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A Literally Massive Problem
A 60-year-old woman presents to dermatology with a longstanding complaint of a tender, irritated mass hanging from her lower abdomen. The patient says it started as a large fold in her lower abdomen but over the years has grown and become more pendulous. It is now large enough to interfere with normal activity, including walking.
Numerous providers, dermatologists included, have rendered diagnoses—most recently, hidradenitis suppurativa. The antibiotics prescribed for that diagnosis have not helped, however. Similarly, cultures performed on samples from draining sores on the mass’s posterior have failed to illuminate the situation, showing only mixed normal flora.
The patient’s primary care provider referred her to surgery for consideration of removal, or at least reduction, of the mass. The surgeon offered a presumptive diagnosis of elephantiasis nostras verrucosa of the pannus and agreed to perform the surgery. But the patient’s primary care provider requested a second opinion from dermatology.
EXAMINATION
The edematous, pendulous mass is the size of a soccer ball and hangs down from its abdominal base. When the patient stands, the mass stretches almost to the level of her knees. The anterior surface is edematous but otherwise normal in appearance. The intertriginous surfaces of the lesion look entirely different, with multiple small, draining puncta and a few open comedones.
The body of the mass is quite indurated but is neither hot nor tender. There are no comedones or cysts in other intertriginous locations, as might be seen in hidradenitis.
What’s the diagnosis?
DISCUSSION
This case involves a rare entity: vast lymphedema of the pannus leading to the formation of a pendulous mass so large that it filled the space between the patient’s legs, causing pain and discomfort. These findings are analogous to those seen in advanced venous insufficiency. Both manifestations share a name: elephantiasis nostras verrucosa. (Neither has anything to do with the more notorious cases of filarial elephantiasis seen in tropical locations.)
Elephantiasis nostras verrucosa of the lower extremities involves striking skin changes: edema, along with extreme thickening, papularity, and roughness of the skin. These typically manifest downward from just below the knee. The condition represents the effects of late-stage chronic venous insufficiency, often worsened by obesity and a sedentary lifestyle. Other causes of dependent lymphedema, such as congestive heart failure, can also contribute to the problem.
This same pathophysiologic process can affect other areas as well—including the pannus, as seen in this case. Since I had only ever encountered this problem in legs, I did a literature search. I found several references, all of which indicated that surgical removal (panniculectomy) was the best treatment. I could not find any information on the success rate of this surgery, but I did refer the patient back to the surgeon, who had made the correct diagnosis.
TAKE-HOME LEARNING POINTS
- Elephantiasis nostras verrucosa (ENV) is a consequence of uncontrolled venous insufficiency that commonly manifests on lower extremities.
- ENV is a distinctly rare (though not unknown) problem when areas other than legs are affected.
- This patient’s condition is, in my opinion, beyond the reach of medical treatment. But in milder cases, approaches such as weight loss and use of diuretics have been tried with mixed success.
- The best treatment appears to be surgical removal, which is not without potential complications: risk for infection, pain, prolonged recovery time, and wound dehiscence; these issues were discussed thoroughly with the case patient.
A 60-year-old woman presents to dermatology with a longstanding complaint of a tender, irritated mass hanging from her lower abdomen. The patient says it started as a large fold in her lower abdomen but over the years has grown and become more pendulous. It is now large enough to interfere with normal activity, including walking.
Numerous providers, dermatologists included, have rendered diagnoses—most recently, hidradenitis suppurativa. The antibiotics prescribed for that diagnosis have not helped, however. Similarly, cultures performed on samples from draining sores on the mass’s posterior have failed to illuminate the situation, showing only mixed normal flora.
The patient’s primary care provider referred her to surgery for consideration of removal, or at least reduction, of the mass. The surgeon offered a presumptive diagnosis of elephantiasis nostras verrucosa of the pannus and agreed to perform the surgery. But the patient’s primary care provider requested a second opinion from dermatology.
EXAMINATION
The edematous, pendulous mass is the size of a soccer ball and hangs down from its abdominal base. When the patient stands, the mass stretches almost to the level of her knees. The anterior surface is edematous but otherwise normal in appearance. The intertriginous surfaces of the lesion look entirely different, with multiple small, draining puncta and a few open comedones.
The body of the mass is quite indurated but is neither hot nor tender. There are no comedones or cysts in other intertriginous locations, as might be seen in hidradenitis.
What’s the diagnosis?
DISCUSSION
This case involves a rare entity: vast lymphedema of the pannus leading to the formation of a pendulous mass so large that it filled the space between the patient’s legs, causing pain and discomfort. These findings are analogous to those seen in advanced venous insufficiency. Both manifestations share a name: elephantiasis nostras verrucosa. (Neither has anything to do with the more notorious cases of filarial elephantiasis seen in tropical locations.)
Elephantiasis nostras verrucosa of the lower extremities involves striking skin changes: edema, along with extreme thickening, papularity, and roughness of the skin. These typically manifest downward from just below the knee. The condition represents the effects of late-stage chronic venous insufficiency, often worsened by obesity and a sedentary lifestyle. Other causes of dependent lymphedema, such as congestive heart failure, can also contribute to the problem.
This same pathophysiologic process can affect other areas as well—including the pannus, as seen in this case. Since I had only ever encountered this problem in legs, I did a literature search. I found several references, all of which indicated that surgical removal (panniculectomy) was the best treatment. I could not find any information on the success rate of this surgery, but I did refer the patient back to the surgeon, who had made the correct diagnosis.
TAKE-HOME LEARNING POINTS
- Elephantiasis nostras verrucosa (ENV) is a consequence of uncontrolled venous insufficiency that commonly manifests on lower extremities.
- ENV is a distinctly rare (though not unknown) problem when areas other than legs are affected.
- This patient’s condition is, in my opinion, beyond the reach of medical treatment. But in milder cases, approaches such as weight loss and use of diuretics have been tried with mixed success.
- The best treatment appears to be surgical removal, which is not without potential complications: risk for infection, pain, prolonged recovery time, and wound dehiscence; these issues were discussed thoroughly with the case patient.
A 60-year-old woman presents to dermatology with a longstanding complaint of a tender, irritated mass hanging from her lower abdomen. The patient says it started as a large fold in her lower abdomen but over the years has grown and become more pendulous. It is now large enough to interfere with normal activity, including walking.
Numerous providers, dermatologists included, have rendered diagnoses—most recently, hidradenitis suppurativa. The antibiotics prescribed for that diagnosis have not helped, however. Similarly, cultures performed on samples from draining sores on the mass’s posterior have failed to illuminate the situation, showing only mixed normal flora.
The patient’s primary care provider referred her to surgery for consideration of removal, or at least reduction, of the mass. The surgeon offered a presumptive diagnosis of elephantiasis nostras verrucosa of the pannus and agreed to perform the surgery. But the patient’s primary care provider requested a second opinion from dermatology.
EXAMINATION
The edematous, pendulous mass is the size of a soccer ball and hangs down from its abdominal base. When the patient stands, the mass stretches almost to the level of her knees. The anterior surface is edematous but otherwise normal in appearance. The intertriginous surfaces of the lesion look entirely different, with multiple small, draining puncta and a few open comedones.
The body of the mass is quite indurated but is neither hot nor tender. There are no comedones or cysts in other intertriginous locations, as might be seen in hidradenitis.
What’s the diagnosis?
DISCUSSION
This case involves a rare entity: vast lymphedema of the pannus leading to the formation of a pendulous mass so large that it filled the space between the patient’s legs, causing pain and discomfort. These findings are analogous to those seen in advanced venous insufficiency. Both manifestations share a name: elephantiasis nostras verrucosa. (Neither has anything to do with the more notorious cases of filarial elephantiasis seen in tropical locations.)
Elephantiasis nostras verrucosa of the lower extremities involves striking skin changes: edema, along with extreme thickening, papularity, and roughness of the skin. These typically manifest downward from just below the knee. The condition represents the effects of late-stage chronic venous insufficiency, often worsened by obesity and a sedentary lifestyle. Other causes of dependent lymphedema, such as congestive heart failure, can also contribute to the problem.
This same pathophysiologic process can affect other areas as well—including the pannus, as seen in this case. Since I had only ever encountered this problem in legs, I did a literature search. I found several references, all of which indicated that surgical removal (panniculectomy) was the best treatment. I could not find any information on the success rate of this surgery, but I did refer the patient back to the surgeon, who had made the correct diagnosis.
TAKE-HOME LEARNING POINTS
- Elephantiasis nostras verrucosa (ENV) is a consequence of uncontrolled venous insufficiency that commonly manifests on lower extremities.
- ENV is a distinctly rare (though not unknown) problem when areas other than legs are affected.
- This patient’s condition is, in my opinion, beyond the reach of medical treatment. But in milder cases, approaches such as weight loss and use of diuretics have been tried with mixed success.
- The best treatment appears to be surgical removal, which is not without potential complications: risk for infection, pain, prolonged recovery time, and wound dehiscence; these issues were discussed thoroughly with the case patient.
Widespread hyperpigmented plaques
The differential diagnosis included psoriasis, drug eruption, and a cutaneous T-cell lymphoma.
A drug eruption could have been due to an over-the-counter medication or supplement, so the lack of improvement from stopping the antihypertensive medication did not rule out this diagnosis. Psoriasis does not always show erythema in persons of color, but these plaques were not typical of psoriasis. (There also were some flat patches that were even less typical of psoriasis.)
The FP performed a 4-mm punch biopsy on one of the hyperpigmented plaques on the abdomen. A 4-mm punch biopsy is generally an ideal method for determining the cause of an unknown skin rash, and it is usually better to choose a lesion on the upper body rather than below the waist if the rash is widespread. (See the Watch & Learn video on “Punch biopsy.”)
The FP also prescribed a 1-pound tub of 0.1% triamcinolone ointment for symptomatic relief as this could help any of the possible diagnoses being considered. The pathology report came back as mycosis fungoides, the most common type of cutaneous T-cell lymphoma.
The patient was sent to Hematology/Oncology for further evaluation and treatment. Mycosis fungoides can have both patches and plaques and frequently involves the trunk more than the extremities (which was the situation in this case). It is important to consider uncommon diagnoses like this in the differential when the initial diagnosis does not appear to be responding to treatment or there is something atypical about the presentation of an expected diagnosis.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Chacon G, Nayar A, Usatine R, Smith M. Cutaneous T-cell lymphoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1124-1131.
To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/
You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com
The differential diagnosis included psoriasis, drug eruption, and a cutaneous T-cell lymphoma.
A drug eruption could have been due to an over-the-counter medication or supplement, so the lack of improvement from stopping the antihypertensive medication did not rule out this diagnosis. Psoriasis does not always show erythema in persons of color, but these plaques were not typical of psoriasis. (There also were some flat patches that were even less typical of psoriasis.)
The FP performed a 4-mm punch biopsy on one of the hyperpigmented plaques on the abdomen. A 4-mm punch biopsy is generally an ideal method for determining the cause of an unknown skin rash, and it is usually better to choose a lesion on the upper body rather than below the waist if the rash is widespread. (See the Watch & Learn video on “Punch biopsy.”)
The FP also prescribed a 1-pound tub of 0.1% triamcinolone ointment for symptomatic relief as this could help any of the possible diagnoses being considered. The pathology report came back as mycosis fungoides, the most common type of cutaneous T-cell lymphoma.
The patient was sent to Hematology/Oncology for further evaluation and treatment. Mycosis fungoides can have both patches and plaques and frequently involves the trunk more than the extremities (which was the situation in this case). It is important to consider uncommon diagnoses like this in the differential when the initial diagnosis does not appear to be responding to treatment or there is something atypical about the presentation of an expected diagnosis.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Chacon G, Nayar A, Usatine R, Smith M. Cutaneous T-cell lymphoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1124-1131.
To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/
You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com
The differential diagnosis included psoriasis, drug eruption, and a cutaneous T-cell lymphoma.
A drug eruption could have been due to an over-the-counter medication or supplement, so the lack of improvement from stopping the antihypertensive medication did not rule out this diagnosis. Psoriasis does not always show erythema in persons of color, but these plaques were not typical of psoriasis. (There also were some flat patches that were even less typical of psoriasis.)
The FP performed a 4-mm punch biopsy on one of the hyperpigmented plaques on the abdomen. A 4-mm punch biopsy is generally an ideal method for determining the cause of an unknown skin rash, and it is usually better to choose a lesion on the upper body rather than below the waist if the rash is widespread. (See the Watch & Learn video on “Punch biopsy.”)
The FP also prescribed a 1-pound tub of 0.1% triamcinolone ointment for symptomatic relief as this could help any of the possible diagnoses being considered. The pathology report came back as mycosis fungoides, the most common type of cutaneous T-cell lymphoma.
The patient was sent to Hematology/Oncology for further evaluation and treatment. Mycosis fungoides can have both patches and plaques and frequently involves the trunk more than the extremities (which was the situation in this case). It is important to consider uncommon diagnoses like this in the differential when the initial diagnosis does not appear to be responding to treatment or there is something atypical about the presentation of an expected diagnosis.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Chacon G, Nayar A, Usatine R, Smith M. Cutaneous T-cell lymphoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1124-1131.
To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/
You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com
LC screening. microRNAs. Impulse oscillometry. PH definition change. LC & women
Interventional Chest/Diagnostic Procedures
Complications and economic burden of diagnostic procedures for lung abnormalities in the community setting
The influential National Lung Screening Trial (NLST) reported a 20% reduction in lung cancer-related deaths using low dose CT scan when compared with plain chest radiography (Aberle et al. N Engl J Med. 2011;365[5]:395). Many medical societies responded by recommending screening individuals at high-risk for lung cancer, and community-based lung cancer screening programs were developed across the US. A concerning feature of the study was the rate (23.3%) of false-positive findings after three rounds of screening and the potential for complications secondary to diagnostic invasive procedures.
Using a 2008-2013 cohort of community inpatient and outpatient practice settings, Hou and colleagues searched administrative databases for procedure and diagnostic codes used in the NLST (Hou et al. JAMA Intern Med. 2019;179[3]:324). The study team created an age-matched control cohort that did not have an invasive procedure and used the difference in complications rates as an indicator of a procedure-related complication. Additionally, they estimated 1-year medical costs associated with complications. More than 340,000 patients were included in the study, and the overall complication rate was far higher than what was reported in the NLST. This difference was more pronounced in the older group in the study cohort (23.8% vs 8.5%). The associated economic burden of complications was substantial, and cost more than the initial procedure itself.
Although this was not a lung cancer screening cohort and used an administrative database, some valuable lessons can be offered from this study. First, complication rates of procedures like those performed in the NLST are likely to be higher in low-volume centers. Second, in order to minimize procedures, associated complications, and costs, we should be cognizant of the diagnostic limitations of each type of intervention when evaluating patients with lung nodules, wisely choosing the correct procedure for the correct patient after multidisciplinary discussion. We should seek to minimize biopsies of lesions that are likely benign. Third, it is evident that more research is needed regarding this topic. The ideal study would need to include both academic and community-based lung cancer screening programs, and, prospectively, analyze the diagnostic yield and complication rates, as well as downstream costs. Finally, the results of this study call all of us to properly follow the lung cancer screening guidelines and reconcile them with our common sense when evaluating a patient with a screen-detected nodule. Injudicious testing invites unnecessary complications, increases the cost of care, and diverts resources from those more likely to benefit from appropriate interventions.
Jose Cardenas-Garcia, MD, FCCP
Steering Committee Member
Douglas Arenberg, MD, FCCP
NetWork Member
Pediatric Chest Medicine
microRNAs: A New Biomarker
Biomarkers are essential tools in a clinician’s armamentarium. Biomarkers have multiple uses being indicators of a pathologic or physiologic process. One promising biomarker, now studied across multiple disorders, is microRNA (miRNA).
miRNAs are short (18–22 nucleotide) regulatory RNAs that bind mRNAs and decrease protein translation. miRNAs are generally co-transcribed with neighboring genes or co-transcribed within a cluster of miRNAs (a polycistronic cluster). Over 2,000 miRNAs are listed on miRBase (http://www.mirbase.org/), considered the central repository.
Function and biomarker utility of miRNAs are specific to the cells in which they are expressed. miRNAs isolated from circulating plasma exosomes have been shown to be stable over time, which is key in establishing their utility (Sanz-Rubio, et al. Sci Rep. 2018;8[1]:10306).
miRNAs have been credited with the function of micromanaging the circadian clock and sleep homeostasis in virtually all living organisms (Goodwin, et al. Cell Rep. 2018;23[13]:3776; Mehta, et al. J Mol Biol. 2013;425[19]:3609).
Preliminary work has identified dysregulated miRNAs in patients with obstructive sleep apnea (Li, et al. Medicine (Baltimore). 2017;96[34]:e7917). Exosomal miRNA has been shown to predict and protect against severe bronchopulmonary dysplasia (Lal, et al. JCI Insight. 2018;3[5]. pii: 93994).
Circadian miRNAs in salivary samples were found to have “altered” expression in autistic children with disordered sleep relative to peers with typical sleep (Hicks, et al. PLoS One. 2018;13[7]:e0198288). Collection from salivary samples facilitates multiple timed collection feasible at home and has multiple benefits.
Work on miRNAs, though preliminary, appears promising in providing a much-needed new perspective on pathophysiology and treatment in many disease processes.
Harish Rao, MD
Steering Committee Member
Pulmonary Physiology, Function, and Rehabilitation
Using impulse oscillometry in clinical practice
Impulse oscillometry (iOS) is an effort-independent test that requires minimal cooperation from the patient. It provides measures of respiratory mechanics during normal tidal breathing, including resistance (R), reactance (X), and impedance (Z) (Oostveen E, et al. Eur Respir J. 2003;22[6]:1026).
Airway R is largely, but not entirely, determined by cross-sectional area (Poiseuille’s Law). X is a surrogate for lung elastance, which is the inverse of compliance. Z is the combination of R and X and isn’t used clinically.
There are several benefits to using iOS, as opposed to or in conjunction with standard spirometry. First, iOS yields respiratory function measurements for patients, like the elderly and young children, who cannot provide acceptable and reproducible spirometry (Pezzoli L, et al. Age Ageing. 2003;32[1]:43). Second, it provides a real-world assessment of lung function because R and X values are obtained during tidal breathing. Humans don’t use the forced maneuvers needed for spirometry during normal daily activities, which weakens the correlation of FEV1 with respiratory symptoms. Forced maneuvers also create artifacts from gas compression and cause small airway closure, which limits inferences made from standard spirometry (Brusasco V, et al. Eur Respir J. 2005;26[5]:948). Lastly, R and X provide information not available from spirometry, and iOS is particularly sensitive for detecting small airway dysfunction (Berger K, et al. Chest. 2015;148[5]:1131).
Clinical and disease-specific indications for iOS are still being established. As discussed above, iOS is appropriate for any patient unable to perform spirometry. As new inhalers designed to deliver medication to the distal airways become available, subtle abnormalities detected via iOS will provide a target for specific therapies (Lipworth B. Ann Allergy Asthma Immunol. 2013;110[4]:233). iOS shows significant promise as a noninvasive assessment for supraglottic diseases, like vocal cord dysfunction, and can quantify changes over time following invasive intervention to relieve upper airway obstruction (Bikov A, et al. Chest. 2015;148[3]:731; Horan T, et al. Chest. 2001:120[1]:69). As their comfort level with interpretation improves, pulmonologists will find iOS is an important tool for disease diagnosis and treatment.
Aaron Holley, MD, FCCP
Steering Committee Member
Pulmonary Vascular Disease
Hemodynamic definition of pulmonary hypertension changed
Many patients worldwide went to bed February 26, 2018, with normal pulmonary pressures and woke up the next morning with pulmonary hypertension (PH). That day, experts met at the World Symposium on PH in Nice, France, and changed the definition of resting PH from a mean pulmonary artery pressure (mPAP) of greater than or equal to 25 mm Hg to a mPAP greater 20 mm Hg (Simmoneau, et al. Eur Respir J. 2019;53:1801913). The First World Health Organization symposium on PH in 1973 established the 25 mm Hg cutoff to distinguish primary PH from what was then considered less severe forms of PH. This definition, acknowledged as arbitrary and conservative at the time, has persisted due to a paucity of data establishing a definitively abnormal mPAP threshold.
Two contemporary findings provide justification for the definition change: (1)Normal mPAP is 14 ± 3.3 mm Hg in healthy subjects (Kovacs, et al. Eur Respir J. 2009;34[4]:888). (2) Patients with mPAP greater than 20 mm Hg suffer worse outcomes compared with control subjects (Maron, et al. Circulation. 2016;133[13]:1240).
Preserving the other hemodynamic criteria for group 1 PH, pulmonary artery wedge pressure less than or equal to 15 mm Hg and pulmonary vascular resistance greater than or equal to 3 Wood units, experts also recommend applying the new definition to all pre-capillary PH, including groups 3, 4, and applicable group 5 diagnoses.
Importantly, new guidelines do not recommend treating PH patients with mPAP 21-24 mm Hg: “A change in the hemodynamic definition of PH due to [pulmonary vascular diseases] does not imply treating these additional patients, but highlights the importance of close monitoring in this population.”
John Kingrey, MD
Steering Committee Member
Thoracic Oncology
Lung Cancer and Women
While the overall incidence of lung cancer (LC) has decreased among both men and women, the decline among men has been steeper compared with women. Further, in women born in the 1950s to 1960s, the incidence has actually increased and cannot be fully explained by sex differences in smoking behavior (Jemal, et al. N Engl J Med. 2018;378:1999). Data suggest that women may be more susceptible to the harmful effects of tobacco and that the biology of LC may be different in women. In addition, LC in nonsmokers is more likely to occur in women.
LC is the leading cause of cancer death in both women and men worldwide, but the dramatic rise in the mortality rate from LC in women was qualified as a “full blown epidemic” in the Surgeon General’s 2001 Women and Smoking report.
The benefits of lung cancer screening (LCS) in the National Lung Screening Trial (NLST) were higher in women than in men and significantly greater in the subset of women (16%) that entered the Nelson trial – reduction in 10-year LC mortality of 61% vs. 26% in men (De Koning, et al. J Thorac Oncol. 2018;13[10]: suppl S185. Abstract PL02.05). A retrospective review of patients diagnosed with LC between 2005 and 2011 showed that only 37% of women vs. 50% of men met LCS criteria (Wang, et al. JAMA 2015;313[8]:853).
Lung cancer needs to be recognized as an important women’s health issue, and there is need for continued attention to sex differences in LC risk, LCS criteria, and outcomes.
Anne Gonzalez, MD, FCCP
Steering Committee Member
Interventional Chest/Diagnostic Procedures
Complications and economic burden of diagnostic procedures for lung abnormalities in the community setting
The influential National Lung Screening Trial (NLST) reported a 20% reduction in lung cancer-related deaths using low dose CT scan when compared with plain chest radiography (Aberle et al. N Engl J Med. 2011;365[5]:395). Many medical societies responded by recommending screening individuals at high-risk for lung cancer, and community-based lung cancer screening programs were developed across the US. A concerning feature of the study was the rate (23.3%) of false-positive findings after three rounds of screening and the potential for complications secondary to diagnostic invasive procedures.
Using a 2008-2013 cohort of community inpatient and outpatient practice settings, Hou and colleagues searched administrative databases for procedure and diagnostic codes used in the NLST (Hou et al. JAMA Intern Med. 2019;179[3]:324). The study team created an age-matched control cohort that did not have an invasive procedure and used the difference in complications rates as an indicator of a procedure-related complication. Additionally, they estimated 1-year medical costs associated with complications. More than 340,000 patients were included in the study, and the overall complication rate was far higher than what was reported in the NLST. This difference was more pronounced in the older group in the study cohort (23.8% vs 8.5%). The associated economic burden of complications was substantial, and cost more than the initial procedure itself.
Although this was not a lung cancer screening cohort and used an administrative database, some valuable lessons can be offered from this study. First, complication rates of procedures like those performed in the NLST are likely to be higher in low-volume centers. Second, in order to minimize procedures, associated complications, and costs, we should be cognizant of the diagnostic limitations of each type of intervention when evaluating patients with lung nodules, wisely choosing the correct procedure for the correct patient after multidisciplinary discussion. We should seek to minimize biopsies of lesions that are likely benign. Third, it is evident that more research is needed regarding this topic. The ideal study would need to include both academic and community-based lung cancer screening programs, and, prospectively, analyze the diagnostic yield and complication rates, as well as downstream costs. Finally, the results of this study call all of us to properly follow the lung cancer screening guidelines and reconcile them with our common sense when evaluating a patient with a screen-detected nodule. Injudicious testing invites unnecessary complications, increases the cost of care, and diverts resources from those more likely to benefit from appropriate interventions.
Jose Cardenas-Garcia, MD, FCCP
Steering Committee Member
Douglas Arenberg, MD, FCCP
NetWork Member
Pediatric Chest Medicine
microRNAs: A New Biomarker
Biomarkers are essential tools in a clinician’s armamentarium. Biomarkers have multiple uses being indicators of a pathologic or physiologic process. One promising biomarker, now studied across multiple disorders, is microRNA (miRNA).
miRNAs are short (18–22 nucleotide) regulatory RNAs that bind mRNAs and decrease protein translation. miRNAs are generally co-transcribed with neighboring genes or co-transcribed within a cluster of miRNAs (a polycistronic cluster). Over 2,000 miRNAs are listed on miRBase (http://www.mirbase.org/), considered the central repository.
Function and biomarker utility of miRNAs are specific to the cells in which they are expressed. miRNAs isolated from circulating plasma exosomes have been shown to be stable over time, which is key in establishing their utility (Sanz-Rubio, et al. Sci Rep. 2018;8[1]:10306).
miRNAs have been credited with the function of micromanaging the circadian clock and sleep homeostasis in virtually all living organisms (Goodwin, et al. Cell Rep. 2018;23[13]:3776; Mehta, et al. J Mol Biol. 2013;425[19]:3609).
Preliminary work has identified dysregulated miRNAs in patients with obstructive sleep apnea (Li, et al. Medicine (Baltimore). 2017;96[34]:e7917). Exosomal miRNA has been shown to predict and protect against severe bronchopulmonary dysplasia (Lal, et al. JCI Insight. 2018;3[5]. pii: 93994).
Circadian miRNAs in salivary samples were found to have “altered” expression in autistic children with disordered sleep relative to peers with typical sleep (Hicks, et al. PLoS One. 2018;13[7]:e0198288). Collection from salivary samples facilitates multiple timed collection feasible at home and has multiple benefits.
Work on miRNAs, though preliminary, appears promising in providing a much-needed new perspective on pathophysiology and treatment in many disease processes.
Harish Rao, MD
Steering Committee Member
Pulmonary Physiology, Function, and Rehabilitation
Using impulse oscillometry in clinical practice
Impulse oscillometry (iOS) is an effort-independent test that requires minimal cooperation from the patient. It provides measures of respiratory mechanics during normal tidal breathing, including resistance (R), reactance (X), and impedance (Z) (Oostveen E, et al. Eur Respir J. 2003;22[6]:1026).
Airway R is largely, but not entirely, determined by cross-sectional area (Poiseuille’s Law). X is a surrogate for lung elastance, which is the inverse of compliance. Z is the combination of R and X and isn’t used clinically.
There are several benefits to using iOS, as opposed to or in conjunction with standard spirometry. First, iOS yields respiratory function measurements for patients, like the elderly and young children, who cannot provide acceptable and reproducible spirometry (Pezzoli L, et al. Age Ageing. 2003;32[1]:43). Second, it provides a real-world assessment of lung function because R and X values are obtained during tidal breathing. Humans don’t use the forced maneuvers needed for spirometry during normal daily activities, which weakens the correlation of FEV1 with respiratory symptoms. Forced maneuvers also create artifacts from gas compression and cause small airway closure, which limits inferences made from standard spirometry (Brusasco V, et al. Eur Respir J. 2005;26[5]:948). Lastly, R and X provide information not available from spirometry, and iOS is particularly sensitive for detecting small airway dysfunction (Berger K, et al. Chest. 2015;148[5]:1131).
Clinical and disease-specific indications for iOS are still being established. As discussed above, iOS is appropriate for any patient unable to perform spirometry. As new inhalers designed to deliver medication to the distal airways become available, subtle abnormalities detected via iOS will provide a target for specific therapies (Lipworth B. Ann Allergy Asthma Immunol. 2013;110[4]:233). iOS shows significant promise as a noninvasive assessment for supraglottic diseases, like vocal cord dysfunction, and can quantify changes over time following invasive intervention to relieve upper airway obstruction (Bikov A, et al. Chest. 2015;148[3]:731; Horan T, et al. Chest. 2001:120[1]:69). As their comfort level with interpretation improves, pulmonologists will find iOS is an important tool for disease diagnosis and treatment.
Aaron Holley, MD, FCCP
Steering Committee Member
Pulmonary Vascular Disease
Hemodynamic definition of pulmonary hypertension changed
Many patients worldwide went to bed February 26, 2018, with normal pulmonary pressures and woke up the next morning with pulmonary hypertension (PH). That day, experts met at the World Symposium on PH in Nice, France, and changed the definition of resting PH from a mean pulmonary artery pressure (mPAP) of greater than or equal to 25 mm Hg to a mPAP greater 20 mm Hg (Simmoneau, et al. Eur Respir J. 2019;53:1801913). The First World Health Organization symposium on PH in 1973 established the 25 mm Hg cutoff to distinguish primary PH from what was then considered less severe forms of PH. This definition, acknowledged as arbitrary and conservative at the time, has persisted due to a paucity of data establishing a definitively abnormal mPAP threshold.
Two contemporary findings provide justification for the definition change: (1)Normal mPAP is 14 ± 3.3 mm Hg in healthy subjects (Kovacs, et al. Eur Respir J. 2009;34[4]:888). (2) Patients with mPAP greater than 20 mm Hg suffer worse outcomes compared with control subjects (Maron, et al. Circulation. 2016;133[13]:1240).
Preserving the other hemodynamic criteria for group 1 PH, pulmonary artery wedge pressure less than or equal to 15 mm Hg and pulmonary vascular resistance greater than or equal to 3 Wood units, experts also recommend applying the new definition to all pre-capillary PH, including groups 3, 4, and applicable group 5 diagnoses.
Importantly, new guidelines do not recommend treating PH patients with mPAP 21-24 mm Hg: “A change in the hemodynamic definition of PH due to [pulmonary vascular diseases] does not imply treating these additional patients, but highlights the importance of close monitoring in this population.”
John Kingrey, MD
Steering Committee Member
Thoracic Oncology
Lung Cancer and Women
While the overall incidence of lung cancer (LC) has decreased among both men and women, the decline among men has been steeper compared with women. Further, in women born in the 1950s to 1960s, the incidence has actually increased and cannot be fully explained by sex differences in smoking behavior (Jemal, et al. N Engl J Med. 2018;378:1999). Data suggest that women may be more susceptible to the harmful effects of tobacco and that the biology of LC may be different in women. In addition, LC in nonsmokers is more likely to occur in women.
LC is the leading cause of cancer death in both women and men worldwide, but the dramatic rise in the mortality rate from LC in women was qualified as a “full blown epidemic” in the Surgeon General’s 2001 Women and Smoking report.
The benefits of lung cancer screening (LCS) in the National Lung Screening Trial (NLST) were higher in women than in men and significantly greater in the subset of women (16%) that entered the Nelson trial – reduction in 10-year LC mortality of 61% vs. 26% in men (De Koning, et al. J Thorac Oncol. 2018;13[10]: suppl S185. Abstract PL02.05). A retrospective review of patients diagnosed with LC between 2005 and 2011 showed that only 37% of women vs. 50% of men met LCS criteria (Wang, et al. JAMA 2015;313[8]:853).
Lung cancer needs to be recognized as an important women’s health issue, and there is need for continued attention to sex differences in LC risk, LCS criteria, and outcomes.
Anne Gonzalez, MD, FCCP
Steering Committee Member
Interventional Chest/Diagnostic Procedures
Complications and economic burden of diagnostic procedures for lung abnormalities in the community setting
The influential National Lung Screening Trial (NLST) reported a 20% reduction in lung cancer-related deaths using low dose CT scan when compared with plain chest radiography (Aberle et al. N Engl J Med. 2011;365[5]:395). Many medical societies responded by recommending screening individuals at high-risk for lung cancer, and community-based lung cancer screening programs were developed across the US. A concerning feature of the study was the rate (23.3%) of false-positive findings after three rounds of screening and the potential for complications secondary to diagnostic invasive procedures.
Using a 2008-2013 cohort of community inpatient and outpatient practice settings, Hou and colleagues searched administrative databases for procedure and diagnostic codes used in the NLST (Hou et al. JAMA Intern Med. 2019;179[3]:324). The study team created an age-matched control cohort that did not have an invasive procedure and used the difference in complications rates as an indicator of a procedure-related complication. Additionally, they estimated 1-year medical costs associated with complications. More than 340,000 patients were included in the study, and the overall complication rate was far higher than what was reported in the NLST. This difference was more pronounced in the older group in the study cohort (23.8% vs 8.5%). The associated economic burden of complications was substantial, and cost more than the initial procedure itself.
Although this was not a lung cancer screening cohort and used an administrative database, some valuable lessons can be offered from this study. First, complication rates of procedures like those performed in the NLST are likely to be higher in low-volume centers. Second, in order to minimize procedures, associated complications, and costs, we should be cognizant of the diagnostic limitations of each type of intervention when evaluating patients with lung nodules, wisely choosing the correct procedure for the correct patient after multidisciplinary discussion. We should seek to minimize biopsies of lesions that are likely benign. Third, it is evident that more research is needed regarding this topic. The ideal study would need to include both academic and community-based lung cancer screening programs, and, prospectively, analyze the diagnostic yield and complication rates, as well as downstream costs. Finally, the results of this study call all of us to properly follow the lung cancer screening guidelines and reconcile them with our common sense when evaluating a patient with a screen-detected nodule. Injudicious testing invites unnecessary complications, increases the cost of care, and diverts resources from those more likely to benefit from appropriate interventions.
Jose Cardenas-Garcia, MD, FCCP
Steering Committee Member
Douglas Arenberg, MD, FCCP
NetWork Member
Pediatric Chest Medicine
microRNAs: A New Biomarker
Biomarkers are essential tools in a clinician’s armamentarium. Biomarkers have multiple uses being indicators of a pathologic or physiologic process. One promising biomarker, now studied across multiple disorders, is microRNA (miRNA).
miRNAs are short (18–22 nucleotide) regulatory RNAs that bind mRNAs and decrease protein translation. miRNAs are generally co-transcribed with neighboring genes or co-transcribed within a cluster of miRNAs (a polycistronic cluster). Over 2,000 miRNAs are listed on miRBase (http://www.mirbase.org/), considered the central repository.
Function and biomarker utility of miRNAs are specific to the cells in which they are expressed. miRNAs isolated from circulating plasma exosomes have been shown to be stable over time, which is key in establishing their utility (Sanz-Rubio, et al. Sci Rep. 2018;8[1]:10306).
miRNAs have been credited with the function of micromanaging the circadian clock and sleep homeostasis in virtually all living organisms (Goodwin, et al. Cell Rep. 2018;23[13]:3776; Mehta, et al. J Mol Biol. 2013;425[19]:3609).
Preliminary work has identified dysregulated miRNAs in patients with obstructive sleep apnea (Li, et al. Medicine (Baltimore). 2017;96[34]:e7917). Exosomal miRNA has been shown to predict and protect against severe bronchopulmonary dysplasia (Lal, et al. JCI Insight. 2018;3[5]. pii: 93994).
Circadian miRNAs in salivary samples were found to have “altered” expression in autistic children with disordered sleep relative to peers with typical sleep (Hicks, et al. PLoS One. 2018;13[7]:e0198288). Collection from salivary samples facilitates multiple timed collection feasible at home and has multiple benefits.
Work on miRNAs, though preliminary, appears promising in providing a much-needed new perspective on pathophysiology and treatment in many disease processes.
Harish Rao, MD
Steering Committee Member
Pulmonary Physiology, Function, and Rehabilitation
Using impulse oscillometry in clinical practice
Impulse oscillometry (iOS) is an effort-independent test that requires minimal cooperation from the patient. It provides measures of respiratory mechanics during normal tidal breathing, including resistance (R), reactance (X), and impedance (Z) (Oostveen E, et al. Eur Respir J. 2003;22[6]:1026).
Airway R is largely, but not entirely, determined by cross-sectional area (Poiseuille’s Law). X is a surrogate for lung elastance, which is the inverse of compliance. Z is the combination of R and X and isn’t used clinically.
There are several benefits to using iOS, as opposed to or in conjunction with standard spirometry. First, iOS yields respiratory function measurements for patients, like the elderly and young children, who cannot provide acceptable and reproducible spirometry (Pezzoli L, et al. Age Ageing. 2003;32[1]:43). Second, it provides a real-world assessment of lung function because R and X values are obtained during tidal breathing. Humans don’t use the forced maneuvers needed for spirometry during normal daily activities, which weakens the correlation of FEV1 with respiratory symptoms. Forced maneuvers also create artifacts from gas compression and cause small airway closure, which limits inferences made from standard spirometry (Brusasco V, et al. Eur Respir J. 2005;26[5]:948). Lastly, R and X provide information not available from spirometry, and iOS is particularly sensitive for detecting small airway dysfunction (Berger K, et al. Chest. 2015;148[5]:1131).
Clinical and disease-specific indications for iOS are still being established. As discussed above, iOS is appropriate for any patient unable to perform spirometry. As new inhalers designed to deliver medication to the distal airways become available, subtle abnormalities detected via iOS will provide a target for specific therapies (Lipworth B. Ann Allergy Asthma Immunol. 2013;110[4]:233). iOS shows significant promise as a noninvasive assessment for supraglottic diseases, like vocal cord dysfunction, and can quantify changes over time following invasive intervention to relieve upper airway obstruction (Bikov A, et al. Chest. 2015;148[3]:731; Horan T, et al. Chest. 2001:120[1]:69). As their comfort level with interpretation improves, pulmonologists will find iOS is an important tool for disease diagnosis and treatment.
Aaron Holley, MD, FCCP
Steering Committee Member
Pulmonary Vascular Disease
Hemodynamic definition of pulmonary hypertension changed
Many patients worldwide went to bed February 26, 2018, with normal pulmonary pressures and woke up the next morning with pulmonary hypertension (PH). That day, experts met at the World Symposium on PH in Nice, France, and changed the definition of resting PH from a mean pulmonary artery pressure (mPAP) of greater than or equal to 25 mm Hg to a mPAP greater 20 mm Hg (Simmoneau, et al. Eur Respir J. 2019;53:1801913). The First World Health Organization symposium on PH in 1973 established the 25 mm Hg cutoff to distinguish primary PH from what was then considered less severe forms of PH. This definition, acknowledged as arbitrary and conservative at the time, has persisted due to a paucity of data establishing a definitively abnormal mPAP threshold.
Two contemporary findings provide justification for the definition change: (1)Normal mPAP is 14 ± 3.3 mm Hg in healthy subjects (Kovacs, et al. Eur Respir J. 2009;34[4]:888). (2) Patients with mPAP greater than 20 mm Hg suffer worse outcomes compared with control subjects (Maron, et al. Circulation. 2016;133[13]:1240).
Preserving the other hemodynamic criteria for group 1 PH, pulmonary artery wedge pressure less than or equal to 15 mm Hg and pulmonary vascular resistance greater than or equal to 3 Wood units, experts also recommend applying the new definition to all pre-capillary PH, including groups 3, 4, and applicable group 5 diagnoses.
Importantly, new guidelines do not recommend treating PH patients with mPAP 21-24 mm Hg: “A change in the hemodynamic definition of PH due to [pulmonary vascular diseases] does not imply treating these additional patients, but highlights the importance of close monitoring in this population.”
John Kingrey, MD
Steering Committee Member
Thoracic Oncology
Lung Cancer and Women
While the overall incidence of lung cancer (LC) has decreased among both men and women, the decline among men has been steeper compared with women. Further, in women born in the 1950s to 1960s, the incidence has actually increased and cannot be fully explained by sex differences in smoking behavior (Jemal, et al. N Engl J Med. 2018;378:1999). Data suggest that women may be more susceptible to the harmful effects of tobacco and that the biology of LC may be different in women. In addition, LC in nonsmokers is more likely to occur in women.
LC is the leading cause of cancer death in both women and men worldwide, but the dramatic rise in the mortality rate from LC in women was qualified as a “full blown epidemic” in the Surgeon General’s 2001 Women and Smoking report.
The benefits of lung cancer screening (LCS) in the National Lung Screening Trial (NLST) were higher in women than in men and significantly greater in the subset of women (16%) that entered the Nelson trial – reduction in 10-year LC mortality of 61% vs. 26% in men (De Koning, et al. J Thorac Oncol. 2018;13[10]: suppl S185. Abstract PL02.05). A retrospective review of patients diagnosed with LC between 2005 and 2011 showed that only 37% of women vs. 50% of men met LCS criteria (Wang, et al. JAMA 2015;313[8]:853).
Lung cancer needs to be recognized as an important women’s health issue, and there is need for continued attention to sex differences in LC risk, LCS criteria, and outcomes.
Anne Gonzalez, MD, FCCP
Steering Committee Member
The burgeoning role of sleep-related chronic hypoxia in long-term outcomes
Clinicians are well aware of the acute effects of hypoxemia when encountered in conditions such as pulmonary embolism, pulmonary edema, COPD exacerbation, and others, whereas effects of chronic hypoxemia, such as pulmonary hypertension and polycythemia, are more difficult to recognize. Chronic hypoxemia is frequent in chronic lung diseases, such as COPD, but how it leads to increased mortality in severe COPD is unknown (NHLBI Working Group for LTOT in COPD. Am J Respir Crit Care Med. 2006;174:373). Chronic hypoxemia following high altitude exposure tends to have more unpredictable effects. Chronic hypoxemia, greater than that expected for the altitude of residence, is encountered frequently in high altitude dwellers. Here it has been implicated in the pathophysiology of chronic mountain sickness (Villafeurte and Corante. High Alt Med Biol. 2016;17[2]:61) and low birth weights (Maatta J, et al. Sci Rep. 2018;8[1]:13583), even though high altitude residence has been linked to better cardiovascular outcomes and reduced cancer-related deaths (Burstcher M. Aging Dis. 2013;5[4]:274). Chronic hypoxia effects at high altitude may, therefore, be variegated depending on a number of factors that include organ-system-specific effects, severity of chronic hypoxia, and a propensity to disease determined by genetic background and generations of residence.
Such diverse effects of chronic sleep-related hypoxemia are also being reported with obstructive sleep apnea (OSA). While sleep can result in sustained drops in ventilation and consequent hypoxemia similar to what is seen in COPD, OSA is typified by a form of sleep-related hypoxemia in a pattern termed as chronic intermittent hypoxia (CIH). CIH is characterized by rapid fluctuations in oxygen saturations (Figure 1) that is virtually pathognomonic of sleep apnea either from recurrent upper airway obstructions (as in OSA) or pauses in respiratory generator firing (as in central sleep apnea). OSA-driven CIH has received most attention, given its purported role in in the causation of the wide range of pathologic conditions associated with OSA. Outcomes from cross-sectional and longitudinal studies have correlated time spent below 90% or recurrent oxygen desaturations to a number of OSA-related outcomes such as cardiovascular disease, diabetes, and cognitive dysfunction (Dewan et al. Chest. 2015;147[1]:266). While these effects of OSA-related intermittent hypoxemia occur over long periods of time, as with other forms of chronic hypoxia, some effects, such as hypertension, are demonstrable in animal models after much shorter durations of sleep-related intermittent hypoxia exposure. As seen with other forms of chronic hypoxemia, an opposing beneficial effect has also been demonstrated on the size of myocardial infarct during acute coronary events and from mild OSA-related mortality in elderly subjects (Javaheri et al. J Am Coll Cardiol. 2017;69[7]:841).
Given how common sleep-related hypoxemia and OSA are, it is important to understand the implications of different patterns of sleep-related hypoxemia that a vast segment of the population experiences on a nightly basis. A number of factors may determine chronic outcomes with sleep-related hypoxemia that include the pattern of sleep-related hypoxemia (chronic sustained hypoxemia associated with sleep-related hypoventilation vs chronic intermittent hypoxemia of OSA), degree of hypoxemia, presence of underlying disease, and hitherto undescribed individual factors. While a correlation between hypoxemic burden secondary to sleep-disordered breathing and cardiovascular outcomes has been shown (Azabarzin A, et al. Eur Heart J. 2018 Oct 30), CPAP interventional studies that address OSA-related CIH have shown mixed results for prevention of cardiovascular disease (McEvoy RD, et al. N Engl J Med. 2016;375[10]:919). It has also been difficult to draw upon results of oxygen supplementation in other forms of hypoxemia, such as COPD, when specifically targeted to addressing the hypoxemia seen only at night or with exercise (LOTT Research Group. N Engl J Med. 2016;375:1617 ). To complicate this further, high altitude residence (that may result in similar levels of sleep-related hypoxemia) is not associated with any differences in life-expectancy but may provide a reduction in cardiovascular outcomes (Ezzati, et al. J Epidemiol Community Health. 2012;66[7]:e17).
How do we reconcile such disparate effects of chronic hypoxemia? Part of difference may be in the pattern of chronic intermittent hypoxemia noted with OSA characterized not only by rapid drops in oxygen but also rapid reoxygenation events secondary to arousals terminating an apnea – these reoxygenation events have been attributed to the increased oxidant stress demonstrable in multiple tissues. While chronic hypoxia itself may cause increased oxidant stress, such effects seen with sustained forms of hypoxia, such as sleep-related hypoventilation or high altitude residence, may be more gradual resulting in lesser degrees of tissue effects and regulation of antioxidant defenses with sustained exposure. Herein lies the importance of understanding physiologic and biological effects stemming from chronic hypoxia to explain its variegated effects on different organ systems. In this regard, the role of carotid body, a structure with unique vascular supply and with the ability to respond to minor changes in oxygen saturation as is seen in patients with OSA is key to the causation of hypertension associated with OSA (Shell et al. Curr Hyperten Rep. 2016;18[3]:19). Carotid body activation by intermittent hypoxia and long-term sensory facilitation drives the elevated sympathetic activity and consequent increases in blood pressure that can be improved by supplemental oxygen (Turnbull CD, et al. Am J Respir Crit Care Med. 2019;199[2]:211).
While carotid body responses are key to the pathophysiology of OSA, every organ in the body (in fact, every cell within the body) has the ability to sense and respond to hypoxia. This ability to sense oxygen tensions is ingrained in every cell by virtue of oxygen’s critical role in the genesis of life and evolution. These cellular responses to hypoxia are mediated by hypoxia-inducible factors (HIFs), isoforms of which include the more ubiquitous HIF-1 found in all parenchymal cells and HIF-2 found in specialized erythropoietin-producing cells of the kidney and the pulmonary circulation (the polycythemia and pulmonary vasoconstrictive responses from hypoxia are mediated through HIF-2 ). HIFs mediate the transcription of hundreds of genes, and they have been implicated in the pathobiology of a wide range of phenomena, from cancer to atherosclerotic vascular disease, metabolic syndrome, neurodegenerative disorders, pulmonary hypertension, and nonalcoholic fatty liver disease (Prabhakar and Semenza. Physiol Rev. 2012;92[3]:967). While HIF activation is an attractive target for examining the effects of chronic hypoxia of high altitude and sleep-disordered breathing, HIF activation varies from tissue to tissue and interacts with a number of other cellular systems in leading to differential effects. The short half-life of HIF proteins make them difficult to detect in tissues, so a number of secondary HIF-effects has been measured with mixed results depending on animal model utilized, pattern and degree of hypoxia studied, and the target effect measured. Comparative effects of intermittent vs sustained hypoxemia need to be systematically studied in different organ systems in different species, given the differing oxygen thresholds of individual cells due to unique blood flows and variations in the system of co-factors and prolyl hydroxylases that regulate the activation of HIFs. While the thrust of the work has been centered on HIF-related effects and the role of NF-kB-driven inflammation seen in OSA, there is substantial evidence to the role of oxidant stress that may be directly related to reoxygenation events occurring with CIH (Lavie L. Sleep Med Rev. 2015;20:27).
For life that has been intricately involved with oxygen from its genesis, it is not unreasonable to expect adaptations of cells, organs, and the whole individual to a wide range of oxygen tensions. Attempts to understand the import of sleep-disordered breathing has led to a need to unravel the implications of OSA-related chronic intermittent hypoxia and sleep-hypoventilation. This has led to a resurgence of interest in hypoxia-related research. Whether such chronic sleep-related sustained and intermittent hypoxemia is a harbinger of chronic disease is still not fully clear. A number of challenges exist with the understanding of these chronic hypoxia effects that include the long time needed for disease occurrence, its differential effects on organ systems, the role of hypoxia vs reoxygenation injury, importance of local blood flow, etc. Understanding these pathways will be crucial in prognosticating the role of sleep-related hypoxemia, the recognition of which has become part and parcel of routine management in sleep medicine.
Dr. Sundar is Medical Director, Sleep-Wake Center, Clinical Professor, Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah.
Clinicians are well aware of the acute effects of hypoxemia when encountered in conditions such as pulmonary embolism, pulmonary edema, COPD exacerbation, and others, whereas effects of chronic hypoxemia, such as pulmonary hypertension and polycythemia, are more difficult to recognize. Chronic hypoxemia is frequent in chronic lung diseases, such as COPD, but how it leads to increased mortality in severe COPD is unknown (NHLBI Working Group for LTOT in COPD. Am J Respir Crit Care Med. 2006;174:373). Chronic hypoxemia following high altitude exposure tends to have more unpredictable effects. Chronic hypoxemia, greater than that expected for the altitude of residence, is encountered frequently in high altitude dwellers. Here it has been implicated in the pathophysiology of chronic mountain sickness (Villafeurte and Corante. High Alt Med Biol. 2016;17[2]:61) and low birth weights (Maatta J, et al. Sci Rep. 2018;8[1]:13583), even though high altitude residence has been linked to better cardiovascular outcomes and reduced cancer-related deaths (Burstcher M. Aging Dis. 2013;5[4]:274). Chronic hypoxia effects at high altitude may, therefore, be variegated depending on a number of factors that include organ-system-specific effects, severity of chronic hypoxia, and a propensity to disease determined by genetic background and generations of residence.
Such diverse effects of chronic sleep-related hypoxemia are also being reported with obstructive sleep apnea (OSA). While sleep can result in sustained drops in ventilation and consequent hypoxemia similar to what is seen in COPD, OSA is typified by a form of sleep-related hypoxemia in a pattern termed as chronic intermittent hypoxia (CIH). CIH is characterized by rapid fluctuations in oxygen saturations (Figure 1) that is virtually pathognomonic of sleep apnea either from recurrent upper airway obstructions (as in OSA) or pauses in respiratory generator firing (as in central sleep apnea). OSA-driven CIH has received most attention, given its purported role in in the causation of the wide range of pathologic conditions associated with OSA. Outcomes from cross-sectional and longitudinal studies have correlated time spent below 90% or recurrent oxygen desaturations to a number of OSA-related outcomes such as cardiovascular disease, diabetes, and cognitive dysfunction (Dewan et al. Chest. 2015;147[1]:266). While these effects of OSA-related intermittent hypoxemia occur over long periods of time, as with other forms of chronic hypoxia, some effects, such as hypertension, are demonstrable in animal models after much shorter durations of sleep-related intermittent hypoxia exposure. As seen with other forms of chronic hypoxemia, an opposing beneficial effect has also been demonstrated on the size of myocardial infarct during acute coronary events and from mild OSA-related mortality in elderly subjects (Javaheri et al. J Am Coll Cardiol. 2017;69[7]:841).
Given how common sleep-related hypoxemia and OSA are, it is important to understand the implications of different patterns of sleep-related hypoxemia that a vast segment of the population experiences on a nightly basis. A number of factors may determine chronic outcomes with sleep-related hypoxemia that include the pattern of sleep-related hypoxemia (chronic sustained hypoxemia associated with sleep-related hypoventilation vs chronic intermittent hypoxemia of OSA), degree of hypoxemia, presence of underlying disease, and hitherto undescribed individual factors. While a correlation between hypoxemic burden secondary to sleep-disordered breathing and cardiovascular outcomes has been shown (Azabarzin A, et al. Eur Heart J. 2018 Oct 30), CPAP interventional studies that address OSA-related CIH have shown mixed results for prevention of cardiovascular disease (McEvoy RD, et al. N Engl J Med. 2016;375[10]:919). It has also been difficult to draw upon results of oxygen supplementation in other forms of hypoxemia, such as COPD, when specifically targeted to addressing the hypoxemia seen only at night or with exercise (LOTT Research Group. N Engl J Med. 2016;375:1617 ). To complicate this further, high altitude residence (that may result in similar levels of sleep-related hypoxemia) is not associated with any differences in life-expectancy but may provide a reduction in cardiovascular outcomes (Ezzati, et al. J Epidemiol Community Health. 2012;66[7]:e17).
How do we reconcile such disparate effects of chronic hypoxemia? Part of difference may be in the pattern of chronic intermittent hypoxemia noted with OSA characterized not only by rapid drops in oxygen but also rapid reoxygenation events secondary to arousals terminating an apnea – these reoxygenation events have been attributed to the increased oxidant stress demonstrable in multiple tissues. While chronic hypoxia itself may cause increased oxidant stress, such effects seen with sustained forms of hypoxia, such as sleep-related hypoventilation or high altitude residence, may be more gradual resulting in lesser degrees of tissue effects and regulation of antioxidant defenses with sustained exposure. Herein lies the importance of understanding physiologic and biological effects stemming from chronic hypoxia to explain its variegated effects on different organ systems. In this regard, the role of carotid body, a structure with unique vascular supply and with the ability to respond to minor changes in oxygen saturation as is seen in patients with OSA is key to the causation of hypertension associated with OSA (Shell et al. Curr Hyperten Rep. 2016;18[3]:19). Carotid body activation by intermittent hypoxia and long-term sensory facilitation drives the elevated sympathetic activity and consequent increases in blood pressure that can be improved by supplemental oxygen (Turnbull CD, et al. Am J Respir Crit Care Med. 2019;199[2]:211).
While carotid body responses are key to the pathophysiology of OSA, every organ in the body (in fact, every cell within the body) has the ability to sense and respond to hypoxia. This ability to sense oxygen tensions is ingrained in every cell by virtue of oxygen’s critical role in the genesis of life and evolution. These cellular responses to hypoxia are mediated by hypoxia-inducible factors (HIFs), isoforms of which include the more ubiquitous HIF-1 found in all parenchymal cells and HIF-2 found in specialized erythropoietin-producing cells of the kidney and the pulmonary circulation (the polycythemia and pulmonary vasoconstrictive responses from hypoxia are mediated through HIF-2 ). HIFs mediate the transcription of hundreds of genes, and they have been implicated in the pathobiology of a wide range of phenomena, from cancer to atherosclerotic vascular disease, metabolic syndrome, neurodegenerative disorders, pulmonary hypertension, and nonalcoholic fatty liver disease (Prabhakar and Semenza. Physiol Rev. 2012;92[3]:967). While HIF activation is an attractive target for examining the effects of chronic hypoxia of high altitude and sleep-disordered breathing, HIF activation varies from tissue to tissue and interacts with a number of other cellular systems in leading to differential effects. The short half-life of HIF proteins make them difficult to detect in tissues, so a number of secondary HIF-effects has been measured with mixed results depending on animal model utilized, pattern and degree of hypoxia studied, and the target effect measured. Comparative effects of intermittent vs sustained hypoxemia need to be systematically studied in different organ systems in different species, given the differing oxygen thresholds of individual cells due to unique blood flows and variations in the system of co-factors and prolyl hydroxylases that regulate the activation of HIFs. While the thrust of the work has been centered on HIF-related effects and the role of NF-kB-driven inflammation seen in OSA, there is substantial evidence to the role of oxidant stress that may be directly related to reoxygenation events occurring with CIH (Lavie L. Sleep Med Rev. 2015;20:27).
For life that has been intricately involved with oxygen from its genesis, it is not unreasonable to expect adaptations of cells, organs, and the whole individual to a wide range of oxygen tensions. Attempts to understand the import of sleep-disordered breathing has led to a need to unravel the implications of OSA-related chronic intermittent hypoxia and sleep-hypoventilation. This has led to a resurgence of interest in hypoxia-related research. Whether such chronic sleep-related sustained and intermittent hypoxemia is a harbinger of chronic disease is still not fully clear. A number of challenges exist with the understanding of these chronic hypoxia effects that include the long time needed for disease occurrence, its differential effects on organ systems, the role of hypoxia vs reoxygenation injury, importance of local blood flow, etc. Understanding these pathways will be crucial in prognosticating the role of sleep-related hypoxemia, the recognition of which has become part and parcel of routine management in sleep medicine.
Dr. Sundar is Medical Director, Sleep-Wake Center, Clinical Professor, Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah.
Clinicians are well aware of the acute effects of hypoxemia when encountered in conditions such as pulmonary embolism, pulmonary edema, COPD exacerbation, and others, whereas effects of chronic hypoxemia, such as pulmonary hypertension and polycythemia, are more difficult to recognize. Chronic hypoxemia is frequent in chronic lung diseases, such as COPD, but how it leads to increased mortality in severe COPD is unknown (NHLBI Working Group for LTOT in COPD. Am J Respir Crit Care Med. 2006;174:373). Chronic hypoxemia following high altitude exposure tends to have more unpredictable effects. Chronic hypoxemia, greater than that expected for the altitude of residence, is encountered frequently in high altitude dwellers. Here it has been implicated in the pathophysiology of chronic mountain sickness (Villafeurte and Corante. High Alt Med Biol. 2016;17[2]:61) and low birth weights (Maatta J, et al. Sci Rep. 2018;8[1]:13583), even though high altitude residence has been linked to better cardiovascular outcomes and reduced cancer-related deaths (Burstcher M. Aging Dis. 2013;5[4]:274). Chronic hypoxia effects at high altitude may, therefore, be variegated depending on a number of factors that include organ-system-specific effects, severity of chronic hypoxia, and a propensity to disease determined by genetic background and generations of residence.
Such diverse effects of chronic sleep-related hypoxemia are also being reported with obstructive sleep apnea (OSA). While sleep can result in sustained drops in ventilation and consequent hypoxemia similar to what is seen in COPD, OSA is typified by a form of sleep-related hypoxemia in a pattern termed as chronic intermittent hypoxia (CIH). CIH is characterized by rapid fluctuations in oxygen saturations (Figure 1) that is virtually pathognomonic of sleep apnea either from recurrent upper airway obstructions (as in OSA) or pauses in respiratory generator firing (as in central sleep apnea). OSA-driven CIH has received most attention, given its purported role in in the causation of the wide range of pathologic conditions associated with OSA. Outcomes from cross-sectional and longitudinal studies have correlated time spent below 90% or recurrent oxygen desaturations to a number of OSA-related outcomes such as cardiovascular disease, diabetes, and cognitive dysfunction (Dewan et al. Chest. 2015;147[1]:266). While these effects of OSA-related intermittent hypoxemia occur over long periods of time, as with other forms of chronic hypoxia, some effects, such as hypertension, are demonstrable in animal models after much shorter durations of sleep-related intermittent hypoxia exposure. As seen with other forms of chronic hypoxemia, an opposing beneficial effect has also been demonstrated on the size of myocardial infarct during acute coronary events and from mild OSA-related mortality in elderly subjects (Javaheri et al. J Am Coll Cardiol. 2017;69[7]:841).
Given how common sleep-related hypoxemia and OSA are, it is important to understand the implications of different patterns of sleep-related hypoxemia that a vast segment of the population experiences on a nightly basis. A number of factors may determine chronic outcomes with sleep-related hypoxemia that include the pattern of sleep-related hypoxemia (chronic sustained hypoxemia associated with sleep-related hypoventilation vs chronic intermittent hypoxemia of OSA), degree of hypoxemia, presence of underlying disease, and hitherto undescribed individual factors. While a correlation between hypoxemic burden secondary to sleep-disordered breathing and cardiovascular outcomes has been shown (Azabarzin A, et al. Eur Heart J. 2018 Oct 30), CPAP interventional studies that address OSA-related CIH have shown mixed results for prevention of cardiovascular disease (McEvoy RD, et al. N Engl J Med. 2016;375[10]:919). It has also been difficult to draw upon results of oxygen supplementation in other forms of hypoxemia, such as COPD, when specifically targeted to addressing the hypoxemia seen only at night or with exercise (LOTT Research Group. N Engl J Med. 2016;375:1617 ). To complicate this further, high altitude residence (that may result in similar levels of sleep-related hypoxemia) is not associated with any differences in life-expectancy but may provide a reduction in cardiovascular outcomes (Ezzati, et al. J Epidemiol Community Health. 2012;66[7]:e17).
How do we reconcile such disparate effects of chronic hypoxemia? Part of difference may be in the pattern of chronic intermittent hypoxemia noted with OSA characterized not only by rapid drops in oxygen but also rapid reoxygenation events secondary to arousals terminating an apnea – these reoxygenation events have been attributed to the increased oxidant stress demonstrable in multiple tissues. While chronic hypoxia itself may cause increased oxidant stress, such effects seen with sustained forms of hypoxia, such as sleep-related hypoventilation or high altitude residence, may be more gradual resulting in lesser degrees of tissue effects and regulation of antioxidant defenses with sustained exposure. Herein lies the importance of understanding physiologic and biological effects stemming from chronic hypoxia to explain its variegated effects on different organ systems. In this regard, the role of carotid body, a structure with unique vascular supply and with the ability to respond to minor changes in oxygen saturation as is seen in patients with OSA is key to the causation of hypertension associated with OSA (Shell et al. Curr Hyperten Rep. 2016;18[3]:19). Carotid body activation by intermittent hypoxia and long-term sensory facilitation drives the elevated sympathetic activity and consequent increases in blood pressure that can be improved by supplemental oxygen (Turnbull CD, et al. Am J Respir Crit Care Med. 2019;199[2]:211).
While carotid body responses are key to the pathophysiology of OSA, every organ in the body (in fact, every cell within the body) has the ability to sense and respond to hypoxia. This ability to sense oxygen tensions is ingrained in every cell by virtue of oxygen’s critical role in the genesis of life and evolution. These cellular responses to hypoxia are mediated by hypoxia-inducible factors (HIFs), isoforms of which include the more ubiquitous HIF-1 found in all parenchymal cells and HIF-2 found in specialized erythropoietin-producing cells of the kidney and the pulmonary circulation (the polycythemia and pulmonary vasoconstrictive responses from hypoxia are mediated through HIF-2 ). HIFs mediate the transcription of hundreds of genes, and they have been implicated in the pathobiology of a wide range of phenomena, from cancer to atherosclerotic vascular disease, metabolic syndrome, neurodegenerative disorders, pulmonary hypertension, and nonalcoholic fatty liver disease (Prabhakar and Semenza. Physiol Rev. 2012;92[3]:967). While HIF activation is an attractive target for examining the effects of chronic hypoxia of high altitude and sleep-disordered breathing, HIF activation varies from tissue to tissue and interacts with a number of other cellular systems in leading to differential effects. The short half-life of HIF proteins make them difficult to detect in tissues, so a number of secondary HIF-effects has been measured with mixed results depending on animal model utilized, pattern and degree of hypoxia studied, and the target effect measured. Comparative effects of intermittent vs sustained hypoxemia need to be systematically studied in different organ systems in different species, given the differing oxygen thresholds of individual cells due to unique blood flows and variations in the system of co-factors and prolyl hydroxylases that regulate the activation of HIFs. While the thrust of the work has been centered on HIF-related effects and the role of NF-kB-driven inflammation seen in OSA, there is substantial evidence to the role of oxidant stress that may be directly related to reoxygenation events occurring with CIH (Lavie L. Sleep Med Rev. 2015;20:27).
For life that has been intricately involved with oxygen from its genesis, it is not unreasonable to expect adaptations of cells, organs, and the whole individual to a wide range of oxygen tensions. Attempts to understand the import of sleep-disordered breathing has led to a need to unravel the implications of OSA-related chronic intermittent hypoxia and sleep-hypoventilation. This has led to a resurgence of interest in hypoxia-related research. Whether such chronic sleep-related sustained and intermittent hypoxemia is a harbinger of chronic disease is still not fully clear. A number of challenges exist with the understanding of these chronic hypoxia effects that include the long time needed for disease occurrence, its differential effects on organ systems, the role of hypoxia vs reoxygenation injury, importance of local blood flow, etc. Understanding these pathways will be crucial in prognosticating the role of sleep-related hypoxemia, the recognition of which has become part and parcel of routine management in sleep medicine.
Dr. Sundar is Medical Director, Sleep-Wake Center, Clinical Professor, Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah.
CMS proposal threatens entire landscape for home mechanical ventilators
CMS announced in a [press release in mid-March that as it revamped the competitive bidding program for durable medical equipment, it would move to include no invasive ventilation (NIV) in the revamped program, slated to take effect January 1, 2021.
While the implementation date is still more than 18 months in the future, the regulatory timetable for a formal announcement, as well as time for CMS to introduce its revamped bidding process, actually creates a relatively short window for aggressive action to thwart the CMS proposal.
In late November 2018, when CMS was seeking public comment on the idea of such a move, CHEST, NAMDRC and numerous other societies submitted strongly worded comments opposed to the recommendation, citing a wide array of clinical risks associated with such a proposal. The comments also highlighted CMS’ total failure to revamp its own coverage policies, frequently cited by the pulmonary medicine community and the Office of the Inspector General as the primary root cause for significant problems.
Background: Under current law, Medicare is required to pay for certain ventilators under a “frequent and substantial servicing” payment methodology, with payment continuing as long as medical necessity is documented. Nearly 2 decades ago, CMS (then HCFA) sought to circumvent those statutory requirements by declaring that some ventilators are really not ventilators (as FDA classifications indicate) but are actually “respiratory assist devices.” The long-term impact of that unilateral policy decision has been ongoing chaos, as well as flawed coverage policies. For example, it is much more challenging for a physician to order a cheaper bi-level device than to order a ventilator for treatment of “respiratory failure.” As there are no limitations or qualifying criteria tied to “respiratory failure,” the community has responded with the path of least resistance while pleading with CMS to restructure their coverage policies to reflect the standards of care for home mechanical ventilation.
Since 2014, the community has repeatedly tried to convince CMS of the importance, and cost savings, associated with such a revamp, to no avail. Given 5 years of well documented efforts, it is likely that the only genuine solution will be a legislative one that forces CMS to behave in certain ways.
The challenges: There are complicating variables that the clinical community will need to address:
1. If the term “ventilator” is included in any legislative effort, CMS could expand its infamous concept “just because FDA calls a device a ventilator doesn’t make it one.” Using particular CPT or HCPCS codes would open the door for CMS to simply change coding to circumvent legislative intent.
2. If a legislative effort receives serious support, it ought to include specific guidance to CMS to force it to change its coverage policies for home mechanical ventilation to reflect standards of care and state-of-the-art devices.
For example, because devices are designed today to serve a wide range of respiratory issues, one device may be used to provide critical life support for an ALS patient, while that same device could also be used to provide nocturnal or intermittent support for other neuromuscular or COPD patients. Because the durable medical equipment benefit is focused on devices, CMS’ move to change to focus from a device to a patient is questionable.
3. Forcing CMS to move in a particular direction regarding coverage and device usage must be flexible enough to allow for technological and medical innovations; after all, no one wants to recommend legislative policies that would have to be revisited to address potential/likely advances in this field.
Broad strategies: While the durable medical equipment community is also challenging this proposal, they agreed that the medical and patient communities should take the lead. And, in principle, we agree. But implementation of that effort is a bit of a challenge as it requires a significant grassroots effort from concerned physicians, as well as patient groups to contact their legislators in Congress. After all, the worst case scenario is for a Senator to say, “How come I haven’t heard from any constituents about this problem if it is as bad as you say it is?” That is a fair and common refrain, and we must be prepared to engage the broad physician and patient communities to ensure success in this effort.
Once there is formal introduction of a proposal to move this matter forward, there will be outreach to physicians and respiratory therapists across the country to urge support of the legislation. Keep watching for such requests for action!
CMS announced in a [press release in mid-March that as it revamped the competitive bidding program for durable medical equipment, it would move to include no invasive ventilation (NIV) in the revamped program, slated to take effect January 1, 2021.
While the implementation date is still more than 18 months in the future, the regulatory timetable for a formal announcement, as well as time for CMS to introduce its revamped bidding process, actually creates a relatively short window for aggressive action to thwart the CMS proposal.
In late November 2018, when CMS was seeking public comment on the idea of such a move, CHEST, NAMDRC and numerous other societies submitted strongly worded comments opposed to the recommendation, citing a wide array of clinical risks associated with such a proposal. The comments also highlighted CMS’ total failure to revamp its own coverage policies, frequently cited by the pulmonary medicine community and the Office of the Inspector General as the primary root cause for significant problems.
Background: Under current law, Medicare is required to pay for certain ventilators under a “frequent and substantial servicing” payment methodology, with payment continuing as long as medical necessity is documented. Nearly 2 decades ago, CMS (then HCFA) sought to circumvent those statutory requirements by declaring that some ventilators are really not ventilators (as FDA classifications indicate) but are actually “respiratory assist devices.” The long-term impact of that unilateral policy decision has been ongoing chaos, as well as flawed coverage policies. For example, it is much more challenging for a physician to order a cheaper bi-level device than to order a ventilator for treatment of “respiratory failure.” As there are no limitations or qualifying criteria tied to “respiratory failure,” the community has responded with the path of least resistance while pleading with CMS to restructure their coverage policies to reflect the standards of care for home mechanical ventilation.
Since 2014, the community has repeatedly tried to convince CMS of the importance, and cost savings, associated with such a revamp, to no avail. Given 5 years of well documented efforts, it is likely that the only genuine solution will be a legislative one that forces CMS to behave in certain ways.
The challenges: There are complicating variables that the clinical community will need to address:
1. If the term “ventilator” is included in any legislative effort, CMS could expand its infamous concept “just because FDA calls a device a ventilator doesn’t make it one.” Using particular CPT or HCPCS codes would open the door for CMS to simply change coding to circumvent legislative intent.
2. If a legislative effort receives serious support, it ought to include specific guidance to CMS to force it to change its coverage policies for home mechanical ventilation to reflect standards of care and state-of-the-art devices.
For example, because devices are designed today to serve a wide range of respiratory issues, one device may be used to provide critical life support for an ALS patient, while that same device could also be used to provide nocturnal or intermittent support for other neuromuscular or COPD patients. Because the durable medical equipment benefit is focused on devices, CMS’ move to change to focus from a device to a patient is questionable.
3. Forcing CMS to move in a particular direction regarding coverage and device usage must be flexible enough to allow for technological and medical innovations; after all, no one wants to recommend legislative policies that would have to be revisited to address potential/likely advances in this field.
Broad strategies: While the durable medical equipment community is also challenging this proposal, they agreed that the medical and patient communities should take the lead. And, in principle, we agree. But implementation of that effort is a bit of a challenge as it requires a significant grassroots effort from concerned physicians, as well as patient groups to contact their legislators in Congress. After all, the worst case scenario is for a Senator to say, “How come I haven’t heard from any constituents about this problem if it is as bad as you say it is?” That is a fair and common refrain, and we must be prepared to engage the broad physician and patient communities to ensure success in this effort.
Once there is formal introduction of a proposal to move this matter forward, there will be outreach to physicians and respiratory therapists across the country to urge support of the legislation. Keep watching for such requests for action!
CMS announced in a [press release in mid-March that as it revamped the competitive bidding program for durable medical equipment, it would move to include no invasive ventilation (NIV) in the revamped program, slated to take effect January 1, 2021.
While the implementation date is still more than 18 months in the future, the regulatory timetable for a formal announcement, as well as time for CMS to introduce its revamped bidding process, actually creates a relatively short window for aggressive action to thwart the CMS proposal.
In late November 2018, when CMS was seeking public comment on the idea of such a move, CHEST, NAMDRC and numerous other societies submitted strongly worded comments opposed to the recommendation, citing a wide array of clinical risks associated with such a proposal. The comments also highlighted CMS’ total failure to revamp its own coverage policies, frequently cited by the pulmonary medicine community and the Office of the Inspector General as the primary root cause for significant problems.
Background: Under current law, Medicare is required to pay for certain ventilators under a “frequent and substantial servicing” payment methodology, with payment continuing as long as medical necessity is documented. Nearly 2 decades ago, CMS (then HCFA) sought to circumvent those statutory requirements by declaring that some ventilators are really not ventilators (as FDA classifications indicate) but are actually “respiratory assist devices.” The long-term impact of that unilateral policy decision has been ongoing chaos, as well as flawed coverage policies. For example, it is much more challenging for a physician to order a cheaper bi-level device than to order a ventilator for treatment of “respiratory failure.” As there are no limitations or qualifying criteria tied to “respiratory failure,” the community has responded with the path of least resistance while pleading with CMS to restructure their coverage policies to reflect the standards of care for home mechanical ventilation.
Since 2014, the community has repeatedly tried to convince CMS of the importance, and cost savings, associated with such a revamp, to no avail. Given 5 years of well documented efforts, it is likely that the only genuine solution will be a legislative one that forces CMS to behave in certain ways.
The challenges: There are complicating variables that the clinical community will need to address:
1. If the term “ventilator” is included in any legislative effort, CMS could expand its infamous concept “just because FDA calls a device a ventilator doesn’t make it one.” Using particular CPT or HCPCS codes would open the door for CMS to simply change coding to circumvent legislative intent.
2. If a legislative effort receives serious support, it ought to include specific guidance to CMS to force it to change its coverage policies for home mechanical ventilation to reflect standards of care and state-of-the-art devices.
For example, because devices are designed today to serve a wide range of respiratory issues, one device may be used to provide critical life support for an ALS patient, while that same device could also be used to provide nocturnal or intermittent support for other neuromuscular or COPD patients. Because the durable medical equipment benefit is focused on devices, CMS’ move to change to focus from a device to a patient is questionable.
3. Forcing CMS to move in a particular direction regarding coverage and device usage must be flexible enough to allow for technological and medical innovations; after all, no one wants to recommend legislative policies that would have to be revisited to address potential/likely advances in this field.
Broad strategies: While the durable medical equipment community is also challenging this proposal, they agreed that the medical and patient communities should take the lead. And, in principle, we agree. But implementation of that effort is a bit of a challenge as it requires a significant grassroots effort from concerned physicians, as well as patient groups to contact their legislators in Congress. After all, the worst case scenario is for a Senator to say, “How come I haven’t heard from any constituents about this problem if it is as bad as you say it is?” That is a fair and common refrain, and we must be prepared to engage the broad physician and patient communities to ensure success in this effort.
Once there is formal introduction of a proposal to move this matter forward, there will be outreach to physicians and respiratory therapists across the country to urge support of the legislation. Keep watching for such requests for action!
News From the Board Highlights from the spring leadership meeting March 2019
CHEST leadership meets quarterly in person, but the fall and spring meetings include all of the combined committees of CHEST. As the fall meeting takes place during the CHEST Annual Scientific Meeting, the spring meeting takes on a particular importance in providing the impetus of the upcoming year. The meeting spanned from March 27 to March 30. Traditionally, the first day consists of committee meetings, such as the Council of Networks, Training and Transition, Education, Membership, Guideline Oversight, and Professional Standards. On the morning of the second day, the following committees met: Finance, Diversity, and the Governance Committee. The afternoon of the second day was a combined boards meeting with all members of the Board of Trustees and the Board of Regents, where we received updates from each of the committees. In addition, all of the board members underwent professional media training as professional development.
On the 29th, the Foundation Board of Trustees had their meeting, which was attended by several of the members of the Board of Regents (highlights listed below). In the afternoon, we had the biannual meeting of the CHEST Industry Advisory Council, where CHEST leadership meets with our industry partners, working together to anticipate the needs of our members and our patients. The Board of Regents convened on March 30 for our formal board meeting.
Highlights of the Spring Combined Meeting:
CHEST Leadership Committees:
Education Committee: Under the leadership of the Chair, Dr. Alex Niven, the Education Committee has grown in scope and focus with the increasing strength of their subcommittees, including Live Learning, Simulation, Peer Review, Outcomes, Innovations, and Educator Development. The Education Committee is now working to develop a revolving education curriculum to ensure that our members have a solid base at the annual meeting, as well as in online learning. The committee is working to increase coordination with the APCCMPD, as well.
Membership Committee: The Membership Committee reported on several accomplishments during the year, including an increase in nonphysician membership and rolling out several new programs, including automatic membership renewal option and adjusted membership fees for international members and retired members.
Finance Committee: The financial report for the last quarter of the CHEST fiscal year was robust with solid outlook for the year.
Training and Transitions: The T & T Committee has had marked success with a dramatic increase in fellow education programs and learners at the CHEST annual meeting. This year will bring new fellow courses in Pulmonary Nodules and Lung Transplantation. In addition, the committee is also reviewing abstract submissions for trainees at a record pace, with case report submissions exceeding last year’s record number of 1,015 submissions.
Guideline Oversight: There are currently 12 guidelines in development, in addition to the 6 guidelines that were completed last fiscal year. This committee updated us regarding the ongoing development of “living guidelines.”
Scientific Program Committee: Dr. Bill Kelly, chairman of CHEST 2019 in New Orleans, reported on the meeting, including the record number of submissions in all curriculum areas. He updated us regarding the ongoing maintenance of certification credits for the meeting, as well as important new initiatives, such as child care and innovative electronic options for the meeting, designed to make the experience “easy” on attendees in New Orleans - The Big Easy.
CHEST Foundation Board of Trustees: Doreen Addrizzo-Harris, MD, FCCP, President of the Foundation, updated us on the quarterly activities of the foundation and guided the board through some of the novel fundraising opportunities, including the 6th Annual Irv Feldman Poker Night, the Inaugural CHEST Foundation Derby Dinner and Auction in New York, and the Popovich Endowment Dinner and future Gala. The Foundation is sponsoring a number of activities at CHEST in New Orleans, including a Lung Health Experience, Breakfast of Champions, Women & Pulmonary Luncheon, the Young Professionals Reception, and the Foundation Reception.
CHEST Board of Regents (BoR): The Board of Regents, led by Clayton Cowl, MD, FCCP, President of CHEST, had a packed session. The session started off with a unique team building exercise. The Board approved the Master Fellow Award selection that will honor Dr. Darcy Marciniuk. The Digital Strategy Task Force, led by Dr. Chris Carroll, Nicki Augustyn, and Ron Moen, reported on their findings, which led to a lively discussion on how to move forward with an innovative and successful digital plan. A report was also given on the membership recruitment and retention initiative. Finally, the BoR approved a new agreement with PA Consulting to assist in the ongoing CHEST Analytics program.
CHEST leadership meets quarterly in person, but the fall and spring meetings include all of the combined committees of CHEST. As the fall meeting takes place during the CHEST Annual Scientific Meeting, the spring meeting takes on a particular importance in providing the impetus of the upcoming year. The meeting spanned from March 27 to March 30. Traditionally, the first day consists of committee meetings, such as the Council of Networks, Training and Transition, Education, Membership, Guideline Oversight, and Professional Standards. On the morning of the second day, the following committees met: Finance, Diversity, and the Governance Committee. The afternoon of the second day was a combined boards meeting with all members of the Board of Trustees and the Board of Regents, where we received updates from each of the committees. In addition, all of the board members underwent professional media training as professional development.
On the 29th, the Foundation Board of Trustees had their meeting, which was attended by several of the members of the Board of Regents (highlights listed below). In the afternoon, we had the biannual meeting of the CHEST Industry Advisory Council, where CHEST leadership meets with our industry partners, working together to anticipate the needs of our members and our patients. The Board of Regents convened on March 30 for our formal board meeting.
Highlights of the Spring Combined Meeting:
CHEST Leadership Committees:
Education Committee: Under the leadership of the Chair, Dr. Alex Niven, the Education Committee has grown in scope and focus with the increasing strength of their subcommittees, including Live Learning, Simulation, Peer Review, Outcomes, Innovations, and Educator Development. The Education Committee is now working to develop a revolving education curriculum to ensure that our members have a solid base at the annual meeting, as well as in online learning. The committee is working to increase coordination with the APCCMPD, as well.
Membership Committee: The Membership Committee reported on several accomplishments during the year, including an increase in nonphysician membership and rolling out several new programs, including automatic membership renewal option and adjusted membership fees for international members and retired members.
Finance Committee: The financial report for the last quarter of the CHEST fiscal year was robust with solid outlook for the year.
Training and Transitions: The T & T Committee has had marked success with a dramatic increase in fellow education programs and learners at the CHEST annual meeting. This year will bring new fellow courses in Pulmonary Nodules and Lung Transplantation. In addition, the committee is also reviewing abstract submissions for trainees at a record pace, with case report submissions exceeding last year’s record number of 1,015 submissions.
Guideline Oversight: There are currently 12 guidelines in development, in addition to the 6 guidelines that were completed last fiscal year. This committee updated us regarding the ongoing development of “living guidelines.”
Scientific Program Committee: Dr. Bill Kelly, chairman of CHEST 2019 in New Orleans, reported on the meeting, including the record number of submissions in all curriculum areas. He updated us regarding the ongoing maintenance of certification credits for the meeting, as well as important new initiatives, such as child care and innovative electronic options for the meeting, designed to make the experience “easy” on attendees in New Orleans - The Big Easy.
CHEST Foundation Board of Trustees: Doreen Addrizzo-Harris, MD, FCCP, President of the Foundation, updated us on the quarterly activities of the foundation and guided the board through some of the novel fundraising opportunities, including the 6th Annual Irv Feldman Poker Night, the Inaugural CHEST Foundation Derby Dinner and Auction in New York, and the Popovich Endowment Dinner and future Gala. The Foundation is sponsoring a number of activities at CHEST in New Orleans, including a Lung Health Experience, Breakfast of Champions, Women & Pulmonary Luncheon, the Young Professionals Reception, and the Foundation Reception.
CHEST Board of Regents (BoR): The Board of Regents, led by Clayton Cowl, MD, FCCP, President of CHEST, had a packed session. The session started off with a unique team building exercise. The Board approved the Master Fellow Award selection that will honor Dr. Darcy Marciniuk. The Digital Strategy Task Force, led by Dr. Chris Carroll, Nicki Augustyn, and Ron Moen, reported on their findings, which led to a lively discussion on how to move forward with an innovative and successful digital plan. A report was also given on the membership recruitment and retention initiative. Finally, the BoR approved a new agreement with PA Consulting to assist in the ongoing CHEST Analytics program.
CHEST leadership meets quarterly in person, but the fall and spring meetings include all of the combined committees of CHEST. As the fall meeting takes place during the CHEST Annual Scientific Meeting, the spring meeting takes on a particular importance in providing the impetus of the upcoming year. The meeting spanned from March 27 to March 30. Traditionally, the first day consists of committee meetings, such as the Council of Networks, Training and Transition, Education, Membership, Guideline Oversight, and Professional Standards. On the morning of the second day, the following committees met: Finance, Diversity, and the Governance Committee. The afternoon of the second day was a combined boards meeting with all members of the Board of Trustees and the Board of Regents, where we received updates from each of the committees. In addition, all of the board members underwent professional media training as professional development.
On the 29th, the Foundation Board of Trustees had their meeting, which was attended by several of the members of the Board of Regents (highlights listed below). In the afternoon, we had the biannual meeting of the CHEST Industry Advisory Council, where CHEST leadership meets with our industry partners, working together to anticipate the needs of our members and our patients. The Board of Regents convened on March 30 for our formal board meeting.
Highlights of the Spring Combined Meeting:
CHEST Leadership Committees:
Education Committee: Under the leadership of the Chair, Dr. Alex Niven, the Education Committee has grown in scope and focus with the increasing strength of their subcommittees, including Live Learning, Simulation, Peer Review, Outcomes, Innovations, and Educator Development. The Education Committee is now working to develop a revolving education curriculum to ensure that our members have a solid base at the annual meeting, as well as in online learning. The committee is working to increase coordination with the APCCMPD, as well.
Membership Committee: The Membership Committee reported on several accomplishments during the year, including an increase in nonphysician membership and rolling out several new programs, including automatic membership renewal option and adjusted membership fees for international members and retired members.
Finance Committee: The financial report for the last quarter of the CHEST fiscal year was robust with solid outlook for the year.
Training and Transitions: The T & T Committee has had marked success with a dramatic increase in fellow education programs and learners at the CHEST annual meeting. This year will bring new fellow courses in Pulmonary Nodules and Lung Transplantation. In addition, the committee is also reviewing abstract submissions for trainees at a record pace, with case report submissions exceeding last year’s record number of 1,015 submissions.
Guideline Oversight: There are currently 12 guidelines in development, in addition to the 6 guidelines that were completed last fiscal year. This committee updated us regarding the ongoing development of “living guidelines.”
Scientific Program Committee: Dr. Bill Kelly, chairman of CHEST 2019 in New Orleans, reported on the meeting, including the record number of submissions in all curriculum areas. He updated us regarding the ongoing maintenance of certification credits for the meeting, as well as important new initiatives, such as child care and innovative electronic options for the meeting, designed to make the experience “easy” on attendees in New Orleans - The Big Easy.
CHEST Foundation Board of Trustees: Doreen Addrizzo-Harris, MD, FCCP, President of the Foundation, updated us on the quarterly activities of the foundation and guided the board through some of the novel fundraising opportunities, including the 6th Annual Irv Feldman Poker Night, the Inaugural CHEST Foundation Derby Dinner and Auction in New York, and the Popovich Endowment Dinner and future Gala. The Foundation is sponsoring a number of activities at CHEST in New Orleans, including a Lung Health Experience, Breakfast of Champions, Women & Pulmonary Luncheon, the Young Professionals Reception, and the Foundation Reception.
CHEST Board of Regents (BoR): The Board of Regents, led by Clayton Cowl, MD, FCCP, President of CHEST, had a packed session. The session started off with a unique team building exercise. The Board approved the Master Fellow Award selection that will honor Dr. Darcy Marciniuk. The Digital Strategy Task Force, led by Dr. Chris Carroll, Nicki Augustyn, and Ron Moen, reported on their findings, which led to a lively discussion on how to move forward with an innovative and successful digital plan. A report was also given on the membership recruitment and retention initiative. Finally, the BoR approved a new agreement with PA Consulting to assist in the ongoing CHEST Analytics program.
From the President: Expanding our educational reach
CHEST Congress Thailand concluded in Bangkok last month with more than 1,000 attendees from 56 countries. Attendees heard experts speak on several clinical tracks, including lung cancer, severe airway disease, pulmonary infections, interventional pulmonary management, and sleep-related disordered breathing. Panel discussions were held covering controversial topics across pulmonary, critical care, and sleep medicine, and close to 400 submitted abstracts were presented. Registration continues to build for the next CHEST international meeting to be held in conjunction with the Hellenic Thoracic Society in Athens, Greece, June 25-27. This meeting will feature clinicians and academicians providing relevant clinical updates to providers throughout that region in more of a “board review-like” format.
Why is it so important that CHEST spread its brand of education to an international audience?
Clinicians are yearning for up-to-date information regardless of geography
Having the opportunity to visit with clinicians from Southeast Asia and Australia, it became clear to me that there is a need for high quality educational opportunities to be shared across the globe. Many attendees in Bangkok had never had the opportunity to attend a CHEST annual meeting within North America; their exposure to state-of-the-art reviews using interactive audience participation was a format that was clearly appreciated. Hands-on educational opportunities through simulation, as well as novel interactive tools such as serious gaming, were modalities not previously available to many attendees and the reviews received were overwhelmingly positive.
Access to cutting-edge training in certain areas in the world has become more limited
Resources for international travel have become more limited. Industry sponsorship in certain regions has dwindled and, for certain countries, the ability to access medical meetings within the United States or other areas in Europe or North America has become burdensome, if not logistically impossible. Bringing the CHEST brand of education to members and other practicing providers outside North America within the represented specialties has allowed access to experts and the most effective formats for education without extended travel and excess cost.
Smaller international meetings allow for more tailored curricula designed to meet local needs
The ability to build the curriculum around specific requests of a national society has allowed for a more focused educational platform designed to meet the needs of what regional leaders feel is the most critical for the highest prevalence of patients seen in that specific area. The international strategy of CHEST calls for an annual congress outside of North America and at least one smaller “board review-type” meeting in a different region elsewhere across the world each academic year. Co-hosting more meetings will not only help address unmet educational needs outside of the United States and Canada but also extend our reach to participants who may not have otherwise had the ability to participate in the CHEST brand of education. During multiple sessions, there were literally dozens of questions for which there was time to address each in real time. The panel discussions were lively, well-moderated, and also stimulated multiple questions and comments from the audience.
Education by podium lecture is fast becoming outdated
Although a compelling lecture using a didactic format from a podium at the front of a room is not going to be replaced completely any time soon, educational delivery trends are moving toward virtual classrooms, use of simulation, problem solving online, serious gaming, and hands-on experiential education. As an innovator and leader in medical education, CHEST will continue to provide a variety of options for delivering education utilizing a variety of platforms. By opening a multimedia production studio at CHEST global headquarters in Glenview, Illinois, this past February, the organization is positioning itself to continue to refine its ability to produce and distribute a variety of courses available to all CHEST members in an archivable, easily accessible format. The Board of Regents has doubled down on its digital strategy toward improving communication across the entire user experience, and offering courses to our international members closer to home is one way to execute this strategy.
Networking and new friendships underscore what’s important
Meeting new colleagues from across the globe has made me realize that we are all focused on providing the very best care possible to our patients every day. Ultimately, education is communication. The ability to share how CHEST educates its membership will improve patient care worldwide and foster lifelong friendships with those we meet in other lands. Those opportunities to share ideas on health-care delivery will keep us on the cutting edge technologically and keep us focused on how to use resources responsibly and in a way that best serves the communities where we practice.
CHEST Congress Thailand concluded in Bangkok last month with more than 1,000 attendees from 56 countries. Attendees heard experts speak on several clinical tracks, including lung cancer, severe airway disease, pulmonary infections, interventional pulmonary management, and sleep-related disordered breathing. Panel discussions were held covering controversial topics across pulmonary, critical care, and sleep medicine, and close to 400 submitted abstracts were presented. Registration continues to build for the next CHEST international meeting to be held in conjunction with the Hellenic Thoracic Society in Athens, Greece, June 25-27. This meeting will feature clinicians and academicians providing relevant clinical updates to providers throughout that region in more of a “board review-like” format.
Why is it so important that CHEST spread its brand of education to an international audience?
Clinicians are yearning for up-to-date information regardless of geography
Having the opportunity to visit with clinicians from Southeast Asia and Australia, it became clear to me that there is a need for high quality educational opportunities to be shared across the globe. Many attendees in Bangkok had never had the opportunity to attend a CHEST annual meeting within North America; their exposure to state-of-the-art reviews using interactive audience participation was a format that was clearly appreciated. Hands-on educational opportunities through simulation, as well as novel interactive tools such as serious gaming, were modalities not previously available to many attendees and the reviews received were overwhelmingly positive.
Access to cutting-edge training in certain areas in the world has become more limited
Resources for international travel have become more limited. Industry sponsorship in certain regions has dwindled and, for certain countries, the ability to access medical meetings within the United States or other areas in Europe or North America has become burdensome, if not logistically impossible. Bringing the CHEST brand of education to members and other practicing providers outside North America within the represented specialties has allowed access to experts and the most effective formats for education without extended travel and excess cost.
Smaller international meetings allow for more tailored curricula designed to meet local needs
The ability to build the curriculum around specific requests of a national society has allowed for a more focused educational platform designed to meet the needs of what regional leaders feel is the most critical for the highest prevalence of patients seen in that specific area. The international strategy of CHEST calls for an annual congress outside of North America and at least one smaller “board review-type” meeting in a different region elsewhere across the world each academic year. Co-hosting more meetings will not only help address unmet educational needs outside of the United States and Canada but also extend our reach to participants who may not have otherwise had the ability to participate in the CHEST brand of education. During multiple sessions, there were literally dozens of questions for which there was time to address each in real time. The panel discussions were lively, well-moderated, and also stimulated multiple questions and comments from the audience.
Education by podium lecture is fast becoming outdated
Although a compelling lecture using a didactic format from a podium at the front of a room is not going to be replaced completely any time soon, educational delivery trends are moving toward virtual classrooms, use of simulation, problem solving online, serious gaming, and hands-on experiential education. As an innovator and leader in medical education, CHEST will continue to provide a variety of options for delivering education utilizing a variety of platforms. By opening a multimedia production studio at CHEST global headquarters in Glenview, Illinois, this past February, the organization is positioning itself to continue to refine its ability to produce and distribute a variety of courses available to all CHEST members in an archivable, easily accessible format. The Board of Regents has doubled down on its digital strategy toward improving communication across the entire user experience, and offering courses to our international members closer to home is one way to execute this strategy.
Networking and new friendships underscore what’s important
Meeting new colleagues from across the globe has made me realize that we are all focused on providing the very best care possible to our patients every day. Ultimately, education is communication. The ability to share how CHEST educates its membership will improve patient care worldwide and foster lifelong friendships with those we meet in other lands. Those opportunities to share ideas on health-care delivery will keep us on the cutting edge technologically and keep us focused on how to use resources responsibly and in a way that best serves the communities where we practice.
CHEST Congress Thailand concluded in Bangkok last month with more than 1,000 attendees from 56 countries. Attendees heard experts speak on several clinical tracks, including lung cancer, severe airway disease, pulmonary infections, interventional pulmonary management, and sleep-related disordered breathing. Panel discussions were held covering controversial topics across pulmonary, critical care, and sleep medicine, and close to 400 submitted abstracts were presented. Registration continues to build for the next CHEST international meeting to be held in conjunction with the Hellenic Thoracic Society in Athens, Greece, June 25-27. This meeting will feature clinicians and academicians providing relevant clinical updates to providers throughout that region in more of a “board review-like” format.
Why is it so important that CHEST spread its brand of education to an international audience?
Clinicians are yearning for up-to-date information regardless of geography
Having the opportunity to visit with clinicians from Southeast Asia and Australia, it became clear to me that there is a need for high quality educational opportunities to be shared across the globe. Many attendees in Bangkok had never had the opportunity to attend a CHEST annual meeting within North America; their exposure to state-of-the-art reviews using interactive audience participation was a format that was clearly appreciated. Hands-on educational opportunities through simulation, as well as novel interactive tools such as serious gaming, were modalities not previously available to many attendees and the reviews received were overwhelmingly positive.
Access to cutting-edge training in certain areas in the world has become more limited
Resources for international travel have become more limited. Industry sponsorship in certain regions has dwindled and, for certain countries, the ability to access medical meetings within the United States or other areas in Europe or North America has become burdensome, if not logistically impossible. Bringing the CHEST brand of education to members and other practicing providers outside North America within the represented specialties has allowed access to experts and the most effective formats for education without extended travel and excess cost.
Smaller international meetings allow for more tailored curricula designed to meet local needs
The ability to build the curriculum around specific requests of a national society has allowed for a more focused educational platform designed to meet the needs of what regional leaders feel is the most critical for the highest prevalence of patients seen in that specific area. The international strategy of CHEST calls for an annual congress outside of North America and at least one smaller “board review-type” meeting in a different region elsewhere across the world each academic year. Co-hosting more meetings will not only help address unmet educational needs outside of the United States and Canada but also extend our reach to participants who may not have otherwise had the ability to participate in the CHEST brand of education. During multiple sessions, there were literally dozens of questions for which there was time to address each in real time. The panel discussions were lively, well-moderated, and also stimulated multiple questions and comments from the audience.
Education by podium lecture is fast becoming outdated
Although a compelling lecture using a didactic format from a podium at the front of a room is not going to be replaced completely any time soon, educational delivery trends are moving toward virtual classrooms, use of simulation, problem solving online, serious gaming, and hands-on experiential education. As an innovator and leader in medical education, CHEST will continue to provide a variety of options for delivering education utilizing a variety of platforms. By opening a multimedia production studio at CHEST global headquarters in Glenview, Illinois, this past February, the organization is positioning itself to continue to refine its ability to produce and distribute a variety of courses available to all CHEST members in an archivable, easily accessible format. The Board of Regents has doubled down on its digital strategy toward improving communication across the entire user experience, and offering courses to our international members closer to home is one way to execute this strategy.
Networking and new friendships underscore what’s important
Meeting new colleagues from across the globe has made me realize that we are all focused on providing the very best care possible to our patients every day. Ultimately, education is communication. The ability to share how CHEST educates its membership will improve patient care worldwide and foster lifelong friendships with those we meet in other lands. Those opportunities to share ideas on health-care delivery will keep us on the cutting edge technologically and keep us focused on how to use resources responsibly and in a way that best serves the communities where we practice.
CHEST 2019 and southern culture
Get a glimpse of the rich southern culture of New Orleans this October by checking out a few of these locations and events.
Visit a Mini Museum – Backstreet Cultural Museum
The Backstreet Cultural Museum is located in a small, former funeral home in the historic Treme neighborhood. The museum displays the permanent collection of Mardi Gras Indians costumes, second-line parade outfits, jazz funeral photos, and music memorabilia from curator Sylvester Francis. Interested in upcoming parades and festivals happening nearly every weekend in New Orleans? Learn about these at the museum, as well as more NOLA arts and traditions.
View the Local Art in Jackson Square
Jackson Square is an area where you’ll see tarot readers, street performers, and artists. It has an open-air artist community where their works are hung on the iron railings around the square. Spend time getting your portrait done, buy a new art piece from a local, or have fun watching a street performance.
Enjoy the architecture of the French Quarter
Explore New Orleans’ oldest neighborhood, The French Quarter, with its mix of French Creole and Spanish influenced architecture. You’ll find hints of this on old tiled street names and the French Fleur de Lys emblem noticeable all around the city. There are also Caribbean, African, and other European influences throughout the area. Take in the gorgeous mansions, the colorful Creole houses with their porches and swing chairs, the townhouses with beautiful ironwork balconies, and more!
Head to Oktoberfest
New Orleans also has a rich German history. You can celebrate this October with the city’s own version of Oktoberfest, which takes place the first three weekends in the month. Experience some of the best of German culture by drinking a rare beer, trying authentic cuisine, and listening to live music during this celebration.
New Orleans Film Festival
From October 16-24, the New Orleans Film Society will be hosting the 2019 New Orleans Film Festival (NOFF). You can check out showings in different venues throughout the city. Local filmmakers are showcased during the festival, and their films and any shown during NOFF can qualify for the Oscars in all three Academy-accredited categories: Narrative Short, Documentary Short, and Animated Short.
Check out more things you can do in NOLA (https://tinyurl.com/yxnqswv5).
Get a glimpse of the rich southern culture of New Orleans this October by checking out a few of these locations and events.
Visit a Mini Museum – Backstreet Cultural Museum
The Backstreet Cultural Museum is located in a small, former funeral home in the historic Treme neighborhood. The museum displays the permanent collection of Mardi Gras Indians costumes, second-line parade outfits, jazz funeral photos, and music memorabilia from curator Sylvester Francis. Interested in upcoming parades and festivals happening nearly every weekend in New Orleans? Learn about these at the museum, as well as more NOLA arts and traditions.
View the Local Art in Jackson Square
Jackson Square is an area where you’ll see tarot readers, street performers, and artists. It has an open-air artist community where their works are hung on the iron railings around the square. Spend time getting your portrait done, buy a new art piece from a local, or have fun watching a street performance.
Enjoy the architecture of the French Quarter
Explore New Orleans’ oldest neighborhood, The French Quarter, with its mix of French Creole and Spanish influenced architecture. You’ll find hints of this on old tiled street names and the French Fleur de Lys emblem noticeable all around the city. There are also Caribbean, African, and other European influences throughout the area. Take in the gorgeous mansions, the colorful Creole houses with their porches and swing chairs, the townhouses with beautiful ironwork balconies, and more!
Head to Oktoberfest
New Orleans also has a rich German history. You can celebrate this October with the city’s own version of Oktoberfest, which takes place the first three weekends in the month. Experience some of the best of German culture by drinking a rare beer, trying authentic cuisine, and listening to live music during this celebration.
New Orleans Film Festival
From October 16-24, the New Orleans Film Society will be hosting the 2019 New Orleans Film Festival (NOFF). You can check out showings in different venues throughout the city. Local filmmakers are showcased during the festival, and their films and any shown during NOFF can qualify for the Oscars in all three Academy-accredited categories: Narrative Short, Documentary Short, and Animated Short.
Check out more things you can do in NOLA (https://tinyurl.com/yxnqswv5).
Get a glimpse of the rich southern culture of New Orleans this October by checking out a few of these locations and events.
Visit a Mini Museum – Backstreet Cultural Museum
The Backstreet Cultural Museum is located in a small, former funeral home in the historic Treme neighborhood. The museum displays the permanent collection of Mardi Gras Indians costumes, second-line parade outfits, jazz funeral photos, and music memorabilia from curator Sylvester Francis. Interested in upcoming parades and festivals happening nearly every weekend in New Orleans? Learn about these at the museum, as well as more NOLA arts and traditions.
View the Local Art in Jackson Square
Jackson Square is an area where you’ll see tarot readers, street performers, and artists. It has an open-air artist community where their works are hung on the iron railings around the square. Spend time getting your portrait done, buy a new art piece from a local, or have fun watching a street performance.
Enjoy the architecture of the French Quarter
Explore New Orleans’ oldest neighborhood, The French Quarter, with its mix of French Creole and Spanish influenced architecture. You’ll find hints of this on old tiled street names and the French Fleur de Lys emblem noticeable all around the city. There are also Caribbean, African, and other European influences throughout the area. Take in the gorgeous mansions, the colorful Creole houses with their porches and swing chairs, the townhouses with beautiful ironwork balconies, and more!
Head to Oktoberfest
New Orleans also has a rich German history. You can celebrate this October with the city’s own version of Oktoberfest, which takes place the first three weekends in the month. Experience some of the best of German culture by drinking a rare beer, trying authentic cuisine, and listening to live music during this celebration.
New Orleans Film Festival
From October 16-24, the New Orleans Film Society will be hosting the 2019 New Orleans Film Festival (NOFF). You can check out showings in different venues throughout the city. Local filmmakers are showcased during the festival, and their films and any shown during NOFF can qualify for the Oscars in all three Academy-accredited categories: Narrative Short, Documentary Short, and Animated Short.
Check out more things you can do in NOLA (https://tinyurl.com/yxnqswv5).
This month in the journal CHEST®
Editor’s Picks
By Richard S. Irwin, MD, Master FCCP
Giants in Chest Medicine
John Heffner, MD, FCCP
ORIGINAL RESEARCH
The Landscape of US Lung Cancer Screening Services-Figure 1By M. S. Kale, et al.
Systemic Markers of Inflammation in Smokers With Symptoms Despite Preserved
Spirometry in SPIROMICSBy S. Garudadri, et al.Prevalence of Atrial Fibrillation in Hospital Encounters With End-Stage COPD on
Home Oxygen:
National Trends in the United States
By X. Xiao, et al.
Editor’s Picks
By Richard S. Irwin, MD, Master FCCP
Giants in Chest Medicine
John Heffner, MD, FCCP
ORIGINAL RESEARCH
The Landscape of US Lung Cancer Screening Services-Figure 1By M. S. Kale, et al.
Systemic Markers of Inflammation in Smokers With Symptoms Despite Preserved
Spirometry in SPIROMICSBy S. Garudadri, et al.Prevalence of Atrial Fibrillation in Hospital Encounters With End-Stage COPD on
Home Oxygen:
National Trends in the United States
By X. Xiao, et al.
Editor’s Picks
By Richard S. Irwin, MD, Master FCCP
Giants in Chest Medicine
John Heffner, MD, FCCP
ORIGINAL RESEARCH
The Landscape of US Lung Cancer Screening Services-Figure 1By M. S. Kale, et al.
Systemic Markers of Inflammation in Smokers With Symptoms Despite Preserved
Spirometry in SPIROMICSBy S. Garudadri, et al.Prevalence of Atrial Fibrillation in Hospital Encounters With End-Stage COPD on
Home Oxygen:
National Trends in the United States
By X. Xiao, et al.
Senators hear what’s wrong with APMs, MIPS
Few advanced alternative payment models plus the sunsetting bonus for participation couple to keep physician interest in value-based payment low, physician groups told the Senate Finance Committee.
“One important goal of MACRA [Medicare Access and CHIP Reauthorization Act] was to provide busy physicians with a path to transition into new, innovated payment models,” Barbara McAneny, MD, president of the American Medical Association testified during a May 8 hearing to review the first 2 years of Medicare’s Quality Payment Program (QPP).
MACRA – the law that created QPP – provided a 5% bonus to physicians and other professionals who participate in the first 6 years of the program; the payment was designed to help cover expenses needed to transition to value-based care.
“Unfortunately, during the first 3 years of the program, too few APM [advanced alternative payment model] options were available for physicians, and now only 3 years remain, which is not enough time for physicians to transition to an APM,” Dr. McAneny said, calling on Congress to extend the APM incentive for an additional 6 years.
John Cullen, MD, president of the American Academy of Family Physicians, also called on legislators to extend the APM bonus for at least 3-5 years.
He also advocated for changes to QPP’s Merit-based Incentive Program (MIPS), calling for the exceptional performance bonus to reward year-over-year improvement versus simply scoring high on MIPS criteria in a given year.
MIPS “has created a burdensome and extremely complex program that has increased practice costs and is contributing to physician burnout, Dr. Cullen testified. “Understanding the requirements and scoring for each MIPS performance category and reporting the required data to CMS is a complex task and detracts from physicians’ ability to focus on patients.”
Dr. McAneny put the costs and rewards of MIPS into perspective for lawmakers.
She testified that, in 2017, her small practice was a participant in MIPS and was able to achieve the highest MIPS score of 100. That score qualified the practice for an exceptional performance bonus, which ended up being a 1.88% bonus to Medicare payments.
“After the adjustment that occurred after that, it lowered that increase to where the entire change that I got was $34,000,” she said. “When I added up how much I had to pay my EMR [electronic medical record] to submit that data, when I added up everything that I had to do in terms of paying staff overtime to make sure the data was accurate, I lost $100,000 to score that perfect score. So we need to modify that. That’s, I think, a great example of why the lower-volume practices need to be kept out of this process so they can continue to use their resources on patient care.”
Scott Hines, MD, member of the AMGA board of directors testified differently, arguing that less exclusion from participation is needed, because with around half of eligible physicians not required to participate, the pool for exceptional performance bonuses is significantly smaller than what would be the maximum available of up to 9% in 2023 as the years in the program advanced.
Between the low-volume exclusion and the budget neutrality of the program, there is little incentive to participate, he noted.
Few advanced alternative payment models plus the sunsetting bonus for participation couple to keep physician interest in value-based payment low, physician groups told the Senate Finance Committee.
“One important goal of MACRA [Medicare Access and CHIP Reauthorization Act] was to provide busy physicians with a path to transition into new, innovated payment models,” Barbara McAneny, MD, president of the American Medical Association testified during a May 8 hearing to review the first 2 years of Medicare’s Quality Payment Program (QPP).
MACRA – the law that created QPP – provided a 5% bonus to physicians and other professionals who participate in the first 6 years of the program; the payment was designed to help cover expenses needed to transition to value-based care.
“Unfortunately, during the first 3 years of the program, too few APM [advanced alternative payment model] options were available for physicians, and now only 3 years remain, which is not enough time for physicians to transition to an APM,” Dr. McAneny said, calling on Congress to extend the APM incentive for an additional 6 years.
John Cullen, MD, president of the American Academy of Family Physicians, also called on legislators to extend the APM bonus for at least 3-5 years.
He also advocated for changes to QPP’s Merit-based Incentive Program (MIPS), calling for the exceptional performance bonus to reward year-over-year improvement versus simply scoring high on MIPS criteria in a given year.
MIPS “has created a burdensome and extremely complex program that has increased practice costs and is contributing to physician burnout, Dr. Cullen testified. “Understanding the requirements and scoring for each MIPS performance category and reporting the required data to CMS is a complex task and detracts from physicians’ ability to focus on patients.”
Dr. McAneny put the costs and rewards of MIPS into perspective for lawmakers.
She testified that, in 2017, her small practice was a participant in MIPS and was able to achieve the highest MIPS score of 100. That score qualified the practice for an exceptional performance bonus, which ended up being a 1.88% bonus to Medicare payments.
“After the adjustment that occurred after that, it lowered that increase to where the entire change that I got was $34,000,” she said. “When I added up how much I had to pay my EMR [electronic medical record] to submit that data, when I added up everything that I had to do in terms of paying staff overtime to make sure the data was accurate, I lost $100,000 to score that perfect score. So we need to modify that. That’s, I think, a great example of why the lower-volume practices need to be kept out of this process so they can continue to use their resources on patient care.”
Scott Hines, MD, member of the AMGA board of directors testified differently, arguing that less exclusion from participation is needed, because with around half of eligible physicians not required to participate, the pool for exceptional performance bonuses is significantly smaller than what would be the maximum available of up to 9% in 2023 as the years in the program advanced.
Between the low-volume exclusion and the budget neutrality of the program, there is little incentive to participate, he noted.
Few advanced alternative payment models plus the sunsetting bonus for participation couple to keep physician interest in value-based payment low, physician groups told the Senate Finance Committee.
“One important goal of MACRA [Medicare Access and CHIP Reauthorization Act] was to provide busy physicians with a path to transition into new, innovated payment models,” Barbara McAneny, MD, president of the American Medical Association testified during a May 8 hearing to review the first 2 years of Medicare’s Quality Payment Program (QPP).
MACRA – the law that created QPP – provided a 5% bonus to physicians and other professionals who participate in the first 6 years of the program; the payment was designed to help cover expenses needed to transition to value-based care.
“Unfortunately, during the first 3 years of the program, too few APM [advanced alternative payment model] options were available for physicians, and now only 3 years remain, which is not enough time for physicians to transition to an APM,” Dr. McAneny said, calling on Congress to extend the APM incentive for an additional 6 years.
John Cullen, MD, president of the American Academy of Family Physicians, also called on legislators to extend the APM bonus for at least 3-5 years.
He also advocated for changes to QPP’s Merit-based Incentive Program (MIPS), calling for the exceptional performance bonus to reward year-over-year improvement versus simply scoring high on MIPS criteria in a given year.
MIPS “has created a burdensome and extremely complex program that has increased practice costs and is contributing to physician burnout, Dr. Cullen testified. “Understanding the requirements and scoring for each MIPS performance category and reporting the required data to CMS is a complex task and detracts from physicians’ ability to focus on patients.”
Dr. McAneny put the costs and rewards of MIPS into perspective for lawmakers.
She testified that, in 2017, her small practice was a participant in MIPS and was able to achieve the highest MIPS score of 100. That score qualified the practice for an exceptional performance bonus, which ended up being a 1.88% bonus to Medicare payments.
“After the adjustment that occurred after that, it lowered that increase to where the entire change that I got was $34,000,” she said. “When I added up how much I had to pay my EMR [electronic medical record] to submit that data, when I added up everything that I had to do in terms of paying staff overtime to make sure the data was accurate, I lost $100,000 to score that perfect score. So we need to modify that. That’s, I think, a great example of why the lower-volume practices need to be kept out of this process so they can continue to use their resources on patient care.”
Scott Hines, MD, member of the AMGA board of directors testified differently, arguing that less exclusion from participation is needed, because with around half of eligible physicians not required to participate, the pool for exceptional performance bonuses is significantly smaller than what would be the maximum available of up to 9% in 2023 as the years in the program advanced.
Between the low-volume exclusion and the budget neutrality of the program, there is little incentive to participate, he noted.
REPORTING FROM A SENATE FINANCE COMMITTEE HEARING