Noninvasive ventilation (NIV) supports patient’s breathing without the immediate need for tracheotomy or intubation. The Center for Medicare and Medicaid Services (CMS) defines respiratory assist devices (RAD) as bi-level devices with back-up respiratory rate capability, which provide noninvasive modes of ventilation for respiratory insufficiency or sleep-related respiratory disorders in a home or hospital setting (21 CFR 868.5895). These devices are smaller in size with provision of the external battery (if needed) but limited by inability to offer daytime ventilatory mode (ie, mouthpiece ventilation). Currently, respiratory assist devices have been in DMEPOS Competitive Bidding Program since 2011, (similar to PAP devices for sleep apnea syndromes), which puts a 13-month capped rental in which the patient gets the device, supplies, and services for 13 months subsequent to which patient owns the device and supplies are paid separately by CMS (https://www.dmecompetitivebid.com/cbic/cbic.nsf/DocsCat/Home).

On the other hand, CMS defines home mechanical ventilators (HMV) as life supporting/sustaining devices for patients of all age groups used in various settings, included but not limited to home, hospital, institutional setting, transportation, or wherever portability is needed. The ventilators have increased portability due to external and internal battery, provision of mouthpiece ventilation, and at least six pressure modes and three volumes modes. Currently, the ventilators are under the frequently and substantially serviced act [42 U.S.C. § 1395m(a)(3)]. Under this act, the patient never owns the device but the device, ancillary supplies, clinical support (trained respiratory therapists), and servicing of the device are included in the monthly payments, which can last indefinitely. Thus, ventilators have both higher reimbursement rates and uncapped rental periods; beneficiaries not only pay higher monthly co-payments for these devices but also pay over a longer rental period. Nonetheless, these services are vital in keeping a certain subset of patients comfortable at home and out of higher cost settings. The current populations that directly benefit from this service are patients with polio, amyotrophic lateral sclerosis, muscular dystrophies, spinal muscle atrophy, thoracic restrictive disorder, and chronic hypercapnic respiratory failure due to COPD, to name a few. Thus, HMV has been vital in “freeing” these frail and vulnerable patient populations from their hospital beds, improving the quality of life, as well as mortality.

With the advent of technologic advancements, HMV, especially the noninvasive pressure support ventilator, is now capable of doing multiple modes, including CPAP, RAD modes, and ventilator modes. This could create a potential of abuse when the durable medical equipment supplier bills CMS for the ventilator but clinically, a lower cost CPAP, auto bi-level PAP, or RAD is indicated. The 2016 report from the Office of Inspector General (OIG) noted that CMS paid 85 times more claims for noninvasive pressure support ventilators in 2015 than in 2009 (from $3.8 million to $340 million). [https://tinyurl.com/y3ckskrb]. Expenditure increased from 2014 to 2015 alone accounted for 47% of the entire $337 million increase from 2009 to 2015. But, the report could not implicate reduced prices for CPAP devices and RADs under the Competitive Bidding Program to be driving increased billing for ventilators. They did find that the diagnoses used for these claims have shifted dramatically from neuromuscular diseases to other chronic respiratory conditions.

Since then, in January 2016, CMS consolidated billing codes for ventilators, and also reduced the reimbursement amount for noninvasive pressure support ventilators. After this change, between 2015 and 2016, median monthly rental rate of products decreased from $1,561 to $1,055; a reduction of 32% [https://tinyurl.com/y3ckskrb]. CMS presently is proposing to include HMV in the competitive bidding program to help with misuse and cost reduction. But proposed addition of the home ventilators in competitive bidding risks elimination of the vital services that are so important to keep a very “vulnerable and frail” population out of higher cost facilities. Because of this, CMS would see increased costs due to frequent emergency rooms visits, frequent intubations, intensive care unit stays, and admissions to long-term care at skilled nursing on one hand, but negatively impacting the quality of life of these patients on the other hand. This addition would have serious unintended consequences on Medicaid recipients, especially the pediatric population.

As a clinical guide, RADs are used for similar clinical conditions as HMV, but are meant for less severe respiratory conditions. Ideally, getting a RAD device for a patient should be governed by the physician’s clinical judgment rather than rigorous qualification criteria, nonetheless current RAD coverage policy in not only difficult but includes unnecessary qualification criteria, and as a result pushing the patient towards more costly ventilators. Unfortunately, CMS policies have not kept up with the technological advances of noninvasive ventilation. This has led to increased costs and utilization of noninvasive ventilators. In our opinion, including noninvasive ventilators in competitive bidding to reduce cost utilization is not the solution.

CMS needs to work with medical providers, beneficiaries, and various stakeholders to revise the current respiratory assist device and home mechanical ventilator guidelines in order to ensure that the appropriate patient is eligible for the correct device, without putting a very vulnerable patient population at risk.
 

Dr. Sahni is Clinical Assistant Professor, Division of Pulmonary, Critical Care, and Sleep Medicine at the University of Illinois at Chicago; Dr. Wolfe is Associate Professor of Medicine (Pulmonary & Critical Care) and Neurology (Sleep Medicine), Northwestern University, Chicago, Illinois.

Noninvasive ventilation (NIV) supports patient’s breathing without the immediate need for tracheotomy or intubation. The Center for Medicare and Medicaid Services (CMS) defines respiratory assist devices (RAD) as bi-level devices with back-up respiratory rate capability, which provide noninvasive modes of ventilation for respiratory insufficiency or sleep-related respiratory disorders in a home or hospital setting (21 CFR 868.5895). These devices are smaller in size with provision of the external battery (if needed) but limited by inability to offer daytime ventilatory mode (ie, mouthpiece ventilation). Currently, respiratory assist devices have been in DMEPOS Competitive Bidding Program since 2011, (similar to PAP devices for sleep apnea syndromes), which puts a 13-month capped rental in which the patient gets the device, supplies, and services for 13 months subsequent to which patient owns the device and supplies are paid separately by CMS (https://www.dmecompetitivebid.com/cbic/cbic.nsf/DocsCat/Home).

On the other hand, CMS defines home mechanical ventilators (HMV) as life supporting/sustaining devices for patients of all age groups used in various settings, included but not limited to home, hospital, institutional setting, transportation, or wherever portability is needed. The ventilators have increased portability due to external and internal battery, provision of mouthpiece ventilation, and at least six pressure modes and three volumes modes. Currently, the ventilators are under the frequently and substantially serviced act [42 U.S.C. § 1395m(a)(3)]. Under this act, the patient never owns the device but the device, ancillary supplies, clinical support (trained respiratory therapists), and servicing of the device are included in the monthly payments, which can last indefinitely. Thus, ventilators have both higher reimbursement rates and uncapped rental periods; beneficiaries not only pay higher monthly co-payments for these devices but also pay over a longer rental period. Nonetheless, these services are vital in keeping a certain subset of patients comfortable at home and out of higher cost settings. The current populations that directly benefit from this service are patients with polio, amyotrophic lateral sclerosis, muscular dystrophies, spinal muscle atrophy, thoracic restrictive disorder, and chronic hypercapnic respiratory failure due to COPD, to name a few. Thus, HMV has been vital in “freeing” these frail and vulnerable patient populations from their hospital beds, improving the quality of life, as well as mortality.

With the advent of technologic advancements, HMV, especially the noninvasive pressure support ventilator, is now capable of doing multiple modes, including CPAP, RAD modes, and ventilator modes. This could create a potential of abuse when the durable medical equipment supplier bills CMS for the ventilator but clinically, a lower cost CPAP, auto bi-level PAP, or RAD is indicated. The 2016 report from the Office of Inspector General (OIG) noted that CMS paid 85 times more claims for noninvasive pressure support ventilators in 2015 than in 2009 (from $3.8 million to $340 million). [https://tinyurl.com/y3ckskrb]. Expenditure increased from 2014 to 2015 alone accounted for 47% of the entire $337 million increase from 2009 to 2015. But, the report could not implicate reduced prices for CPAP devices and RADs under the Competitive Bidding Program to be driving increased billing for ventilators. They did find that the diagnoses used for these claims have shifted dramatically from neuromuscular diseases to other chronic respiratory conditions.

Since then, in January 2016, CMS consolidated billing codes for ventilators, and also reduced the reimbursement amount for noninvasive pressure support ventilators. After this change, between 2015 and 2016, median monthly rental rate of products decreased from $1,561 to $1,055; a reduction of 32% [https://tinyurl.com/y3ckskrb]. CMS presently is proposing to include HMV in the competitive bidding program to help with misuse and cost reduction. But proposed addition of the home ventilators in competitive bidding risks elimination of the vital services that are so important to keep a very “vulnerable and frail” population out of higher cost facilities. Because of this, CMS would see increased costs due to frequent emergency rooms visits, frequent intubations, intensive care unit stays, and admissions to long-term care at skilled nursing on one hand, but negatively impacting the quality of life of these patients on the other hand. This addition would have serious unintended consequences on Medicaid recipients, especially the pediatric population.

As a clinical guide, RADs are used for similar clinical conditions as HMV, but are meant for less severe respiratory conditions. Ideally, getting a RAD device for a patient should be governed by the physician’s clinical judgment rather than rigorous qualification criteria, nonetheless current RAD coverage policy in not only difficult but includes unnecessary qualification criteria, and as a result pushing the patient towards more costly ventilators. Unfortunately, CMS policies have not kept up with the technological advances of noninvasive ventilation. This has led to increased costs and utilization of noninvasive ventilators. In our opinion, including noninvasive ventilators in competitive bidding to reduce cost utilization is not the solution.

CMS needs to work with medical providers, beneficiaries, and various stakeholders to revise the current respiratory assist device and home mechanical ventilator guidelines in order to ensure that the appropriate patient is eligible for the correct device, without putting a very vulnerable patient population at risk.
 

Dr. Sahni is Clinical Assistant Professor, Division of Pulmonary, Critical Care, and Sleep Medicine at the University of Illinois at Chicago; Dr. Wolfe is Associate Professor of Medicine (Pulmonary & Critical Care) and Neurology (Sleep Medicine), Northwestern University, Chicago, Illinois.

Noninvasive ventilation (NIV) supports patient’s breathing without the immediate need for tracheotomy or intubation. The Center for Medicare and Medicaid Services (CMS) defines respiratory assist devices (RAD) as bi-level devices with back-up respiratory rate capability, which provide noninvasive modes of ventilation for respiratory insufficiency or sleep-related respiratory disorders in a home or hospital setting (21 CFR 868.5895). These devices are smaller in size with provision of the external battery (if needed) but limited by inability to offer daytime ventilatory mode (ie, mouthpiece ventilation). Currently, respiratory assist devices have been in DMEPOS Competitive Bidding Program since 2011, (similar to PAP devices for sleep apnea syndromes), which puts a 13-month capped rental in which the patient gets the device, supplies, and services for 13 months subsequent to which patient owns the device and supplies are paid separately by CMS (https://www.dmecompetitivebid.com/cbic/cbic.nsf/DocsCat/Home).

On the other hand, CMS defines home mechanical ventilators (HMV) as life supporting/sustaining devices for patients of all age groups used in various settings, included but not limited to home, hospital, institutional setting, transportation, or wherever portability is needed. The ventilators have increased portability due to external and internal battery, provision of mouthpiece ventilation, and at least six pressure modes and three volumes modes. Currently, the ventilators are under the frequently and substantially serviced act [42 U.S.C. § 1395m(a)(3)]. Under this act, the patient never owns the device but the device, ancillary supplies, clinical support (trained respiratory therapists), and servicing of the device are included in the monthly payments, which can last indefinitely. Thus, ventilators have both higher reimbursement rates and uncapped rental periods; beneficiaries not only pay higher monthly co-payments for these devices but also pay over a longer rental period. Nonetheless, these services are vital in keeping a certain subset of patients comfortable at home and out of higher cost settings. The current populations that directly benefit from this service are patients with polio, amyotrophic lateral sclerosis, muscular dystrophies, spinal muscle atrophy, thoracic restrictive disorder, and chronic hypercapnic respiratory failure due to COPD, to name a few. Thus, HMV has been vital in “freeing” these frail and vulnerable patient populations from their hospital beds, improving the quality of life, as well as mortality.

With the advent of technologic advancements, HMV, especially the noninvasive pressure support ventilator, is now capable of doing multiple modes, including CPAP, RAD modes, and ventilator modes. This could create a potential of abuse when the durable medical equipment supplier bills CMS for the ventilator but clinically, a lower cost CPAP, auto bi-level PAP, or RAD is indicated. The 2016 report from the Office of Inspector General (OIG) noted that CMS paid 85 times more claims for noninvasive pressure support ventilators in 2015 than in 2009 (from $3.8 million to $340 million). [https://tinyurl.com/y3ckskrb]. Expenditure increased from 2014 to 2015 alone accounted for 47% of the entire $337 million increase from 2009 to 2015. But, the report could not implicate reduced prices for CPAP devices and RADs under the Competitive Bidding Program to be driving increased billing for ventilators. They did find that the diagnoses used for these claims have shifted dramatically from neuromuscular diseases to other chronic respiratory conditions.

Since then, in January 2016, CMS consolidated billing codes for ventilators, and also reduced the reimbursement amount for noninvasive pressure support ventilators. After this change, between 2015 and 2016, median monthly rental rate of products decreased from $1,561 to $1,055; a reduction of 32% [https://tinyurl.com/y3ckskrb]. CMS presently is proposing to include HMV in the competitive bidding program to help with misuse and cost reduction. But proposed addition of the home ventilators in competitive bidding risks elimination of the vital services that are so important to keep a very “vulnerable and frail” population out of higher cost facilities. Because of this, CMS would see increased costs due to frequent emergency rooms visits, frequent intubations, intensive care unit stays, and admissions to long-term care at skilled nursing on one hand, but negatively impacting the quality of life of these patients on the other hand. This addition would have serious unintended consequences on Medicaid recipients, especially the pediatric population.

As a clinical guide, RADs are used for similar clinical conditions as HMV, but are meant for less severe respiratory conditions. Ideally, getting a RAD device for a patient should be governed by the physician’s clinical judgment rather than rigorous qualification criteria, nonetheless current RAD coverage policy in not only difficult but includes unnecessary qualification criteria, and as a result pushing the patient towards more costly ventilators. Unfortunately, CMS policies have not kept up with the technological advances of noninvasive ventilation. This has led to increased costs and utilization of noninvasive ventilators. In our opinion, including noninvasive ventilators in competitive bidding to reduce cost utilization is not the solution.

CMS needs to work with medical providers, beneficiaries, and various stakeholders to revise the current respiratory assist device and home mechanical ventilator guidelines in order to ensure that the appropriate patient is eligible for the correct device, without putting a very vulnerable patient population at risk.
 

Dr. Sahni is Clinical Assistant Professor, Division of Pulmonary, Critical Care, and Sleep Medicine at the University of Illinois at Chicago; Dr. Wolfe is Associate Professor of Medicine (Pulmonary & Critical Care) and Neurology (Sleep Medicine), Northwestern University, Chicago, Illinois.

COMMENTARY

Rare Lung Disease Research: National Heart, Lung, and Blood Institute’s Commitment to Partnership and Progress.
By L. J. Vuga, et al



ORIGINAL RESEARCH

Validation of Predictive Metabolic Syndrome Biomarkers of World Trade Center Lung Injury: A 16-Year Longitudinal Study
By S. Kwon, et al.
 

Association of Short Sleep Duration and Atrial Fibrillation
By M. W. Genuardi, et al.

Determinants of Depressive Symptoms at 1 Year Following ICU Discharge in Survivors of 7 or More Days of Mechanical Ventilation: Results From the RECOVER Program, a Secondary Analysis of a Prospective Multicenter Cohort Study 
By M. Hamilton, et al.

TOPICS IN PRACTICE MANAGEMENT

Clinician Strategies to Improve the Care of Patients Using Supplemental Oxygen
By S. S. Jacobs

COMMENTARY

Rare Lung Disease Research: National Heart, Lung, and Blood Institute’s Commitment to Partnership and Progress.
By L. J. Vuga, et al



ORIGINAL RESEARCH

Validation of Predictive Metabolic Syndrome Biomarkers of World Trade Center Lung Injury: A 16-Year Longitudinal Study
By S. Kwon, et al.
 

Association of Short Sleep Duration and Atrial Fibrillation
By M. W. Genuardi, et al.

Determinants of Depressive Symptoms at 1 Year Following ICU Discharge in Survivors of 7 or More Days of Mechanical Ventilation: Results From the RECOVER Program, a Secondary Analysis of a Prospective Multicenter Cohort Study 
By M. Hamilton, et al.

TOPICS IN PRACTICE MANAGEMENT

Clinician Strategies to Improve the Care of Patients Using Supplemental Oxygen
By S. S. Jacobs

COMMENTARY

Rare Lung Disease Research: National Heart, Lung, and Blood Institute’s Commitment to Partnership and Progress.
By L. J. Vuga, et al



ORIGINAL RESEARCH

Validation of Predictive Metabolic Syndrome Biomarkers of World Trade Center Lung Injury: A 16-Year Longitudinal Study
By S. Kwon, et al.
 

Association of Short Sleep Duration and Atrial Fibrillation
By M. W. Genuardi, et al.

Determinants of Depressive Symptoms at 1 Year Following ICU Discharge in Survivors of 7 or More Days of Mechanical Ventilation: Results From the RECOVER Program, a Secondary Analysis of a Prospective Multicenter Cohort Study 
By M. Hamilton, et al.

TOPICS IN PRACTICE MANAGEMENT

Clinician Strategies to Improve the Care of Patients Using Supplemental Oxygen
By S. S. Jacobs

Working as a clinician doesn’t always allow for extra time to focus on the wellness of your body and mind. After taking care of patients all day, it’s important to find the time to also take care of yourself.

This year’s CHEST’s Annual Meeting is introducing a new interactive experience that aims to provide physicians with the necessary tools to decompress from the stressors of work. Visit the CHEST Wellness Zone at CHEST Annual Meeting 2019 to learn easy methods to handle stress and relax after a long day at work.

CHEST 2019 attendees will learn tips and tricks geared toward improving health, and consultants will provide attendees with personalized methods to maintain a healthy lifestyle in the workplace and at home. For those who have yet to register for the annual meeting, this new initiative might change your mind.

At the Wellness Zone, you can relax while getting your feet massaged at one of the four massage machine stations. Clinicians are always on the go, and this station will help to relieve the pressures of being on your feet all day at work.

Essential oils will also be on display for you to smell. Experts will show you the best oil combinations to use in and out of the office.

With a daily strenuous workload, clinicians often forget about their own health, which can lead to poor posture. The Wellness Zone is equipped with consultants who will examine your posture to provide you with feedback to improve your stance. You will walk away after an evaluation with before and after pictures from your consult and a full posture analysis report.

Do you want to try meditation? There is a space dedicated to guiding you through a first-time practice equipped with headphones. You can visit this area to learn about guided meditation apps that make it easy to follow along when meditating at work and home.

The Wellness Zone will feature a variety of 15- to 30-minute sessions focused on providing you with the resources to create a new wellness routine after the annual meeting’s conclusion.

Geared toward improving both one’s physical and mental health, these sessions will dive deeper into maintaining a healthy lifestyle while at work and home. You will walk away from the Wellness Zone with new habits that you are encouraged to incorporate into your daily life to keep your stress levels down to avoid burnout.

The Wellness Zone will be located in the lobby/foyer space inside the New Orleans Ernest N. Morial Convention Center and will be open all day October 20-23, except for during the Opening Sessions. Attendees can visit the Wellness Zone at any time with no appointment necessary.

Visit chestmeeting.chestnet.org for a list of sessions that are offered in the Wellness Zone, including Creating Well-Being in the Workplace and more. Plan your visit now to enjoy all the benefits CHEST 2019 has to offer.

Working as a clinician doesn’t always allow for extra time to focus on the wellness of your body and mind. After taking care of patients all day, it’s important to find the time to also take care of yourself.

This year’s CHEST’s Annual Meeting is introducing a new interactive experience that aims to provide physicians with the necessary tools to decompress from the stressors of work. Visit the CHEST Wellness Zone at CHEST Annual Meeting 2019 to learn easy methods to handle stress and relax after a long day at work.

CHEST 2019 attendees will learn tips and tricks geared toward improving health, and consultants will provide attendees with personalized methods to maintain a healthy lifestyle in the workplace and at home. For those who have yet to register for the annual meeting, this new initiative might change your mind.

At the Wellness Zone, you can relax while getting your feet massaged at one of the four massage machine stations. Clinicians are always on the go, and this station will help to relieve the pressures of being on your feet all day at work.

Essential oils will also be on display for you to smell. Experts will show you the best oil combinations to use in and out of the office.

With a daily strenuous workload, clinicians often forget about their own health, which can lead to poor posture. The Wellness Zone is equipped with consultants who will examine your posture to provide you with feedback to improve your stance. You will walk away after an evaluation with before and after pictures from your consult and a full posture analysis report.

Do you want to try meditation? There is a space dedicated to guiding you through a first-time practice equipped with headphones. You can visit this area to learn about guided meditation apps that make it easy to follow along when meditating at work and home.

The Wellness Zone will feature a variety of 15- to 30-minute sessions focused on providing you with the resources to create a new wellness routine after the annual meeting’s conclusion.

Geared toward improving both one’s physical and mental health, these sessions will dive deeper into maintaining a healthy lifestyle while at work and home. You will walk away from the Wellness Zone with new habits that you are encouraged to incorporate into your daily life to keep your stress levels down to avoid burnout.

The Wellness Zone will be located in the lobby/foyer space inside the New Orleans Ernest N. Morial Convention Center and will be open all day October 20-23, except for during the Opening Sessions. Attendees can visit the Wellness Zone at any time with no appointment necessary.

Visit chestmeeting.chestnet.org for a list of sessions that are offered in the Wellness Zone, including Creating Well-Being in the Workplace and more. Plan your visit now to enjoy all the benefits CHEST 2019 has to offer.

Working as a clinician doesn’t always allow for extra time to focus on the wellness of your body and mind. After taking care of patients all day, it’s important to find the time to also take care of yourself.

This year’s CHEST’s Annual Meeting is introducing a new interactive experience that aims to provide physicians with the necessary tools to decompress from the stressors of work. Visit the CHEST Wellness Zone at CHEST Annual Meeting 2019 to learn easy methods to handle stress and relax after a long day at work.

CHEST 2019 attendees will learn tips and tricks geared toward improving health, and consultants will provide attendees with personalized methods to maintain a healthy lifestyle in the workplace and at home. For those who have yet to register for the annual meeting, this new initiative might change your mind.

At the Wellness Zone, you can relax while getting your feet massaged at one of the four massage machine stations. Clinicians are always on the go, and this station will help to relieve the pressures of being on your feet all day at work.

Essential oils will also be on display for you to smell. Experts will show you the best oil combinations to use in and out of the office.

With a daily strenuous workload, clinicians often forget about their own health, which can lead to poor posture. The Wellness Zone is equipped with consultants who will examine your posture to provide you with feedback to improve your stance. You will walk away after an evaluation with before and after pictures from your consult and a full posture analysis report.

Do you want to try meditation? There is a space dedicated to guiding you through a first-time practice equipped with headphones. You can visit this area to learn about guided meditation apps that make it easy to follow along when meditating at work and home.

The Wellness Zone will feature a variety of 15- to 30-minute sessions focused on providing you with the resources to create a new wellness routine after the annual meeting’s conclusion.

Geared toward improving both one’s physical and mental health, these sessions will dive deeper into maintaining a healthy lifestyle while at work and home. You will walk away from the Wellness Zone with new habits that you are encouraged to incorporate into your daily life to keep your stress levels down to avoid burnout.

The Wellness Zone will be located in the lobby/foyer space inside the New Orleans Ernest N. Morial Convention Center and will be open all day October 20-23, except for during the Opening Sessions. Attendees can visit the Wellness Zone at any time with no appointment necessary.

Visit chestmeeting.chestnet.org for a list of sessions that are offered in the Wellness Zone, including Creating Well-Being in the Workplace and more. Plan your visit now to enjoy all the benefits CHEST 2019 has to offer.

Occupational and Environmental Health

New guidelines for latent TB testing in health-care personnel

Latent infection with Mycobacterium tuberculosis (TB) infection is of public health concern because of the lifetime risk of reactivation, a risk highest in the first 2 years after TB infection. Treatment of latent TB infection (LTBI) reduces the risk of reactivation by as much as 90%, and, thus, screening for LTBI in high-risk populations can identify patients eligible for treatment (Horsburgh & Rubin. N Engl J Med. 2011;364[15]:1441). The Centers for Disease Control and Prevention (CDC) previously recommended annual testing for LTBI in health-care personnel (HCP) as a high-risk group for developing LTBI (Jensen et al. MMWR Recomm Rep. 2005;54[No. RR-17]).

The annual national TB rate in the United States has decreased by 73% since 1991 (Stewart et al. MMWR Morb Mortal Wkly Rep. 2018;67[11]:317), and surveillance data show that TB incidence among HCPs does not differ significantly from the general population. The CDC thus formed the National Tuberculosis Controllers Association (NTCA)-CDC work group to revisit the recommendations for LTBI screening in HCPs. A systematic evidence review of all studies of LTBI testing in HCPs since 2005 was performed. Analysis of data from identified studies showed that less than 5% of HCPs converted from baseline negative to positive on routine annual screening.

Based on this, the CDC updated their recommendations from the 2005 guidelines: (1) Serial annual LTBI testing is no longer routinely recommended for all HCPs but may be considered for select HCPs (eg, pulmonologists, infectious disease specialists, respiratory therapists); (2) Treatment is encouraged for all HCPs with positive LTBI testing, unless medically contraindicated; (3) The recommendations for baseline LTBI and postexposure testing in all HCPs remain unchanged (Sosa et al. MMWR Morb Mortal Wkly Rep. 2019;68[19]:439).

Sujith Cherian, MD, FCCP
Steering Committee Member

Amy Ahasic, MD, MPH, FCCP
Chair
 

Respiratory Care

Aerosol drug delivery via high-flow nasal cannula

As a noninvasive, easy-to-use oxygen device, high-flow nasal cannula (HFNC) meets patients’ inspiratory demands, increases functional residual capacity, and decreases the need for intubation (Rochwerg, et al. Intensive Care Med. 2019;45[5]:563).

Using HFNC for aerosol drug delivery is an innovative approach (Ari, et al. Pediatr Pulmonol. 2011;46[8]:795) and the seven most important things about aerosol delivery via HFNC are listed below for clinicians:

1. Aerosols can be delivered via HFNC in the treatment of patients with respiratory distress through all age groups.

2. Delivery efficiency of mesh nebulizers is greater than jet nebulizers during HFNC. Unlike jet nebulizers, they do not interfere with FiO2 and the function of HFNC by adding extra gas flow to the system.

3. Placing mesh nebulizers before the humidifier improves aerosol delivery via HFNC.

4. Higher inspiratory flow rates with HFNC decreases aerosol delivery due to increased turbulence and impactive loss of aerosols during therapy.

5. While aerosol deposition is greater with the larger prong sizes, its size should not block more than 50% of the cross-sectional area of each nostril to allow gas leakage around the cannula.

6. Although oxygen is commonly used with HFNC, administering aerosolized medications with heliox during HFNC improves lung deposition more than oxygen.

7. Training patients on the closed mouth technique and nasal breathing during therapy may improve aerosol drug delivery via HFNC.

HFNC is a promising tool in aerosol therapy, and developing clinical guidelines on aerosol delivery via HFNC is needed to improve its effectiveness in drug delivery.

Arzu Ari, PhD, RRT
Steering Committee Member

Jessica Overgoner, RRT
NetWork Member
 

Sleep Medicine

Statins in OSA

Obstructive sleep apnea is linked with cardiovascular disease (CVD) (Wolk R, et al. Circulation. 2003;108[1]:9), and the primary treatment of OSA, ie, continuous positive airway pressure (CPAP), may reverse the adverse CVD sequelae associated with OSA. However, recent randomized controlled trials, including SAVE and RICCADSA, fail to show significant reductions in CVD events with CPAP therapy (McEvoy RD, et al. J Thorac Dis. 2010;2[3]:138; Peker Y, et al. Am J Respir Crit Care Med. 2016;194[5]:613). Although numerous reasons are postulated for these unexpected trial findings, one potential explanation is that individuals in these trials were already on CVD protective drugs. One such drug category is statins. Statins are prescribed for their lipid lowering effects; however, they have pleiotropic properties including reduction in vascular inflammation and oxidative stress. Statins also enhance endothelial function and improve blood pressure. In animal studies, statins prevented the adverse effects of chronic intermittent hypoxemia on systolic blood pressure, endothelial function, and carotid artery compliance. Human studies confirm some of the aforementioned animal study findings. In a study of patients with OSA, statin therapy preserved the anti-inflammatory cell surface proteins that are typically reduced in these patients (Emin M, et al. Sci Transl Med. 2016;8[320]:320ra1). In a randomized controlled trial of patients with OSA, statin therapy significantly improved systolic blood pressure but did not improve reactive hyperemia index, which is a marker of endothelial dysfunction (Joyeux-Faure M, et al. Mediators Inflamm. 2014 Aug 25. doi: 10.1155/2014/423120).

Therefore, the jury is still out regarding the independent impact of statin therapy on CVD risk reduction in patients with OSA. Yet, there is select evidence suggesting there may be a role for statins in patients with OSA to mitigate the CVD risk associated with OSA. It remains unknown whether statins work synergistically with CPAP to further reduce CVD risk.

Neomi Shah, MD
Steering Committee Member

Occupational and Environmental Health

New guidelines for latent TB testing in health-care personnel

Latent infection with Mycobacterium tuberculosis (TB) infection is of public health concern because of the lifetime risk of reactivation, a risk highest in the first 2 years after TB infection. Treatment of latent TB infection (LTBI) reduces the risk of reactivation by as much as 90%, and, thus, screening for LTBI in high-risk populations can identify patients eligible for treatment (Horsburgh & Rubin. N Engl J Med. 2011;364[15]:1441). The Centers for Disease Control and Prevention (CDC) previously recommended annual testing for LTBI in health-care personnel (HCP) as a high-risk group for developing LTBI (Jensen et al. MMWR Recomm Rep. 2005;54[No. RR-17]).

The annual national TB rate in the United States has decreased by 73% since 1991 (Stewart et al. MMWR Morb Mortal Wkly Rep. 2018;67[11]:317), and surveillance data show that TB incidence among HCPs does not differ significantly from the general population. The CDC thus formed the National Tuberculosis Controllers Association (NTCA)-CDC work group to revisit the recommendations for LTBI screening in HCPs. A systematic evidence review of all studies of LTBI testing in HCPs since 2005 was performed. Analysis of data from identified studies showed that less than 5% of HCPs converted from baseline negative to positive on routine annual screening.

Based on this, the CDC updated their recommendations from the 2005 guidelines: (1) Serial annual LTBI testing is no longer routinely recommended for all HCPs but may be considered for select HCPs (eg, pulmonologists, infectious disease specialists, respiratory therapists); (2) Treatment is encouraged for all HCPs with positive LTBI testing, unless medically contraindicated; (3) The recommendations for baseline LTBI and postexposure testing in all HCPs remain unchanged (Sosa et al. MMWR Morb Mortal Wkly Rep. 2019;68[19]:439).

Sujith Cherian, MD, FCCP
Steering Committee Member

Amy Ahasic, MD, MPH, FCCP
Chair
 

Respiratory Care

Aerosol drug delivery via high-flow nasal cannula

As a noninvasive, easy-to-use oxygen device, high-flow nasal cannula (HFNC) meets patients’ inspiratory demands, increases functional residual capacity, and decreases the need for intubation (Rochwerg, et al. Intensive Care Med. 2019;45[5]:563).

Using HFNC for aerosol drug delivery is an innovative approach (Ari, et al. Pediatr Pulmonol. 2011;46[8]:795) and the seven most important things about aerosol delivery via HFNC are listed below for clinicians:

1. Aerosols can be delivered via HFNC in the treatment of patients with respiratory distress through all age groups.

2. Delivery efficiency of mesh nebulizers is greater than jet nebulizers during HFNC. Unlike jet nebulizers, they do not interfere with FiO2 and the function of HFNC by adding extra gas flow to the system.

3. Placing mesh nebulizers before the humidifier improves aerosol delivery via HFNC.

4. Higher inspiratory flow rates with HFNC decreases aerosol delivery due to increased turbulence and impactive loss of aerosols during therapy.

5. While aerosol deposition is greater with the larger prong sizes, its size should not block more than 50% of the cross-sectional area of each nostril to allow gas leakage around the cannula.

6. Although oxygen is commonly used with HFNC, administering aerosolized medications with heliox during HFNC improves lung deposition more than oxygen.

7. Training patients on the closed mouth technique and nasal breathing during therapy may improve aerosol drug delivery via HFNC.

HFNC is a promising tool in aerosol therapy, and developing clinical guidelines on aerosol delivery via HFNC is needed to improve its effectiveness in drug delivery.

Arzu Ari, PhD, RRT
Steering Committee Member

Jessica Overgoner, RRT
NetWork Member
 

Sleep Medicine

Statins in OSA

Obstructive sleep apnea is linked with cardiovascular disease (CVD) (Wolk R, et al. Circulation. 2003;108[1]:9), and the primary treatment of OSA, ie, continuous positive airway pressure (CPAP), may reverse the adverse CVD sequelae associated with OSA. However, recent randomized controlled trials, including SAVE and RICCADSA, fail to show significant reductions in CVD events with CPAP therapy (McEvoy RD, et al. J Thorac Dis. 2010;2[3]:138; Peker Y, et al. Am J Respir Crit Care Med. 2016;194[5]:613). Although numerous reasons are postulated for these unexpected trial findings, one potential explanation is that individuals in these trials were already on CVD protective drugs. One such drug category is statins. Statins are prescribed for their lipid lowering effects; however, they have pleiotropic properties including reduction in vascular inflammation and oxidative stress. Statins also enhance endothelial function and improve blood pressure. In animal studies, statins prevented the adverse effects of chronic intermittent hypoxemia on systolic blood pressure, endothelial function, and carotid artery compliance. Human studies confirm some of the aforementioned animal study findings. In a study of patients with OSA, statin therapy preserved the anti-inflammatory cell surface proteins that are typically reduced in these patients (Emin M, et al. Sci Transl Med. 2016;8[320]:320ra1). In a randomized controlled trial of patients with OSA, statin therapy significantly improved systolic blood pressure but did not improve reactive hyperemia index, which is a marker of endothelial dysfunction (Joyeux-Faure M, et al. Mediators Inflamm. 2014 Aug 25. doi: 10.1155/2014/423120).

Therefore, the jury is still out regarding the independent impact of statin therapy on CVD risk reduction in patients with OSA. Yet, there is select evidence suggesting there may be a role for statins in patients with OSA to mitigate the CVD risk associated with OSA. It remains unknown whether statins work synergistically with CPAP to further reduce CVD risk.

Neomi Shah, MD
Steering Committee Member

Occupational and Environmental Health

New guidelines for latent TB testing in health-care personnel

Latent infection with Mycobacterium tuberculosis (TB) infection is of public health concern because of the lifetime risk of reactivation, a risk highest in the first 2 years after TB infection. Treatment of latent TB infection (LTBI) reduces the risk of reactivation by as much as 90%, and, thus, screening for LTBI in high-risk populations can identify patients eligible for treatment (Horsburgh & Rubin. N Engl J Med. 2011;364[15]:1441). The Centers for Disease Control and Prevention (CDC) previously recommended annual testing for LTBI in health-care personnel (HCP) as a high-risk group for developing LTBI (Jensen et al. MMWR Recomm Rep. 2005;54[No. RR-17]).

The annual national TB rate in the United States has decreased by 73% since 1991 (Stewart et al. MMWR Morb Mortal Wkly Rep. 2018;67[11]:317), and surveillance data show that TB incidence among HCPs does not differ significantly from the general population. The CDC thus formed the National Tuberculosis Controllers Association (NTCA)-CDC work group to revisit the recommendations for LTBI screening in HCPs. A systematic evidence review of all studies of LTBI testing in HCPs since 2005 was performed. Analysis of data from identified studies showed that less than 5% of HCPs converted from baseline negative to positive on routine annual screening.

Based on this, the CDC updated their recommendations from the 2005 guidelines: (1) Serial annual LTBI testing is no longer routinely recommended for all HCPs but may be considered for select HCPs (eg, pulmonologists, infectious disease specialists, respiratory therapists); (2) Treatment is encouraged for all HCPs with positive LTBI testing, unless medically contraindicated; (3) The recommendations for baseline LTBI and postexposure testing in all HCPs remain unchanged (Sosa et al. MMWR Morb Mortal Wkly Rep. 2019;68[19]:439).

Sujith Cherian, MD, FCCP
Steering Committee Member

Amy Ahasic, MD, MPH, FCCP
Chair
 

Respiratory Care

Aerosol drug delivery via high-flow nasal cannula

As a noninvasive, easy-to-use oxygen device, high-flow nasal cannula (HFNC) meets patients’ inspiratory demands, increases functional residual capacity, and decreases the need for intubation (Rochwerg, et al. Intensive Care Med. 2019;45[5]:563).

Using HFNC for aerosol drug delivery is an innovative approach (Ari, et al. Pediatr Pulmonol. 2011;46[8]:795) and the seven most important things about aerosol delivery via HFNC are listed below for clinicians:

1. Aerosols can be delivered via HFNC in the treatment of patients with respiratory distress through all age groups.

2. Delivery efficiency of mesh nebulizers is greater than jet nebulizers during HFNC. Unlike jet nebulizers, they do not interfere with FiO2 and the function of HFNC by adding extra gas flow to the system.

3. Placing mesh nebulizers before the humidifier improves aerosol delivery via HFNC.

4. Higher inspiratory flow rates with HFNC decreases aerosol delivery due to increased turbulence and impactive loss of aerosols during therapy.

5. While aerosol deposition is greater with the larger prong sizes, its size should not block more than 50% of the cross-sectional area of each nostril to allow gas leakage around the cannula.

6. Although oxygen is commonly used with HFNC, administering aerosolized medications with heliox during HFNC improves lung deposition more than oxygen.

7. Training patients on the closed mouth technique and nasal breathing during therapy may improve aerosol drug delivery via HFNC.

HFNC is a promising tool in aerosol therapy, and developing clinical guidelines on aerosol delivery via HFNC is needed to improve its effectiveness in drug delivery.

Arzu Ari, PhD, RRT
Steering Committee Member

Jessica Overgoner, RRT
NetWork Member
 

Sleep Medicine

Statins in OSA

Obstructive sleep apnea is linked with cardiovascular disease (CVD) (Wolk R, et al. Circulation. 2003;108[1]:9), and the primary treatment of OSA, ie, continuous positive airway pressure (CPAP), may reverse the adverse CVD sequelae associated with OSA. However, recent randomized controlled trials, including SAVE and RICCADSA, fail to show significant reductions in CVD events with CPAP therapy (McEvoy RD, et al. J Thorac Dis. 2010;2[3]:138; Peker Y, et al. Am J Respir Crit Care Med. 2016;194[5]:613). Although numerous reasons are postulated for these unexpected trial findings, one potential explanation is that individuals in these trials were already on CVD protective drugs. One such drug category is statins. Statins are prescribed for their lipid lowering effects; however, they have pleiotropic properties including reduction in vascular inflammation and oxidative stress. Statins also enhance endothelial function and improve blood pressure. In animal studies, statins prevented the adverse effects of chronic intermittent hypoxemia on systolic blood pressure, endothelial function, and carotid artery compliance. Human studies confirm some of the aforementioned animal study findings. In a study of patients with OSA, statin therapy preserved the anti-inflammatory cell surface proteins that are typically reduced in these patients (Emin M, et al. Sci Transl Med. 2016;8[320]:320ra1). In a randomized controlled trial of patients with OSA, statin therapy significantly improved systolic blood pressure but did not improve reactive hyperemia index, which is a marker of endothelial dysfunction (Joyeux-Faure M, et al. Mediators Inflamm. 2014 Aug 25. doi: 10.1155/2014/423120).

Therefore, the jury is still out regarding the independent impact of statin therapy on CVD risk reduction in patients with OSA. Yet, there is select evidence suggesting there may be a role for statins in patients with OSA to mitigate the CVD risk associated with OSA. It remains unknown whether statins work synergistically with CPAP to further reduce CVD risk.

Neomi Shah, MD
Steering Committee Member

Stephanie M. Levine, MD, FCCP, is an expert in lung transplantation, and pulmonary and critical care issues in pregnancy and women’s lung health. She is a Professor of Medicine in the Division of Pulmonary Diseases and Critical Care Medicine at the University of Texas Health Science Center in San Antonio, Texas; the Program Director of the Pulmonary and Critical Care Fellowship at the University of Texas Health Science Center; and the Co-Director of the Medical Intensive Care Unit at the University Hospital. She is also a staff physician at the Audie Murphy Veteran Administration Hospital.

Dr. Levine has been Editor for both CHEST SEEK Critical Care Medicine and Pulmonary Medicine editions. In 2009 she received the CHEST Presidential Citation Award; in 2010, the CHEST Distinguished Service Award; and in 2017, the Master Clinician Educator Award. She has also been recognized as a Distinguished CHEST Educator in 2017, 2018, and 2019.

Dr. Levine has been active in CHEST international activities with CHEST World Congress meetings, the 2017 Basel Joint CHEST/SPG Congress in collaboration with the Swiss Lung Association, and with the pulmonary/critical care subspecialty training programs being developed in China. She was President and Chair of the CHEST Foundation from 2010-2014 and is currently on the CHEST Board of Regents.

We asked Dr. Levine for some thoughts on her upcoming CHEST presidency.
 

What would you like to accomplish as President of CHEST?

Every 5 years, the Board of Regents sets forth a new 5-year strategic plan, which is re-evaluated annually. We try to make sure all our decisions and actions align with this strategic plan. As President, I will promote the vision and mission of CHEST while guiding our organization to succeed in our 2018-2022 strategic plan. What will this include? This will include developing new innovative, evidenced-based, education and educational products in the areas of pulmonary, critical care, and sleep medicine; producing evidence-based guidelines; and expanding our educational expertise both nationally and globally. I am committed to actively engage and retain our fellows-in-training (being a longstanding program director), and to mentor our future leaders. I will reach out to engage and educate advanced practice providers, who are an integral part of our patient care teams. We will grow the CHEST Foundation in the areas of patient education and access, clinical research funding, and community service. On the global front, we will continue with our new global strategy of holding congresses based on the annual meeting content and smaller board review format regional conferences in different parts of the world seeking education in pulmonary, critical care, and sleep medicine. Our next meeting is in Bologna, Italy, in June of 2020. I will build on our collaborative inter-societal relationships with our related societies. Some of the specific areas I plan to focus on are defining the true value of CHEST membership, engaging all members of the health-care team, and revisiting the structure and function of our NetWorks to ensure the maximum opportunities for leadership and engagement.

What do you consider to be the greatest strength of CHEST, and how will you build upon this during your Presidency?

Our greatest strengths are the education we deliver; the people at all levels who deliver, learn from, and support the delivery of this core component of our vision and mission; and the culture in which this all takes place. These people include leaders, volunteers, faculty, members and all clinicians on the health-care team, and our top-notch staff (our EVP/CEO, Executive and Operations Team and staff at all levels). To build upon this, we need to strive for continued educational innovation and relevance and creative delivery of our educational products.

What are some challenges facing CHEST, and how will you address these challenges?

Ironically, maintaining our greatest strengths in the setting of a changing health-care environment can also be one of the greatest challenges. We must continue to make our education vibrant, relevant, and experiential. To do this, we need to ensure innovative, year-round education, whether at the annual meeting or through our e-learning platforms, simulation activities, SEEK, state-of the-art guidelines, board review courses, and courses and meetings at CHEST Global Headquarters in Glenview, Illinois, or at a global destination. We also need to stay relevant from the point of view of the value of membership and engagement. We must be cognizant of what members and others who engage with CHEST are looking for and ensure that we are meeting those ongoing expectations. Also, the need to identify, attract, develop, and retain talented and diverse members, volunteers, faculty, and future leaders and staff is imperative. As a program director, I am particularly interested in the retention of our fellows-in-training.

And finally, what is your charge to the members and new Fellows (FCCPs) of CHEST?

Get involved and stay involved. There are so many opportunities to do this! Attend the CHEST Annual Meeting. Join a NetWork. Submit articles to the journal CHEST or abstracts and case reports to the meeting. Participate in a Board Review Course or one of our e-learning opportunities. Come to a live course at headquarters or at a global destination. Participate in a simulation experience. Network at a meeting or a course. Engage with the CHEST Foundation. Connect with us on social media. Sign up to be a moderator and/or grader at the CHEST Annual Meeting. Become an FCCP. Apply for leadership openings, and if you don’t get it the first time, try again! You will be impressed with all that CHEST has to offer!!

Stephanie M. Levine, MD, FCCP, is an expert in lung transplantation, and pulmonary and critical care issues in pregnancy and women’s lung health. She is a Professor of Medicine in the Division of Pulmonary Diseases and Critical Care Medicine at the University of Texas Health Science Center in San Antonio, Texas; the Program Director of the Pulmonary and Critical Care Fellowship at the University of Texas Health Science Center; and the Co-Director of the Medical Intensive Care Unit at the University Hospital. She is also a staff physician at the Audie Murphy Veteran Administration Hospital.

Dr. Levine has been Editor for both CHEST SEEK Critical Care Medicine and Pulmonary Medicine editions. In 2009 she received the CHEST Presidential Citation Award; in 2010, the CHEST Distinguished Service Award; and in 2017, the Master Clinician Educator Award. She has also been recognized as a Distinguished CHEST Educator in 2017, 2018, and 2019.

Dr. Levine has been active in CHEST international activities with CHEST World Congress meetings, the 2017 Basel Joint CHEST/SPG Congress in collaboration with the Swiss Lung Association, and with the pulmonary/critical care subspecialty training programs being developed in China. She was President and Chair of the CHEST Foundation from 2010-2014 and is currently on the CHEST Board of Regents.

We asked Dr. Levine for some thoughts on her upcoming CHEST presidency.
 

What would you like to accomplish as President of CHEST?

Every 5 years, the Board of Regents sets forth a new 5-year strategic plan, which is re-evaluated annually. We try to make sure all our decisions and actions align with this strategic plan. As President, I will promote the vision and mission of CHEST while guiding our organization to succeed in our 2018-2022 strategic plan. What will this include? This will include developing new innovative, evidenced-based, education and educational products in the areas of pulmonary, critical care, and sleep medicine; producing evidence-based guidelines; and expanding our educational expertise both nationally and globally. I am committed to actively engage and retain our fellows-in-training (being a longstanding program director), and to mentor our future leaders. I will reach out to engage and educate advanced practice providers, who are an integral part of our patient care teams. We will grow the CHEST Foundation in the areas of patient education and access, clinical research funding, and community service. On the global front, we will continue with our new global strategy of holding congresses based on the annual meeting content and smaller board review format regional conferences in different parts of the world seeking education in pulmonary, critical care, and sleep medicine. Our next meeting is in Bologna, Italy, in June of 2020. I will build on our collaborative inter-societal relationships with our related societies. Some of the specific areas I plan to focus on are defining the true value of CHEST membership, engaging all members of the health-care team, and revisiting the structure and function of our NetWorks to ensure the maximum opportunities for leadership and engagement.

What do you consider to be the greatest strength of CHEST, and how will you build upon this during your Presidency?

Our greatest strengths are the education we deliver; the people at all levels who deliver, learn from, and support the delivery of this core component of our vision and mission; and the culture in which this all takes place. These people include leaders, volunteers, faculty, members and all clinicians on the health-care team, and our top-notch staff (our EVP/CEO, Executive and Operations Team and staff at all levels). To build upon this, we need to strive for continued educational innovation and relevance and creative delivery of our educational products.

What are some challenges facing CHEST, and how will you address these challenges?

Ironically, maintaining our greatest strengths in the setting of a changing health-care environment can also be one of the greatest challenges. We must continue to make our education vibrant, relevant, and experiential. To do this, we need to ensure innovative, year-round education, whether at the annual meeting or through our e-learning platforms, simulation activities, SEEK, state-of the-art guidelines, board review courses, and courses and meetings at CHEST Global Headquarters in Glenview, Illinois, or at a global destination. We also need to stay relevant from the point of view of the value of membership and engagement. We must be cognizant of what members and others who engage with CHEST are looking for and ensure that we are meeting those ongoing expectations. Also, the need to identify, attract, develop, and retain talented and diverse members, volunteers, faculty, and future leaders and staff is imperative. As a program director, I am particularly interested in the retention of our fellows-in-training.

And finally, what is your charge to the members and new Fellows (FCCPs) of CHEST?

Get involved and stay involved. There are so many opportunities to do this! Attend the CHEST Annual Meeting. Join a NetWork. Submit articles to the journal CHEST or abstracts and case reports to the meeting. Participate in a Board Review Course or one of our e-learning opportunities. Come to a live course at headquarters or at a global destination. Participate in a simulation experience. Network at a meeting or a course. Engage with the CHEST Foundation. Connect with us on social media. Sign up to be a moderator and/or grader at the CHEST Annual Meeting. Become an FCCP. Apply for leadership openings, and if you don’t get it the first time, try again! You will be impressed with all that CHEST has to offer!!

Stephanie M. Levine, MD, FCCP, is an expert in lung transplantation, and pulmonary and critical care issues in pregnancy and women’s lung health. She is a Professor of Medicine in the Division of Pulmonary Diseases and Critical Care Medicine at the University of Texas Health Science Center in San Antonio, Texas; the Program Director of the Pulmonary and Critical Care Fellowship at the University of Texas Health Science Center; and the Co-Director of the Medical Intensive Care Unit at the University Hospital. She is also a staff physician at the Audie Murphy Veteran Administration Hospital.

Dr. Levine has been Editor for both CHEST SEEK Critical Care Medicine and Pulmonary Medicine editions. In 2009 she received the CHEST Presidential Citation Award; in 2010, the CHEST Distinguished Service Award; and in 2017, the Master Clinician Educator Award. She has also been recognized as a Distinguished CHEST Educator in 2017, 2018, and 2019.

Dr. Levine has been active in CHEST international activities with CHEST World Congress meetings, the 2017 Basel Joint CHEST/SPG Congress in collaboration with the Swiss Lung Association, and with the pulmonary/critical care subspecialty training programs being developed in China. She was President and Chair of the CHEST Foundation from 2010-2014 and is currently on the CHEST Board of Regents.

We asked Dr. Levine for some thoughts on her upcoming CHEST presidency.
 

What would you like to accomplish as President of CHEST?

Every 5 years, the Board of Regents sets forth a new 5-year strategic plan, which is re-evaluated annually. We try to make sure all our decisions and actions align with this strategic plan. As President, I will promote the vision and mission of CHEST while guiding our organization to succeed in our 2018-2022 strategic plan. What will this include? This will include developing new innovative, evidenced-based, education and educational products in the areas of pulmonary, critical care, and sleep medicine; producing evidence-based guidelines; and expanding our educational expertise both nationally and globally. I am committed to actively engage and retain our fellows-in-training (being a longstanding program director), and to mentor our future leaders. I will reach out to engage and educate advanced practice providers, who are an integral part of our patient care teams. We will grow the CHEST Foundation in the areas of patient education and access, clinical research funding, and community service. On the global front, we will continue with our new global strategy of holding congresses based on the annual meeting content and smaller board review format regional conferences in different parts of the world seeking education in pulmonary, critical care, and sleep medicine. Our next meeting is in Bologna, Italy, in June of 2020. I will build on our collaborative inter-societal relationships with our related societies. Some of the specific areas I plan to focus on are defining the true value of CHEST membership, engaging all members of the health-care team, and revisiting the structure and function of our NetWorks to ensure the maximum opportunities for leadership and engagement.

What do you consider to be the greatest strength of CHEST, and how will you build upon this during your Presidency?

Our greatest strengths are the education we deliver; the people at all levels who deliver, learn from, and support the delivery of this core component of our vision and mission; and the culture in which this all takes place. These people include leaders, volunteers, faculty, members and all clinicians on the health-care team, and our top-notch staff (our EVP/CEO, Executive and Operations Team and staff at all levels). To build upon this, we need to strive for continued educational innovation and relevance and creative delivery of our educational products.

What are some challenges facing CHEST, and how will you address these challenges?

Ironically, maintaining our greatest strengths in the setting of a changing health-care environment can also be one of the greatest challenges. We must continue to make our education vibrant, relevant, and experiential. To do this, we need to ensure innovative, year-round education, whether at the annual meeting or through our e-learning platforms, simulation activities, SEEK, state-of the-art guidelines, board review courses, and courses and meetings at CHEST Global Headquarters in Glenview, Illinois, or at a global destination. We also need to stay relevant from the point of view of the value of membership and engagement. We must be cognizant of what members and others who engage with CHEST are looking for and ensure that we are meeting those ongoing expectations. Also, the need to identify, attract, develop, and retain talented and diverse members, volunteers, faculty, and future leaders and staff is imperative. As a program director, I am particularly interested in the retention of our fellows-in-training.

And finally, what is your charge to the members and new Fellows (FCCPs) of CHEST?

Get involved and stay involved. There are so many opportunities to do this! Attend the CHEST Annual Meeting. Join a NetWork. Submit articles to the journal CHEST or abstracts and case reports to the meeting. Participate in a Board Review Course or one of our e-learning opportunities. Come to a live course at headquarters or at a global destination. Participate in a simulation experience. Network at a meeting or a course. Engage with the CHEST Foundation. Connect with us on social media. Sign up to be a moderator and/or grader at the CHEST Annual Meeting. Become an FCCP. Apply for leadership openings, and if you don’t get it the first time, try again! You will be impressed with all that CHEST has to offer!!

NAMDRC will host its Annual Educational Conference at the Scottsdale Resort at McCormick Ranch in Scottsdale, Arizona, March 12-14, 2020, and features a wide cross section of clinical, management, and health policy issues.

The NAMDRC Educational Conference is unlike other medical conferences you have attended. Conference sessions begin early each day and conclude by 12:30 so attendees, spouses, and guests can enjoy the venue, this year in Scottsdale, Arizona. All registrants and their guests enjoy numerous complimentary meals, and speakers and corporate partners invariably linger with the attendees during receptions for those more casual opportunities for conversations and less formal Q&A.

The Program Committee has announced its plans to focus the first day of the 3-day event on lung cancer, severe asthma, and pulmonary hypertension. Speakers include Maxwell Smith, MD from the Mayo Clinic, Arizona; James Herman, MD, Co-Director of the Lung Cancer Program at UPMC, and Colleen Channick, MD, FCCP, Director of Interventional Pulmonary at UCLA Medical Center to address timely updates on lung cancer diagnosis and treatment. The morning sessions also include a presentation on severe asthma by Monica Kraft, MD, FCCP, University of Arizona; and Richard Channick, MD, Geffen School of Medicine, UCLA, examining pulmonary hypertension with a concentration on current approaches to diagnosis and treatment.

On Friday, March 13, the focus shifts from the clinical to the changing landscape in the delivery of medicine, with a concentrated focus on innovation and new tools available to guide physicians in treatment of their patients. Claibe Yarbrough, MD, National Program Director of Pulmonary, Critical Care and Sleep at the VA, University of Texas, will examine the growth of telemedicine in the ICU. Steve Peters, MD, FCCP, a past President of NAMDRC and a current Board member, will look at artificial intelligence and the future of medicine. Dr. Peters will also present a practice management update in partnership with Alan Plummer, MD, FCCP, as he addresses coding changes in the practice of pulmonary, critical care, and sleep medicine effective 2020-21.

Shifting back to a clinical focus, the Walter J. O’Donohue memorial lecture will be given by Gerald Criner, MD, FCCP, Temple University, to examine endobronchial valve therapy for emphysema. Rounding out the presentations will be luncheon speaker Susan Tanski, MD, looking at electronic nicotine delivery systems.

On Saturday, the topics turn to sleep and mechanical ventilation. Insomnia is the subject matter for Jennifer Martin, MD, Geffen School of Medicine at UCLA; Sairam Parthasarathy, MD, at the University of Arizona, will address sleep and noninvasive mechanical ventilation. And, in a corollary presentation, home mechanical ventilation is the topic for John Hansen-Flaschen, MD, FCCP, Hospital of the University of Pennsylvania.

The final morning rounds out with controversies in septic shock, Rodrigo Cartin-Ceba, MD, at the Mayo Clinic in Scottsdale, and palliative care in the ICU, Mark Edwin, also from the Mayo Clinic.

For more information about membership in NAMDRC and conference information, visit its website at www.namdrc.org.

NAMDRC will host its Annual Educational Conference at the Scottsdale Resort at McCormick Ranch in Scottsdale, Arizona, March 12-14, 2020, and features a wide cross section of clinical, management, and health policy issues.

The NAMDRC Educational Conference is unlike other medical conferences you have attended. Conference sessions begin early each day and conclude by 12:30 so attendees, spouses, and guests can enjoy the venue, this year in Scottsdale, Arizona. All registrants and their guests enjoy numerous complimentary meals, and speakers and corporate partners invariably linger with the attendees during receptions for those more casual opportunities for conversations and less formal Q&A.

The Program Committee has announced its plans to focus the first day of the 3-day event on lung cancer, severe asthma, and pulmonary hypertension. Speakers include Maxwell Smith, MD from the Mayo Clinic, Arizona; James Herman, MD, Co-Director of the Lung Cancer Program at UPMC, and Colleen Channick, MD, FCCP, Director of Interventional Pulmonary at UCLA Medical Center to address timely updates on lung cancer diagnosis and treatment. The morning sessions also include a presentation on severe asthma by Monica Kraft, MD, FCCP, University of Arizona; and Richard Channick, MD, Geffen School of Medicine, UCLA, examining pulmonary hypertension with a concentration on current approaches to diagnosis and treatment.

On Friday, March 13, the focus shifts from the clinical to the changing landscape in the delivery of medicine, with a concentrated focus on innovation and new tools available to guide physicians in treatment of their patients. Claibe Yarbrough, MD, National Program Director of Pulmonary, Critical Care and Sleep at the VA, University of Texas, will examine the growth of telemedicine in the ICU. Steve Peters, MD, FCCP, a past President of NAMDRC and a current Board member, will look at artificial intelligence and the future of medicine. Dr. Peters will also present a practice management update in partnership with Alan Plummer, MD, FCCP, as he addresses coding changes in the practice of pulmonary, critical care, and sleep medicine effective 2020-21.

Shifting back to a clinical focus, the Walter J. O’Donohue memorial lecture will be given by Gerald Criner, MD, FCCP, Temple University, to examine endobronchial valve therapy for emphysema. Rounding out the presentations will be luncheon speaker Susan Tanski, MD, looking at electronic nicotine delivery systems.

On Saturday, the topics turn to sleep and mechanical ventilation. Insomnia is the subject matter for Jennifer Martin, MD, Geffen School of Medicine at UCLA; Sairam Parthasarathy, MD, at the University of Arizona, will address sleep and noninvasive mechanical ventilation. And, in a corollary presentation, home mechanical ventilation is the topic for John Hansen-Flaschen, MD, FCCP, Hospital of the University of Pennsylvania.

The final morning rounds out with controversies in septic shock, Rodrigo Cartin-Ceba, MD, at the Mayo Clinic in Scottsdale, and palliative care in the ICU, Mark Edwin, also from the Mayo Clinic.

For more information about membership in NAMDRC and conference information, visit its website at www.namdrc.org.

NAMDRC will host its Annual Educational Conference at the Scottsdale Resort at McCormick Ranch in Scottsdale, Arizona, March 12-14, 2020, and features a wide cross section of clinical, management, and health policy issues.

The NAMDRC Educational Conference is unlike other medical conferences you have attended. Conference sessions begin early each day and conclude by 12:30 so attendees, spouses, and guests can enjoy the venue, this year in Scottsdale, Arizona. All registrants and their guests enjoy numerous complimentary meals, and speakers and corporate partners invariably linger with the attendees during receptions for those more casual opportunities for conversations and less formal Q&A.

The Program Committee has announced its plans to focus the first day of the 3-day event on lung cancer, severe asthma, and pulmonary hypertension. Speakers include Maxwell Smith, MD from the Mayo Clinic, Arizona; James Herman, MD, Co-Director of the Lung Cancer Program at UPMC, and Colleen Channick, MD, FCCP, Director of Interventional Pulmonary at UCLA Medical Center to address timely updates on lung cancer diagnosis and treatment. The morning sessions also include a presentation on severe asthma by Monica Kraft, MD, FCCP, University of Arizona; and Richard Channick, MD, Geffen School of Medicine, UCLA, examining pulmonary hypertension with a concentration on current approaches to diagnosis and treatment.

On Friday, March 13, the focus shifts from the clinical to the changing landscape in the delivery of medicine, with a concentrated focus on innovation and new tools available to guide physicians in treatment of their patients. Claibe Yarbrough, MD, National Program Director of Pulmonary, Critical Care and Sleep at the VA, University of Texas, will examine the growth of telemedicine in the ICU. Steve Peters, MD, FCCP, a past President of NAMDRC and a current Board member, will look at artificial intelligence and the future of medicine. Dr. Peters will also present a practice management update in partnership with Alan Plummer, MD, FCCP, as he addresses coding changes in the practice of pulmonary, critical care, and sleep medicine effective 2020-21.

Shifting back to a clinical focus, the Walter J. O’Donohue memorial lecture will be given by Gerald Criner, MD, FCCP, Temple University, to examine endobronchial valve therapy for emphysema. Rounding out the presentations will be luncheon speaker Susan Tanski, MD, looking at electronic nicotine delivery systems.

On Saturday, the topics turn to sleep and mechanical ventilation. Insomnia is the subject matter for Jennifer Martin, MD, Geffen School of Medicine at UCLA; Sairam Parthasarathy, MD, at the University of Arizona, will address sleep and noninvasive mechanical ventilation. And, in a corollary presentation, home mechanical ventilation is the topic for John Hansen-Flaschen, MD, FCCP, Hospital of the University of Pennsylvania.

The final morning rounds out with controversies in septic shock, Rodrigo Cartin-Ceba, MD, at the Mayo Clinic in Scottsdale, and palliative care in the ICU, Mark Edwin, also from the Mayo Clinic.

For more information about membership in NAMDRC and conference information, visit its website at www.namdrc.org.

Although only a small percentage of non–small cell lung cancers are positive for HER2 mutations, HER2-mutant lung cancers are associated with a high incidence of brain metastases, investigators have found.

Among 98 consecutive patients with HER2-mutant non–small cell lung cancer (NSCLC), the incidence of brain metastases at initial diagnosis was comparable with or slightly lower than that seen with other, more common mutations, but the incidence during treatment was significantly higher than in patients with KRAS-mutant NSCLC, and trended higher than the incidence rate of brain metastases in patients with epidermal growth factor receptor (EGFR)–mutated NSCLC, reported Michael Offin, MD, and colleagues from Memorial Sloan Kettering Cancer in New York.

“This finding provides a framework for CNS surveillance and treatment strategies, including radiotherapy, for patients with HER2-mutant lung cancers and underlines the urgent need for the development of novel HER2-targeted agents with activity in the CNS,” they wrote in Cancer.

NSCLC with oncogenic driver mutations in HER2 account for 2% of adenocarcinomas of the lung, but relatively little is known about the risk for brain metastases in patients HER2-mutant lung cancer, the authors wrote.

“Because HER2-amplified breast cancers are more likely to develop brain metastases through constitutive HER2 signaling, we hypothesize that HER2-mutant lung cancers are also more apt to develop brain metastases in comparison with lung cancers driven by other oncogenes,” they wrote.

To explore this hypothesis, they conducted a retrospective record review of 98 patients treated at their center with metastatic HER2-mutant NSCLC, and compared them with 200 patients with metastatic KRAS-mutant NSCLC, and 200 with metastatic, sensitizing EGFR-mutant NSCLC.

They found that at the initial diagnosis of metastatic disease, the percentage of patients with brain metastases was similar between patients with HER2 mutations and those with KRAS mutations (19% vs. 24%; odds ratio for HER2 vs. KRAS, 0.7; P = .33). However significantly more patients with EGFR-mutant tumors had brain metastases at diagnosis, compared with patients HER2 mutations (31% vs. 19%; OR, 0.5; P = .03).

Interestingly, significantly more patients with HER2-mutant tumors developed brain metastases on treatment than patients with KRAS-mutant tumors (28% vs. 8%; hazard ratio, 5.2; P less than .001). There was also a trend toward more on-treatment brain metastases among patients with HER2 mutations, compared with patients with EGFR mutation (28% vs .16%; HR, 1.7), but this difference was not statistically significant.

The risk for on-treatment brain metastases was even higher among patients with a HER2 mutation characterized by a 12 base–pair, in-frame insertion in exon 20 (HER2 YVMA). In these patients, the OR for brain metastases developing during treatment versus patients with KRAS mutations was 5.9 (P less than .001).

The median overall survival was worse for patients with KRAS-mutant NSCLC (1.1 years) and HER2-mutant cancers (1.6 years) versus 3 years for patients with EFGR-mutant cancers (P less than .001 for KRAS; P = .002 for HER2 vs. EGFR).

The use of HER2-targeted therapies did not have an effect on either the development of brain metastases or survival, and overall survival was slightly but significantly worse for patients with HER2-mutant tumors who had radiotherapy of the brain.

The study was supported by the National Institutes of Health through a National Cancer Institute Cancer Center support grant and by the Eloise Briskin Foundation. Dr. Offin reported honoraria from Bristol-Myers Squibb, Merck, PharmaMar, Novartis, and Targeted Oncology. Multiple coauthors had similar disclosures.

SOURCE: Offin M et al. Cancer. 2019 Aug 30. doi: 10.1002/cncr.32461.

Although only a small percentage of non–small cell lung cancers are positive for HER2 mutations, HER2-mutant lung cancers are associated with a high incidence of brain metastases, investigators have found.

Among 98 consecutive patients with HER2-mutant non–small cell lung cancer (NSCLC), the incidence of brain metastases at initial diagnosis was comparable with or slightly lower than that seen with other, more common mutations, but the incidence during treatment was significantly higher than in patients with KRAS-mutant NSCLC, and trended higher than the incidence rate of brain metastases in patients with epidermal growth factor receptor (EGFR)–mutated NSCLC, reported Michael Offin, MD, and colleagues from Memorial Sloan Kettering Cancer in New York.

“This finding provides a framework for CNS surveillance and treatment strategies, including radiotherapy, for patients with HER2-mutant lung cancers and underlines the urgent need for the development of novel HER2-targeted agents with activity in the CNS,” they wrote in Cancer.

NSCLC with oncogenic driver mutations in HER2 account for 2% of adenocarcinomas of the lung, but relatively little is known about the risk for brain metastases in patients HER2-mutant lung cancer, the authors wrote.

“Because HER2-amplified breast cancers are more likely to develop brain metastases through constitutive HER2 signaling, we hypothesize that HER2-mutant lung cancers are also more apt to develop brain metastases in comparison with lung cancers driven by other oncogenes,” they wrote.

To explore this hypothesis, they conducted a retrospective record review of 98 patients treated at their center with metastatic HER2-mutant NSCLC, and compared them with 200 patients with metastatic KRAS-mutant NSCLC, and 200 with metastatic, sensitizing EGFR-mutant NSCLC.

They found that at the initial diagnosis of metastatic disease, the percentage of patients with brain metastases was similar between patients with HER2 mutations and those with KRAS mutations (19% vs. 24%; odds ratio for HER2 vs. KRAS, 0.7; P = .33). However significantly more patients with EGFR-mutant tumors had brain metastases at diagnosis, compared with patients HER2 mutations (31% vs. 19%; OR, 0.5; P = .03).

Interestingly, significantly more patients with HER2-mutant tumors developed brain metastases on treatment than patients with KRAS-mutant tumors (28% vs. 8%; hazard ratio, 5.2; P less than .001). There was also a trend toward more on-treatment brain metastases among patients with HER2 mutations, compared with patients with EGFR mutation (28% vs .16%; HR, 1.7), but this difference was not statistically significant.

The risk for on-treatment brain metastases was even higher among patients with a HER2 mutation characterized by a 12 base–pair, in-frame insertion in exon 20 (HER2 YVMA). In these patients, the OR for brain metastases developing during treatment versus patients with KRAS mutations was 5.9 (P less than .001).

The median overall survival was worse for patients with KRAS-mutant NSCLC (1.1 years) and HER2-mutant cancers (1.6 years) versus 3 years for patients with EFGR-mutant cancers (P less than .001 for KRAS; P = .002 for HER2 vs. EGFR).

The use of HER2-targeted therapies did not have an effect on either the development of brain metastases or survival, and overall survival was slightly but significantly worse for patients with HER2-mutant tumors who had radiotherapy of the brain.

The study was supported by the National Institutes of Health through a National Cancer Institute Cancer Center support grant and by the Eloise Briskin Foundation. Dr. Offin reported honoraria from Bristol-Myers Squibb, Merck, PharmaMar, Novartis, and Targeted Oncology. Multiple coauthors had similar disclosures.

SOURCE: Offin M et al. Cancer. 2019 Aug 30. doi: 10.1002/cncr.32461.

Although only a small percentage of non–small cell lung cancers are positive for HER2 mutations, HER2-mutant lung cancers are associated with a high incidence of brain metastases, investigators have found.

Among 98 consecutive patients with HER2-mutant non–small cell lung cancer (NSCLC), the incidence of brain metastases at initial diagnosis was comparable with or slightly lower than that seen with other, more common mutations, but the incidence during treatment was significantly higher than in patients with KRAS-mutant NSCLC, and trended higher than the incidence rate of brain metastases in patients with epidermal growth factor receptor (EGFR)–mutated NSCLC, reported Michael Offin, MD, and colleagues from Memorial Sloan Kettering Cancer in New York.

“This finding provides a framework for CNS surveillance and treatment strategies, including radiotherapy, for patients with HER2-mutant lung cancers and underlines the urgent need for the development of novel HER2-targeted agents with activity in the CNS,” they wrote in Cancer.

NSCLC with oncogenic driver mutations in HER2 account for 2% of adenocarcinomas of the lung, but relatively little is known about the risk for brain metastases in patients HER2-mutant lung cancer, the authors wrote.

“Because HER2-amplified breast cancers are more likely to develop brain metastases through constitutive HER2 signaling, we hypothesize that HER2-mutant lung cancers are also more apt to develop brain metastases in comparison with lung cancers driven by other oncogenes,” they wrote.

To explore this hypothesis, they conducted a retrospective record review of 98 patients treated at their center with metastatic HER2-mutant NSCLC, and compared them with 200 patients with metastatic KRAS-mutant NSCLC, and 200 with metastatic, sensitizing EGFR-mutant NSCLC.

They found that at the initial diagnosis of metastatic disease, the percentage of patients with brain metastases was similar between patients with HER2 mutations and those with KRAS mutations (19% vs. 24%; odds ratio for HER2 vs. KRAS, 0.7; P = .33). However significantly more patients with EGFR-mutant tumors had brain metastases at diagnosis, compared with patients HER2 mutations (31% vs. 19%; OR, 0.5; P = .03).

Interestingly, significantly more patients with HER2-mutant tumors developed brain metastases on treatment than patients with KRAS-mutant tumors (28% vs. 8%; hazard ratio, 5.2; P less than .001). There was also a trend toward more on-treatment brain metastases among patients with HER2 mutations, compared with patients with EGFR mutation (28% vs .16%; HR, 1.7), but this difference was not statistically significant.

The risk for on-treatment brain metastases was even higher among patients with a HER2 mutation characterized by a 12 base–pair, in-frame insertion in exon 20 (HER2 YVMA). In these patients, the OR for brain metastases developing during treatment versus patients with KRAS mutations was 5.9 (P less than .001).

The median overall survival was worse for patients with KRAS-mutant NSCLC (1.1 years) and HER2-mutant cancers (1.6 years) versus 3 years for patients with EFGR-mutant cancers (P less than .001 for KRAS; P = .002 for HER2 vs. EGFR).

The use of HER2-targeted therapies did not have an effect on either the development of brain metastases or survival, and overall survival was slightly but significantly worse for patients with HER2-mutant tumors who had radiotherapy of the brain.

The study was supported by the National Institutes of Health through a National Cancer Institute Cancer Center support grant and by the Eloise Briskin Foundation. Dr. Offin reported honoraria from Bristol-Myers Squibb, Merck, PharmaMar, Novartis, and Targeted Oncology. Multiple coauthors had similar disclosures.

SOURCE: Offin M et al. Cancer. 2019 Aug 30. doi: 10.1002/cncr.32461.

Background: Despite multiple guidelines that support outpatient management of acute PE in the appropriate patient population, the rate of hospital admission for patients eligible for outpatient management remains high. One explanation is that physicians may have difficulty identifying which patients meet discharge criteria.

Dr. Bordin-Wosk is an assistant clinical professor in the division of hospital medicine at the University of California, San Diego.

Background: Despite multiple guidelines that support outpatient management of acute PE in the appropriate patient population, the rate of hospital admission for patients eligible for outpatient management remains high. One explanation is that physicians may have difficulty identifying which patients meet discharge criteria.

Dr. Bordin-Wosk is an assistant clinical professor in the division of hospital medicine at the University of California, San Diego.

Background: Despite multiple guidelines that support outpatient management of acute PE in the appropriate patient population, the rate of hospital admission for patients eligible for outpatient management remains high. One explanation is that physicians may have difficulty identifying which patients meet discharge criteria.

Dr. Bordin-Wosk is an assistant clinical professor in the division of hospital medicine at the University of California, San Diego.

It is estimated that there are 1.1 million people in the United States living with HIV and that 15% of those people do not know they have HIV. Although the number of new cases reported each year is decreasing, there were still 38,281 new diagnoses in 2017. New cases might be decreasing overall, but the incidence of HIV is rising in some groups including people aged 25-29 years old and American Indian/Alaska Native and Asian populations. In addition, HIV disproportionately affects men who have sex with men, black/African American populations, and Hispanic/Latino populations, according to the USPSTF statement.

Given the prevalence of HIV and rising new cases in certain groups, it is thought that preexposure prophylaxis (PrEP) is being underutilized. The CDC reported that, in 2015, 1.2 million people were candidates for PrEP, but in 2017, only 100,282 people were using PrEP. The USPSTF performed a meta-analysis of 12 RCTs comparing rates of HIV infection in groups treated with PrEP versus those treated with placebo or no treatment and found a risk ratio of 0.46 (95% confidence interval, 0.33-0.66) and absolute risk reduction of –2% (95% CI, –2.8% to –1.2%) after 4 months and 4 years.

With this epidemiologic data and the meta-analysis, the USPSTF offered the following recommendations.
 

Screening

In order to decrease the rates of transmission and incidence of HIV infection, we must appropriately identify those who would be good candidates for PrEP. That begins with taking a complete and thorough sexual and injection drug use history in a manner that does not make patients feel stigmatized or discriminated against. The USPSTF recommends screening for HIV infection in patients aged 15-65 years old, in younger and older patients who have increased risk factors, and all pregnant patients. PrEP is not an appropriate choice in those who have HIV because it can lead to drug resistance.

When screening for HIV and considering starting PrEP, it is recommended that clinicians also test for kidney function, hepatitis B and C, other STIs, and pregnancy. The USPSTF suggests that the following groups be considered for PrEP given the increased risk of HIV infection:

• Men who have sex with men, are sexually active, and have one of these additional characteristics: a serodiscordant sex partner, inconsistent use of condoms during receptive or insertive anal sex, or infection with syphilis, gonorrhea, or chlamydia in the past 6 months.
• Heterosexual men or women who are sexually active with one or more of these additional characteristics: a serodiscordant sex partner, inconsistent use of condoms during sex with a partner whose HIV status is unknown and who is at high risk, and infection with syphilis or gonorrhea in the past 6 months.
• Patients who inject drugs with one or more of the following characteristics: shared use of drug injection equipment and risk of sexual acquisition (as in the categories above).

The USPSTF also notes that those who engage in transactional sex (for money, drugs, or housing) and transgender patients are at an increased risk of HIV infection.

Treatment

The only FDA approved treatment for the prevention HIV infection is once daily oral combined tenofovir disoproxil fumarate and emtricitabine; however, some studies have found that tenofovir disproxil fumarate monotherapy is also effective. Considering these trials, the CDC has suggested that tenofovir disoproxil fumarate monotherapy can be used as an alternative for men and women at high risk and those who inject drugs.

Tenofovir disoproxil fumarate/emtricitabine can also be used in pregnant patients, however the USPSTF notes that no PrEP trials included pregnant women. Additionally, tenofovir disoproxil fumarate/emtricitabine can be used in adolescents who weigh more than 35 kg. It is unknown how much time it takes to achieve protection against HIV infection after starting PrEP, and there is no clear timeline for how long patients should be on PrEP. Patients may discontinue medication because of preference, decreased risk of HIV exposure, or side effects.

Side effects include renal adverse events (serum creatinine rise), gastrointestinal adverse events (mostly nausea), and bone loss and increased fracture risk, although none were statistically significant when PrEP and placebo groups were compared. The USPSTF’s recommendations note that the effectiveness of PrEP is dependent on medication adherence.

While PrEP is an important part of preventing HIV, it is always important to counsel patients on other ways to reduce risk. The USPSTF notes that consistent condom use reduces the risk of HIV infection by around 80% in addition to reducing the risk of other STIs. All trials studied by the USPSTF for these recommendations included counseling on behavior, adherence, and condom use.
 

Bottom Line

It is estimated that 1.1 million Americans are living with HIV and 15% are unaware that they are positive for HIV. Overall cases of new HIV diagnoses are down, but they are rising in some groups. PrEP is an effective medication for reducing the risk of HIV infection, but is currently underutilized. Every patient should be screened for high-risk sexual behavior and drug use with a thorough history. Patients aged 15-65 years should be screened for HIV. If patients are negative for HIV, but participate in high-risk sexual behaviors and drug injection, they should be offered PrEP along with counseling on, medication adherence, condom use, and reduction of high-risk behaviors.
 

Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Sprogell is a second-year resident in the Family Medicine Residency Program at Abington Jefferson Health

Reference

Owens DK et al. “Preexposure prophylaxis for the prevention of HIV infection: US Preventive Services Task Force recommendation statement.” JAMA. 2019 Jun 11;321(22):2203-13.

It is estimated that there are 1.1 million people in the United States living with HIV and that 15% of those people do not know they have HIV. Although the number of new cases reported each year is decreasing, there were still 38,281 new diagnoses in 2017. New cases might be decreasing overall, but the incidence of HIV is rising in some groups including people aged 25-29 years old and American Indian/Alaska Native and Asian populations. In addition, HIV disproportionately affects men who have sex with men, black/African American populations, and Hispanic/Latino populations, according to the USPSTF statement.

Given the prevalence of HIV and rising new cases in certain groups, it is thought that preexposure prophylaxis (PrEP) is being underutilized. The CDC reported that, in 2015, 1.2 million people were candidates for PrEP, but in 2017, only 100,282 people were using PrEP. The USPSTF performed a meta-analysis of 12 RCTs comparing rates of HIV infection in groups treated with PrEP versus those treated with placebo or no treatment and found a risk ratio of 0.46 (95% confidence interval, 0.33-0.66) and absolute risk reduction of –2% (95% CI, –2.8% to –1.2%) after 4 months and 4 years.

With this epidemiologic data and the meta-analysis, the USPSTF offered the following recommendations.
 

Screening

In order to decrease the rates of transmission and incidence of HIV infection, we must appropriately identify those who would be good candidates for PrEP. That begins with taking a complete and thorough sexual and injection drug use history in a manner that does not make patients feel stigmatized or discriminated against. The USPSTF recommends screening for HIV infection in patients aged 15-65 years old, in younger and older patients who have increased risk factors, and all pregnant patients. PrEP is not an appropriate choice in those who have HIV because it can lead to drug resistance.

When screening for HIV and considering starting PrEP, it is recommended that clinicians also test for kidney function, hepatitis B and C, other STIs, and pregnancy. The USPSTF suggests that the following groups be considered for PrEP given the increased risk of HIV infection:

• Men who have sex with men, are sexually active, and have one of these additional characteristics: a serodiscordant sex partner, inconsistent use of condoms during receptive or insertive anal sex, or infection with syphilis, gonorrhea, or chlamydia in the past 6 months.
• Heterosexual men or women who are sexually active with one or more of these additional characteristics: a serodiscordant sex partner, inconsistent use of condoms during sex with a partner whose HIV status is unknown and who is at high risk, and infection with syphilis or gonorrhea in the past 6 months.
• Patients who inject drugs with one or more of the following characteristics: shared use of drug injection equipment and risk of sexual acquisition (as in the categories above).

The USPSTF also notes that those who engage in transactional sex (for money, drugs, or housing) and transgender patients are at an increased risk of HIV infection.

Treatment

The only FDA approved treatment for the prevention HIV infection is once daily oral combined tenofovir disoproxil fumarate and emtricitabine; however, some studies have found that tenofovir disproxil fumarate monotherapy is also effective. Considering these trials, the CDC has suggested that tenofovir disoproxil fumarate monotherapy can be used as an alternative for men and women at high risk and those who inject drugs.

Tenofovir disoproxil fumarate/emtricitabine can also be used in pregnant patients, however the USPSTF notes that no PrEP trials included pregnant women. Additionally, tenofovir disoproxil fumarate/emtricitabine can be used in adolescents who weigh more than 35 kg. It is unknown how much time it takes to achieve protection against HIV infection after starting PrEP, and there is no clear timeline for how long patients should be on PrEP. Patients may discontinue medication because of preference, decreased risk of HIV exposure, or side effects.

Side effects include renal adverse events (serum creatinine rise), gastrointestinal adverse events (mostly nausea), and bone loss and increased fracture risk, although none were statistically significant when PrEP and placebo groups were compared. The USPSTF’s recommendations note that the effectiveness of PrEP is dependent on medication adherence.

While PrEP is an important part of preventing HIV, it is always important to counsel patients on other ways to reduce risk. The USPSTF notes that consistent condom use reduces the risk of HIV infection by around 80% in addition to reducing the risk of other STIs. All trials studied by the USPSTF for these recommendations included counseling on behavior, adherence, and condom use.
 

Bottom Line

It is estimated that 1.1 million Americans are living with HIV and 15% are unaware that they are positive for HIV. Overall cases of new HIV diagnoses are down, but they are rising in some groups. PrEP is an effective medication for reducing the risk of HIV infection, but is currently underutilized. Every patient should be screened for high-risk sexual behavior and drug use with a thorough history. Patients aged 15-65 years should be screened for HIV. If patients are negative for HIV, but participate in high-risk sexual behaviors and drug injection, they should be offered PrEP along with counseling on, medication adherence, condom use, and reduction of high-risk behaviors.
 

Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Sprogell is a second-year resident in the Family Medicine Residency Program at Abington Jefferson Health

Reference

Owens DK et al. “Preexposure prophylaxis for the prevention of HIV infection: US Preventive Services Task Force recommendation statement.” JAMA. 2019 Jun 11;321(22):2203-13.

It is estimated that there are 1.1 million people in the United States living with HIV and that 15% of those people do not know they have HIV. Although the number of new cases reported each year is decreasing, there were still 38,281 new diagnoses in 2017. New cases might be decreasing overall, but the incidence of HIV is rising in some groups including people aged 25-29 years old and American Indian/Alaska Native and Asian populations. In addition, HIV disproportionately affects men who have sex with men, black/African American populations, and Hispanic/Latino populations, according to the USPSTF statement.

Given the prevalence of HIV and rising new cases in certain groups, it is thought that preexposure prophylaxis (PrEP) is being underutilized. The CDC reported that, in 2015, 1.2 million people were candidates for PrEP, but in 2017, only 100,282 people were using PrEP. The USPSTF performed a meta-analysis of 12 RCTs comparing rates of HIV infection in groups treated with PrEP versus those treated with placebo or no treatment and found a risk ratio of 0.46 (95% confidence interval, 0.33-0.66) and absolute risk reduction of –2% (95% CI, –2.8% to –1.2%) after 4 months and 4 years.

With this epidemiologic data and the meta-analysis, the USPSTF offered the following recommendations.
 

Screening

In order to decrease the rates of transmission and incidence of HIV infection, we must appropriately identify those who would be good candidates for PrEP. That begins with taking a complete and thorough sexual and injection drug use history in a manner that does not make patients feel stigmatized or discriminated against. The USPSTF recommends screening for HIV infection in patients aged 15-65 years old, in younger and older patients who have increased risk factors, and all pregnant patients. PrEP is not an appropriate choice in those who have HIV because it can lead to drug resistance.

When screening for HIV and considering starting PrEP, it is recommended that clinicians also test for kidney function, hepatitis B and C, other STIs, and pregnancy. The USPSTF suggests that the following groups be considered for PrEP given the increased risk of HIV infection:

• Men who have sex with men, are sexually active, and have one of these additional characteristics: a serodiscordant sex partner, inconsistent use of condoms during receptive or insertive anal sex, or infection with syphilis, gonorrhea, or chlamydia in the past 6 months.
• Heterosexual men or women who are sexually active with one or more of these additional characteristics: a serodiscordant sex partner, inconsistent use of condoms during sex with a partner whose HIV status is unknown and who is at high risk, and infection with syphilis or gonorrhea in the past 6 months.
• Patients who inject drugs with one or more of the following characteristics: shared use of drug injection equipment and risk of sexual acquisition (as in the categories above).

The USPSTF also notes that those who engage in transactional sex (for money, drugs, or housing) and transgender patients are at an increased risk of HIV infection.

Treatment

The only FDA approved treatment for the prevention HIV infection is once daily oral combined tenofovir disoproxil fumarate and emtricitabine; however, some studies have found that tenofovir disproxil fumarate monotherapy is also effective. Considering these trials, the CDC has suggested that tenofovir disoproxil fumarate monotherapy can be used as an alternative for men and women at high risk and those who inject drugs.

Tenofovir disoproxil fumarate/emtricitabine can also be used in pregnant patients, however the USPSTF notes that no PrEP trials included pregnant women. Additionally, tenofovir disoproxil fumarate/emtricitabine can be used in adolescents who weigh more than 35 kg. It is unknown how much time it takes to achieve protection against HIV infection after starting PrEP, and there is no clear timeline for how long patients should be on PrEP. Patients may discontinue medication because of preference, decreased risk of HIV exposure, or side effects.

Side effects include renal adverse events (serum creatinine rise), gastrointestinal adverse events (mostly nausea), and bone loss and increased fracture risk, although none were statistically significant when PrEP and placebo groups were compared. The USPSTF’s recommendations note that the effectiveness of PrEP is dependent on medication adherence.

While PrEP is an important part of preventing HIV, it is always important to counsel patients on other ways to reduce risk. The USPSTF notes that consistent condom use reduces the risk of HIV infection by around 80% in addition to reducing the risk of other STIs. All trials studied by the USPSTF for these recommendations included counseling on behavior, adherence, and condom use.
 

Bottom Line

It is estimated that 1.1 million Americans are living with HIV and 15% are unaware that they are positive for HIV. Overall cases of new HIV diagnoses are down, but they are rising in some groups. PrEP is an effective medication for reducing the risk of HIV infection, but is currently underutilized. Every patient should be screened for high-risk sexual behavior and drug use with a thorough history. Patients aged 15-65 years should be screened for HIV. If patients are negative for HIV, but participate in high-risk sexual behaviors and drug injection, they should be offered PrEP along with counseling on, medication adherence, condom use, and reduction of high-risk behaviors.
 

Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Sprogell is a second-year resident in the Family Medicine Residency Program at Abington Jefferson Health

Reference

Owens DK et al. “Preexposure prophylaxis for the prevention of HIV infection: US Preventive Services Task Force recommendation statement.” JAMA. 2019 Jun 11;321(22):2203-13.

Four modifiable lifestyle risk factors account for a substantial proportion of gout cases in the United States, suggesting greater public health efforts could reduce the frequency of the condition, according to a paper published Sept. 4 in Arthritis & Rheumatology.

Hyon K. Choi, MD, DrPH, of the department of medicine at Massachusetts General Hospital, Boston, and his coauthors analyzed data from 14,624 adults involved in the third National Health and Nutrition Examination Survey. From this, they calculated prevalence ratios for hyperuricemia, the population attributable risks, and the variance associated with the risk factors of body mass index, alcohol intake, nonadherence to a Dietary Approaches to Stop Hypertension (DASH) diet, and diuretic use.

They found that 21% of men and 19% of women in the study were hyperuricemic, which they defined as having a serum urate level greater than 417 micromol/L (7.0 mg/dL) for men and greater than 340 micromol/L (5.7 mg/dL) for women.

BMI was the most important risk factor for hyperuricemia, accounting for 44% of cases overall. The prevalence of hyperuricemia was 85% higher in individuals with a BMI of 25.0-29.9 kg/m2, 2.72-fold higher in those with a BMI of 30.0-34.9, and 3.53-fold higher for those with a BMI of 35.0 or above when compared against people with a BMI less than 25.0.

The researchers found that adherence to a DASH-style diet could have prevented 9% of hyperuricemia cases, as those in the lowest quintile of DASH-style dietary score had a 22% higher prevalence of hyperuricemia, compared with those in the highest quintile.

There was also a dose-response relationship between alcohol intake and hyperuricemia prevalence, and the authors calculated that 8% of cases could have been avoided through abstaining from alcohol consumption.

Individuals taking diuretics had a 2.24-fold greater risk of gout, and the population attributable risk for diuretic use was 12%.

However the authors noted that the serum urate variance explained by these individual risk factors was very small; for example, the serum urate variance attributed to the DASH diet was just 0.1%.

“How can dietary changes over time (together with a Western lifestyle) be associated with obesity and gout epidemics, yet also paradoxically appear extremely insignificant according to the variance measure?” they asked. “This occurs because the variance measure does not incorporate how common the exposure is (i.e., its prevalence).”

In contrast, the population attributable risk of these factors did reflect the contribution of effect size as well as the high prevalence, particularly with respect to dietary factors, where less than 1% of the U.S. population is believed to be adherent to the DASH diet.

“These data collectively indicate there is substantial room for improvement in dietary factors to help prevent hyperuricemia and gout, as well as hypertension and related cardiovascular outcomes.”

The study and one author were supported by the National Institutes of Health. Two authors were also supported by awards from the Canadian Institutes of Health Research. No conflicts of interest were declared.

SOURCE: Choi H et al. Arthritis Rheumatol. 2019 Sep 4. doi: 10.1002/art.41067.

Four modifiable lifestyle risk factors account for a substantial proportion of gout cases in the United States, suggesting greater public health efforts could reduce the frequency of the condition, according to a paper published Sept. 4 in Arthritis & Rheumatology.

Hyon K. Choi, MD, DrPH, of the department of medicine at Massachusetts General Hospital, Boston, and his coauthors analyzed data from 14,624 adults involved in the third National Health and Nutrition Examination Survey. From this, they calculated prevalence ratios for hyperuricemia, the population attributable risks, and the variance associated with the risk factors of body mass index, alcohol intake, nonadherence to a Dietary Approaches to Stop Hypertension (DASH) diet, and diuretic use.

They found that 21% of men and 19% of women in the study were hyperuricemic, which they defined as having a serum urate level greater than 417 micromol/L (7.0 mg/dL) for men and greater than 340 micromol/L (5.7 mg/dL) for women.

BMI was the most important risk factor for hyperuricemia, accounting for 44% of cases overall. The prevalence of hyperuricemia was 85% higher in individuals with a BMI of 25.0-29.9 kg/m2, 2.72-fold higher in those with a BMI of 30.0-34.9, and 3.53-fold higher for those with a BMI of 35.0 or above when compared against people with a BMI less than 25.0.

The researchers found that adherence to a DASH-style diet could have prevented 9% of hyperuricemia cases, as those in the lowest quintile of DASH-style dietary score had a 22% higher prevalence of hyperuricemia, compared with those in the highest quintile.

There was also a dose-response relationship between alcohol intake and hyperuricemia prevalence, and the authors calculated that 8% of cases could have been avoided through abstaining from alcohol consumption.

Individuals taking diuretics had a 2.24-fold greater risk of gout, and the population attributable risk for diuretic use was 12%.

However the authors noted that the serum urate variance explained by these individual risk factors was very small; for example, the serum urate variance attributed to the DASH diet was just 0.1%.

“How can dietary changes over time (together with a Western lifestyle) be associated with obesity and gout epidemics, yet also paradoxically appear extremely insignificant according to the variance measure?” they asked. “This occurs because the variance measure does not incorporate how common the exposure is (i.e., its prevalence).”

In contrast, the population attributable risk of these factors did reflect the contribution of effect size as well as the high prevalence, particularly with respect to dietary factors, where less than 1% of the U.S. population is believed to be adherent to the DASH diet.

“These data collectively indicate there is substantial room for improvement in dietary factors to help prevent hyperuricemia and gout, as well as hypertension and related cardiovascular outcomes.”

The study and one author were supported by the National Institutes of Health. Two authors were also supported by awards from the Canadian Institutes of Health Research. No conflicts of interest were declared.

SOURCE: Choi H et al. Arthritis Rheumatol. 2019 Sep 4. doi: 10.1002/art.41067.

Four modifiable lifestyle risk factors account for a substantial proportion of gout cases in the United States, suggesting greater public health efforts could reduce the frequency of the condition, according to a paper published Sept. 4 in Arthritis & Rheumatology.

Hyon K. Choi, MD, DrPH, of the department of medicine at Massachusetts General Hospital, Boston, and his coauthors analyzed data from 14,624 adults involved in the third National Health and Nutrition Examination Survey. From this, they calculated prevalence ratios for hyperuricemia, the population attributable risks, and the variance associated with the risk factors of body mass index, alcohol intake, nonadherence to a Dietary Approaches to Stop Hypertension (DASH) diet, and diuretic use.

They found that 21% of men and 19% of women in the study were hyperuricemic, which they defined as having a serum urate level greater than 417 micromol/L (7.0 mg/dL) for men and greater than 340 micromol/L (5.7 mg/dL) for women.

BMI was the most important risk factor for hyperuricemia, accounting for 44% of cases overall. The prevalence of hyperuricemia was 85% higher in individuals with a BMI of 25.0-29.9 kg/m2, 2.72-fold higher in those with a BMI of 30.0-34.9, and 3.53-fold higher for those with a BMI of 35.0 or above when compared against people with a BMI less than 25.0.

The researchers found that adherence to a DASH-style diet could have prevented 9% of hyperuricemia cases, as those in the lowest quintile of DASH-style dietary score had a 22% higher prevalence of hyperuricemia, compared with those in the highest quintile.

There was also a dose-response relationship between alcohol intake and hyperuricemia prevalence, and the authors calculated that 8% of cases could have been avoided through abstaining from alcohol consumption.

Individuals taking diuretics had a 2.24-fold greater risk of gout, and the population attributable risk for diuretic use was 12%.

However the authors noted that the serum urate variance explained by these individual risk factors was very small; for example, the serum urate variance attributed to the DASH diet was just 0.1%.

“How can dietary changes over time (together with a Western lifestyle) be associated with obesity and gout epidemics, yet also paradoxically appear extremely insignificant according to the variance measure?” they asked. “This occurs because the variance measure does not incorporate how common the exposure is (i.e., its prevalence).”

In contrast, the population attributable risk of these factors did reflect the contribution of effect size as well as the high prevalence, particularly with respect to dietary factors, where less than 1% of the U.S. population is believed to be adherent to the DASH diet.

“These data collectively indicate there is substantial room for improvement in dietary factors to help prevent hyperuricemia and gout, as well as hypertension and related cardiovascular outcomes.”

The study and one author were supported by the National Institutes of Health. Two authors were also supported by awards from the Canadian Institutes of Health Research. No conflicts of interest were declared.

SOURCE: Choi H et al. Arthritis Rheumatol. 2019 Sep 4. doi: 10.1002/art.41067.