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Tic disorders are associated with obesity and diabetes
The movement disorders are associated with cardiometabolic problems “even after taking into account a number of covariates and shared familial confounders and excluding relevant psychiatric comorbidities,” the researchers wrote. “The results highlight the importance of carefully monitoring cardiometabolic health in patients with Tourette syndrome or chronic tic disorder across the lifespan, particularly in those with comorbid attention-deficit/hyperactivity disorder (ADHD).”
Gustaf Brander, a researcher in the department of clinical neuroscience at Karolinska Institutet in Stockholm, and his colleagues conducted a longitudinal population-based cohort study of individuals living in Sweden between Jan. 1, 1973, and Dec. 31, 2013. The researchers assessed outcomes for patients with previously validated diagnoses of Tourette syndrome or chronic tic disorder in the Swedish National Patient Register. Main outcomes included obesity, dyslipidemia, hypertension, T2DM, and cardiovascular diseases, including ischemic heart diseases, arrhythmia, cerebrovascular diseases, transient ischemic attack, and arteriosclerosis. In addition, the researchers identified families with full siblings discordant for Tourette syndrome or chronic tic disorder.
Of the more than 14 million individuals in the cohort, 7,804 (76.4% male; median age at first diagnosis, 13.3 years) had a diagnosis of Tourette syndrome or chronic tic disorder in specialist care. Furthermore, the cohort included 5,141 families with full siblings who were discordant for these disorders.
Individuals with Tourette syndrome or chronic tic disorder had a higher risk for any metabolic or cardiovascular disorder, compared with the general population (hazard ratio adjusted by sex and birth year [aHR], 1.99) and sibling controls (aHR, 1.37). Specifically, individuals with Tourette syndrome or chronic tic disorder had higher risks for obesity (aHR, 2.76), T2DM(aHR, 1.67), and circulatory system diseases (aHR, 1.76).
The increased risk of any cardiometabolic disorder was significantly greater for males than it was for females (aHRs, 2.13 vs. 1.79), as was the risk of obesity (aHRs, 3.24 vs. 1.97).
The increased risk for cardiometabolic disorders in this patient population was evident by age 8 years. Exclusion of those patients with comorbid ADHD reduced but did not eliminate the risk (aHR, 1.52). The exclusion of other comorbidities did not significantly affect the results. Among patients with Tourette syndrome or chronic tic disorder, those who had received antipsychotic treatment for more than 1 year were significantly less likely to have metabolic and cardiovascular disorders, compared with patients not taking antipsychotic medication. This association may be related to “greater medical vigilance” and “should not be taken as evidence that antipsychotics are free from cardiometabolic adverse effects,” the authors noted.
The study was supported by a research grant from Tourettes Action. In addition, authors reported support from the Swedish Research Council and a Karolinska Institutet PhD stipend. Two authors disclosed personal fees from publishers, and one author disclosed grants and other funding from Shire.
SOURCE: Brander G et al. JAMA Neurol. 2019 Jan 14. doi: 10.1001/jamaneurol.2018.4279.
The movement disorders are associated with cardiometabolic problems “even after taking into account a number of covariates and shared familial confounders and excluding relevant psychiatric comorbidities,” the researchers wrote. “The results highlight the importance of carefully monitoring cardiometabolic health in patients with Tourette syndrome or chronic tic disorder across the lifespan, particularly in those with comorbid attention-deficit/hyperactivity disorder (ADHD).”
Gustaf Brander, a researcher in the department of clinical neuroscience at Karolinska Institutet in Stockholm, and his colleagues conducted a longitudinal population-based cohort study of individuals living in Sweden between Jan. 1, 1973, and Dec. 31, 2013. The researchers assessed outcomes for patients with previously validated diagnoses of Tourette syndrome or chronic tic disorder in the Swedish National Patient Register. Main outcomes included obesity, dyslipidemia, hypertension, T2DM, and cardiovascular diseases, including ischemic heart diseases, arrhythmia, cerebrovascular diseases, transient ischemic attack, and arteriosclerosis. In addition, the researchers identified families with full siblings discordant for Tourette syndrome or chronic tic disorder.
Of the more than 14 million individuals in the cohort, 7,804 (76.4% male; median age at first diagnosis, 13.3 years) had a diagnosis of Tourette syndrome or chronic tic disorder in specialist care. Furthermore, the cohort included 5,141 families with full siblings who were discordant for these disorders.
Individuals with Tourette syndrome or chronic tic disorder had a higher risk for any metabolic or cardiovascular disorder, compared with the general population (hazard ratio adjusted by sex and birth year [aHR], 1.99) and sibling controls (aHR, 1.37). Specifically, individuals with Tourette syndrome or chronic tic disorder had higher risks for obesity (aHR, 2.76), T2DM(aHR, 1.67), and circulatory system diseases (aHR, 1.76).
The increased risk of any cardiometabolic disorder was significantly greater for males than it was for females (aHRs, 2.13 vs. 1.79), as was the risk of obesity (aHRs, 3.24 vs. 1.97).
The increased risk for cardiometabolic disorders in this patient population was evident by age 8 years. Exclusion of those patients with comorbid ADHD reduced but did not eliminate the risk (aHR, 1.52). The exclusion of other comorbidities did not significantly affect the results. Among patients with Tourette syndrome or chronic tic disorder, those who had received antipsychotic treatment for more than 1 year were significantly less likely to have metabolic and cardiovascular disorders, compared with patients not taking antipsychotic medication. This association may be related to “greater medical vigilance” and “should not be taken as evidence that antipsychotics are free from cardiometabolic adverse effects,” the authors noted.
The study was supported by a research grant from Tourettes Action. In addition, authors reported support from the Swedish Research Council and a Karolinska Institutet PhD stipend. Two authors disclosed personal fees from publishers, and one author disclosed grants and other funding from Shire.
SOURCE: Brander G et al. JAMA Neurol. 2019 Jan 14. doi: 10.1001/jamaneurol.2018.4279.
The movement disorders are associated with cardiometabolic problems “even after taking into account a number of covariates and shared familial confounders and excluding relevant psychiatric comorbidities,” the researchers wrote. “The results highlight the importance of carefully monitoring cardiometabolic health in patients with Tourette syndrome or chronic tic disorder across the lifespan, particularly in those with comorbid attention-deficit/hyperactivity disorder (ADHD).”
Gustaf Brander, a researcher in the department of clinical neuroscience at Karolinska Institutet in Stockholm, and his colleagues conducted a longitudinal population-based cohort study of individuals living in Sweden between Jan. 1, 1973, and Dec. 31, 2013. The researchers assessed outcomes for patients with previously validated diagnoses of Tourette syndrome or chronic tic disorder in the Swedish National Patient Register. Main outcomes included obesity, dyslipidemia, hypertension, T2DM, and cardiovascular diseases, including ischemic heart diseases, arrhythmia, cerebrovascular diseases, transient ischemic attack, and arteriosclerosis. In addition, the researchers identified families with full siblings discordant for Tourette syndrome or chronic tic disorder.
Of the more than 14 million individuals in the cohort, 7,804 (76.4% male; median age at first diagnosis, 13.3 years) had a diagnosis of Tourette syndrome or chronic tic disorder in specialist care. Furthermore, the cohort included 5,141 families with full siblings who were discordant for these disorders.
Individuals with Tourette syndrome or chronic tic disorder had a higher risk for any metabolic or cardiovascular disorder, compared with the general population (hazard ratio adjusted by sex and birth year [aHR], 1.99) and sibling controls (aHR, 1.37). Specifically, individuals with Tourette syndrome or chronic tic disorder had higher risks for obesity (aHR, 2.76), T2DM(aHR, 1.67), and circulatory system diseases (aHR, 1.76).
The increased risk of any cardiometabolic disorder was significantly greater for males than it was for females (aHRs, 2.13 vs. 1.79), as was the risk of obesity (aHRs, 3.24 vs. 1.97).
The increased risk for cardiometabolic disorders in this patient population was evident by age 8 years. Exclusion of those patients with comorbid ADHD reduced but did not eliminate the risk (aHR, 1.52). The exclusion of other comorbidities did not significantly affect the results. Among patients with Tourette syndrome or chronic tic disorder, those who had received antipsychotic treatment for more than 1 year were significantly less likely to have metabolic and cardiovascular disorders, compared with patients not taking antipsychotic medication. This association may be related to “greater medical vigilance” and “should not be taken as evidence that antipsychotics are free from cardiometabolic adverse effects,” the authors noted.
The study was supported by a research grant from Tourettes Action. In addition, authors reported support from the Swedish Research Council and a Karolinska Institutet PhD stipend. Two authors disclosed personal fees from publishers, and one author disclosed grants and other funding from Shire.
SOURCE: Brander G et al. JAMA Neurol. 2019 Jan 14. doi: 10.1001/jamaneurol.2018.4279.
FROM JAMA NEUROLOGY
Key clinical point: Monitor cardiometabolic health in patients with Tourette syndrome or chronic tic disorder.
Major finding: Patients with Tourette syndrome or chronic tic disorder have a higher risk of metabolic or cardiovascular disorders, compared with the general population (adjusted hazard ratio, 1.99) and sibling controls (adjusted hazard ratio, 1.37).
Study details: A Swedish longitudinal, population-based cohort study of 7,804 individuals with Tourette syndrome or chronic tic disorder.
Disclosures: The study was supported by a research grant from Tourettes Action. Authors reported support from the Swedish Research Council and a Karolinska Institutet PhD stipend. Two authors disclosed personal fees from publishers, and one author disclosed grants and other funding from Shire.
Source: Brander G et al. JAMA Neurol. 2019 Jan 14. doi: 10.1001/jamaneurol.2018.4279.
Lung screening complications costly, more prevalent than in trial setting
The real-world rate of is substantially higher than in clinical trials, a study suggests.
Those complications related to low-dose computed tomography (LDCT) screening are potentially costly, according to the analysis of commercial and Medicare claims data for nearly 350,000 individuals.
While tentative, these results emphasize the need to discuss the risk of adverse events and their costs as part of the shared decision-making process between physicians and patients, researchers said in a report on their study in JAMA Internal Medicine.
“As the number of individuals seeking lung cancer screening with LDCT increases, so too will the number of individuals undergoing invasive diagnostic procedures as a results of abnormal findings,” said Jinhai Huo, MD, PhD, of the department of health services research, management, and policy at the University of Florida, Gainesville.
The retrospective cohort study included 174,702 individuals who underwent an invasive diagnostic procedure related to lung cancer screening and 169,808 control subjects.
All individuals studied were between 55 and 77 years old, the targeted age range for lung cancer screening specified by the Centers for Medicare & Medicaid Services.
Complication rates were about twice as high as they were in the landmark National Lung Screening Trial (NLST), both for a younger cohort of individuals aged 55-64 years, and an older Medicare age group of individuals aged 65 to 77 years, Dr. Huo and coinvestigators reported.
The estimated rate of complications was 22.0% (95% confidence interval, 21.7%-22.7%) in the younger age group, and even higher in the older age group, at 23.8% (95% CI, 23.0%-24.6%), according to investigators. By contrast, complication rates in the NLST were 9.8% and 8.5% for younger and older age cohorts, respectively.
The cost of managing postprocedural complications was higher than the cost of the diagnostic procedures, investigators said.
Mean costs ranged from $6,320 for minor complications to $56,845 for major complications, they reported.
The most common invasive diagnostic procedure in the study cohort was cytology test or biopsy in 26.1%, followed by bronchoscopy in 25.6%, according to study data. Another 5.4% underwent thoracic surgery.
In a previous Medicare advisory committee meeting, some experts expressed concern that complication rates in settings outside of the NLST would be higher than what was reported in that study, Dr. Huo and coauthors noted in their report.
“Our findings echoed this concern,” they said in a discussion of their results.
Dr. Huo and coauthors reported no conflicts of interest related to the research, which was supported in part by grants or fellowships from the University of Texas MD Anderson Cancer Center, the University of Florida, the National Cancer Institute, and the National Institutes of Health.
SOURCE: Huo J et al. JAMA Intern Med. 2019 Jan 14.
“The conversations that are occurring about lung cancer screening are woefully inadequate and do not discuss harms,” wrote Rita F. Redberg, MD, in an editorial note. Shared decision-making visits were made mandatory prior to lung cancer screening by the Centers for Medicare & Medicaid Services. That decision was made because of an evidence review suggesting a “low likelihood” that benefits of lung cancer screening would exceed harms in the Medicare population, Dr. Redberg wrote. Despite that, most Medicare beneficiaries are not having the required visit for shared decision making before they undergo the CT scan.
“It is likely that patients’ decisions not to undergo low-dose computed tomography for lung cancer screening are driven by the high false-positive rate, high chance of incidental findings, and subsequent need for invasive procedures, and small chance of benefit,” she said in her comment.
Shared decision-making visits are also rarely happening in the privately insured population, as shown in previous research, Dr. Redberg noted.
She reported no conflicts of interest related to her Editor’s Note, which appears in JAMA Internal Medicine (2019 Jan 14).
Dr. Redberg is with the department of medicine, University of California, San Francisco.
“The conversations that are occurring about lung cancer screening are woefully inadequate and do not discuss harms,” wrote Rita F. Redberg, MD, in an editorial note. Shared decision-making visits were made mandatory prior to lung cancer screening by the Centers for Medicare & Medicaid Services. That decision was made because of an evidence review suggesting a “low likelihood” that benefits of lung cancer screening would exceed harms in the Medicare population, Dr. Redberg wrote. Despite that, most Medicare beneficiaries are not having the required visit for shared decision making before they undergo the CT scan.
“It is likely that patients’ decisions not to undergo low-dose computed tomography for lung cancer screening are driven by the high false-positive rate, high chance of incidental findings, and subsequent need for invasive procedures, and small chance of benefit,” she said in her comment.
Shared decision-making visits are also rarely happening in the privately insured population, as shown in previous research, Dr. Redberg noted.
She reported no conflicts of interest related to her Editor’s Note, which appears in JAMA Internal Medicine (2019 Jan 14).
Dr. Redberg is with the department of medicine, University of California, San Francisco.
“The conversations that are occurring about lung cancer screening are woefully inadequate and do not discuss harms,” wrote Rita F. Redberg, MD, in an editorial note. Shared decision-making visits were made mandatory prior to lung cancer screening by the Centers for Medicare & Medicaid Services. That decision was made because of an evidence review suggesting a “low likelihood” that benefits of lung cancer screening would exceed harms in the Medicare population, Dr. Redberg wrote. Despite that, most Medicare beneficiaries are not having the required visit for shared decision making before they undergo the CT scan.
“It is likely that patients’ decisions not to undergo low-dose computed tomography for lung cancer screening are driven by the high false-positive rate, high chance of incidental findings, and subsequent need for invasive procedures, and small chance of benefit,” she said in her comment.
Shared decision-making visits are also rarely happening in the privately insured population, as shown in previous research, Dr. Redberg noted.
She reported no conflicts of interest related to her Editor’s Note, which appears in JAMA Internal Medicine (2019 Jan 14).
Dr. Redberg is with the department of medicine, University of California, San Francisco.
The real-world rate of is substantially higher than in clinical trials, a study suggests.
Those complications related to low-dose computed tomography (LDCT) screening are potentially costly, according to the analysis of commercial and Medicare claims data for nearly 350,000 individuals.
While tentative, these results emphasize the need to discuss the risk of adverse events and their costs as part of the shared decision-making process between physicians and patients, researchers said in a report on their study in JAMA Internal Medicine.
“As the number of individuals seeking lung cancer screening with LDCT increases, so too will the number of individuals undergoing invasive diagnostic procedures as a results of abnormal findings,” said Jinhai Huo, MD, PhD, of the department of health services research, management, and policy at the University of Florida, Gainesville.
The retrospective cohort study included 174,702 individuals who underwent an invasive diagnostic procedure related to lung cancer screening and 169,808 control subjects.
All individuals studied were between 55 and 77 years old, the targeted age range for lung cancer screening specified by the Centers for Medicare & Medicaid Services.
Complication rates were about twice as high as they were in the landmark National Lung Screening Trial (NLST), both for a younger cohort of individuals aged 55-64 years, and an older Medicare age group of individuals aged 65 to 77 years, Dr. Huo and coinvestigators reported.
The estimated rate of complications was 22.0% (95% confidence interval, 21.7%-22.7%) in the younger age group, and even higher in the older age group, at 23.8% (95% CI, 23.0%-24.6%), according to investigators. By contrast, complication rates in the NLST were 9.8% and 8.5% for younger and older age cohorts, respectively.
The cost of managing postprocedural complications was higher than the cost of the diagnostic procedures, investigators said.
Mean costs ranged from $6,320 for minor complications to $56,845 for major complications, they reported.
The most common invasive diagnostic procedure in the study cohort was cytology test or biopsy in 26.1%, followed by bronchoscopy in 25.6%, according to study data. Another 5.4% underwent thoracic surgery.
In a previous Medicare advisory committee meeting, some experts expressed concern that complication rates in settings outside of the NLST would be higher than what was reported in that study, Dr. Huo and coauthors noted in their report.
“Our findings echoed this concern,” they said in a discussion of their results.
Dr. Huo and coauthors reported no conflicts of interest related to the research, which was supported in part by grants or fellowships from the University of Texas MD Anderson Cancer Center, the University of Florida, the National Cancer Institute, and the National Institutes of Health.
SOURCE: Huo J et al. JAMA Intern Med. 2019 Jan 14.
The real-world rate of is substantially higher than in clinical trials, a study suggests.
Those complications related to low-dose computed tomography (LDCT) screening are potentially costly, according to the analysis of commercial and Medicare claims data for nearly 350,000 individuals.
While tentative, these results emphasize the need to discuss the risk of adverse events and their costs as part of the shared decision-making process between physicians and patients, researchers said in a report on their study in JAMA Internal Medicine.
“As the number of individuals seeking lung cancer screening with LDCT increases, so too will the number of individuals undergoing invasive diagnostic procedures as a results of abnormal findings,” said Jinhai Huo, MD, PhD, of the department of health services research, management, and policy at the University of Florida, Gainesville.
The retrospective cohort study included 174,702 individuals who underwent an invasive diagnostic procedure related to lung cancer screening and 169,808 control subjects.
All individuals studied were between 55 and 77 years old, the targeted age range for lung cancer screening specified by the Centers for Medicare & Medicaid Services.
Complication rates were about twice as high as they were in the landmark National Lung Screening Trial (NLST), both for a younger cohort of individuals aged 55-64 years, and an older Medicare age group of individuals aged 65 to 77 years, Dr. Huo and coinvestigators reported.
The estimated rate of complications was 22.0% (95% confidence interval, 21.7%-22.7%) in the younger age group, and even higher in the older age group, at 23.8% (95% CI, 23.0%-24.6%), according to investigators. By contrast, complication rates in the NLST were 9.8% and 8.5% for younger and older age cohorts, respectively.
The cost of managing postprocedural complications was higher than the cost of the diagnostic procedures, investigators said.
Mean costs ranged from $6,320 for minor complications to $56,845 for major complications, they reported.
The most common invasive diagnostic procedure in the study cohort was cytology test or biopsy in 26.1%, followed by bronchoscopy in 25.6%, according to study data. Another 5.4% underwent thoracic surgery.
In a previous Medicare advisory committee meeting, some experts expressed concern that complication rates in settings outside of the NLST would be higher than what was reported in that study, Dr. Huo and coauthors noted in their report.
“Our findings echoed this concern,” they said in a discussion of their results.
Dr. Huo and coauthors reported no conflicts of interest related to the research, which was supported in part by grants or fellowships from the University of Texas MD Anderson Cancer Center, the University of Florida, the National Cancer Institute, and the National Institutes of Health.
SOURCE: Huo J et al. JAMA Intern Med. 2019 Jan 14.
FROM JAMA INTERNAL MEDICINE
Key clinical point: The risk of complications following lung cancer screening is higher in a real-world setting as compared with the landmark National Lung Screening Trial (NLST).
Major finding: Estimated complication rates were 22.0%-23.8%, compared with 8.5%-9.8% in the NLST.
Study details: A retrospective cohort study including 174,702 individuals who underwent an invasive diagnostic procedure related to lung cancer screening and 169,808 controls.
Disclosures: Authors reported no conflicts of interest. The research was supported in part by grants or fellowships from the University of Texas MD Anderson Cancer Center, the University of Florida, the National Cancer Institute, and the National Institutes of Health.
Source: Huo J et al. JAMA Intern Med. 2019 Jan 14.
ATTRACT trial shouldn’t detract from pharmacomechanical thrombolysis
CHICAGO – A closer look at the landmark ATTRACT trial of pharmacomechanical catheter-directed thrombolysis for acute deep vein thrombosis (DVT) shows multiple benefits for the intervention versus standard anticoagulation alone in the subset of participants with iliofemoral DVT, Kush R. Desai, MD, said at a symposium on vascular surgery sponsored by Northwestern University.
ATTRACT, a National Institutes of Health–sponsored, phase 3, multicenter, open-label, assessor-blinded study, was the first-ever randomized trial of pharmacomechanical catheter-directed thrombolysis (PCDT) for acute DVT.
The results caused a major stir because, despite a sound therapeutic rationale for the procedure, the incidence of chronic postthrombotic syndrome (PTS) at 24 months of follow-up was 47% in the PCDT plus anticoagulation group and 48% in controls on anticoagulation alone (N Engl J Med. 2017 Dec 7;377[23]:2240-52). Since then, that overall negative trial has been one of the hottest topics in DVT.
“This is the first thing your educated patients who come to the emergency department with DVT will ask about. It’s the first thing they’ll see when they go online and type in ‘thrombolysis DVT,’ ” noted Dr. Desai, an interventional radiologist at Northwestern University, Chicago.
But the trial has several major flaws, he cautioned. And contrary to popular opinion, ATTRACT is not the death knell for PCDT. Far from it.
“I don’t think the story stops with ATTRACT. This isn’t the end for PCDT in patients with iliofemoral DVT,” he asserted.
That’s in part because 301 of the 692 participants in ATTRACT had DVT of the femoropopliteal segment. That’s a population in which Dr. Desai and other interventionalists wouldn’t have anticipated seeing a benefit for PCDT, because their risk of PTS is so low.
“We know through historical data that patients with iliofemoral DVT are much more likely to develop PTS and to have recurrent DVT, so this is probably one of the major shortcomings of the trial,” he explained. “It’s through no fault of the trial investigators, because the study was planned years ago when we just didn’t know as much about PTS as we do now.
“The way I look at it is, I don’t practice in the way that ATTRACT was designed,” Dr. Desai said. “I don’t typically lyse or get referrals for lysis or thrombectomy in patients who have isolated femoropopliteal DVT. It has to involve at least the common femoral vein and frequently goes up to the iliac vein.”
The ATTRACT investigators’ recent subanalysis of the 391 participants with iliofemoral DVT showed that, although there was no difference between the two study arms in the occurrence of PTS through the first 24 months of follow-up, PCDT led to a 35% reduction in the incidence of moderate or severe PTS – by a margin of 18% versus 28% in controls.
Patients in the PCDT arm also experienced significantly greater improvement in venous disease-specific quality of life through 24 months, and a greater reduction in leg pain and swelling at 10 and 30 days (Circulation. 2018 Dec 4. doi: 10.1161/CIRCULATIONAHA.118.037425).
And moderate to severe PTS is a key outcome, Dr. Desai continued. Multiple studies have shown that patients with PTS have a worse quality of life than those with chronic lung disease, arthritis, or diabetes. Moreover, the 5%-10% of patients with symptomatic DVT who develop the most-severe form of PTS – characterized by severe pain, chronic ulcerations, stasis dermatitis, venous claudication, and intractable edema – have a quality of life comparable with patients with cancer or heart failure.
The 1.5% incidence of major bleeding within 10 days in the PCDT group was 200% higher than in controls, but none of it was life threatening.
“This is reassuring: Nobody had intracranial hemorrhage; nobody had a GUSTO 5 bleed,” Dr. Desai said.
Another limitation of the ATTRACT trial is that all but one of the devices utilized for PCDT were used off label. They weren’t designed for venous application. Several on-label rheolytic, rotational thrombectomy, or clot aspiration devices have been approved since enrollment in ATTRACT was closed. Future randomized trials will utilize on-label devices in patients with acute iliofemoral DVT to clarify the role of PCDT.
It’s noteworthy that nearly half of ATTRACT participants developed PTS within 24 months of their DVT despite being on optimal anticoagulation. It’s a finding that underscores the need for improved therapies. That was the impetus for development of first-generation catheter-directed thrombolysis utilizing a percutaneously inserted catheter to infuse a fibrinolytic drug directly to the thrombus to dissolve it rapidly.
But that form of catheter-directed thrombolysis has major disadvantages, Dr. Desai explained: It’s a multiday procedure requiring ICU-level care and prolonged exposure to powerful lytic agents.
“This is where things have changed with PCDT,” he said. “We can now, with on-label devices, accelerate the thrombolysis time, reduce lytic exposure, and I think also reduce the bleeding risk, although that hasn’t been shown in a trial yet. PCDT also reduces the necessity for ICU-level care and prolonged hospitalization.”
Dr. Desai no longer performs multiday lytic procedures. “In fact, with the introduction of the newer on-label devices, I haven’t done a multiday unilateral limb lytic procedure in a couple years. I think we’ve gotten to the point where we don’t need to do that anymore.”
Indeed, PCDT makes recanalization possible as a single-day, single-session procedure.
Dr. Desai views the recent ATTRACT subanalysis as hypothesis generating.
“Should PCDT be the first-line treatment in all proximal DVT patients? No it should not – and that’s not what I would have advocated even before ATTRACT came out,” he explained. “It’s sort of a salvage procedure for patients with iliofemoral DVT and moderate to severe symptoms. And there are a significant number of such patients.”
Current understanding of the pathophysiology of PTS is that a nondissolved thrombus at the valve leaflets becomes inflammatory, with resultant valvular dysfunction leading to venous reflux and venous hypertension. PCDT is consistent with the open-vein hypothesis, which posits that, by eliminating thrombus much faster than achievable via anticoagulation, valve integrity is maintained and PTS is prevented.
Dr. Desai reported receiving consulting fees from AngioDynamics, Boston Scientific, Cook Medical, and Spectranetics.
CHICAGO – A closer look at the landmark ATTRACT trial of pharmacomechanical catheter-directed thrombolysis for acute deep vein thrombosis (DVT) shows multiple benefits for the intervention versus standard anticoagulation alone in the subset of participants with iliofemoral DVT, Kush R. Desai, MD, said at a symposium on vascular surgery sponsored by Northwestern University.
ATTRACT, a National Institutes of Health–sponsored, phase 3, multicenter, open-label, assessor-blinded study, was the first-ever randomized trial of pharmacomechanical catheter-directed thrombolysis (PCDT) for acute DVT.
The results caused a major stir because, despite a sound therapeutic rationale for the procedure, the incidence of chronic postthrombotic syndrome (PTS) at 24 months of follow-up was 47% in the PCDT plus anticoagulation group and 48% in controls on anticoagulation alone (N Engl J Med. 2017 Dec 7;377[23]:2240-52). Since then, that overall negative trial has been one of the hottest topics in DVT.
“This is the first thing your educated patients who come to the emergency department with DVT will ask about. It’s the first thing they’ll see when they go online and type in ‘thrombolysis DVT,’ ” noted Dr. Desai, an interventional radiologist at Northwestern University, Chicago.
But the trial has several major flaws, he cautioned. And contrary to popular opinion, ATTRACT is not the death knell for PCDT. Far from it.
“I don’t think the story stops with ATTRACT. This isn’t the end for PCDT in patients with iliofemoral DVT,” he asserted.
That’s in part because 301 of the 692 participants in ATTRACT had DVT of the femoropopliteal segment. That’s a population in which Dr. Desai and other interventionalists wouldn’t have anticipated seeing a benefit for PCDT, because their risk of PTS is so low.
“We know through historical data that patients with iliofemoral DVT are much more likely to develop PTS and to have recurrent DVT, so this is probably one of the major shortcomings of the trial,” he explained. “It’s through no fault of the trial investigators, because the study was planned years ago when we just didn’t know as much about PTS as we do now.
“The way I look at it is, I don’t practice in the way that ATTRACT was designed,” Dr. Desai said. “I don’t typically lyse or get referrals for lysis or thrombectomy in patients who have isolated femoropopliteal DVT. It has to involve at least the common femoral vein and frequently goes up to the iliac vein.”
The ATTRACT investigators’ recent subanalysis of the 391 participants with iliofemoral DVT showed that, although there was no difference between the two study arms in the occurrence of PTS through the first 24 months of follow-up, PCDT led to a 35% reduction in the incidence of moderate or severe PTS – by a margin of 18% versus 28% in controls.
Patients in the PCDT arm also experienced significantly greater improvement in venous disease-specific quality of life through 24 months, and a greater reduction in leg pain and swelling at 10 and 30 days (Circulation. 2018 Dec 4. doi: 10.1161/CIRCULATIONAHA.118.037425).
And moderate to severe PTS is a key outcome, Dr. Desai continued. Multiple studies have shown that patients with PTS have a worse quality of life than those with chronic lung disease, arthritis, or diabetes. Moreover, the 5%-10% of patients with symptomatic DVT who develop the most-severe form of PTS – characterized by severe pain, chronic ulcerations, stasis dermatitis, venous claudication, and intractable edema – have a quality of life comparable with patients with cancer or heart failure.
The 1.5% incidence of major bleeding within 10 days in the PCDT group was 200% higher than in controls, but none of it was life threatening.
“This is reassuring: Nobody had intracranial hemorrhage; nobody had a GUSTO 5 bleed,” Dr. Desai said.
Another limitation of the ATTRACT trial is that all but one of the devices utilized for PCDT were used off label. They weren’t designed for venous application. Several on-label rheolytic, rotational thrombectomy, or clot aspiration devices have been approved since enrollment in ATTRACT was closed. Future randomized trials will utilize on-label devices in patients with acute iliofemoral DVT to clarify the role of PCDT.
It’s noteworthy that nearly half of ATTRACT participants developed PTS within 24 months of their DVT despite being on optimal anticoagulation. It’s a finding that underscores the need for improved therapies. That was the impetus for development of first-generation catheter-directed thrombolysis utilizing a percutaneously inserted catheter to infuse a fibrinolytic drug directly to the thrombus to dissolve it rapidly.
But that form of catheter-directed thrombolysis has major disadvantages, Dr. Desai explained: It’s a multiday procedure requiring ICU-level care and prolonged exposure to powerful lytic agents.
“This is where things have changed with PCDT,” he said. “We can now, with on-label devices, accelerate the thrombolysis time, reduce lytic exposure, and I think also reduce the bleeding risk, although that hasn’t been shown in a trial yet. PCDT also reduces the necessity for ICU-level care and prolonged hospitalization.”
Dr. Desai no longer performs multiday lytic procedures. “In fact, with the introduction of the newer on-label devices, I haven’t done a multiday unilateral limb lytic procedure in a couple years. I think we’ve gotten to the point where we don’t need to do that anymore.”
Indeed, PCDT makes recanalization possible as a single-day, single-session procedure.
Dr. Desai views the recent ATTRACT subanalysis as hypothesis generating.
“Should PCDT be the first-line treatment in all proximal DVT patients? No it should not – and that’s not what I would have advocated even before ATTRACT came out,” he explained. “It’s sort of a salvage procedure for patients with iliofemoral DVT and moderate to severe symptoms. And there are a significant number of such patients.”
Current understanding of the pathophysiology of PTS is that a nondissolved thrombus at the valve leaflets becomes inflammatory, with resultant valvular dysfunction leading to venous reflux and venous hypertension. PCDT is consistent with the open-vein hypothesis, which posits that, by eliminating thrombus much faster than achievable via anticoagulation, valve integrity is maintained and PTS is prevented.
Dr. Desai reported receiving consulting fees from AngioDynamics, Boston Scientific, Cook Medical, and Spectranetics.
CHICAGO – A closer look at the landmark ATTRACT trial of pharmacomechanical catheter-directed thrombolysis for acute deep vein thrombosis (DVT) shows multiple benefits for the intervention versus standard anticoagulation alone in the subset of participants with iliofemoral DVT, Kush R. Desai, MD, said at a symposium on vascular surgery sponsored by Northwestern University.
ATTRACT, a National Institutes of Health–sponsored, phase 3, multicenter, open-label, assessor-blinded study, was the first-ever randomized trial of pharmacomechanical catheter-directed thrombolysis (PCDT) for acute DVT.
The results caused a major stir because, despite a sound therapeutic rationale for the procedure, the incidence of chronic postthrombotic syndrome (PTS) at 24 months of follow-up was 47% in the PCDT plus anticoagulation group and 48% in controls on anticoagulation alone (N Engl J Med. 2017 Dec 7;377[23]:2240-52). Since then, that overall negative trial has been one of the hottest topics in DVT.
“This is the first thing your educated patients who come to the emergency department with DVT will ask about. It’s the first thing they’ll see when they go online and type in ‘thrombolysis DVT,’ ” noted Dr. Desai, an interventional radiologist at Northwestern University, Chicago.
But the trial has several major flaws, he cautioned. And contrary to popular opinion, ATTRACT is not the death knell for PCDT. Far from it.
“I don’t think the story stops with ATTRACT. This isn’t the end for PCDT in patients with iliofemoral DVT,” he asserted.
That’s in part because 301 of the 692 participants in ATTRACT had DVT of the femoropopliteal segment. That’s a population in which Dr. Desai and other interventionalists wouldn’t have anticipated seeing a benefit for PCDT, because their risk of PTS is so low.
“We know through historical data that patients with iliofemoral DVT are much more likely to develop PTS and to have recurrent DVT, so this is probably one of the major shortcomings of the trial,” he explained. “It’s through no fault of the trial investigators, because the study was planned years ago when we just didn’t know as much about PTS as we do now.
“The way I look at it is, I don’t practice in the way that ATTRACT was designed,” Dr. Desai said. “I don’t typically lyse or get referrals for lysis or thrombectomy in patients who have isolated femoropopliteal DVT. It has to involve at least the common femoral vein and frequently goes up to the iliac vein.”
The ATTRACT investigators’ recent subanalysis of the 391 participants with iliofemoral DVT showed that, although there was no difference between the two study arms in the occurrence of PTS through the first 24 months of follow-up, PCDT led to a 35% reduction in the incidence of moderate or severe PTS – by a margin of 18% versus 28% in controls.
Patients in the PCDT arm also experienced significantly greater improvement in venous disease-specific quality of life through 24 months, and a greater reduction in leg pain and swelling at 10 and 30 days (Circulation. 2018 Dec 4. doi: 10.1161/CIRCULATIONAHA.118.037425).
And moderate to severe PTS is a key outcome, Dr. Desai continued. Multiple studies have shown that patients with PTS have a worse quality of life than those with chronic lung disease, arthritis, or diabetes. Moreover, the 5%-10% of patients with symptomatic DVT who develop the most-severe form of PTS – characterized by severe pain, chronic ulcerations, stasis dermatitis, venous claudication, and intractable edema – have a quality of life comparable with patients with cancer or heart failure.
The 1.5% incidence of major bleeding within 10 days in the PCDT group was 200% higher than in controls, but none of it was life threatening.
“This is reassuring: Nobody had intracranial hemorrhage; nobody had a GUSTO 5 bleed,” Dr. Desai said.
Another limitation of the ATTRACT trial is that all but one of the devices utilized for PCDT were used off label. They weren’t designed for venous application. Several on-label rheolytic, rotational thrombectomy, or clot aspiration devices have been approved since enrollment in ATTRACT was closed. Future randomized trials will utilize on-label devices in patients with acute iliofemoral DVT to clarify the role of PCDT.
It’s noteworthy that nearly half of ATTRACT participants developed PTS within 24 months of their DVT despite being on optimal anticoagulation. It’s a finding that underscores the need for improved therapies. That was the impetus for development of first-generation catheter-directed thrombolysis utilizing a percutaneously inserted catheter to infuse a fibrinolytic drug directly to the thrombus to dissolve it rapidly.
But that form of catheter-directed thrombolysis has major disadvantages, Dr. Desai explained: It’s a multiday procedure requiring ICU-level care and prolonged exposure to powerful lytic agents.
“This is where things have changed with PCDT,” he said. “We can now, with on-label devices, accelerate the thrombolysis time, reduce lytic exposure, and I think also reduce the bleeding risk, although that hasn’t been shown in a trial yet. PCDT also reduces the necessity for ICU-level care and prolonged hospitalization.”
Dr. Desai no longer performs multiday lytic procedures. “In fact, with the introduction of the newer on-label devices, I haven’t done a multiday unilateral limb lytic procedure in a couple years. I think we’ve gotten to the point where we don’t need to do that anymore.”
Indeed, PCDT makes recanalization possible as a single-day, single-session procedure.
Dr. Desai views the recent ATTRACT subanalysis as hypothesis generating.
“Should PCDT be the first-line treatment in all proximal DVT patients? No it should not – and that’s not what I would have advocated even before ATTRACT came out,” he explained. “It’s sort of a salvage procedure for patients with iliofemoral DVT and moderate to severe symptoms. And there are a significant number of such patients.”
Current understanding of the pathophysiology of PTS is that a nondissolved thrombus at the valve leaflets becomes inflammatory, with resultant valvular dysfunction leading to venous reflux and venous hypertension. PCDT is consistent with the open-vein hypothesis, which posits that, by eliminating thrombus much faster than achievable via anticoagulation, valve integrity is maintained and PTS is prevented.
Dr. Desai reported receiving consulting fees from AngioDynamics, Boston Scientific, Cook Medical, and Spectranetics.
EXPERT ANALYSIS FROM THE NORTHWESTERN VASCULAR SYMPOSIUM
Dermatologic comorbidities of atopic dermatitis
Also today, flu season is showing signs of slowing, BMI changes in adolescence is linked to cancer risk later in life, and does reduced degradation of insulin by the liver cause type 2 diabetes.
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Also today, flu season is showing signs of slowing, BMI changes in adolescence is linked to cancer risk later in life, and does reduced degradation of insulin by the liver cause type 2 diabetes.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
Also today, flu season is showing signs of slowing, BMI changes in adolescence is linked to cancer risk later in life, and does reduced degradation of insulin by the liver cause type 2 diabetes.
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Apple Podcasts
Google Podcasts
Spotify
This month in the journal CHEST®Editor’s Picks
Giants in Chest Medicine
Emeritus Professor Peter D. Wagner, MD
By Dr. Tatum S. Simonson
State of the Journal Editorial
Spread the Word About CHEST in 2019: Innovations, Introductions,
and Farewells. By Dr. R. S. Irwin, et al.
Original Research
Meta-analysis of Gastroesophageal Reflux Disease and Idiopathic Pulmonary Fibrosis. By Dr. D. Bedard, et al.
Surgical Disparities Among Patients With Stage I Lung Cancer in the National Lung
Screening Trial. By Dr. A. A. Balekian, et al.
Evidence-Based Medicine
Clinically Diagnosing Pertussis-Associated Cough in Adults and Children: CHEST Guideline and Expert Panel Report. By Dr. A. Moore, et al.
Adult Outpatients With Acute Cough Due to Suspected Pneumonia or Influenza: CHEST Guideline and Expert Panel Report. By Dr. A. T. Hill, et al.
Giants in Chest Medicine
Emeritus Professor Peter D. Wagner, MD
By Dr. Tatum S. Simonson
State of the Journal Editorial
Spread the Word About CHEST in 2019: Innovations, Introductions,
and Farewells. By Dr. R. S. Irwin, et al.
Original Research
Meta-analysis of Gastroesophageal Reflux Disease and Idiopathic Pulmonary Fibrosis. By Dr. D. Bedard, et al.
Surgical Disparities Among Patients With Stage I Lung Cancer in the National Lung
Screening Trial. By Dr. A. A. Balekian, et al.
Evidence-Based Medicine
Clinically Diagnosing Pertussis-Associated Cough in Adults and Children: CHEST Guideline and Expert Panel Report. By Dr. A. Moore, et al.
Adult Outpatients With Acute Cough Due to Suspected Pneumonia or Influenza: CHEST Guideline and Expert Panel Report. By Dr. A. T. Hill, et al.
Giants in Chest Medicine
Emeritus Professor Peter D. Wagner, MD
By Dr. Tatum S. Simonson
State of the Journal Editorial
Spread the Word About CHEST in 2019: Innovations, Introductions,
and Farewells. By Dr. R. S. Irwin, et al.
Original Research
Meta-analysis of Gastroesophageal Reflux Disease and Idiopathic Pulmonary Fibrosis. By Dr. D. Bedard, et al.
Surgical Disparities Among Patients With Stage I Lung Cancer in the National Lung
Screening Trial. By Dr. A. A. Balekian, et al.
Evidence-Based Medicine
Clinically Diagnosing Pertussis-Associated Cough in Adults and Children: CHEST Guideline and Expert Panel Report. By Dr. A. Moore, et al.
Adult Outpatients With Acute Cough Due to Suspected Pneumonia or Influenza: CHEST Guideline and Expert Panel Report. By Dr. A. T. Hill, et al.
Seeking the Wisdom of the CHEST Crowd
The wisdom of the crowd is the collective opinion of a group of individuals rather than that of a single expert. At CHEST, the makeup of our membership is diverse and energetic, and it comprises individuals with unique expertise who not only serve as faculty but who are also eager for opportunities themselves to learn. That collective wisdom, leveraged over the entire membership, is what the leadership of CHEST will be listening to this year as we create new educational products and continuously improve the annual meeting and other courses held throughout the year. From broad-based general overviews such as CHEST’s board reviews, to more specific courses such as training in bedside ultrasound or ventilator management, each are geared to make all of us better clinicians who will recognize and provide the latest and most effective treatments for our patients. If you had the opportunity to attend my opening address at the CHEST annual meeting in San Antonio in October, you heard me talk about the innate wisdom of “the crowd.” We all have various “crowds” in our lives -- our work colleagues, families, and relationships in professional societies. I reminded the audience that if we take the time to listen to each of these “crowds,” they usually know the answers. In the coming year, we, as a leadership team for CHEST, will be focusing on being better listeners and utilizing “our crowd” of members to better connect in order to develop educational products that will train clinicians, educators, and researchers in the very latest and most effective care in pulmonary, critical care, and sleep medicine.
Here are just a few initiatives planned this year that have come in response to member comments and suggestions:
•Digital Strategy Task Force – This multidisciplinary group, composed of both volunteer members and association staff, has been assigned to evaluate the user experience associated with existing CHEST content delivery platforms and highlight opportunities for improvements. In this effort, they will identify trends that will enable the organization to better execute on the digital-dependent strategies in the organization’s strategic plan in a successful way. The group will be making recommendations to the Board of Regents that will include timelines, goals, and specific objectives, define organizational voice and brand messaging present on web and other platforms, and create specific metrics to measure the user experience on an ongoing basis.
•Optimizing Board Review Courses – CHEST will be looking at ways to present some content on digital platforms that are difficult to teach in a classic didactic format. Topics such as acid-base disturbances and biostatistics are more effectively presented using a digital, problem-based format. Efforts will be made to shorten board review courses slightly without compromising quality or jeopardizing coverage of content and to incorporate succinct bulleted summaries of each topic covered. In addition, plans are in place to create new courses that will train learners the techniques for passing the new “low stakes” board examination offered by the ABIM.
•Making membership more affordable for international colleagues – New discounted membership rates have been launched to allow international members to obtain the “Enhanced” level of membership to be eligible for fellowship in the association (ie, the FCCP designation). Volume discounts have been introduced for regional chapters and organizations to allow health-care team members from around the world to join CHEST in conjunction with their local society at a fraction of the cost of a single member rate.
•Patient education modules from the CHEST Foundation – A variety of patient education modules are now available to providers, as well as to the general public for information on a wide array of topics – from correct use of inhalers to state-of-the-art therapies for COPD or lung cancer.
Improved opportunities for member participation -- From improved instructions for joining a CHEST NetWork to specific orientation instructions for new members of the Board of Regents, improved communications have become available to help members become better acquainted with the framework of the organization and allow them to become more effective once they begin new leadership roles.
•Embracing innovation -- This year, the organization will launch CHEST Inspiration, a program that involves development of an environmental scan to be shared with our members regarding how CHEST can be a differentiator in an environment where quality education is becoming more accessible and, as a result, more competitive. As part of this initiative, CHEST will plan to host a series of focus group sessions to act on the environmental scan and will also roll out an innovation competition at the 2019 annual meeting in New Orleans in October.
•Expanded international strategy – CHEST is responding to the requests from member groups in countries within Asia, Europe, Latin America, and the Middle East to hold a CHEST Congress each spring to bring the best of the CHEST annual meeting to our colleagues from around the world who may not be able to travel to the meeting held in the U.S., as well as a more intimate board review-like meeting each summer in various regions of the world. For example, this year, the College will host a CHEST Congress in Bangkok, Thailand, April 10-12, and a regional meeting in Athens, Greece, June 27-29.
We are committed to improving communication with our members and encouraging innovation regardless of their prior participation levels. CHEST will continue to bring its brand of education focused on more hands-on learning and team-based knowledge using simulation, serious gaming, and artificial intelligence in the years ahead. CHEST leaders have begun to be active on social media, and we will be introducing new platforms for all members to better understand what is happening from a leadership perspective. Together, we will be able to harness the collective wisdom of our talented and innovative members in order to make a lasting difference for our patients.
The wisdom of the crowd is the collective opinion of a group of individuals rather than that of a single expert. At CHEST, the makeup of our membership is diverse and energetic, and it comprises individuals with unique expertise who not only serve as faculty but who are also eager for opportunities themselves to learn. That collective wisdom, leveraged over the entire membership, is what the leadership of CHEST will be listening to this year as we create new educational products and continuously improve the annual meeting and other courses held throughout the year. From broad-based general overviews such as CHEST’s board reviews, to more specific courses such as training in bedside ultrasound or ventilator management, each are geared to make all of us better clinicians who will recognize and provide the latest and most effective treatments for our patients. If you had the opportunity to attend my opening address at the CHEST annual meeting in San Antonio in October, you heard me talk about the innate wisdom of “the crowd.” We all have various “crowds” in our lives -- our work colleagues, families, and relationships in professional societies. I reminded the audience that if we take the time to listen to each of these “crowds,” they usually know the answers. In the coming year, we, as a leadership team for CHEST, will be focusing on being better listeners and utilizing “our crowd” of members to better connect in order to develop educational products that will train clinicians, educators, and researchers in the very latest and most effective care in pulmonary, critical care, and sleep medicine.
Here are just a few initiatives planned this year that have come in response to member comments and suggestions:
•Digital Strategy Task Force – This multidisciplinary group, composed of both volunteer members and association staff, has been assigned to evaluate the user experience associated with existing CHEST content delivery platforms and highlight opportunities for improvements. In this effort, they will identify trends that will enable the organization to better execute on the digital-dependent strategies in the organization’s strategic plan in a successful way. The group will be making recommendations to the Board of Regents that will include timelines, goals, and specific objectives, define organizational voice and brand messaging present on web and other platforms, and create specific metrics to measure the user experience on an ongoing basis.
•Optimizing Board Review Courses – CHEST will be looking at ways to present some content on digital platforms that are difficult to teach in a classic didactic format. Topics such as acid-base disturbances and biostatistics are more effectively presented using a digital, problem-based format. Efforts will be made to shorten board review courses slightly without compromising quality or jeopardizing coverage of content and to incorporate succinct bulleted summaries of each topic covered. In addition, plans are in place to create new courses that will train learners the techniques for passing the new “low stakes” board examination offered by the ABIM.
•Making membership more affordable for international colleagues – New discounted membership rates have been launched to allow international members to obtain the “Enhanced” level of membership to be eligible for fellowship in the association (ie, the FCCP designation). Volume discounts have been introduced for regional chapters and organizations to allow health-care team members from around the world to join CHEST in conjunction with their local society at a fraction of the cost of a single member rate.
•Patient education modules from the CHEST Foundation – A variety of patient education modules are now available to providers, as well as to the general public for information on a wide array of topics – from correct use of inhalers to state-of-the-art therapies for COPD or lung cancer.
Improved opportunities for member participation -- From improved instructions for joining a CHEST NetWork to specific orientation instructions for new members of the Board of Regents, improved communications have become available to help members become better acquainted with the framework of the organization and allow them to become more effective once they begin new leadership roles.
•Embracing innovation -- This year, the organization will launch CHEST Inspiration, a program that involves development of an environmental scan to be shared with our members regarding how CHEST can be a differentiator in an environment where quality education is becoming more accessible and, as a result, more competitive. As part of this initiative, CHEST will plan to host a series of focus group sessions to act on the environmental scan and will also roll out an innovation competition at the 2019 annual meeting in New Orleans in October.
•Expanded international strategy – CHEST is responding to the requests from member groups in countries within Asia, Europe, Latin America, and the Middle East to hold a CHEST Congress each spring to bring the best of the CHEST annual meeting to our colleagues from around the world who may not be able to travel to the meeting held in the U.S., as well as a more intimate board review-like meeting each summer in various regions of the world. For example, this year, the College will host a CHEST Congress in Bangkok, Thailand, April 10-12, and a regional meeting in Athens, Greece, June 27-29.
We are committed to improving communication with our members and encouraging innovation regardless of their prior participation levels. CHEST will continue to bring its brand of education focused on more hands-on learning and team-based knowledge using simulation, serious gaming, and artificial intelligence in the years ahead. CHEST leaders have begun to be active on social media, and we will be introducing new platforms for all members to better understand what is happening from a leadership perspective. Together, we will be able to harness the collective wisdom of our talented and innovative members in order to make a lasting difference for our patients.
The wisdom of the crowd is the collective opinion of a group of individuals rather than that of a single expert. At CHEST, the makeup of our membership is diverse and energetic, and it comprises individuals with unique expertise who not only serve as faculty but who are also eager for opportunities themselves to learn. That collective wisdom, leveraged over the entire membership, is what the leadership of CHEST will be listening to this year as we create new educational products and continuously improve the annual meeting and other courses held throughout the year. From broad-based general overviews such as CHEST’s board reviews, to more specific courses such as training in bedside ultrasound or ventilator management, each are geared to make all of us better clinicians who will recognize and provide the latest and most effective treatments for our patients. If you had the opportunity to attend my opening address at the CHEST annual meeting in San Antonio in October, you heard me talk about the innate wisdom of “the crowd.” We all have various “crowds” in our lives -- our work colleagues, families, and relationships in professional societies. I reminded the audience that if we take the time to listen to each of these “crowds,” they usually know the answers. In the coming year, we, as a leadership team for CHEST, will be focusing on being better listeners and utilizing “our crowd” of members to better connect in order to develop educational products that will train clinicians, educators, and researchers in the very latest and most effective care in pulmonary, critical care, and sleep medicine.
Here are just a few initiatives planned this year that have come in response to member comments and suggestions:
•Digital Strategy Task Force – This multidisciplinary group, composed of both volunteer members and association staff, has been assigned to evaluate the user experience associated with existing CHEST content delivery platforms and highlight opportunities for improvements. In this effort, they will identify trends that will enable the organization to better execute on the digital-dependent strategies in the organization’s strategic plan in a successful way. The group will be making recommendations to the Board of Regents that will include timelines, goals, and specific objectives, define organizational voice and brand messaging present on web and other platforms, and create specific metrics to measure the user experience on an ongoing basis.
•Optimizing Board Review Courses – CHEST will be looking at ways to present some content on digital platforms that are difficult to teach in a classic didactic format. Topics such as acid-base disturbances and biostatistics are more effectively presented using a digital, problem-based format. Efforts will be made to shorten board review courses slightly without compromising quality or jeopardizing coverage of content and to incorporate succinct bulleted summaries of each topic covered. In addition, plans are in place to create new courses that will train learners the techniques for passing the new “low stakes” board examination offered by the ABIM.
•Making membership more affordable for international colleagues – New discounted membership rates have been launched to allow international members to obtain the “Enhanced” level of membership to be eligible for fellowship in the association (ie, the FCCP designation). Volume discounts have been introduced for regional chapters and organizations to allow health-care team members from around the world to join CHEST in conjunction with their local society at a fraction of the cost of a single member rate.
•Patient education modules from the CHEST Foundation – A variety of patient education modules are now available to providers, as well as to the general public for information on a wide array of topics – from correct use of inhalers to state-of-the-art therapies for COPD or lung cancer.
Improved opportunities for member participation -- From improved instructions for joining a CHEST NetWork to specific orientation instructions for new members of the Board of Regents, improved communications have become available to help members become better acquainted with the framework of the organization and allow them to become more effective once they begin new leadership roles.
•Embracing innovation -- This year, the organization will launch CHEST Inspiration, a program that involves development of an environmental scan to be shared with our members regarding how CHEST can be a differentiator in an environment where quality education is becoming more accessible and, as a result, more competitive. As part of this initiative, CHEST will plan to host a series of focus group sessions to act on the environmental scan and will also roll out an innovation competition at the 2019 annual meeting in New Orleans in October.
•Expanded international strategy – CHEST is responding to the requests from member groups in countries within Asia, Europe, Latin America, and the Middle East to hold a CHEST Congress each spring to bring the best of the CHEST annual meeting to our colleagues from around the world who may not be able to travel to the meeting held in the U.S., as well as a more intimate board review-like meeting each summer in various regions of the world. For example, this year, the College will host a CHEST Congress in Bangkok, Thailand, April 10-12, and a regional meeting in Athens, Greece, June 27-29.
We are committed to improving communication with our members and encouraging innovation regardless of their prior participation levels. CHEST will continue to bring its brand of education focused on more hands-on learning and team-based knowledge using simulation, serious gaming, and artificial intelligence in the years ahead. CHEST leaders have begun to be active on social media, and we will be introducing new platforms for all members to better understand what is happening from a leadership perspective. Together, we will be able to harness the collective wisdom of our talented and innovative members in order to make a lasting difference for our patients.
The Emerging Role of Sleep in the Development of Alzheimer Disease
More than 5 million Americans are living with Alzheimer disease (AD), making this the leading cause of dementia in the United States. This number is projected to nearly triple to 14 million people by 2060 (Matthews KA, et al. Alzheimers Dement. 2018 Sep 17. doi: 10.1016/j.jalz.2018.06.3063. [Epub ahead of print]).
Experts predict estimated costs related to AD to be more than $500 billion annually starting in 2040 (Hurd MD, et al. N Engl J Med. 2013;368[14]:1326). AD is a neurodegenerative disorder characterized by gradual, progressive decline in memory along with other cognitive functions, eventually leading to impairment in activities of daily living. Most current treatments for AD are symptomatic and only minimally slow progression of disease. The increasing prevalence, overwhelming costs to society, and the absence of a cure for AD have created an impending national health crisis.
As the dementia progresses, sleep also tends to worsen. Currently, clinicians improve sleep in patients already diagnosed with AD through diagnosis and treatment of sleep disorders, such as insomnia and sleep apnea to improve overall functioning and quality of life. Treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) in patients diagnosed with AD has shown to improve cognition and other neurocognitive measures (Ancoli-Israel S, et al. J Am Geriatr Soc. 2008;56[11]:2076).
However, there is mounting interest in evaluating how poor sleep could lead to future development of AD or serve as a marker for AD disease in preclinical or asymptomatic populations. Sleep symptoms can be a precursor of other neurological diseases; for example, dream enactment (REM sleep behavior disorder) can precede onset of neurodegenerative disease (Parkinson disease) by decades. Increasing evidence suggests that sleep disruption seen in early or even preclinical AD contributes to its onset and progression. In response to this growing body of research, in June 2018, the American Academy of Sleep Medicine (AASM) issued a health advisory to patients and providers to consider early intervention to ensure sufficient sleep and to treat sleep disorders to assist prevention or delaying onset of AD.
Poor Sleep as a Risk Factor for Alzheimer Disease
Epidemiologic studies (both cross-sectional and prospective studies) have demonstrated that fragmented sleep in cognitively normal individuals is a risk factor for the future development of symptomatic AD (Bubu OM, et al. Sleep. 2017[Jan]:1;40). The pathogenesis of AD includes abnormal accumulation of the protein, amyloid-β (Aβ), in the brain as insoluble extracellular plaques followed by intracellular aggregation of tau, neuronal loss, and cognitive dysfunction. Aβ deposition in the brain begins approximately15 to 20 years before the onset of cognitive impairment and serves as an early biomarker of AD. Accumulation of Aβ results from imbalance between production and clearance of the protein from the central nervous system.
Numerous studies have demonstrated that people with disrupted sleep may show early evidence of AD disease, such as Aβ deposition compared with healthy sleepers. In one study, cognitively normal people with Aβ plaque disease had worse sleep efficiency and increased nap frequency measured by actigraphy as compared with cognitively normal individuals without Aβ plaques (Ju YE, et al. JAMA Neurol. 2013 [May];70[5]:587). Further, a recent study found that self-reported daytime sleepiness was associated with
Possible Mechanisms
Possible mechanisms have been suggested to explain how poor sleep may lead to AD. Over the past 10 years, sleep deprivation was found to increase Aβ concentrations in both a mouse model (Kang JE, et al. Science. 2009; 326:1005) and humans, most likely through increased production and/or release of Aβ (Lucey BP, et al. Ann Neurol. 2018; 83[1]:197). Sleep also appears to increase clearance of proteins and other molecules via bulk fluid flow (“glymphatic” clearance). Glymphatic clearance may enable the removal of interstitial toxic proteins, such as Aβ, through a dynamic interaction between the cerebrospinal fluid and the interstitial fluid, where astrocytes facilitate extracellular fluid transit though the brain during sleep (Xie L, et al. Science. 2013;342:373). Since Aβ deposition in the brain is concentration-dependent, higher Aβ levels from sleep disturbance could lead to greater deposition in the brain.
Circadian Rhythm and Alzheimer Disease
Another mechanism linking sleep to the pathogenesis of AD includes disruption of the circadian rhythm, which is commonly seen in patients with AD. Studies have linked populations who suffer from circadian rhythm disorders to higher rates of dementia (Tranah GJ, et al. Ann Neurol. 2011;70[5]:722). Circadian disruption may predispose the brain to neurodegenerative conditions by altering immune function, disrupting endocrine function, increasing inflammation and oxidative stress, or affecting neurogenesis (in specific areas such as the hippocampus). Thus, inadequate sleep could prime the brain for neurodegeneration by multiple pathways.
Obstructive Sleep Apnea and Alzheimer’s Disease
Sleep disruption and chronic intermittent hypoxia secondary to untreated OSA has also been associated with AD. Numerous studies have shown that sleep-disordered breathing is associated with AD risk and that AD patients have higher rates of OSA. For instance, a study in older women found that moderate and severe sleep-disordered breathing was associated with an increased risk of future cognitive impairment and dementia (Yaffe K, et al. JAMA. 2011[Aug]:10;306[6]:613). In addition to sleep disruption from sleep apnea affecting Aβ as detailed above, hypoxia from sleep apnea may also alter risk of future AD.
Future Directions
Studies support a clear bidirectional relationship between AD and sleep. As researchers continue to investigate sleep as a marker for AD, others are exploring the implications of using sleep interventions to prevent and/or delay the onset of AD. Patients with poor and disrupted sleep may be the ideal candidates for sleep interventions to lower the risk of AD, such as treating OSA with CPAP therapy or insomnia with hypnotic medication or cognitive behavioral therapy. These therapies are already well-studied and approved for human use, allowing for rapid translation to future intervention trials.
Dr. Malhotra is Associate Professor, Sleep Medicine Section; and Dr. Lucey is Assistant Professor, Director-Sleep Medicine Section; Department of Neurology, Washington University School of Medicine, St Louis, Missouri.
More than 5 million Americans are living with Alzheimer disease (AD), making this the leading cause of dementia in the United States. This number is projected to nearly triple to 14 million people by 2060 (Matthews KA, et al. Alzheimers Dement. 2018 Sep 17. doi: 10.1016/j.jalz.2018.06.3063. [Epub ahead of print]).
Experts predict estimated costs related to AD to be more than $500 billion annually starting in 2040 (Hurd MD, et al. N Engl J Med. 2013;368[14]:1326). AD is a neurodegenerative disorder characterized by gradual, progressive decline in memory along with other cognitive functions, eventually leading to impairment in activities of daily living. Most current treatments for AD are symptomatic and only minimally slow progression of disease. The increasing prevalence, overwhelming costs to society, and the absence of a cure for AD have created an impending national health crisis.
As the dementia progresses, sleep also tends to worsen. Currently, clinicians improve sleep in patients already diagnosed with AD through diagnosis and treatment of sleep disorders, such as insomnia and sleep apnea to improve overall functioning and quality of life. Treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) in patients diagnosed with AD has shown to improve cognition and other neurocognitive measures (Ancoli-Israel S, et al. J Am Geriatr Soc. 2008;56[11]:2076).
However, there is mounting interest in evaluating how poor sleep could lead to future development of AD or serve as a marker for AD disease in preclinical or asymptomatic populations. Sleep symptoms can be a precursor of other neurological diseases; for example, dream enactment (REM sleep behavior disorder) can precede onset of neurodegenerative disease (Parkinson disease) by decades. Increasing evidence suggests that sleep disruption seen in early or even preclinical AD contributes to its onset and progression. In response to this growing body of research, in June 2018, the American Academy of Sleep Medicine (AASM) issued a health advisory to patients and providers to consider early intervention to ensure sufficient sleep and to treat sleep disorders to assist prevention or delaying onset of AD.
Poor Sleep as a Risk Factor for Alzheimer Disease
Epidemiologic studies (both cross-sectional and prospective studies) have demonstrated that fragmented sleep in cognitively normal individuals is a risk factor for the future development of symptomatic AD (Bubu OM, et al. Sleep. 2017[Jan]:1;40). The pathogenesis of AD includes abnormal accumulation of the protein, amyloid-β (Aβ), in the brain as insoluble extracellular plaques followed by intracellular aggregation of tau, neuronal loss, and cognitive dysfunction. Aβ deposition in the brain begins approximately15 to 20 years before the onset of cognitive impairment and serves as an early biomarker of AD. Accumulation of Aβ results from imbalance between production and clearance of the protein from the central nervous system.
Numerous studies have demonstrated that people with disrupted sleep may show early evidence of AD disease, such as Aβ deposition compared with healthy sleepers. In one study, cognitively normal people with Aβ plaque disease had worse sleep efficiency and increased nap frequency measured by actigraphy as compared with cognitively normal individuals without Aβ plaques (Ju YE, et al. JAMA Neurol. 2013 [May];70[5]:587). Further, a recent study found that self-reported daytime sleepiness was associated with
Possible Mechanisms
Possible mechanisms have been suggested to explain how poor sleep may lead to AD. Over the past 10 years, sleep deprivation was found to increase Aβ concentrations in both a mouse model (Kang JE, et al. Science. 2009; 326:1005) and humans, most likely through increased production and/or release of Aβ (Lucey BP, et al. Ann Neurol. 2018; 83[1]:197). Sleep also appears to increase clearance of proteins and other molecules via bulk fluid flow (“glymphatic” clearance). Glymphatic clearance may enable the removal of interstitial toxic proteins, such as Aβ, through a dynamic interaction between the cerebrospinal fluid and the interstitial fluid, where astrocytes facilitate extracellular fluid transit though the brain during sleep (Xie L, et al. Science. 2013;342:373). Since Aβ deposition in the brain is concentration-dependent, higher Aβ levels from sleep disturbance could lead to greater deposition in the brain.
Circadian Rhythm and Alzheimer Disease
Another mechanism linking sleep to the pathogenesis of AD includes disruption of the circadian rhythm, which is commonly seen in patients with AD. Studies have linked populations who suffer from circadian rhythm disorders to higher rates of dementia (Tranah GJ, et al. Ann Neurol. 2011;70[5]:722). Circadian disruption may predispose the brain to neurodegenerative conditions by altering immune function, disrupting endocrine function, increasing inflammation and oxidative stress, or affecting neurogenesis (in specific areas such as the hippocampus). Thus, inadequate sleep could prime the brain for neurodegeneration by multiple pathways.
Obstructive Sleep Apnea and Alzheimer’s Disease
Sleep disruption and chronic intermittent hypoxia secondary to untreated OSA has also been associated with AD. Numerous studies have shown that sleep-disordered breathing is associated with AD risk and that AD patients have higher rates of OSA. For instance, a study in older women found that moderate and severe sleep-disordered breathing was associated with an increased risk of future cognitive impairment and dementia (Yaffe K, et al. JAMA. 2011[Aug]:10;306[6]:613). In addition to sleep disruption from sleep apnea affecting Aβ as detailed above, hypoxia from sleep apnea may also alter risk of future AD.
Future Directions
Studies support a clear bidirectional relationship between AD and sleep. As researchers continue to investigate sleep as a marker for AD, others are exploring the implications of using sleep interventions to prevent and/or delay the onset of AD. Patients with poor and disrupted sleep may be the ideal candidates for sleep interventions to lower the risk of AD, such as treating OSA with CPAP therapy or insomnia with hypnotic medication or cognitive behavioral therapy. These therapies are already well-studied and approved for human use, allowing for rapid translation to future intervention trials.
Dr. Malhotra is Associate Professor, Sleep Medicine Section; and Dr. Lucey is Assistant Professor, Director-Sleep Medicine Section; Department of Neurology, Washington University School of Medicine, St Louis, Missouri.
More than 5 million Americans are living with Alzheimer disease (AD), making this the leading cause of dementia in the United States. This number is projected to nearly triple to 14 million people by 2060 (Matthews KA, et al. Alzheimers Dement. 2018 Sep 17. doi: 10.1016/j.jalz.2018.06.3063. [Epub ahead of print]).
Experts predict estimated costs related to AD to be more than $500 billion annually starting in 2040 (Hurd MD, et al. N Engl J Med. 2013;368[14]:1326). AD is a neurodegenerative disorder characterized by gradual, progressive decline in memory along with other cognitive functions, eventually leading to impairment in activities of daily living. Most current treatments for AD are symptomatic and only minimally slow progression of disease. The increasing prevalence, overwhelming costs to society, and the absence of a cure for AD have created an impending national health crisis.
As the dementia progresses, sleep also tends to worsen. Currently, clinicians improve sleep in patients already diagnosed with AD through diagnosis and treatment of sleep disorders, such as insomnia and sleep apnea to improve overall functioning and quality of life. Treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) in patients diagnosed with AD has shown to improve cognition and other neurocognitive measures (Ancoli-Israel S, et al. J Am Geriatr Soc. 2008;56[11]:2076).
However, there is mounting interest in evaluating how poor sleep could lead to future development of AD or serve as a marker for AD disease in preclinical or asymptomatic populations. Sleep symptoms can be a precursor of other neurological diseases; for example, dream enactment (REM sleep behavior disorder) can precede onset of neurodegenerative disease (Parkinson disease) by decades. Increasing evidence suggests that sleep disruption seen in early or even preclinical AD contributes to its onset and progression. In response to this growing body of research, in June 2018, the American Academy of Sleep Medicine (AASM) issued a health advisory to patients and providers to consider early intervention to ensure sufficient sleep and to treat sleep disorders to assist prevention or delaying onset of AD.
Poor Sleep as a Risk Factor for Alzheimer Disease
Epidemiologic studies (both cross-sectional and prospective studies) have demonstrated that fragmented sleep in cognitively normal individuals is a risk factor for the future development of symptomatic AD (Bubu OM, et al. Sleep. 2017[Jan]:1;40). The pathogenesis of AD includes abnormal accumulation of the protein, amyloid-β (Aβ), in the brain as insoluble extracellular plaques followed by intracellular aggregation of tau, neuronal loss, and cognitive dysfunction. Aβ deposition in the brain begins approximately15 to 20 years before the onset of cognitive impairment and serves as an early biomarker of AD. Accumulation of Aβ results from imbalance between production and clearance of the protein from the central nervous system.
Numerous studies have demonstrated that people with disrupted sleep may show early evidence of AD disease, such as Aβ deposition compared with healthy sleepers. In one study, cognitively normal people with Aβ plaque disease had worse sleep efficiency and increased nap frequency measured by actigraphy as compared with cognitively normal individuals without Aβ plaques (Ju YE, et al. JAMA Neurol. 2013 [May];70[5]:587). Further, a recent study found that self-reported daytime sleepiness was associated with
Possible Mechanisms
Possible mechanisms have been suggested to explain how poor sleep may lead to AD. Over the past 10 years, sleep deprivation was found to increase Aβ concentrations in both a mouse model (Kang JE, et al. Science. 2009; 326:1005) and humans, most likely through increased production and/or release of Aβ (Lucey BP, et al. Ann Neurol. 2018; 83[1]:197). Sleep also appears to increase clearance of proteins and other molecules via bulk fluid flow (“glymphatic” clearance). Glymphatic clearance may enable the removal of interstitial toxic proteins, such as Aβ, through a dynamic interaction between the cerebrospinal fluid and the interstitial fluid, where astrocytes facilitate extracellular fluid transit though the brain during sleep (Xie L, et al. Science. 2013;342:373). Since Aβ deposition in the brain is concentration-dependent, higher Aβ levels from sleep disturbance could lead to greater deposition in the brain.
Circadian Rhythm and Alzheimer Disease
Another mechanism linking sleep to the pathogenesis of AD includes disruption of the circadian rhythm, which is commonly seen in patients with AD. Studies have linked populations who suffer from circadian rhythm disorders to higher rates of dementia (Tranah GJ, et al. Ann Neurol. 2011;70[5]:722). Circadian disruption may predispose the brain to neurodegenerative conditions by altering immune function, disrupting endocrine function, increasing inflammation and oxidative stress, or affecting neurogenesis (in specific areas such as the hippocampus). Thus, inadequate sleep could prime the brain for neurodegeneration by multiple pathways.
Obstructive Sleep Apnea and Alzheimer’s Disease
Sleep disruption and chronic intermittent hypoxia secondary to untreated OSA has also been associated with AD. Numerous studies have shown that sleep-disordered breathing is associated with AD risk and that AD patients have higher rates of OSA. For instance, a study in older women found that moderate and severe sleep-disordered breathing was associated with an increased risk of future cognitive impairment and dementia (Yaffe K, et al. JAMA. 2011[Aug]:10;306[6]:613). In addition to sleep disruption from sleep apnea affecting Aβ as detailed above, hypoxia from sleep apnea may also alter risk of future AD.
Future Directions
Studies support a clear bidirectional relationship between AD and sleep. As researchers continue to investigate sleep as a marker for AD, others are exploring the implications of using sleep interventions to prevent and/or delay the onset of AD. Patients with poor and disrupted sleep may be the ideal candidates for sleep interventions to lower the risk of AD, such as treating OSA with CPAP therapy or insomnia with hypnotic medication or cognitive behavioral therapy. These therapies are already well-studied and approved for human use, allowing for rapid translation to future intervention trials.
Dr. Malhotra is Associate Professor, Sleep Medicine Section; and Dr. Lucey is Assistant Professor, Director-Sleep Medicine Section; Department of Neurology, Washington University School of Medicine, St Louis, Missouri.
NIH funds project of CHEST Foundation grant winner Drew Harris
While in San Antonio for CHEST 2018, CHEST Foundation caught up with the recipient of our 2017 CHEST Foundation Research Grant in Asthma, Drew Harris, MD, to learn about the impact of winning a CHEST Foundation Research grant had on his community and career. Dr. Harris’ project created a medical-legal partnership to target many of the social determinants of asthma and help address them beyond the typical scope a provider can offer in a traditional visit.
“Currently, we have a full-time lawyer, two social workers, and people in Public Health Sciences program as well as law students at The University of Virginia (UVA) all working together to address the needs of the community,” Harris stated. “Public health students conduct asthma screenings in any of the four clinics we partner with within the UVA system and bring their findings to the larger group. From there, we figure out how to best intervene for these people and connect them with our lawyer if there are housing or workplace discrimination concerns.”
Dr. Harris recently received NIH funding for his approach and has since expanded this medical-legal partnership at the University of Virginia. “The grant I received last year from the CHEST Foundation funded a pilot version of my project that I then was able to share with a larger audience and ultimately secure federal funding for,” Dr. Harris shared.
“The NIH grant was awarded through the lens of implementation science. We know what works in asthma medication and environmental and social factors that help improve patients’ lives. But we do a poor job on actually DOING it. Our project addresses barriers to fixing these social needs and brings a team together to help fix these other problems that are hard for just a medical provider to address.” Dr. Harris continued, “Social needs and determinants of health are starting to receive more attention in pulmonary medicine, so we are really hitting the ground at the right time. Everyone understands that these are important determinants of health, but they lack the tools to help improve patients’ lives. We are creating those.”
Your donations support clinical research projects like this grant for Dr.Harris. Please consider making a donation to support next year’s grants. https://foundation.chestnet.org/donate/
“A middle-aged textile worker who entered Charlottesville as a Syrian refugee several years ago had been unable to work much in Charlottesville due to work-related asthma. She was denied disability due to insufficient work time. Without a network of friends or family to turn to, this family was struggling in poverty with housing and food insecurity. By connecting with this CHEST Foundation-supported program, this patient received needed advocacy and support of doctors, social workers, and legal aid attorneys. She is now supported in an application for a monthly subsidy to help her immediate social needs while we work towards a more permanent solution. Our program has also helped patients with health-harming social needs, including lack of access to care (by helping patients apply for and enroll in Medicaid, for example), housing issues (such as mold and unresponsive landlords), and intimate partner violence. Working together as a team, we are able to provide advocacy to improve the health and well-being of our vulnerable community members. This program addresses issues that are important to my community. Without the hard work and dedication of my colleagues, the community at large, and all those committed to confronting these problems, many families would not get what they need to thrive. I am proud and feel lucky to dedicate my time to support my patients and my community. Thank you to the CHEST Foundation and all those who support it to ensure that ALL patients receive the care they deserve.”
—Drew Harris, MD
While in San Antonio for CHEST 2018, CHEST Foundation caught up with the recipient of our 2017 CHEST Foundation Research Grant in Asthma, Drew Harris, MD, to learn about the impact of winning a CHEST Foundation Research grant had on his community and career. Dr. Harris’ project created a medical-legal partnership to target many of the social determinants of asthma and help address them beyond the typical scope a provider can offer in a traditional visit.
“Currently, we have a full-time lawyer, two social workers, and people in Public Health Sciences program as well as law students at The University of Virginia (UVA) all working together to address the needs of the community,” Harris stated. “Public health students conduct asthma screenings in any of the four clinics we partner with within the UVA system and bring their findings to the larger group. From there, we figure out how to best intervene for these people and connect them with our lawyer if there are housing or workplace discrimination concerns.”
Dr. Harris recently received NIH funding for his approach and has since expanded this medical-legal partnership at the University of Virginia. “The grant I received last year from the CHEST Foundation funded a pilot version of my project that I then was able to share with a larger audience and ultimately secure federal funding for,” Dr. Harris shared.
“The NIH grant was awarded through the lens of implementation science. We know what works in asthma medication and environmental and social factors that help improve patients’ lives. But we do a poor job on actually DOING it. Our project addresses barriers to fixing these social needs and brings a team together to help fix these other problems that are hard for just a medical provider to address.” Dr. Harris continued, “Social needs and determinants of health are starting to receive more attention in pulmonary medicine, so we are really hitting the ground at the right time. Everyone understands that these are important determinants of health, but they lack the tools to help improve patients’ lives. We are creating those.”
Your donations support clinical research projects like this grant for Dr.Harris. Please consider making a donation to support next year’s grants. https://foundation.chestnet.org/donate/
“A middle-aged textile worker who entered Charlottesville as a Syrian refugee several years ago had been unable to work much in Charlottesville due to work-related asthma. She was denied disability due to insufficient work time. Without a network of friends or family to turn to, this family was struggling in poverty with housing and food insecurity. By connecting with this CHEST Foundation-supported program, this patient received needed advocacy and support of doctors, social workers, and legal aid attorneys. She is now supported in an application for a monthly subsidy to help her immediate social needs while we work towards a more permanent solution. Our program has also helped patients with health-harming social needs, including lack of access to care (by helping patients apply for and enroll in Medicaid, for example), housing issues (such as mold and unresponsive landlords), and intimate partner violence. Working together as a team, we are able to provide advocacy to improve the health and well-being of our vulnerable community members. This program addresses issues that are important to my community. Without the hard work and dedication of my colleagues, the community at large, and all those committed to confronting these problems, many families would not get what they need to thrive. I am proud and feel lucky to dedicate my time to support my patients and my community. Thank you to the CHEST Foundation and all those who support it to ensure that ALL patients receive the care they deserve.”
—Drew Harris, MD
While in San Antonio for CHEST 2018, CHEST Foundation caught up with the recipient of our 2017 CHEST Foundation Research Grant in Asthma, Drew Harris, MD, to learn about the impact of winning a CHEST Foundation Research grant had on his community and career. Dr. Harris’ project created a medical-legal partnership to target many of the social determinants of asthma and help address them beyond the typical scope a provider can offer in a traditional visit.
“Currently, we have a full-time lawyer, two social workers, and people in Public Health Sciences program as well as law students at The University of Virginia (UVA) all working together to address the needs of the community,” Harris stated. “Public health students conduct asthma screenings in any of the four clinics we partner with within the UVA system and bring their findings to the larger group. From there, we figure out how to best intervene for these people and connect them with our lawyer if there are housing or workplace discrimination concerns.”
Dr. Harris recently received NIH funding for his approach and has since expanded this medical-legal partnership at the University of Virginia. “The grant I received last year from the CHEST Foundation funded a pilot version of my project that I then was able to share with a larger audience and ultimately secure federal funding for,” Dr. Harris shared.
“The NIH grant was awarded through the lens of implementation science. We know what works in asthma medication and environmental and social factors that help improve patients’ lives. But we do a poor job on actually DOING it. Our project addresses barriers to fixing these social needs and brings a team together to help fix these other problems that are hard for just a medical provider to address.” Dr. Harris continued, “Social needs and determinants of health are starting to receive more attention in pulmonary medicine, so we are really hitting the ground at the right time. Everyone understands that these are important determinants of health, but they lack the tools to help improve patients’ lives. We are creating those.”
Your donations support clinical research projects like this grant for Dr.Harris. Please consider making a donation to support next year’s grants. https://foundation.chestnet.org/donate/
“A middle-aged textile worker who entered Charlottesville as a Syrian refugee several years ago had been unable to work much in Charlottesville due to work-related asthma. She was denied disability due to insufficient work time. Without a network of friends or family to turn to, this family was struggling in poverty with housing and food insecurity. By connecting with this CHEST Foundation-supported program, this patient received needed advocacy and support of doctors, social workers, and legal aid attorneys. She is now supported in an application for a monthly subsidy to help her immediate social needs while we work towards a more permanent solution. Our program has also helped patients with health-harming social needs, including lack of access to care (by helping patients apply for and enroll in Medicaid, for example), housing issues (such as mold and unresponsive landlords), and intimate partner violence. Working together as a team, we are able to provide advocacy to improve the health and well-being of our vulnerable community members. This program addresses issues that are important to my community. Without the hard work and dedication of my colleagues, the community at large, and all those committed to confronting these problems, many families would not get what they need to thrive. I am proud and feel lucky to dedicate my time to support my patients and my community. Thank you to the CHEST Foundation and all those who support it to ensure that ALL patients receive the care they deserve.”
—Drew Harris, MD
Pneumonia, PIONEER-HF, malignant pleural effusion
Cardiovascular Medicine and Surgery
PIONEER-HF trial: Changing practice in patients hospitalized for heart failure
Renin-angiotensin system (RAS) inhibition forms a pivotal part of guideline-recommended therapy for patients with heart failure with reduced ejection fraction (HFrEF).1 Inhibition of the neutral endopeptidase neprilysin increases levels of several vasoactive peptides that inhibit progression of HF.2 The randomized PARADIGM HF trial compared sacubitril/valsartan (angiotensin receptor neprilysin inhibition, ARNI) to enalapril in 8,434 patients with HFrEF and demonstrated a 20% reduction in the primary outcome of cardiovascular death or HF hospitalization (HR 0.80; CI 0.73– 0.87; P <.001) in patients treated with ARNI; mortality and rehospitalization were decreased significantly, as well.3 Importantly, patients had to be clinically stable and complete a sequential run-in period to be eligible for randomization. On this basis, the 2017 HF guideline update recommended transition from RAS inhibition to ARNI in trial-eligible patients.4
The recent PIONEER-HF trial now provides important evidence to support safety of careful initiation of sacubitril-valsartan for hospitalized patients with and without prior exposure to RAS.5 Hemodynamically stable patients were started on a regimen of sacubitril-valsartan, usually at doses half of those used in PARADIGM-HF. The primary endpoint of a decrease in BNP levels was improved significantly with sacubitril-valsartan (ratio 0.71, CI 0.63–0.81; P<.001), and this translated into a significant decrease in the important patient-centered secondary endpoint of rehospitalization.5 ARNI are underutilized in eligible patients; complexity of outpatient drug initiation may contribute.6
Data from this important trial suggest that clinicians should consider initiation of ARNI during hospitalization for acute heart failure. This could increase the number of patients receiving a guideline-recommended therapy that improves outcomes.
Steven M. Hollenberg, MD, FCCP
Steering Committee Chair
References:
1. Yancy CW et al. 2013 ACCF/ AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62:e147.
2. Vardeny O et al. Combined neprilysin and renin-angiotensin system inhibition for the treatment of heart failure. JACC Heart Fail. 2014;2:663.
3. McMurray JJ, et al. Angiotensin– neprilysin inhibition versus enalapril in heart failure. N Engl J Med. 2014;371:993.
4. Yancy CW, et al. 2017 ACC/ AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2017;70:776.
5. Velasquez EJ, et al. Angiotensin-neprilysin inhibition in acute decompensated heart failure. N Engl J Med. 2018 Nov 11. doi: 10.1056/NEJMoa1812851. Epub ahead of print.
6. Luo N, et al. Early adoption of sacubitril/valsartan for patients with heart failure with reduced ejection fraction: insights from get with the guidelines-heart failure (GWTG-HF). JACC Heart Fail. 2017; 5:305.
Chest Infections
Pneumonia: It is NOW time to act!
The upper part of the globe is going through another winter season and this brings large numbers of patients visiting emergency departments and requiring admission to the hospital due to pneumonia and influenza. It is concerning to see that despite our knowledge that these events will occur during this season every year, there are no significant improvements in place compared to the prior year. But the most concerning aspect of all is lack of perception that pneumonia and influenza remain among the most important diseases resulting in morbidity and mortality to both children and adults (GBD 2016 Lower Respiratory Infections Collaborators. Lancet Infect Dis 2018; S1473-3099[18]30310).
Every year we read, listen or watch the alarming news regarding the increasing number of cases of influenza and pneumonia, the number of deaths, the lack of vaccine protection, the concerns about human-to-human transmission, the development of resistance, and the lack of resources to deal with this problem. We wonder why we tolerate this difficult situation over and over again? What can we do as a society to help fight this problem? What else needs to happen so we take this issue seriously? Why can we not improve the care of patients who suffer from pneumonia? We as part of the Chest Infections NetWork would like to raise the awareness of the pneumonia and influenza problem and unite with our communities to address this calamity once and for all! A recent editorial proposes a series of strategic solutions to address this situation that include increasing the overall resources, more funding for research, and the development of advocacy groups and education programs (Aliberti S, et al. Lancet Respir Med. 2018;S2213-2600(18):30470).
Marcos I. Restrepo, MD, MSc, PhD.
Steering Committee Vice-Chair
Clinical Research
Guidelines for the management of malignant pleural effusion
A multisociety multidisciplinary panel developed recommendations for management of malignant pleural effusions (MPE) by using the PICO (Population, Intervention, Comparator, and Outcomes) format. As per these guidelines, definitive therapy is aimed at
minimizing symptoms, re-accumulation and repeated pleural interventions, and risk of interventions in asymptomatic MPE outweighing benefits. Pleural interventions were suggested for indications such as clinical staging, obtaining molecular markers, etc. (Tremblay A. J Bronchology Interv Pulmonol. 2007;14:98). Large-volume thoracentesis is suggested for symptomatic patients and for those where lung entrapment is a concern (Lan RS. Ann Intern Med. 1997;126:768). In light of available evidence, the panel noted that the outcomes of definitive therapy for symptomatic MPE are equivocal between indwelling pleural catheter (IPC) and pleurodesis. IPC, which was restricted to un-expandable lungs in the previous guidelines, are now suggested for both expandable and un-expandable lungs (Feller-Kopman, et al. Am J Respir Crit Care Med. 2018;198[7]:839). Talc, being the most effective and widely use pleurodesis agent, is suggested to be delivered by poudrage or slurry. Higher treatment failure rates with chemical pleurodesis, as well as low Incidence rates of IPC-related cellulitis and pleural space infections, led the panel to suggest IPC for un-expanded lungs, treatment failures, and residual symptomatic loculated effusions. In patients with IPC-related infections, treatment of the infection rather than removal of the catheter was suggested unless in events where the infection failed to respond (Feller-Kopman, et al. Am J Respir Crit Care Med. 2018;198[7]:839). In view of evidence suggesting improved safety outcomes with ultrasound-guided pleural interventions (Abusedera M, et al. J Bronchology Interv Pulmonol. 2016;23:138), ultrasound guidance was recommended.
Bharat Bajantri, MD
Steering Committee Fellow-in-Training
Interprofessional Team
Difficult-to-control asthma, defined as: uncontrolled asthma despite use of maximum dose inhaled corticosteroids or chronic oral corticosteroids with daily asthma symptoms, frequent exacerbations, and/or hospitalization results in a substantial medical and financial burden with a resultant decrease in quality-of-life. Extrapulmonary co-morbidities, such as obesity, nicotine use, GERD, allergic rhinitis, chronic rhinosinusitis, sleep apnea, anxiety/depression, females of older age, vocal cord dysfunction (VCD), and type 2 diabetes mellitus (T2DM) have been shown to increase exacerbation frequency, missed days of school/work, and lessened quality-of life. Of these comorbidities, that latter has garnered recent attention as a focal point for asthma management.
As many as one in six asthmatics has T2DM, and the obvious impact of oral/systemic corticosteroids runs counter to the treatment armamentarium for difficult-to-control asthma. Furthermore, patients with concomitant T2DM and asthma have poor glycemic control, higher risk of pneumococcal pneumonia, and poor quality-adjusted life expectancy (Black MH et al. Pediatrics. 2014;128:e839-47) Of growing interest is the use of metformin in the treatment of Type 2 diabetes mellitus in patients with asthma. Metformin attenuates eosinophilic airway inflammation and theoretically inhibits airway remodeling through AMP-activated protein kinase (Li, et al. Respirology. 2016;21:1210).
The management of this heterogeneous group of patients with difficult-to-control asthma and the aforementioned comorbidities underscores the need for interdisciplinary collaboration as well as orchestration with specialty providers (family/internal medicine, GI, ENT, endocrine, psych/mental health, et al). Further studies are needed to evaluate the anti-inflammatory properties of metformin and its role in asthma management and improvement in outcome.
David W. Unkle, MSN, APRN, FCCP
Steering Committee Chair
Cardiovascular Medicine and Surgery
PIONEER-HF trial: Changing practice in patients hospitalized for heart failure
Renin-angiotensin system (RAS) inhibition forms a pivotal part of guideline-recommended therapy for patients with heart failure with reduced ejection fraction (HFrEF).1 Inhibition of the neutral endopeptidase neprilysin increases levels of several vasoactive peptides that inhibit progression of HF.2 The randomized PARADIGM HF trial compared sacubitril/valsartan (angiotensin receptor neprilysin inhibition, ARNI) to enalapril in 8,434 patients with HFrEF and demonstrated a 20% reduction in the primary outcome of cardiovascular death or HF hospitalization (HR 0.80; CI 0.73– 0.87; P <.001) in patients treated with ARNI; mortality and rehospitalization were decreased significantly, as well.3 Importantly, patients had to be clinically stable and complete a sequential run-in period to be eligible for randomization. On this basis, the 2017 HF guideline update recommended transition from RAS inhibition to ARNI in trial-eligible patients.4
The recent PIONEER-HF trial now provides important evidence to support safety of careful initiation of sacubitril-valsartan for hospitalized patients with and without prior exposure to RAS.5 Hemodynamically stable patients were started on a regimen of sacubitril-valsartan, usually at doses half of those used in PARADIGM-HF. The primary endpoint of a decrease in BNP levels was improved significantly with sacubitril-valsartan (ratio 0.71, CI 0.63–0.81; P<.001), and this translated into a significant decrease in the important patient-centered secondary endpoint of rehospitalization.5 ARNI are underutilized in eligible patients; complexity of outpatient drug initiation may contribute.6
Data from this important trial suggest that clinicians should consider initiation of ARNI during hospitalization for acute heart failure. This could increase the number of patients receiving a guideline-recommended therapy that improves outcomes.
Steven M. Hollenberg, MD, FCCP
Steering Committee Chair
References:
1. Yancy CW et al. 2013 ACCF/ AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62:e147.
2. Vardeny O et al. Combined neprilysin and renin-angiotensin system inhibition for the treatment of heart failure. JACC Heart Fail. 2014;2:663.
3. McMurray JJ, et al. Angiotensin– neprilysin inhibition versus enalapril in heart failure. N Engl J Med. 2014;371:993.
4. Yancy CW, et al. 2017 ACC/ AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2017;70:776.
5. Velasquez EJ, et al. Angiotensin-neprilysin inhibition in acute decompensated heart failure. N Engl J Med. 2018 Nov 11. doi: 10.1056/NEJMoa1812851. Epub ahead of print.
6. Luo N, et al. Early adoption of sacubitril/valsartan for patients with heart failure with reduced ejection fraction: insights from get with the guidelines-heart failure (GWTG-HF). JACC Heart Fail. 2017; 5:305.
Chest Infections
Pneumonia: It is NOW time to act!
The upper part of the globe is going through another winter season and this brings large numbers of patients visiting emergency departments and requiring admission to the hospital due to pneumonia and influenza. It is concerning to see that despite our knowledge that these events will occur during this season every year, there are no significant improvements in place compared to the prior year. But the most concerning aspect of all is lack of perception that pneumonia and influenza remain among the most important diseases resulting in morbidity and mortality to both children and adults (GBD 2016 Lower Respiratory Infections Collaborators. Lancet Infect Dis 2018; S1473-3099[18]30310).
Every year we read, listen or watch the alarming news regarding the increasing number of cases of influenza and pneumonia, the number of deaths, the lack of vaccine protection, the concerns about human-to-human transmission, the development of resistance, and the lack of resources to deal with this problem. We wonder why we tolerate this difficult situation over and over again? What can we do as a society to help fight this problem? What else needs to happen so we take this issue seriously? Why can we not improve the care of patients who suffer from pneumonia? We as part of the Chest Infections NetWork would like to raise the awareness of the pneumonia and influenza problem and unite with our communities to address this calamity once and for all! A recent editorial proposes a series of strategic solutions to address this situation that include increasing the overall resources, more funding for research, and the development of advocacy groups and education programs (Aliberti S, et al. Lancet Respir Med. 2018;S2213-2600(18):30470).
Marcos I. Restrepo, MD, MSc, PhD.
Steering Committee Vice-Chair
Clinical Research
Guidelines for the management of malignant pleural effusion
A multisociety multidisciplinary panel developed recommendations for management of malignant pleural effusions (MPE) by using the PICO (Population, Intervention, Comparator, and Outcomes) format. As per these guidelines, definitive therapy is aimed at
minimizing symptoms, re-accumulation and repeated pleural interventions, and risk of interventions in asymptomatic MPE outweighing benefits. Pleural interventions were suggested for indications such as clinical staging, obtaining molecular markers, etc. (Tremblay A. J Bronchology Interv Pulmonol. 2007;14:98). Large-volume thoracentesis is suggested for symptomatic patients and for those where lung entrapment is a concern (Lan RS. Ann Intern Med. 1997;126:768). In light of available evidence, the panel noted that the outcomes of definitive therapy for symptomatic MPE are equivocal between indwelling pleural catheter (IPC) and pleurodesis. IPC, which was restricted to un-expandable lungs in the previous guidelines, are now suggested for both expandable and un-expandable lungs (Feller-Kopman, et al. Am J Respir Crit Care Med. 2018;198[7]:839). Talc, being the most effective and widely use pleurodesis agent, is suggested to be delivered by poudrage or slurry. Higher treatment failure rates with chemical pleurodesis, as well as low Incidence rates of IPC-related cellulitis and pleural space infections, led the panel to suggest IPC for un-expanded lungs, treatment failures, and residual symptomatic loculated effusions. In patients with IPC-related infections, treatment of the infection rather than removal of the catheter was suggested unless in events where the infection failed to respond (Feller-Kopman, et al. Am J Respir Crit Care Med. 2018;198[7]:839). In view of evidence suggesting improved safety outcomes with ultrasound-guided pleural interventions (Abusedera M, et al. J Bronchology Interv Pulmonol. 2016;23:138), ultrasound guidance was recommended.
Bharat Bajantri, MD
Steering Committee Fellow-in-Training
Interprofessional Team
Difficult-to-control asthma, defined as: uncontrolled asthma despite use of maximum dose inhaled corticosteroids or chronic oral corticosteroids with daily asthma symptoms, frequent exacerbations, and/or hospitalization results in a substantial medical and financial burden with a resultant decrease in quality-of-life. Extrapulmonary co-morbidities, such as obesity, nicotine use, GERD, allergic rhinitis, chronic rhinosinusitis, sleep apnea, anxiety/depression, females of older age, vocal cord dysfunction (VCD), and type 2 diabetes mellitus (T2DM) have been shown to increase exacerbation frequency, missed days of school/work, and lessened quality-of life. Of these comorbidities, that latter has garnered recent attention as a focal point for asthma management.
As many as one in six asthmatics has T2DM, and the obvious impact of oral/systemic corticosteroids runs counter to the treatment armamentarium for difficult-to-control asthma. Furthermore, patients with concomitant T2DM and asthma have poor glycemic control, higher risk of pneumococcal pneumonia, and poor quality-adjusted life expectancy (Black MH et al. Pediatrics. 2014;128:e839-47) Of growing interest is the use of metformin in the treatment of Type 2 diabetes mellitus in patients with asthma. Metformin attenuates eosinophilic airway inflammation and theoretically inhibits airway remodeling through AMP-activated protein kinase (Li, et al. Respirology. 2016;21:1210).
The management of this heterogeneous group of patients with difficult-to-control asthma and the aforementioned comorbidities underscores the need for interdisciplinary collaboration as well as orchestration with specialty providers (family/internal medicine, GI, ENT, endocrine, psych/mental health, et al). Further studies are needed to evaluate the anti-inflammatory properties of metformin and its role in asthma management and improvement in outcome.
David W. Unkle, MSN, APRN, FCCP
Steering Committee Chair
Cardiovascular Medicine and Surgery
PIONEER-HF trial: Changing practice in patients hospitalized for heart failure
Renin-angiotensin system (RAS) inhibition forms a pivotal part of guideline-recommended therapy for patients with heart failure with reduced ejection fraction (HFrEF).1 Inhibition of the neutral endopeptidase neprilysin increases levels of several vasoactive peptides that inhibit progression of HF.2 The randomized PARADIGM HF trial compared sacubitril/valsartan (angiotensin receptor neprilysin inhibition, ARNI) to enalapril in 8,434 patients with HFrEF and demonstrated a 20% reduction in the primary outcome of cardiovascular death or HF hospitalization (HR 0.80; CI 0.73– 0.87; P <.001) in patients treated with ARNI; mortality and rehospitalization were decreased significantly, as well.3 Importantly, patients had to be clinically stable and complete a sequential run-in period to be eligible for randomization. On this basis, the 2017 HF guideline update recommended transition from RAS inhibition to ARNI in trial-eligible patients.4
The recent PIONEER-HF trial now provides important evidence to support safety of careful initiation of sacubitril-valsartan for hospitalized patients with and without prior exposure to RAS.5 Hemodynamically stable patients were started on a regimen of sacubitril-valsartan, usually at doses half of those used in PARADIGM-HF. The primary endpoint of a decrease in BNP levels was improved significantly with sacubitril-valsartan (ratio 0.71, CI 0.63–0.81; P<.001), and this translated into a significant decrease in the important patient-centered secondary endpoint of rehospitalization.5 ARNI are underutilized in eligible patients; complexity of outpatient drug initiation may contribute.6
Data from this important trial suggest that clinicians should consider initiation of ARNI during hospitalization for acute heart failure. This could increase the number of patients receiving a guideline-recommended therapy that improves outcomes.
Steven M. Hollenberg, MD, FCCP
Steering Committee Chair
References:
1. Yancy CW et al. 2013 ACCF/ AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62:e147.
2. Vardeny O et al. Combined neprilysin and renin-angiotensin system inhibition for the treatment of heart failure. JACC Heart Fail. 2014;2:663.
3. McMurray JJ, et al. Angiotensin– neprilysin inhibition versus enalapril in heart failure. N Engl J Med. 2014;371:993.
4. Yancy CW, et al. 2017 ACC/ AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2017;70:776.
5. Velasquez EJ, et al. Angiotensin-neprilysin inhibition in acute decompensated heart failure. N Engl J Med. 2018 Nov 11. doi: 10.1056/NEJMoa1812851. Epub ahead of print.
6. Luo N, et al. Early adoption of sacubitril/valsartan for patients with heart failure with reduced ejection fraction: insights from get with the guidelines-heart failure (GWTG-HF). JACC Heart Fail. 2017; 5:305.
Chest Infections
Pneumonia: It is NOW time to act!
The upper part of the globe is going through another winter season and this brings large numbers of patients visiting emergency departments and requiring admission to the hospital due to pneumonia and influenza. It is concerning to see that despite our knowledge that these events will occur during this season every year, there are no significant improvements in place compared to the prior year. But the most concerning aspect of all is lack of perception that pneumonia and influenza remain among the most important diseases resulting in morbidity and mortality to both children and adults (GBD 2016 Lower Respiratory Infections Collaborators. Lancet Infect Dis 2018; S1473-3099[18]30310).
Every year we read, listen or watch the alarming news regarding the increasing number of cases of influenza and pneumonia, the number of deaths, the lack of vaccine protection, the concerns about human-to-human transmission, the development of resistance, and the lack of resources to deal with this problem. We wonder why we tolerate this difficult situation over and over again? What can we do as a society to help fight this problem? What else needs to happen so we take this issue seriously? Why can we not improve the care of patients who suffer from pneumonia? We as part of the Chest Infections NetWork would like to raise the awareness of the pneumonia and influenza problem and unite with our communities to address this calamity once and for all! A recent editorial proposes a series of strategic solutions to address this situation that include increasing the overall resources, more funding for research, and the development of advocacy groups and education programs (Aliberti S, et al. Lancet Respir Med. 2018;S2213-2600(18):30470).
Marcos I. Restrepo, MD, MSc, PhD.
Steering Committee Vice-Chair
Clinical Research
Guidelines for the management of malignant pleural effusion
A multisociety multidisciplinary panel developed recommendations for management of malignant pleural effusions (MPE) by using the PICO (Population, Intervention, Comparator, and Outcomes) format. As per these guidelines, definitive therapy is aimed at
minimizing symptoms, re-accumulation and repeated pleural interventions, and risk of interventions in asymptomatic MPE outweighing benefits. Pleural interventions were suggested for indications such as clinical staging, obtaining molecular markers, etc. (Tremblay A. J Bronchology Interv Pulmonol. 2007;14:98). Large-volume thoracentesis is suggested for symptomatic patients and for those where lung entrapment is a concern (Lan RS. Ann Intern Med. 1997;126:768). In light of available evidence, the panel noted that the outcomes of definitive therapy for symptomatic MPE are equivocal between indwelling pleural catheter (IPC) and pleurodesis. IPC, which was restricted to un-expandable lungs in the previous guidelines, are now suggested for both expandable and un-expandable lungs (Feller-Kopman, et al. Am J Respir Crit Care Med. 2018;198[7]:839). Talc, being the most effective and widely use pleurodesis agent, is suggested to be delivered by poudrage or slurry. Higher treatment failure rates with chemical pleurodesis, as well as low Incidence rates of IPC-related cellulitis and pleural space infections, led the panel to suggest IPC for un-expanded lungs, treatment failures, and residual symptomatic loculated effusions. In patients with IPC-related infections, treatment of the infection rather than removal of the catheter was suggested unless in events where the infection failed to respond (Feller-Kopman, et al. Am J Respir Crit Care Med. 2018;198[7]:839). In view of evidence suggesting improved safety outcomes with ultrasound-guided pleural interventions (Abusedera M, et al. J Bronchology Interv Pulmonol. 2016;23:138), ultrasound guidance was recommended.
Bharat Bajantri, MD
Steering Committee Fellow-in-Training
Interprofessional Team
Difficult-to-control asthma, defined as: uncontrolled asthma despite use of maximum dose inhaled corticosteroids or chronic oral corticosteroids with daily asthma symptoms, frequent exacerbations, and/or hospitalization results in a substantial medical and financial burden with a resultant decrease in quality-of-life. Extrapulmonary co-morbidities, such as obesity, nicotine use, GERD, allergic rhinitis, chronic rhinosinusitis, sleep apnea, anxiety/depression, females of older age, vocal cord dysfunction (VCD), and type 2 diabetes mellitus (T2DM) have been shown to increase exacerbation frequency, missed days of school/work, and lessened quality-of life. Of these comorbidities, that latter has garnered recent attention as a focal point for asthma management.
As many as one in six asthmatics has T2DM, and the obvious impact of oral/systemic corticosteroids runs counter to the treatment armamentarium for difficult-to-control asthma. Furthermore, patients with concomitant T2DM and asthma have poor glycemic control, higher risk of pneumococcal pneumonia, and poor quality-adjusted life expectancy (Black MH et al. Pediatrics. 2014;128:e839-47) Of growing interest is the use of metformin in the treatment of Type 2 diabetes mellitus in patients with asthma. Metformin attenuates eosinophilic airway inflammation and theoretically inhibits airway remodeling through AMP-activated protein kinase (Li, et al. Respirology. 2016;21:1210).
The management of this heterogeneous group of patients with difficult-to-control asthma and the aforementioned comorbidities underscores the need for interdisciplinary collaboration as well as orchestration with specialty providers (family/internal medicine, GI, ENT, endocrine, psych/mental health, et al). Further studies are needed to evaluate the anti-inflammatory properties of metformin and its role in asthma management and improvement in outcome.
David W. Unkle, MSN, APRN, FCCP
Steering Committee Chair
New Section Editor for Pulmonary Perspectives®
We are pleased to announce Corey Kershaw, MD, as the new Section Editor for Pulmonary Perspectives. Dr. Kershaw is the Medical Director of the Medical Intensive Care Unit at Clements University Hospital and an Associate Professor, Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, in Dallas, Texas. He currently serves on the American College of Chest Physicians Interstitial and Diffuse Lung Disease NetWork. Dr. Kershaw’s research interests revolve around clinical trials for the treatment of idiopathic pulmonary fibrosis and other fibrosing interstitial lung diseases.
We thank Nitin Puri, MD, FCCP, for his outstanding service as the Pulmonary Perspectives Section Editor for the previous 3
We are pleased to announce Corey Kershaw, MD, as the new Section Editor for Pulmonary Perspectives. Dr. Kershaw is the Medical Director of the Medical Intensive Care Unit at Clements University Hospital and an Associate Professor, Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, in Dallas, Texas. He currently serves on the American College of Chest Physicians Interstitial and Diffuse Lung Disease NetWork. Dr. Kershaw’s research interests revolve around clinical trials for the treatment of idiopathic pulmonary fibrosis and other fibrosing interstitial lung diseases.
We thank Nitin Puri, MD, FCCP, for his outstanding service as the Pulmonary Perspectives Section Editor for the previous 3
We are pleased to announce Corey Kershaw, MD, as the new Section Editor for Pulmonary Perspectives. Dr. Kershaw is the Medical Director of the Medical Intensive Care Unit at Clements University Hospital and an Associate Professor, Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, in Dallas, Texas. He currently serves on the American College of Chest Physicians Interstitial and Diffuse Lung Disease NetWork. Dr. Kershaw’s research interests revolve around clinical trials for the treatment of idiopathic pulmonary fibrosis and other fibrosing interstitial lung diseases.
We thank Nitin Puri, MD, FCCP, for his outstanding service as the Pulmonary Perspectives Section Editor for the previous 3