a set guideline on confirmation of bronchial hyperresponsiveness (Sá-Sousa A et al. Clin Transl Allergy. 2014 Aug 4;4:24). In addition, once adequately treated, there is an absence of an algorithm to diagnose disease remission (Aaron SD et al. Am J Respir Crit Care Med. 2018 Oct 15;198[8]:1012-20). It is estimated that 20%-70% of people with asthma worldwide across the spectrum of all ages remain undiagnosed.

Spirometry and bronchoprovocation challenges with fixed cut-off values demonstrate reduced sensitivity with day-to-day, diurnal, and long-term variation in airflow obstruction, inflammation, and bronchial hyperresponsiveness (Wang R et al. Thorax. 2021 Jun;76[6]:624-31). Inflammatory biomarkers like fractional exhaled nitric oxide (FeNO) have higher specificity but are subject to diurnal variation and confounding diagnoses.

Overdiagnosis of asthma can result in lost opportunity to diagnose significant cardiopulmonary diseases, unnecessary escalation of the asthma treatment regimen for poorly controlled respiratory symptoms, potential for medication adverse effects, and, increased cost burden to the patient and to the health care system (Aaron SD et al. JAMA. 2017;317:269-79; Shaw D et al. Prim Care Respir J. 2012;21:283-7). Among the newly physician-diagnosed asthmatics, <50% have spirometry performed within 1 year of diagnosis (Sokol KC et al. Am J Med. 2015 May;128[5]:502-8). Spirometry was further underutilized with limit on aerosol-generating procedures during COVID-19 pandemic (Kankaanranta H et al. J Allergy Clin Immunol Pract. 2021 Dec;9[12]:4252-3); 30%-35% obese and nonobese patients with physician-diagnosed asthma did not have current asthma when objectively assessed for airflow limitation (Aaron SD et al. JAMA. 2017;317:269-79; van Huisstede A, et al. Respir Med. 2013;107:1356-64).

Clinical remission is greater in early-onset asthma as compared with late-onset asthma (De Marco R et al. J Allergy Clin Immunol. 2002;110:228-35). If asthma is well controlled, a stepping down treatment regimen is suggested (Global Initiative for Asthma 2021;Usmani  et al. J Allergy Clin Immunol Pract. 2017 Sep-Oct;5[5]:1378-87.e5; Hagan JB et al. Allergy. 2014 Apr;69[4]:510-6), and although a randomized trial is lacking, it may be feasible to “undiagnose” patients who don’t experience clinical worsening, airflow obstruction, or bronchial hyperresponsiveness after being tapered off all asthma medications with a low relapse rate (Aaron SD et al. JAMA. 2017;317:269-79; J Fam Pract. 2018;67(11):704-7).

Asthma over- and underdiagnosis is prevalent and has clinical and global health consequences. New standardized algorithms with improved biomarkers may help alter this oversight.

Richa Nahar, MD 

Network Member-at-Large

Allen J. Blaivas, DO, FCCP 

Network Steering Committee Chair

Diffuse lung disease and lung transplant network: Interstitial lung disease section

Future therapies for IPF

Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease characterized by progressive fibrosis, respiratory failure, and a mortality rate of 80% at 5 years. Only two drugs are currently FDA-approved for IPF treatment.

The antifibrotics pirfenidone and nintedanib reduce the rate of forced vital capacity (FVC) decline and improve progression free survival (King TE et al. N Engl J Med. 2014;370:2083-92; King TE et al. N Engl J Med. 2014;370:2071-82). While considered revolutionary when introduced, these medications neither reverse disease progression nor improve symptoms. More recently, the Galapagos ISABELA Phase III clinical trial of ziritaxestat in IPF was discontinued due to an unfavorable risk-benefit profile. Despite this, several prospects for IPF therapy exist.

Post hoc analysis of the INCREASE Trial demonstrated a positive effect of inhaled treprostinil on FVC in patients with IPF and group 3 pulmonary hypertension (Waxman A et al. N Engl J Med. 2021;384:325-34). Consequently, a phase 3 randomized trial investigating its safety and efficacy in patients with IPF alone is ongoing. Additional targeted therapies for IPF are also emerging. Recombinant human pentraxin-2, an inhibitor of monocyte differentiation into proinflammatory macrophages, and pamrevlumab, a recombinant human monoclonal antibody against connective tissue growth factor, both demonstrated attenuation of FVC decline compared with placebo in phase 2 trials. Both are currently in phase 3 studies (Raghu G et al. JAMA. 2018 Jun 12;319[22]:2299-307; Sgalla G et al. Expert Opin Investig Drugs. 2020 Aug;29[8]:771-7) Lastly, in February the Food and Drug Administration granted breakthrough therapy designation to BI 1015550 for treatment of IPF based on a 12-week phase 2 randomized, double-blind, placebo-controlled trial. (Data will be presented at ATS). BI 1015550 is an oral, phosphodiesterase 4B (PDE4B) inhibitor with both antifibrotic and anti-inflammatory properties. These advances in drug development provide hope for a future where IPF is transformed from a fatal disease to one manageable over many years.

Adrian Shifren, MD

Network Member-at-Large

Gabriel Schroeder, MD

Network Member-at-Large

Sleep medicine network: Home-based mechanical ventilation and neuromuscular section

Role of airway clearance therapies in neuromuscular disease

Individuals with neuromuscular weakness have an impaired ability to cough and clear secretions from the airway, which can result in atelectasis and pneumonia. Proximal airway clearance therapies (ACT), including manual lung volume recruitment (LVR) and mechanical in-exsufflation (MI-E), mobilize secretions, improve cough efficacy, maintain chest wall compliance, and slow progression of restrictive lung impairment (Chatwin et al. Respir Med. 2018;136:98-110; Sheers et al. Respirology. 2019;24:512-520).

ACT are recommended in international care guidelines for respiratory management of individuals with neuromuscular disease. At a recent Home-based Mechanical Ventilation and Neuromuscular Disease Section “PEEPS Talking PAP” rounds, participants discussed their approach to ACT. Practices varied by country and between adult/pediatric care providers. MI-E is most often used in the United States, but elsewhere in the world, LVR with a self-inflating bag and one-way valve is first-line therapy. Clinical care guidelines suggest initiation of regular ACT when cough peak flow is < 270 L/minute, forced vital capacity < 40%-60% predicted, or with subjectively weak cough (Hull et al. Thorax. 2012;67(7):654-655; Amin et al. Can J Resp Crit Care Sleep Med. 2017;1(1):7-36; McKim et al. Can Resp J. 2011;18(4):197-215; Birnkrant et al. Lancet Neurol. 2018;17(4):347-361; Sheehan et al. Pediatrics. 2018;142(Suppl 2):S62-s71).

Optimal timing for initiation of routine ACT, however, is not clear. A newly published randomized controlled trial of twice daily LVR in boys with Duchenne muscular dystrophy with relatively normal baseline lung function did not demonstrate a significant slowing of decline in forced vital capacity over 2 years. In individuals with preserved lung function, the burden of regular therapy may outweigh benefit (Katz et al. Thorax. 2022; doi: 10.1136/thoraxjnl-2021-218196). (While we are still learning about how best to apply this therapy in less advanced neuromuscular disease, ACT has demonstrated benefits during respiratory exacerbations, and routine use plays a role in preservation of lung function in more advanced disease (Katz et al. Ann Am Thorac Soc. 2016;13(2):217-222; McKim et al. Arch Phys Med Rehab. 2012;93(7):1117-1122; O’Sullivan et al. Arch Phys Med Rehabil. 2021;102(5):976-983; Bach et al. Am J Phys Med Rehab. 2008;87(9):720-725).

Sherri Katz, MD, FCCP

Section Steering Committee Chair

Critical care network: Mechanical ventilation and airways management section

NIV following extubation: Which devices and which patients?

For those of us interested in studying mechanical ventilation, an interesting paradox exists: despite our interest and enthusiasm in studying it, our patients benefit from avoiding it! Patients who require re-intubation are at high risk of in-hospital mortality (Frutos-Vivar et al. J Crit Care. 2011;26:502-9). 

Studies in high-risk patients receiving mechanical ventilation have demonstrated that patients treated with immediate noninvasive ventilation (NIV) following extubation had reduced risk of re-intubation. CHEST guidelines focused on ventilator liberation considered these studies in a metanalysis which led to recommendations to employ NIV immediately after extubation in high-risk patients to reduce re-intubation rates (Ouellette D et al. Chest. 2017;151:166-80). 

In the years since the publication of the CHEST guidelines, more information has been forthcoming. Evidence has emerged that treatment with high-flow nasal cannula devices following extubation may mitigate against re-intubation. An interesting strategy from the High-Wean Study Group suggested that postextubation combination therapy with both a high-flow cannula and NIV leads to improved outcomes compared with high-flow alone (Thille AW et al. JAMA. 2019;322:1465-75).   

Thille and coworkers recently broadened our concept of patients who may benefit from NIV post extubation. They examined a cohort of obese patients requiring mechanical ventilation, finding that when patients were treated with NIV and high-flow nasal cannula post extubation, that they had a reduced risk of re-intubation compared with a group receiving high flow alone (Thille AW, et al. Am J Respir Crit Care Med. 2022;205:440-9). 

As the incoming chair of the Mechanical Ventilation and Airways Management Section of the CHEST Critical Care Network, I look forward during the next 2 years to having interesting conversations about topics like this one and working with section members to develop exciting new projects concerning mechanical ventilation. 

Daniel Ouellette, MD, MS, FCCP

Section Steering Committee Chair
 

Thoracic oncology and chest procedures network: Pleural disease section

Management of recurrent transudative pleural effusions (REDUCE trial)

Nonmalignant pleural effusions contribute significantly to health care costs and mortality (Mummadi SR et al. CHEST. 2021 Oct;160[4]:1534-51; Walker SP et al. CHEST. 2017 May;151[5]:1099-105). Management of transudative effusions has traditionally been to treat the underlying etiology. However, despite maximal medical therapies, these recurrent effusions may add to patients’ symptom burden and often create a challenge for the clinician. In 2017, the FDA approved the use of indwelling pleural catheters (IPC) in patients with recurrent transudative effusions, but data are limited.

In a recent prospective multicenter randomized control trial, Walker and colleagues (Eur Respir J. 2022 Feb;59:2101362) aimed to compare IPCs to repeated therapeutic thoracentesis (TT) in the management of transudative effusions. Pleural fluid etiologies included heart (68%), liver (24%), and renal failure (8%). The primary outcome was mean dyspnea score (daily visual analog scales) over 12 weeks, and there was no significant difference noted (39.7 vs. 45.0, mean difference –2.9 mm, 95% confidence interval [CI] –16.1 to 10.3; P = .67). Secondary outcomes demonstrated increased overall drainage in the IPC vs. TT group (17,412 mL vs. 2,901 mL, difference 13,892 mL, 95% CI, 7,669-20,116 mL; P < .001) and fewer invasive procedures required in the IPC group. Adverse events were noted in 59% of the IPC group compared with 37% managed with TT (OR, 3.13, 95% CI, 1.07-9.13, P = .04).

The REDUCE trial offers valuable data, but failure to meet primary outcome, study size, and adverse events highlight limitations to a definitive change in practice. Further study with specific-disease processes (ie, cardiac) may be helpful in the future. As in malignant pleural effusions, the selection of definitive pleural intervention should be tailored for each patient.

Maria Azhar, MD

Network Member-at-Large

Saadia A. Faiz, MD FCCP

Section Steering Committee Chair

Barriers and Enablers to Objective Testing for Asthma and COPD in Primary Care: A Systematic Review Using the Theoretical Domains Framework
By Dr. Janet Yamada et al.

COVID Complications: Diagnostic and Therapeutic Considerations for Critical Covid
By Dr. David M. Maslove et al.

Interstitial Lung Abnormalities, Emphysema, and Spirometry in Smokers
By Dr. Aravind A. Menon et al.

Sleep-Disordered Breathing in Hospitalized Patients: A Game Changer?
By Dr. Sunil Sharma and Dr. Robert Stansbury.

Distribution, Risk Factors, and Temporal Trends for Lung Cancer Incidence and Mortality: A Global Analysis 
By Dr. Junjie Huang et al.

Barriers and Enablers to Objective Testing for Asthma and COPD in Primary Care: A Systematic Review Using the Theoretical Domains Framework
By Dr. Janet Yamada et al.

COVID Complications: Diagnostic and Therapeutic Considerations for Critical Covid
By Dr. David M. Maslove et al.

Interstitial Lung Abnormalities, Emphysema, and Spirometry in Smokers
By Dr. Aravind A. Menon et al.

Sleep-Disordered Breathing in Hospitalized Patients: A Game Changer?
By Dr. Sunil Sharma and Dr. Robert Stansbury.

Distribution, Risk Factors, and Temporal Trends for Lung Cancer Incidence and Mortality: A Global Analysis 
By Dr. Junjie Huang et al.

Barriers and Enablers to Objective Testing for Asthma and COPD in Primary Care: A Systematic Review Using the Theoretical Domains Framework
By Dr. Janet Yamada et al.

COVID Complications: Diagnostic and Therapeutic Considerations for Critical Covid
By Dr. David M. Maslove et al.

Interstitial Lung Abnormalities, Emphysema, and Spirometry in Smokers
By Dr. Aravind A. Menon et al.

Sleep-Disordered Breathing in Hospitalized Patients: A Game Changer?
By Dr. Sunil Sharma and Dr. Robert Stansbury.

Distribution, Risk Factors, and Temporal Trends for Lung Cancer Incidence and Mortality: A Global Analysis 
By Dr. Junjie Huang et al.

Bone strength and microarchitecture remained stronger at 24 months after treatment with denosumab compared to risedronate, in a study of 110 adults using glucocorticoids.

Patients using glucocorticoids are at increased risk for vertebral and nonvertebral fractures at both the start of treatment or as treatment continues, wrote Piet Geusens, MD, of Maastricht University, the Netherlands, and colleagues.

Imaging data collected via high-resolution peripheral quantitative computed tomography (HR-pQCT) allow for the assessment of bone microarchitecture and strength, but specific data comparing the impact of bone treatment in patients using glucocorticoids are lacking, they said.

In a study published in the Journal of Bone and Mineral Research, the researchers identified a subset of 56 patients randomized to denosumab and 54 to risedronate patients out of a total of 590 patients who were enrolled in a phase 3 randomized, controlled trial of denosumab vs. risedronate for bone mineral density. The main results of the larger trial – presented at EULAR 2018 – showed greater increases in bone strength with denosumab over risedronate in patients receiving glucocorticoids.

In the current study, the researchers reviewed HR-pQCT scans of the distal radius and tibia at baseline, 12 months, and 24 months. Bone strength and microarchitecture were defined in terms of failure load (FL) as a primary outcome. Patients also were divided into subpopulations of those initiating glucocorticoid treatment (GC-I) and continuing treatment (GC-C).

Baseline characteristics were mainly balanced among the treatment groups within the GC-I and GC-C categories.

Among the GC-I patients, in the denosumab group, FL increased significantly from baseline to 12 months at the radius at tibia (1.8% and 1.7%, respectively) but did not change significantly in the risedronate group, which translated to a significant treatment difference between the drugs of 3.3% for radius and 2.5% for tibia.

At 24 months, the radius measure of FL was unchanged from baseline in denosumab patients but significantly decreased in risedronate patients, with a difference of –4.1%, which translated to a significant between-treatment difference at the radius of 5.6% (P < .001). Changes at the tibia were not significantly different between the groups at 24 months.

Among the GC-C patients, FL was unchanged from baseline to 12 months for both the denosumab and risedronate groups. However, FL significantly increased with denosumab (4.3%) and remained unchanged in the risedronate group.

The researchers also found significant differences between denosumab and risedronate in percentage changes in cortical bone mineral density, and less prominent changes and differences in trabecular bone mineral density.

The study findings were limited by several factors including the use of the HR-pQCT scanner, which limits the measurement of trabecular microarchitecture, and the use of only standard HR-pQCT parameters, which do not allow insight into endosteal changes, and the inability to correct for multiplicity of data, the researchers noted.

However, the results support the superiority of denosumab over risedronate for preventing FL and total bone mineral density loss at the radius and tibia in new glucocorticoid users, and for increasing FL and total bone mineral density at the radius in long-term glucocorticoid users, they said.

Denosumab therefore could be a useful therapeutic option and could inform decision-making in patients initiating GC-therapy or on long-term GC-therapy, they concluded.

The study was supported by Amgen. Dr. Geusens disclosed grants from Amgen, Celgene, Lilly, Merck, Pfizer, Roche, UCB, Fresenius, Mylan, and Sandoz, and grants and other funding from AbbVie, outside the current study.

Bone strength and microarchitecture remained stronger at 24 months after treatment with denosumab compared to risedronate, in a study of 110 adults using glucocorticoids.

Patients using glucocorticoids are at increased risk for vertebral and nonvertebral fractures at both the start of treatment or as treatment continues, wrote Piet Geusens, MD, of Maastricht University, the Netherlands, and colleagues.

Imaging data collected via high-resolution peripheral quantitative computed tomography (HR-pQCT) allow for the assessment of bone microarchitecture and strength, but specific data comparing the impact of bone treatment in patients using glucocorticoids are lacking, they said.

In a study published in the Journal of Bone and Mineral Research, the researchers identified a subset of 56 patients randomized to denosumab and 54 to risedronate patients out of a total of 590 patients who were enrolled in a phase 3 randomized, controlled trial of denosumab vs. risedronate for bone mineral density. The main results of the larger trial – presented at EULAR 2018 – showed greater increases in bone strength with denosumab over risedronate in patients receiving glucocorticoids.

In the current study, the researchers reviewed HR-pQCT scans of the distal radius and tibia at baseline, 12 months, and 24 months. Bone strength and microarchitecture were defined in terms of failure load (FL) as a primary outcome. Patients also were divided into subpopulations of those initiating glucocorticoid treatment (GC-I) and continuing treatment (GC-C).

Baseline characteristics were mainly balanced among the treatment groups within the GC-I and GC-C categories.

Among the GC-I patients, in the denosumab group, FL increased significantly from baseline to 12 months at the radius at tibia (1.8% and 1.7%, respectively) but did not change significantly in the risedronate group, which translated to a significant treatment difference between the drugs of 3.3% for radius and 2.5% for tibia.

At 24 months, the radius measure of FL was unchanged from baseline in denosumab patients but significantly decreased in risedronate patients, with a difference of –4.1%, which translated to a significant between-treatment difference at the radius of 5.6% (P < .001). Changes at the tibia were not significantly different between the groups at 24 months.

Among the GC-C patients, FL was unchanged from baseline to 12 months for both the denosumab and risedronate groups. However, FL significantly increased with denosumab (4.3%) and remained unchanged in the risedronate group.

The researchers also found significant differences between denosumab and risedronate in percentage changes in cortical bone mineral density, and less prominent changes and differences in trabecular bone mineral density.

The study findings were limited by several factors including the use of the HR-pQCT scanner, which limits the measurement of trabecular microarchitecture, and the use of only standard HR-pQCT parameters, which do not allow insight into endosteal changes, and the inability to correct for multiplicity of data, the researchers noted.

However, the results support the superiority of denosumab over risedronate for preventing FL and total bone mineral density loss at the radius and tibia in new glucocorticoid users, and for increasing FL and total bone mineral density at the radius in long-term glucocorticoid users, they said.

Denosumab therefore could be a useful therapeutic option and could inform decision-making in patients initiating GC-therapy or on long-term GC-therapy, they concluded.

The study was supported by Amgen. Dr. Geusens disclosed grants from Amgen, Celgene, Lilly, Merck, Pfizer, Roche, UCB, Fresenius, Mylan, and Sandoz, and grants and other funding from AbbVie, outside the current study.

Bone strength and microarchitecture remained stronger at 24 months after treatment with denosumab compared to risedronate, in a study of 110 adults using glucocorticoids.

Patients using glucocorticoids are at increased risk for vertebral and nonvertebral fractures at both the start of treatment or as treatment continues, wrote Piet Geusens, MD, of Maastricht University, the Netherlands, and colleagues.

Imaging data collected via high-resolution peripheral quantitative computed tomography (HR-pQCT) allow for the assessment of bone microarchitecture and strength, but specific data comparing the impact of bone treatment in patients using glucocorticoids are lacking, they said.

In a study published in the Journal of Bone and Mineral Research, the researchers identified a subset of 56 patients randomized to denosumab and 54 to risedronate patients out of a total of 590 patients who were enrolled in a phase 3 randomized, controlled trial of denosumab vs. risedronate for bone mineral density. The main results of the larger trial – presented at EULAR 2018 – showed greater increases in bone strength with denosumab over risedronate in patients receiving glucocorticoids.

In the current study, the researchers reviewed HR-pQCT scans of the distal radius and tibia at baseline, 12 months, and 24 months. Bone strength and microarchitecture were defined in terms of failure load (FL) as a primary outcome. Patients also were divided into subpopulations of those initiating glucocorticoid treatment (GC-I) and continuing treatment (GC-C).

Baseline characteristics were mainly balanced among the treatment groups within the GC-I and GC-C categories.

Among the GC-I patients, in the denosumab group, FL increased significantly from baseline to 12 months at the radius at tibia (1.8% and 1.7%, respectively) but did not change significantly in the risedronate group, which translated to a significant treatment difference between the drugs of 3.3% for radius and 2.5% for tibia.

At 24 months, the radius measure of FL was unchanged from baseline in denosumab patients but significantly decreased in risedronate patients, with a difference of –4.1%, which translated to a significant between-treatment difference at the radius of 5.6% (P < .001). Changes at the tibia were not significantly different between the groups at 24 months.

Among the GC-C patients, FL was unchanged from baseline to 12 months for both the denosumab and risedronate groups. However, FL significantly increased with denosumab (4.3%) and remained unchanged in the risedronate group.

The researchers also found significant differences between denosumab and risedronate in percentage changes in cortical bone mineral density, and less prominent changes and differences in trabecular bone mineral density.

The study findings were limited by several factors including the use of the HR-pQCT scanner, which limits the measurement of trabecular microarchitecture, and the use of only standard HR-pQCT parameters, which do not allow insight into endosteal changes, and the inability to correct for multiplicity of data, the researchers noted.

However, the results support the superiority of denosumab over risedronate for preventing FL and total bone mineral density loss at the radius and tibia in new glucocorticoid users, and for increasing FL and total bone mineral density at the radius in long-term glucocorticoid users, they said.

Denosumab therefore could be a useful therapeutic option and could inform decision-making in patients initiating GC-therapy or on long-term GC-therapy, they concluded.

The study was supported by Amgen. Dr. Geusens disclosed grants from Amgen, Celgene, Lilly, Merck, Pfizer, Roche, UCB, Fresenius, Mylan, and Sandoz, and grants and other funding from AbbVie, outside the current study.

Though overall COVID-19 case counts continue to drop nationally, that’s not the story in every U.S. state.

About half the states have reported increases in COVID cases fueled by the Omicron subvariant, Axios reported. Alaska, Vermont, and Rhode Island had the highest increases, with more than 20 new cases per 100,000 people.

Nationally, the statistics are encouraging, with the 7-day average of daily cases around 26,000 on April 6, down from around 41,000 on March 6, according to the Centers for Disease Control and Prevention. The number of deaths has dropped to an average of around 600 a day, down 34% from 2 weeks ago.

National health officials have said some spots would have a lot of COVID cases.

“Looking across the country, we see that 95% of counties are reporting low COVID-19 community levels, which represent over 97% of the U.S. population,” CDC Director Rochelle Walensky, MD, said April 5 at a White House news briefing.

“If we look more closely at the local level, we find a handful of counties where we are seeing increases in both cases and markers of more severe disease, like hospitalizations and in-patient bed capacity, which have resulted in an increased COVID-19 community level in some areas.”

Meanwhile, the Commonwealth Fund issued a report April 8 saying the U.S. vaccine program had prevented an estimated 2.2 million deaths and 17 million hospitalizations.

If the vaccine program didn’t exist, the United States would have had another 66 million COVID infections and spent about $900 billion more on health care, the foundation said.

The United States has reported about 982,000 COVID-related deaths so far with about 80 million COVID cases, according to the CDC.

“Our findings highlight the profound and ongoing impact of the vaccination program in reducing infections, hospitalizations, and deaths,” the Commonwealth Fund said.

“Investing in vaccination programs also has produced substantial cost savings – approximately the size of one-fifth of annual national health expenditures – by dramatically reducing the amount spent on COVID-19 hospitalizations.”

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

Though overall COVID-19 case counts continue to drop nationally, that’s not the story in every U.S. state.

About half the states have reported increases in COVID cases fueled by the Omicron subvariant, Axios reported. Alaska, Vermont, and Rhode Island had the highest increases, with more than 20 new cases per 100,000 people.

Nationally, the statistics are encouraging, with the 7-day average of daily cases around 26,000 on April 6, down from around 41,000 on March 6, according to the Centers for Disease Control and Prevention. The number of deaths has dropped to an average of around 600 a day, down 34% from 2 weeks ago.

National health officials have said some spots would have a lot of COVID cases.

“Looking across the country, we see that 95% of counties are reporting low COVID-19 community levels, which represent over 97% of the U.S. population,” CDC Director Rochelle Walensky, MD, said April 5 at a White House news briefing.

“If we look more closely at the local level, we find a handful of counties where we are seeing increases in both cases and markers of more severe disease, like hospitalizations and in-patient bed capacity, which have resulted in an increased COVID-19 community level in some areas.”

Meanwhile, the Commonwealth Fund issued a report April 8 saying the U.S. vaccine program had prevented an estimated 2.2 million deaths and 17 million hospitalizations.

If the vaccine program didn’t exist, the United States would have had another 66 million COVID infections and spent about $900 billion more on health care, the foundation said.

The United States has reported about 982,000 COVID-related deaths so far with about 80 million COVID cases, according to the CDC.

“Our findings highlight the profound and ongoing impact of the vaccination program in reducing infections, hospitalizations, and deaths,” the Commonwealth Fund said.

“Investing in vaccination programs also has produced substantial cost savings – approximately the size of one-fifth of annual national health expenditures – by dramatically reducing the amount spent on COVID-19 hospitalizations.”

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

Though overall COVID-19 case counts continue to drop nationally, that’s not the story in every U.S. state.

About half the states have reported increases in COVID cases fueled by the Omicron subvariant, Axios reported. Alaska, Vermont, and Rhode Island had the highest increases, with more than 20 new cases per 100,000 people.

Nationally, the statistics are encouraging, with the 7-day average of daily cases around 26,000 on April 6, down from around 41,000 on March 6, according to the Centers for Disease Control and Prevention. The number of deaths has dropped to an average of around 600 a day, down 34% from 2 weeks ago.

National health officials have said some spots would have a lot of COVID cases.

“Looking across the country, we see that 95% of counties are reporting low COVID-19 community levels, which represent over 97% of the U.S. population,” CDC Director Rochelle Walensky, MD, said April 5 at a White House news briefing.

“If we look more closely at the local level, we find a handful of counties where we are seeing increases in both cases and markers of more severe disease, like hospitalizations and in-patient bed capacity, which have resulted in an increased COVID-19 community level in some areas.”

Meanwhile, the Commonwealth Fund issued a report April 8 saying the U.S. vaccine program had prevented an estimated 2.2 million deaths and 17 million hospitalizations.

If the vaccine program didn’t exist, the United States would have had another 66 million COVID infections and spent about $900 billion more on health care, the foundation said.

The United States has reported about 982,000 COVID-related deaths so far with about 80 million COVID cases, according to the CDC.

“Our findings highlight the profound and ongoing impact of the vaccination program in reducing infections, hospitalizations, and deaths,” the Commonwealth Fund said.

“Investing in vaccination programs also has produced substantial cost savings – approximately the size of one-fifth of annual national health expenditures – by dramatically reducing the amount spent on COVID-19 hospitalizations.”

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

In recent years, patients with advanced lung cancer have benefited from the advent of immune therapies and genotype-directed therapies –both of which have led to improved survival rates. But what will lung cancer look like in 2030?

Pasi A. Janne, MD, PhD, of the Dana-Farber Cancer Institute, Boston, hopes to see improved access to tumor and blood-based genotyping.

Dr. Janne, who serves as director of the Lowe Center for Thoracic Oncology at Dana-Farber, gave a keynote presentation at the 2022 European Lung Cancer Congress, where he highlighted the need to broaden the scope of targeted therapies, make “great drugs work even better,” improve the ability to treat patients based on risk level, and expand the use of targeted therapies in the adjuvant and neoadjuvant setting to make significant progress in the treatment lung cancer treatment in coming years.

Genotyping is underutilized, he said. A 2019 multicenter study reported at the annual meeting of the American Society of Clinical Oncology showed that only 54% of 1,203 patients underwent testing for EGFR mutations, 22% were tested for EGFR, ALK, ROS1, and BRAF mutations, and only 7% were tested for all biomarkers recommended by National Comprehensive Cancer Network guidelines at the time.

That study also showed that only 45% of patients received biomarker-driven treatment, even when driver mutations were detected.

“Immunotherapy was often prescribed instead of targeted therapy, even when molecular results were available,” Dr. Janne said.

Another study, reported at the 2021 ASCO annual meeting, showed some improvement in testing rates, but still, only 37% of patients were tested for all biomarkers as recommended.

Racial disparities in testing have also been observed. Bruno and colleagues found that any next-generation sequencing was performed in 50.1% of White patients, compared with 39.8% of black patients, and NGS prior to first-line therapy was performed in 35.5% and 25.8%, respectively.

The study, also reported at ASCO in 2021, showed that trial participation was observed among 3.9% of White patients and 1.9% of Black patients.

“The studies really highlight the need for increased testing rates and appropriate utilization of testing results to deliver optimal care to our patients with advanced lung cancer. We have a long way to go. To live the promise and appreciate the promise of precision therapy ... we need to be able to offer this testing to all of our patients with lung cancer,” he said.

Dr. Janne reported relationships with numerous pharmaceutical companies, including consulting, research support and stock ownership. He also receives postmarketing royalties from Dana-Farber Cancer Institute–owned intellectual property on EGFR mutations.

In recent years, patients with advanced lung cancer have benefited from the advent of immune therapies and genotype-directed therapies –both of which have led to improved survival rates. But what will lung cancer look like in 2030?

Pasi A. Janne, MD, PhD, of the Dana-Farber Cancer Institute, Boston, hopes to see improved access to tumor and blood-based genotyping.

Dr. Janne, who serves as director of the Lowe Center for Thoracic Oncology at Dana-Farber, gave a keynote presentation at the 2022 European Lung Cancer Congress, where he highlighted the need to broaden the scope of targeted therapies, make “great drugs work even better,” improve the ability to treat patients based on risk level, and expand the use of targeted therapies in the adjuvant and neoadjuvant setting to make significant progress in the treatment lung cancer treatment in coming years.

Genotyping is underutilized, he said. A 2019 multicenter study reported at the annual meeting of the American Society of Clinical Oncology showed that only 54% of 1,203 patients underwent testing for EGFR mutations, 22% were tested for EGFR, ALK, ROS1, and BRAF mutations, and only 7% were tested for all biomarkers recommended by National Comprehensive Cancer Network guidelines at the time.

That study also showed that only 45% of patients received biomarker-driven treatment, even when driver mutations were detected.

“Immunotherapy was often prescribed instead of targeted therapy, even when molecular results were available,” Dr. Janne said.

Another study, reported at the 2021 ASCO annual meeting, showed some improvement in testing rates, but still, only 37% of patients were tested for all biomarkers as recommended.

Racial disparities in testing have also been observed. Bruno and colleagues found that any next-generation sequencing was performed in 50.1% of White patients, compared with 39.8% of black patients, and NGS prior to first-line therapy was performed in 35.5% and 25.8%, respectively.

The study, also reported at ASCO in 2021, showed that trial participation was observed among 3.9% of White patients and 1.9% of Black patients.

“The studies really highlight the need for increased testing rates and appropriate utilization of testing results to deliver optimal care to our patients with advanced lung cancer. We have a long way to go. To live the promise and appreciate the promise of precision therapy ... we need to be able to offer this testing to all of our patients with lung cancer,” he said.

Dr. Janne reported relationships with numerous pharmaceutical companies, including consulting, research support and stock ownership. He also receives postmarketing royalties from Dana-Farber Cancer Institute–owned intellectual property on EGFR mutations.

In recent years, patients with advanced lung cancer have benefited from the advent of immune therapies and genotype-directed therapies –both of which have led to improved survival rates. But what will lung cancer look like in 2030?

Pasi A. Janne, MD, PhD, of the Dana-Farber Cancer Institute, Boston, hopes to see improved access to tumor and blood-based genotyping.

Dr. Janne, who serves as director of the Lowe Center for Thoracic Oncology at Dana-Farber, gave a keynote presentation at the 2022 European Lung Cancer Congress, where he highlighted the need to broaden the scope of targeted therapies, make “great drugs work even better,” improve the ability to treat patients based on risk level, and expand the use of targeted therapies in the adjuvant and neoadjuvant setting to make significant progress in the treatment lung cancer treatment in coming years.

Genotyping is underutilized, he said. A 2019 multicenter study reported at the annual meeting of the American Society of Clinical Oncology showed that only 54% of 1,203 patients underwent testing for EGFR mutations, 22% were tested for EGFR, ALK, ROS1, and BRAF mutations, and only 7% were tested for all biomarkers recommended by National Comprehensive Cancer Network guidelines at the time.

That study also showed that only 45% of patients received biomarker-driven treatment, even when driver mutations were detected.

“Immunotherapy was often prescribed instead of targeted therapy, even when molecular results were available,” Dr. Janne said.

Another study, reported at the 2021 ASCO annual meeting, showed some improvement in testing rates, but still, only 37% of patients were tested for all biomarkers as recommended.

Racial disparities in testing have also been observed. Bruno and colleagues found that any next-generation sequencing was performed in 50.1% of White patients, compared with 39.8% of black patients, and NGS prior to first-line therapy was performed in 35.5% and 25.8%, respectively.

The study, also reported at ASCO in 2021, showed that trial participation was observed among 3.9% of White patients and 1.9% of Black patients.

“The studies really highlight the need for increased testing rates and appropriate utilization of testing results to deliver optimal care to our patients with advanced lung cancer. We have a long way to go. To live the promise and appreciate the promise of precision therapy ... we need to be able to offer this testing to all of our patients with lung cancer,” he said.

Dr. Janne reported relationships with numerous pharmaceutical companies, including consulting, research support and stock ownership. He also receives postmarketing royalties from Dana-Farber Cancer Institute–owned intellectual property on EGFR mutations.

Pathological response has emerged as a valuable endpoint and surrogate marker for overall survival in lung cancer studies, but much work remains to be done, said William D. Travis, MD, director of thoracic pathology at Memorial Sloan Kettering Cancer Center, New York.

In a keynote address at the 2022 European Lung Cancer Conference, Dr. Travis highlighted advances in the use of pathological response in this setting and outlined areas that need refinement. “Pathologic response after preoperative therapy is important because the extent of pathologic response strongly correlates with improved overall survival, and it is reflective of neoadjuvant therapy. The degree of response is associated with the degree of benefit in survival, and it’s being used as a surrogate for survival in phase 2 and 3 neoadjuvant clinical trials.”

In fact, multiple studies have demonstrated that non–small cell lung cancer patients with 10% or less viable residual tumor after treatment have improved overall survival and disease-free survival, compared with patients who have more residual tumor, he explained.

Recent studies have demonstrated the value of pathological response as an endpoint in the neoadjuvant therapy and molecular targeted therapy setting, he said, citing a study published in the Journal of Clinical Oncology that showed major pathological response rates of 14%-45% and pathological complete response rates up to 29% in patients treated with single-agent checkpoint inhibition.

In the CheckMate 816 trial, both major pathologic response and pathological complete response were significantly higher in patients treated with combination nivolumab and chemotherapy, compared with those treated with chemotherapy alone (37% vs. 8.9% and 24% vs. 2%, respectively).

“This high rate of responses with combined immunotherapy and chemotherapy is quite exciting,” he said.

Dr. Travis also stressed the importance of consulting the current International Association for the Study of Lung Cancer Recommendations for Pathologic Assessment of Lung Cancer Resection Specimens After Neoadjuvant Therapy.

He highlighted several key points regarding pathological response in lung cancer:

• Major pathological response (MPR) is calculated as the estimated size of viable tumor divided by the size of the tumor bed.
• Optimal cutoffs for determining MPR is currently 10%, but recent data suggest that in the conventional chemotherapy setting this may vary by tumor histology, with much higher cutoffs of about 65% for adenocarcinoma.
• Estimating the amount of viable tumor is “quite complicated and requires quite a number of steps,” and one the most important steps is “for the surgeon to the pathologist know that given specimen is from a patient who received neoadjuvant therapy.”
• Determining the border of the tumor bed can be challenging, therefore “resection specimens after neoadjuvant therapy should be sampled to optimize comprehensive gross and histologic assessment of the lung tumor bed for pathologic response ... as outlined in the guidelines.”
• The IASLC panel determined that having a single approach for estimating treatment effect would be best, despite the different therapy types and combinations used, but “it is recognized that there may be certain types of features that need to be addressed,” such as immune cell infiltrates in pats who received immunotherapy.
• The recommendations provide specific guidance for measuring tumor size for staging, including for special circumstances.

As for future direction, Dr. Travis said, “one question is how to assess treatment effect in lymph node samples.

“This is done for lymph nodes in breast cancer but not in lung cancer. We need system[s] for lung cancer.”

Good “infrastructure for pathology departments” is needed to support clinical trials, he said, noting that the team at Memorial Sloan Kettering Cancer Center includes physician assistants, tissue procurement staff, frozen section techs, research fellows, and research assistants.

Future work should also aim to standardize pathology assessment for clinical trials, improve the current recommendations, make use of new technology like artificial intelligence, optimize banking protocols and special techniques, and identify radiologic-pathological correlations, he said.

He added that “IASLC is promoting the design and implementation of an international database to collect uniformly clinical and pathologic information with the ultimate goal of fostering collaboration and to facilitate the identification of surrogate endpoints of long-term survival.”

Dr. Travis is a nonpaid pathology consultant for the LCMC3 and LCMC4 trials.

Pathological response has emerged as a valuable endpoint and surrogate marker for overall survival in lung cancer studies, but much work remains to be done, said William D. Travis, MD, director of thoracic pathology at Memorial Sloan Kettering Cancer Center, New York.

In a keynote address at the 2022 European Lung Cancer Conference, Dr. Travis highlighted advances in the use of pathological response in this setting and outlined areas that need refinement. “Pathologic response after preoperative therapy is important because the extent of pathologic response strongly correlates with improved overall survival, and it is reflective of neoadjuvant therapy. The degree of response is associated with the degree of benefit in survival, and it’s being used as a surrogate for survival in phase 2 and 3 neoadjuvant clinical trials.”

In fact, multiple studies have demonstrated that non–small cell lung cancer patients with 10% or less viable residual tumor after treatment have improved overall survival and disease-free survival, compared with patients who have more residual tumor, he explained.

Recent studies have demonstrated the value of pathological response as an endpoint in the neoadjuvant therapy and molecular targeted therapy setting, he said, citing a study published in the Journal of Clinical Oncology that showed major pathological response rates of 14%-45% and pathological complete response rates up to 29% in patients treated with single-agent checkpoint inhibition.

In the CheckMate 816 trial, both major pathologic response and pathological complete response were significantly higher in patients treated with combination nivolumab and chemotherapy, compared with those treated with chemotherapy alone (37% vs. 8.9% and 24% vs. 2%, respectively).

“This high rate of responses with combined immunotherapy and chemotherapy is quite exciting,” he said.

Dr. Travis also stressed the importance of consulting the current International Association for the Study of Lung Cancer Recommendations for Pathologic Assessment of Lung Cancer Resection Specimens After Neoadjuvant Therapy.

He highlighted several key points regarding pathological response in lung cancer:

• Major pathological response (MPR) is calculated as the estimated size of viable tumor divided by the size of the tumor bed.
• Optimal cutoffs for determining MPR is currently 10%, but recent data suggest that in the conventional chemotherapy setting this may vary by tumor histology, with much higher cutoffs of about 65% for adenocarcinoma.
• Estimating the amount of viable tumor is “quite complicated and requires quite a number of steps,” and one the most important steps is “for the surgeon to the pathologist know that given specimen is from a patient who received neoadjuvant therapy.”
• Determining the border of the tumor bed can be challenging, therefore “resection specimens after neoadjuvant therapy should be sampled to optimize comprehensive gross and histologic assessment of the lung tumor bed for pathologic response ... as outlined in the guidelines.”
• The IASLC panel determined that having a single approach for estimating treatment effect would be best, despite the different therapy types and combinations used, but “it is recognized that there may be certain types of features that need to be addressed,” such as immune cell infiltrates in pats who received immunotherapy.
• The recommendations provide specific guidance for measuring tumor size for staging, including for special circumstances.

As for future direction, Dr. Travis said, “one question is how to assess treatment effect in lymph node samples.

“This is done for lymph nodes in breast cancer but not in lung cancer. We need system[s] for lung cancer.”

Good “infrastructure for pathology departments” is needed to support clinical trials, he said, noting that the team at Memorial Sloan Kettering Cancer Center includes physician assistants, tissue procurement staff, frozen section techs, research fellows, and research assistants.

Future work should also aim to standardize pathology assessment for clinical trials, improve the current recommendations, make use of new technology like artificial intelligence, optimize banking protocols and special techniques, and identify radiologic-pathological correlations, he said.

He added that “IASLC is promoting the design and implementation of an international database to collect uniformly clinical and pathologic information with the ultimate goal of fostering collaboration and to facilitate the identification of surrogate endpoints of long-term survival.”

Dr. Travis is a nonpaid pathology consultant for the LCMC3 and LCMC4 trials.

Pathological response has emerged as a valuable endpoint and surrogate marker for overall survival in lung cancer studies, but much work remains to be done, said William D. Travis, MD, director of thoracic pathology at Memorial Sloan Kettering Cancer Center, New York.

In a keynote address at the 2022 European Lung Cancer Conference, Dr. Travis highlighted advances in the use of pathological response in this setting and outlined areas that need refinement. “Pathologic response after preoperative therapy is important because the extent of pathologic response strongly correlates with improved overall survival, and it is reflective of neoadjuvant therapy. The degree of response is associated with the degree of benefit in survival, and it’s being used as a surrogate for survival in phase 2 and 3 neoadjuvant clinical trials.”

In fact, multiple studies have demonstrated that non–small cell lung cancer patients with 10% or less viable residual tumor after treatment have improved overall survival and disease-free survival, compared with patients who have more residual tumor, he explained.

Recent studies have demonstrated the value of pathological response as an endpoint in the neoadjuvant therapy and molecular targeted therapy setting, he said, citing a study published in the Journal of Clinical Oncology that showed major pathological response rates of 14%-45% and pathological complete response rates up to 29% in patients treated with single-agent checkpoint inhibition.

In the CheckMate 816 trial, both major pathologic response and pathological complete response were significantly higher in patients treated with combination nivolumab and chemotherapy, compared with those treated with chemotherapy alone (37% vs. 8.9% and 24% vs. 2%, respectively).

“This high rate of responses with combined immunotherapy and chemotherapy is quite exciting,” he said.

Dr. Travis also stressed the importance of consulting the current International Association for the Study of Lung Cancer Recommendations for Pathologic Assessment of Lung Cancer Resection Specimens After Neoadjuvant Therapy.

He highlighted several key points regarding pathological response in lung cancer:

• Major pathological response (MPR) is calculated as the estimated size of viable tumor divided by the size of the tumor bed.
• Optimal cutoffs for determining MPR is currently 10%, but recent data suggest that in the conventional chemotherapy setting this may vary by tumor histology, with much higher cutoffs of about 65% for adenocarcinoma.
• Estimating the amount of viable tumor is “quite complicated and requires quite a number of steps,” and one the most important steps is “for the surgeon to the pathologist know that given specimen is from a patient who received neoadjuvant therapy.”
• Determining the border of the tumor bed can be challenging, therefore “resection specimens after neoadjuvant therapy should be sampled to optimize comprehensive gross and histologic assessment of the lung tumor bed for pathologic response ... as outlined in the guidelines.”
• The IASLC panel determined that having a single approach for estimating treatment effect would be best, despite the different therapy types and combinations used, but “it is recognized that there may be certain types of features that need to be addressed,” such as immune cell infiltrates in pats who received immunotherapy.
• The recommendations provide specific guidance for measuring tumor size for staging, including for special circumstances.

As for future direction, Dr. Travis said, “one question is how to assess treatment effect in lymph node samples.

“This is done for lymph nodes in breast cancer but not in lung cancer. We need system[s] for lung cancer.”

Good “infrastructure for pathology departments” is needed to support clinical trials, he said, noting that the team at Memorial Sloan Kettering Cancer Center includes physician assistants, tissue procurement staff, frozen section techs, research fellows, and research assistants.

Future work should also aim to standardize pathology assessment for clinical trials, improve the current recommendations, make use of new technology like artificial intelligence, optimize banking protocols and special techniques, and identify radiologic-pathological correlations, he said.

He added that “IASLC is promoting the design and implementation of an international database to collect uniformly clinical and pathologic information with the ultimate goal of fostering collaboration and to facilitate the identification of surrogate endpoints of long-term survival.”

Dr. Travis is a nonpaid pathology consultant for the LCMC3 and LCMC4 trials.

Decades after hospitalists took over inpatient care in the 1990s, hospitalists and primary care physicians (PCPs) still struggle with a communication divide, researchers at one teaching hospital found.

Hospitalists and PCPs want more dialogue while patients are in the hospital in order to coordinate and personalize care, according to data collected at Beth Israel Deaconess Medical Center, Boston. The results were presented at the annual meeting of the Society of General Internal Medicine.

“I think a major takeaway is that both hospitalists and primary care doctors agree that it’s important for primary care doctors to be involved in a patient’s hospitalization. They both identified a value that PCPs can bring to the table,” coresearcher Kristen Flint, MD, a primary care resident, told this news organization.

A majority in both camps reported that communication with the other party occurred in less than 25% of cases, whereas ideally it would happen half of the time. Dr. Flint noted that communication tools differ among hospitals, limiting the applicability of the findings.

The research team surveyed 39 hospitalists and 28 PCPs employed by the medical center during the first half of 2021. They also interviewed six hospitalists as they admitted and discharged patients.

The hospitalist movement, which took hold in response to cost and efficiency demands of managed care, led to the start of inpatient specialists, thereby reducing the need for PCPs to commute between their offices and the hospital to care for patients in both settings. 
 

Primary care involvement is important during hospitalization

In the Beth Israel Deaconess survey, four out of five hospitalists and three-quarters of PCPs agreed that primary care involvement is still important during hospitalization, most critically during discharge and admission. Hospitalists reported that PCPs provide valuable data about a patient’s medical status, social supports, mental health, and goals for care. They also said having such data helps to boost patient trust and improve the quality of inpatient care.

“Most projects around communication between inpatient and outpatient doctors have really focused on the time of discharge,” when clinicians identify what care a patient will need after they leave the hospital, Dr. Flint said. “But we found that both sides felt increased communication at time of admission would also be beneficial.”

The biggest barrier for PCPs, cited by 82% of respondents, was lack of time. Hospitalists’ top impediment was being unable to find contact information for the other party, which was cited by 79% of these survey participants.
 

Hospitalists operate ‘in a very stressful environment’

The Beth Israel Deaconess research “documents what has largely been suspected,” said primary care general internist Allan Goroll, MD.

Dr. Goroll, a professor of medicine at Harvard Medical School, Boston, said in an interview that hospitalists operate “in a very stressful environment.”

“They [hospitalists] appreciate accurate information about a patient’s recent medical history, test results, and responses to treatment as well as a briefing on patient values and preferences, family dynamics, and priorities for the admission. It makes for a safer, more personalized, and more efficient hospital admission,” said Dr. Goroll, who was not involved in the research.

In a 2015 article in the New England Journal of Medicine, Dr. Goroll and Daniel Hunt, MD, director of hospital medicine at Emory University, Atlanta, proposed a collaborative model in which PCPs visit hospitalized patients and serve as consultants to inpatient staff. Dr. Goroll said Massachusetts General Hospital in Boston, where he practices, initiated a study of that approach, but it was interrupted by the pandemic.

“As limited time is the most often cited barrier to communication, future interventions such as asynchronous forms of communication between the two groups should be considered,” the researchers wrote in the NEJM perspective.

To narrow the gap, Beth Israel Deaconess will study converting an admission notification letter sent to PCPs into a two-way communication tool in which PCPs can insert patient information, Dr. Flint said.

Dr. Flint and Dr. Goroll have disclosed no relevant financial relationships.

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

Decades after hospitalists took over inpatient care in the 1990s, hospitalists and primary care physicians (PCPs) still struggle with a communication divide, researchers at one teaching hospital found.

Hospitalists and PCPs want more dialogue while patients are in the hospital in order to coordinate and personalize care, according to data collected at Beth Israel Deaconess Medical Center, Boston. The results were presented at the annual meeting of the Society of General Internal Medicine.

“I think a major takeaway is that both hospitalists and primary care doctors agree that it’s important for primary care doctors to be involved in a patient’s hospitalization. They both identified a value that PCPs can bring to the table,” coresearcher Kristen Flint, MD, a primary care resident, told this news organization.

A majority in both camps reported that communication with the other party occurred in less than 25% of cases, whereas ideally it would happen half of the time. Dr. Flint noted that communication tools differ among hospitals, limiting the applicability of the findings.

The research team surveyed 39 hospitalists and 28 PCPs employed by the medical center during the first half of 2021. They also interviewed six hospitalists as they admitted and discharged patients.

The hospitalist movement, which took hold in response to cost and efficiency demands of managed care, led to the start of inpatient specialists, thereby reducing the need for PCPs to commute between their offices and the hospital to care for patients in both settings. 
 

Primary care involvement is important during hospitalization

In the Beth Israel Deaconess survey, four out of five hospitalists and three-quarters of PCPs agreed that primary care involvement is still important during hospitalization, most critically during discharge and admission. Hospitalists reported that PCPs provide valuable data about a patient’s medical status, social supports, mental health, and goals for care. They also said having such data helps to boost patient trust and improve the quality of inpatient care.

“Most projects around communication between inpatient and outpatient doctors have really focused on the time of discharge,” when clinicians identify what care a patient will need after they leave the hospital, Dr. Flint said. “But we found that both sides felt increased communication at time of admission would also be beneficial.”

The biggest barrier for PCPs, cited by 82% of respondents, was lack of time. Hospitalists’ top impediment was being unable to find contact information for the other party, which was cited by 79% of these survey participants.
 

Hospitalists operate ‘in a very stressful environment’

The Beth Israel Deaconess research “documents what has largely been suspected,” said primary care general internist Allan Goroll, MD.

Dr. Goroll, a professor of medicine at Harvard Medical School, Boston, said in an interview that hospitalists operate “in a very stressful environment.”

“They [hospitalists] appreciate accurate information about a patient’s recent medical history, test results, and responses to treatment as well as a briefing on patient values and preferences, family dynamics, and priorities for the admission. It makes for a safer, more personalized, and more efficient hospital admission,” said Dr. Goroll, who was not involved in the research.

In a 2015 article in the New England Journal of Medicine, Dr. Goroll and Daniel Hunt, MD, director of hospital medicine at Emory University, Atlanta, proposed a collaborative model in which PCPs visit hospitalized patients and serve as consultants to inpatient staff. Dr. Goroll said Massachusetts General Hospital in Boston, where he practices, initiated a study of that approach, but it was interrupted by the pandemic.

“As limited time is the most often cited barrier to communication, future interventions such as asynchronous forms of communication between the two groups should be considered,” the researchers wrote in the NEJM perspective.

To narrow the gap, Beth Israel Deaconess will study converting an admission notification letter sent to PCPs into a two-way communication tool in which PCPs can insert patient information, Dr. Flint said.

Dr. Flint and Dr. Goroll have disclosed no relevant financial relationships.

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

Decades after hospitalists took over inpatient care in the 1990s, hospitalists and primary care physicians (PCPs) still struggle with a communication divide, researchers at one teaching hospital found.

Hospitalists and PCPs want more dialogue while patients are in the hospital in order to coordinate and personalize care, according to data collected at Beth Israel Deaconess Medical Center, Boston. The results were presented at the annual meeting of the Society of General Internal Medicine.

“I think a major takeaway is that both hospitalists and primary care doctors agree that it’s important for primary care doctors to be involved in a patient’s hospitalization. They both identified a value that PCPs can bring to the table,” coresearcher Kristen Flint, MD, a primary care resident, told this news organization.

A majority in both camps reported that communication with the other party occurred in less than 25% of cases, whereas ideally it would happen half of the time. Dr. Flint noted that communication tools differ among hospitals, limiting the applicability of the findings.

The research team surveyed 39 hospitalists and 28 PCPs employed by the medical center during the first half of 2021. They also interviewed six hospitalists as they admitted and discharged patients.

The hospitalist movement, which took hold in response to cost and efficiency demands of managed care, led to the start of inpatient specialists, thereby reducing the need for PCPs to commute between their offices and the hospital to care for patients in both settings. 
 

Primary care involvement is important during hospitalization

In the Beth Israel Deaconess survey, four out of five hospitalists and three-quarters of PCPs agreed that primary care involvement is still important during hospitalization, most critically during discharge and admission. Hospitalists reported that PCPs provide valuable data about a patient’s medical status, social supports, mental health, and goals for care. They also said having such data helps to boost patient trust and improve the quality of inpatient care.

“Most projects around communication between inpatient and outpatient doctors have really focused on the time of discharge,” when clinicians identify what care a patient will need after they leave the hospital, Dr. Flint said. “But we found that both sides felt increased communication at time of admission would also be beneficial.”

The biggest barrier for PCPs, cited by 82% of respondents, was lack of time. Hospitalists’ top impediment was being unable to find contact information for the other party, which was cited by 79% of these survey participants.
 

Hospitalists operate ‘in a very stressful environment’

The Beth Israel Deaconess research “documents what has largely been suspected,” said primary care general internist Allan Goroll, MD.

Dr. Goroll, a professor of medicine at Harvard Medical School, Boston, said in an interview that hospitalists operate “in a very stressful environment.”

“They [hospitalists] appreciate accurate information about a patient’s recent medical history, test results, and responses to treatment as well as a briefing on patient values and preferences, family dynamics, and priorities for the admission. It makes for a safer, more personalized, and more efficient hospital admission,” said Dr. Goroll, who was not involved in the research.

In a 2015 article in the New England Journal of Medicine, Dr. Goroll and Daniel Hunt, MD, director of hospital medicine at Emory University, Atlanta, proposed a collaborative model in which PCPs visit hospitalized patients and serve as consultants to inpatient staff. Dr. Goroll said Massachusetts General Hospital in Boston, where he practices, initiated a study of that approach, but it was interrupted by the pandemic.

“As limited time is the most often cited barrier to communication, future interventions such as asynchronous forms of communication between the two groups should be considered,” the researchers wrote in the NEJM perspective.

To narrow the gap, Beth Israel Deaconess will study converting an admission notification letter sent to PCPs into a two-way communication tool in which PCPs can insert patient information, Dr. Flint said.

Dr. Flint and Dr. Goroll have disclosed no relevant financial relationships.

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

In a deep dive into obscure Chinese language transplant journals, a pair of researchers from Australia and Israel have added a new layer of horror to what’s already known about forced organ harvesting in China.

Searching for documentation that vital organs are being harvested from nonconsenting executed prisoners, a practice that the China Tribunal confirmed “beyond any reasonable doubt” in 2020, Jacob Lavee, MD, an Israeli heart transplant surgeon, and Matthew Roberston, a PhD student at Australian National University, uncovered something even more shocking: that vital organs are being explanted from patients who are still alive.

“We have shown for the first time that the transplant surgeons are the executioners – that the mode of execution is organ procurement. These are self-admissions of executing the patient,” Dr. Lavee told this news organization. “Up until now, there has been what we call circumstantial evidence of this, but our paper is what you’d call the smoking gun, because it’s in the words of the physicians themselves that they are doing it. In the words of these surgeons, intubation was done only after the beginning of surgery, which means the patients were breathing spontaneously up until the moment the operation started ... meaning they were not brain dead.”

The research, published in the American Journal of Transplantation, involved intricate analysis of thousands of Chinese language transplant articles and identified 71 articles in which transplant surgeons describe starting organ procurement surgery before declaring their patients brain dead.

“What we found were improper, illegitimate, nonexistent, or false declarations of brain death,” Mr. Robertson said in an interview. He explained that this violates what’s known as the dead donor rule, which is fundamental in transplant ethics. “The surgeons wrote that the donor was brain dead, but according to everything we know about medical science, they could not possibly have been brain dead because there was no apnea test performed. Brain death is not just something you say, there’s this whole battery of tests, and the key is the apnea test, [in which] the patient is already intubated and ventilated, they turn the machine off, and they’re looking for carbon dioxide in the blood above a certain level.”

Mr. Robertson and Dr. Lavee have painstakingly documented “incriminating sentences” in each of the 71 articles proving that brain death had not occurred before the organ explantation procedure began. “There were two criteria by which we claimed a problematic brain death declaration,” said Mr. Robertson, who translated the Chinese. “One was where the patient was not ventilated and was only intubated after they were declared brain dead; the other was that the intubation took place immediately prior to the surgery beginning.”

“It was mind-boggling,” said Dr. Lavee, from Tel Aviv University. “When I first started reading, my initial reaction is, ‘This can’t be.’ I read it once, and again, and I insisted that Matt get another independent translation of the Chinese just to be sure. I told him, ‘There’s no way a physician, a surgeon could write this – it doesn’t make sense.’ But the more of these papers we read, we saw it was a pattern – and they didn’t come out of a single medical center, they are spread all over China.”

For the analysis, Mr. Robertson wrote code and customized an algorithm to examine 124,770 medical articles from official Chinese databases between 1980 and 2020. The 71 articles revealing cases involving problematic brain death came from 56 hospitals (of which 12 were military) in 33 cities across 15 provinces, they report. In total, 348 surgeons, nurses, anesthesiologists, and other medical workers or researchers were listed as authors of these publications.

Why would these medical personnel write such self-incriminating evidence? The researchers say it’s unclear. “They don’t think anyone’s reading this stuff,” Mr. Robertson suggests. “Sometimes it’s revealed in just five or six characters in a paper of eight pages.” Dr. Lavee wonders if it’s also ignorance. “If this has been a practice for 20 or 30 years in China, I guess nobody at that time was aware they were doing something wrong, although how to declare brain death is something that is known in China. They’ve published a lot about it.”

The article is “evidence that this barbarity continues and is a very valuable contribution that continues to bring attention to an enormous human rights violation,” said Arthur Caplan, PhD, head of the Division of Medical Ethics at New York University’s Grossman School of Medicine. “What they’ve reported has been going on for many, many years, the data are very clear that China’s doing many more transplants than they have cadaver organ donors,” he said, adding that the country’s well-documented and lucrative involvement in transplant tourism “means you have to have a donor ready when the would-be recipient appears; you have to have a matched organ available, and that’s hard to do waiting on a cadaver donor.”

Although the researchers found no incriminating publications after 2015, they speculate that this is likely due to growing awareness among Chinese surgeons that publishing the information would attract international condemnation. “We think these practices are continuing to go on,” said Dr. Lavee. He acknowledged that a voluntary organ donation program is slowly developing in parallel to this. He said, given China’s place as the world’s second largest transplant country behind the U.S., as well as its low rate of voluntary donation, it’s reasonable to conclude that the main source of organs remains prisoners on death row.

Dr. Caplan and the researchers have called for academic institutions and medical journals to resume their previous boycotts of Chinese transplant publications and speakers, but as long as China denies the practices, economic and political leaders will turn a blind eye. “In the past, I don’t think the question of China’s medical professional involvement in the execution of donors has been taken as seriously as it should have,” said Mr. Robertson. “I certainly hope that with the publication of this paper in the leading journal in the field, this will change.”

The study was supported by the Google Cloud Research Credits program, the Australian Government Research Training Program Scholarship, and the Victims of Communism Memorial Foundation. Mr. Robertson, Dr. Lavee, and Dr. Caplan have disclosed no relevant financial relationships.

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

In a deep dive into obscure Chinese language transplant journals, a pair of researchers from Australia and Israel have added a new layer of horror to what’s already known about forced organ harvesting in China.

Searching for documentation that vital organs are being harvested from nonconsenting executed prisoners, a practice that the China Tribunal confirmed “beyond any reasonable doubt” in 2020, Jacob Lavee, MD, an Israeli heart transplant surgeon, and Matthew Roberston, a PhD student at Australian National University, uncovered something even more shocking: that vital organs are being explanted from patients who are still alive.

“We have shown for the first time that the transplant surgeons are the executioners – that the mode of execution is organ procurement. These are self-admissions of executing the patient,” Dr. Lavee told this news organization. “Up until now, there has been what we call circumstantial evidence of this, but our paper is what you’d call the smoking gun, because it’s in the words of the physicians themselves that they are doing it. In the words of these surgeons, intubation was done only after the beginning of surgery, which means the patients were breathing spontaneously up until the moment the operation started ... meaning they were not brain dead.”

The research, published in the American Journal of Transplantation, involved intricate analysis of thousands of Chinese language transplant articles and identified 71 articles in which transplant surgeons describe starting organ procurement surgery before declaring their patients brain dead.

“What we found were improper, illegitimate, nonexistent, or false declarations of brain death,” Mr. Robertson said in an interview. He explained that this violates what’s known as the dead donor rule, which is fundamental in transplant ethics. “The surgeons wrote that the donor was brain dead, but according to everything we know about medical science, they could not possibly have been brain dead because there was no apnea test performed. Brain death is not just something you say, there’s this whole battery of tests, and the key is the apnea test, [in which] the patient is already intubated and ventilated, they turn the machine off, and they’re looking for carbon dioxide in the blood above a certain level.”

Mr. Robertson and Dr. Lavee have painstakingly documented “incriminating sentences” in each of the 71 articles proving that brain death had not occurred before the organ explantation procedure began. “There were two criteria by which we claimed a problematic brain death declaration,” said Mr. Robertson, who translated the Chinese. “One was where the patient was not ventilated and was only intubated after they were declared brain dead; the other was that the intubation took place immediately prior to the surgery beginning.”

“It was mind-boggling,” said Dr. Lavee, from Tel Aviv University. “When I first started reading, my initial reaction is, ‘This can’t be.’ I read it once, and again, and I insisted that Matt get another independent translation of the Chinese just to be sure. I told him, ‘There’s no way a physician, a surgeon could write this – it doesn’t make sense.’ But the more of these papers we read, we saw it was a pattern – and they didn’t come out of a single medical center, they are spread all over China.”

For the analysis, Mr. Robertson wrote code and customized an algorithm to examine 124,770 medical articles from official Chinese databases between 1980 and 2020. The 71 articles revealing cases involving problematic brain death came from 56 hospitals (of which 12 were military) in 33 cities across 15 provinces, they report. In total, 348 surgeons, nurses, anesthesiologists, and other medical workers or researchers were listed as authors of these publications.

Why would these medical personnel write such self-incriminating evidence? The researchers say it’s unclear. “They don’t think anyone’s reading this stuff,” Mr. Robertson suggests. “Sometimes it’s revealed in just five or six characters in a paper of eight pages.” Dr. Lavee wonders if it’s also ignorance. “If this has been a practice for 20 or 30 years in China, I guess nobody at that time was aware they were doing something wrong, although how to declare brain death is something that is known in China. They’ve published a lot about it.”

The article is “evidence that this barbarity continues and is a very valuable contribution that continues to bring attention to an enormous human rights violation,” said Arthur Caplan, PhD, head of the Division of Medical Ethics at New York University’s Grossman School of Medicine. “What they’ve reported has been going on for many, many years, the data are very clear that China’s doing many more transplants than they have cadaver organ donors,” he said, adding that the country’s well-documented and lucrative involvement in transplant tourism “means you have to have a donor ready when the would-be recipient appears; you have to have a matched organ available, and that’s hard to do waiting on a cadaver donor.”

Although the researchers found no incriminating publications after 2015, they speculate that this is likely due to growing awareness among Chinese surgeons that publishing the information would attract international condemnation. “We think these practices are continuing to go on,” said Dr. Lavee. He acknowledged that a voluntary organ donation program is slowly developing in parallel to this. He said, given China’s place as the world’s second largest transplant country behind the U.S., as well as its low rate of voluntary donation, it’s reasonable to conclude that the main source of organs remains prisoners on death row.

Dr. Caplan and the researchers have called for academic institutions and medical journals to resume their previous boycotts of Chinese transplant publications and speakers, but as long as China denies the practices, economic and political leaders will turn a blind eye. “In the past, I don’t think the question of China’s medical professional involvement in the execution of donors has been taken as seriously as it should have,” said Mr. Robertson. “I certainly hope that with the publication of this paper in the leading journal in the field, this will change.”

The study was supported by the Google Cloud Research Credits program, the Australian Government Research Training Program Scholarship, and the Victims of Communism Memorial Foundation. Mr. Robertson, Dr. Lavee, and Dr. Caplan have disclosed no relevant financial relationships.

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

In a deep dive into obscure Chinese language transplant journals, a pair of researchers from Australia and Israel have added a new layer of horror to what’s already known about forced organ harvesting in China.

Searching for documentation that vital organs are being harvested from nonconsenting executed prisoners, a practice that the China Tribunal confirmed “beyond any reasonable doubt” in 2020, Jacob Lavee, MD, an Israeli heart transplant surgeon, and Matthew Roberston, a PhD student at Australian National University, uncovered something even more shocking: that vital organs are being explanted from patients who are still alive.

“We have shown for the first time that the transplant surgeons are the executioners – that the mode of execution is organ procurement. These are self-admissions of executing the patient,” Dr. Lavee told this news organization. “Up until now, there has been what we call circumstantial evidence of this, but our paper is what you’d call the smoking gun, because it’s in the words of the physicians themselves that they are doing it. In the words of these surgeons, intubation was done only after the beginning of surgery, which means the patients were breathing spontaneously up until the moment the operation started ... meaning they were not brain dead.”

The research, published in the American Journal of Transplantation, involved intricate analysis of thousands of Chinese language transplant articles and identified 71 articles in which transplant surgeons describe starting organ procurement surgery before declaring their patients brain dead.

“What we found were improper, illegitimate, nonexistent, or false declarations of brain death,” Mr. Robertson said in an interview. He explained that this violates what’s known as the dead donor rule, which is fundamental in transplant ethics. “The surgeons wrote that the donor was brain dead, but according to everything we know about medical science, they could not possibly have been brain dead because there was no apnea test performed. Brain death is not just something you say, there’s this whole battery of tests, and the key is the apnea test, [in which] the patient is already intubated and ventilated, they turn the machine off, and they’re looking for carbon dioxide in the blood above a certain level.”

Mr. Robertson and Dr. Lavee have painstakingly documented “incriminating sentences” in each of the 71 articles proving that brain death had not occurred before the organ explantation procedure began. “There were two criteria by which we claimed a problematic brain death declaration,” said Mr. Robertson, who translated the Chinese. “One was where the patient was not ventilated and was only intubated after they were declared brain dead; the other was that the intubation took place immediately prior to the surgery beginning.”

“It was mind-boggling,” said Dr. Lavee, from Tel Aviv University. “When I first started reading, my initial reaction is, ‘This can’t be.’ I read it once, and again, and I insisted that Matt get another independent translation of the Chinese just to be sure. I told him, ‘There’s no way a physician, a surgeon could write this – it doesn’t make sense.’ But the more of these papers we read, we saw it was a pattern – and they didn’t come out of a single medical center, they are spread all over China.”

For the analysis, Mr. Robertson wrote code and customized an algorithm to examine 124,770 medical articles from official Chinese databases between 1980 and 2020. The 71 articles revealing cases involving problematic brain death came from 56 hospitals (of which 12 were military) in 33 cities across 15 provinces, they report. In total, 348 surgeons, nurses, anesthesiologists, and other medical workers or researchers were listed as authors of these publications.

Why would these medical personnel write such self-incriminating evidence? The researchers say it’s unclear. “They don’t think anyone’s reading this stuff,” Mr. Robertson suggests. “Sometimes it’s revealed in just five or six characters in a paper of eight pages.” Dr. Lavee wonders if it’s also ignorance. “If this has been a practice for 20 or 30 years in China, I guess nobody at that time was aware they were doing something wrong, although how to declare brain death is something that is known in China. They’ve published a lot about it.”

The article is “evidence that this barbarity continues and is a very valuable contribution that continues to bring attention to an enormous human rights violation,” said Arthur Caplan, PhD, head of the Division of Medical Ethics at New York University’s Grossman School of Medicine. “What they’ve reported has been going on for many, many years, the data are very clear that China’s doing many more transplants than they have cadaver organ donors,” he said, adding that the country’s well-documented and lucrative involvement in transplant tourism “means you have to have a donor ready when the would-be recipient appears; you have to have a matched organ available, and that’s hard to do waiting on a cadaver donor.”

Although the researchers found no incriminating publications after 2015, they speculate that this is likely due to growing awareness among Chinese surgeons that publishing the information would attract international condemnation. “We think these practices are continuing to go on,” said Dr. Lavee. He acknowledged that a voluntary organ donation program is slowly developing in parallel to this. He said, given China’s place as the world’s second largest transplant country behind the U.S., as well as its low rate of voluntary donation, it’s reasonable to conclude that the main source of organs remains prisoners on death row.

Dr. Caplan and the researchers have called for academic institutions and medical journals to resume their previous boycotts of Chinese transplant publications and speakers, but as long as China denies the practices, economic and political leaders will turn a blind eye. “In the past, I don’t think the question of China’s medical professional involvement in the execution of donors has been taken as seriously as it should have,” said Mr. Robertson. “I certainly hope that with the publication of this paper in the leading journal in the field, this will change.”

The study was supported by the Google Cloud Research Credits program, the Australian Government Research Training Program Scholarship, and the Victims of Communism Memorial Foundation. Mr. Robertson, Dr. Lavee, and Dr. Caplan have disclosed no relevant financial relationships.

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