An update to CHEST’s lung cancer screening guideline, Screening for Lung Cancer: CHEST Guideline and Expert Panel Report, has just been published online in the journal CHEST®. This update was made possible by the hard work of my co-authors and the amazing support of the CHEST staff.

Our goal was to update the evidence base for the benefit, harms, and implementation of low-radiation dose chest CT screening, then use this evidence base to produce meaningful and usable recommendations. The process for developing the guideline followed the rigorous methodological standards of CHEST in which the evidence was gathered from a systematic literature review, and the overall quality of the body of evidence was assessed using the GRADE approach. Recommendations were developed and graded based on this assessment.

There are a few aspects of the new guidelines to highlight. First, we have updated some of the core recommendations; second, we have developed new recommendations related to the implementation of high-quality screening; and third, the CHEST approach to guideline development has evolved to allow us to provide recommendations in which the evidence allows and statements based on experience and expert consensus in which it does not. Through this process, we developed six graded recommendations and nine ungraded consensus-based statements.

In this update, a few changes to the core recommendations about who should be screened are worthy to note:

• We have recommended an increase to the upper age of the screen-eligible cohort from 74 to 77, in line with CMS coverage and reflecting the oldest age of participants in the National Lung Screening Trial at the end of the screening period.
• We have directly addressed the cohort of individuals who are at high risk for having/developing lung cancer based on clinical risk prediction calculators but do not meet the current eligibility criteria. We recommended that this cohort should not be routinely screened given the greater potential for this cohort to have comorbid conditions that would influence morbidity from the evaluation and treatment of screen-detected findings and death from any cause. We did, however, state that there will be individuals within the cohort deemed to be at high risk for lung cancer from a clinical risk prediction calculator who are healthy enough to benefit from lung cancer screening and that low-radiation dose CT screening could be considered in these individuals.
• We recommended against low-radiation dose CT screening in cohorts at low risk of developing lung cancer and in individuals with comorbidities that adversely influence their ability to tolerate the evaluation of screen-detected findings, tolerate treatment of an early stage screen-detected lung cancer, or that substantially limit their life expectancy.
• We also highlighted that screening is reserved for patients without symptoms that could be caused by the presence of lung cancer, stressing that all symptomatic patients should receive an appropriate diagnostic evaluation.

Our remaining recommendation and statements are focused on aspects of screening implementation that influence the balance of benefit and harms of screening and lend to an approach to screening that respects patient values. An extensive literature review, followed by a recommendation or statement, is provided to guide programs in the following areas:

• the choice of nodule size to define what constitutes a positive test;
• maximizing compliance with annual screening exams;
• developing a comprehensive approach to lung nodule management;
• minimizing overtreatment of potentially indolent lung cancers;
• the provision of evidence-based tobacco cessation treatment;
• providing effective counseling and shared decision-making visits prior to the low-radiation dose CT scan;
• how to perform the low-radiation dose CT scan;
• structured reporting of the exam results, management of non-nodule findings on the low radiation dose CT; and
• the development of data collection and reporting tools that are capable of assisting with quality improvement initiatives.

Throughout the recommendations and statements, we have tried to be sensitive to the variety of acceptable approaches to screening program organization, ranging from program structures that are entirely decentralized (test ordering, counseling, and management of the findings by the referring provider) to those that are entirely centralized (test ordering, counseling, and management of the findings by the screening program).

Though we have attempted to comprehensively evaluate the literature and balance available evidence with pragmatism and the needs of our patients, we recognize that well-intentioned and informed experts can have different opinions about aspects of our guidelines. This highlights the need for further research to guide the screening community. Most will agree that it is time to increase access to high- quality lung cancer screening programs across the country. We hope that the updated CHEST lung cancer screening guidelines can help catalyze this.

Coinciding with the publication of the guideline, CHEST has developed new e-learning modules on the benefits and harms of CT screening for lung cancer. The modules are based on the CHEST 2018 educational session on the Screening for Lung Cancer Guidelines. The modules are available at chestnet.org/lungcancerscreening.

An update to CHEST’s lung cancer screening guideline, Screening for Lung Cancer: CHEST Guideline and Expert Panel Report, has just been published online in the journal CHEST®. This update was made possible by the hard work of my co-authors and the amazing support of the CHEST staff.

Our goal was to update the evidence base for the benefit, harms, and implementation of low-radiation dose chest CT screening, then use this evidence base to produce meaningful and usable recommendations. The process for developing the guideline followed the rigorous methodological standards of CHEST in which the evidence was gathered from a systematic literature review, and the overall quality of the body of evidence was assessed using the GRADE approach. Recommendations were developed and graded based on this assessment.

There are a few aspects of the new guidelines to highlight. First, we have updated some of the core recommendations; second, we have developed new recommendations related to the implementation of high-quality screening; and third, the CHEST approach to guideline development has evolved to allow us to provide recommendations in which the evidence allows and statements based on experience and expert consensus in which it does not. Through this process, we developed six graded recommendations and nine ungraded consensus-based statements.

In this update, a few changes to the core recommendations about who should be screened are worthy to note:

• We have recommended an increase to the upper age of the screen-eligible cohort from 74 to 77, in line with CMS coverage and reflecting the oldest age of participants in the National Lung Screening Trial at the end of the screening period.
• We have directly addressed the cohort of individuals who are at high risk for having/developing lung cancer based on clinical risk prediction calculators but do not meet the current eligibility criteria. We recommended that this cohort should not be routinely screened given the greater potential for this cohort to have comorbid conditions that would influence morbidity from the evaluation and treatment of screen-detected findings and death from any cause. We did, however, state that there will be individuals within the cohort deemed to be at high risk for lung cancer from a clinical risk prediction calculator who are healthy enough to benefit from lung cancer screening and that low-radiation dose CT screening could be considered in these individuals.
• We recommended against low-radiation dose CT screening in cohorts at low risk of developing lung cancer and in individuals with comorbidities that adversely influence their ability to tolerate the evaluation of screen-detected findings, tolerate treatment of an early stage screen-detected lung cancer, or that substantially limit their life expectancy.
• We also highlighted that screening is reserved for patients without symptoms that could be caused by the presence of lung cancer, stressing that all symptomatic patients should receive an appropriate diagnostic evaluation.

Our remaining recommendation and statements are focused on aspects of screening implementation that influence the balance of benefit and harms of screening and lend to an approach to screening that respects patient values. An extensive literature review, followed by a recommendation or statement, is provided to guide programs in the following areas:

• the choice of nodule size to define what constitutes a positive test;
• maximizing compliance with annual screening exams;
• developing a comprehensive approach to lung nodule management;
• minimizing overtreatment of potentially indolent lung cancers;
• the provision of evidence-based tobacco cessation treatment;
• providing effective counseling and shared decision-making visits prior to the low-radiation dose CT scan;
• how to perform the low-radiation dose CT scan;
• structured reporting of the exam results, management of non-nodule findings on the low radiation dose CT; and
• the development of data collection and reporting tools that are capable of assisting with quality improvement initiatives.

Throughout the recommendations and statements, we have tried to be sensitive to the variety of acceptable approaches to screening program organization, ranging from program structures that are entirely decentralized (test ordering, counseling, and management of the findings by the referring provider) to those that are entirely centralized (test ordering, counseling, and management of the findings by the screening program).

Though we have attempted to comprehensively evaluate the literature and balance available evidence with pragmatism and the needs of our patients, we recognize that well-intentioned and informed experts can have different opinions about aspects of our guidelines. This highlights the need for further research to guide the screening community. Most will agree that it is time to increase access to high- quality lung cancer screening programs across the country. We hope that the updated CHEST lung cancer screening guidelines can help catalyze this.

Coinciding with the publication of the guideline, CHEST has developed new e-learning modules on the benefits and harms of CT screening for lung cancer. The modules are based on the CHEST 2018 educational session on the Screening for Lung Cancer Guidelines. The modules are available at chestnet.org/lungcancerscreening.

An update to CHEST’s lung cancer screening guideline, Screening for Lung Cancer: CHEST Guideline and Expert Panel Report, has just been published online in the journal CHEST®. This update was made possible by the hard work of my co-authors and the amazing support of the CHEST staff.

Our goal was to update the evidence base for the benefit, harms, and implementation of low-radiation dose chest CT screening, then use this evidence base to produce meaningful and usable recommendations. The process for developing the guideline followed the rigorous methodological standards of CHEST in which the evidence was gathered from a systematic literature review, and the overall quality of the body of evidence was assessed using the GRADE approach. Recommendations were developed and graded based on this assessment.

There are a few aspects of the new guidelines to highlight. First, we have updated some of the core recommendations; second, we have developed new recommendations related to the implementation of high-quality screening; and third, the CHEST approach to guideline development has evolved to allow us to provide recommendations in which the evidence allows and statements based on experience and expert consensus in which it does not. Through this process, we developed six graded recommendations and nine ungraded consensus-based statements.

In this update, a few changes to the core recommendations about who should be screened are worthy to note:

• We have recommended an increase to the upper age of the screen-eligible cohort from 74 to 77, in line with CMS coverage and reflecting the oldest age of participants in the National Lung Screening Trial at the end of the screening period.
• We have directly addressed the cohort of individuals who are at high risk for having/developing lung cancer based on clinical risk prediction calculators but do not meet the current eligibility criteria. We recommended that this cohort should not be routinely screened given the greater potential for this cohort to have comorbid conditions that would influence morbidity from the evaluation and treatment of screen-detected findings and death from any cause. We did, however, state that there will be individuals within the cohort deemed to be at high risk for lung cancer from a clinical risk prediction calculator who are healthy enough to benefit from lung cancer screening and that low-radiation dose CT screening could be considered in these individuals.
• We recommended against low-radiation dose CT screening in cohorts at low risk of developing lung cancer and in individuals with comorbidities that adversely influence their ability to tolerate the evaluation of screen-detected findings, tolerate treatment of an early stage screen-detected lung cancer, or that substantially limit their life expectancy.
• We also highlighted that screening is reserved for patients without symptoms that could be caused by the presence of lung cancer, stressing that all symptomatic patients should receive an appropriate diagnostic evaluation.

Our remaining recommendation and statements are focused on aspects of screening implementation that influence the balance of benefit and harms of screening and lend to an approach to screening that respects patient values. An extensive literature review, followed by a recommendation or statement, is provided to guide programs in the following areas:

• the choice of nodule size to define what constitutes a positive test;
• maximizing compliance with annual screening exams;
• developing a comprehensive approach to lung nodule management;
• minimizing overtreatment of potentially indolent lung cancers;
• the provision of evidence-based tobacco cessation treatment;
• providing effective counseling and shared decision-making visits prior to the low-radiation dose CT scan;
• how to perform the low-radiation dose CT scan;
• structured reporting of the exam results, management of non-nodule findings on the low radiation dose CT; and
• the development of data collection and reporting tools that are capable of assisting with quality improvement initiatives.

Throughout the recommendations and statements, we have tried to be sensitive to the variety of acceptable approaches to screening program organization, ranging from program structures that are entirely decentralized (test ordering, counseling, and management of the findings by the referring provider) to those that are entirely centralized (test ordering, counseling, and management of the findings by the screening program).

Though we have attempted to comprehensively evaluate the literature and balance available evidence with pragmatism and the needs of our patients, we recognize that well-intentioned and informed experts can have different opinions about aspects of our guidelines. This highlights the need for further research to guide the screening community. Most will agree that it is time to increase access to high- quality lung cancer screening programs across the country. We hope that the updated CHEST lung cancer screening guidelines can help catalyze this.

Coinciding with the publication of the guideline, CHEST has developed new e-learning modules on the benefits and harms of CT screening for lung cancer. The modules are based on the CHEST 2018 educational session on the Screening for Lung Cancer Guidelines. The modules are available at chestnet.org/lungcancerscreening.

Hypotension is an often-underestimated adversary. Even brief periods of intraoperative mean arterial pressure (MAP) <65 mm Hg increase the odds of both myocardial ischemia and acute kidney injury in the postoperative period. The threshold may be even higher in the postoperative critically ill population (Khanna, et al. Crit Care Med. 2018;46(1):71). Hypotension that is refractory to high-dose vasopressors is associated with an all-cause mortality of 50% to 80%.

The vasopressor toolbox centers around escalating doses of catecholamines with or without the addition of vasopressin. High-dose catecholamines, albeit a frequent choice, is associated with adverse cardiac events (Schmittinger, et al. Intensive Care Med. 2012;38[6]:950) and is an independent predictor of ICU mortality (Sviri, et al. J Crit Care. 2014;29[1]:157).
 

The evidence behind angiotensin II

Angiotensin II (AT II) is a naturally occurring hormone in the renin-angiotensin-aldosterone (RAA) system that modulates blood pressure through direct arterial vasoconstriction and direct stimulation of the kidneys and adrenal cortex to release vasopressin and aldosterone, respectively.

Positive results from the recent phase 3 trial for AT II have offered hope that this agent would add the needed balance to the current scarcity of vasopressor options (Khanna, et al. N Engl J Med. 2017;377[5]:419). AT II would provide the missing piece in the jigsaw that would allow the intensivist to manage refractory hypotension, while keeping a multimodal vasopressor dosing regimen within therapeutic limits.

Is there a downside?

Appropriate caution is necessary when interpreting these outcomes. One criticism that ATHOS-3 received was the use of a MAP goal of 75 mm Hg, a higher value than currently recommended by clinical guidelines, in the first 3 hours of AT II administration. Because this was a phase 3 trial, both the safety and efficacy of the drug were examined. These goals are difficult to accomplish if simultaneously manipulating other variables. Therefore, to isolate the effects of drug efficacy and safety, a higher MAP goal (75 mm Hg) was established to minimize any effect from varying background vasopressor doses during the first 3 hours of the study.

Furthermore, ATHOS-3 did find an increase in venous and arterial thromboembolic events in patients who received AT II (13% AT II vs 5% placebo). Previously, a systematic review of over 30,000 patients did not report this increased thromboembolic risk (Busse, et al. Crit Care. 2017;21[1]:324). According to the package insert, all patients receiving AT II should receive appropriate thromboembolic prophylaxis if medically indicated.
 

Where does AT II fit in our algorithm for resuscitation and the vasopressor toolbox?

Data from Wunderink et al indicate a potential mortality benefit in populations who are AT II depleted. However, we can only infer who these patients may be, as no commonly available assay can measure AT I and AT II levels. ATHOS and ATHOS-3 used AT II late during resuscitation, as did the Expanded Access Program (EAP) of the FDA, which gave physicians preliminary access to AT II while it was undergoing FDA review. Using similar inclusion criteria as ATHOS-3, the EAP did not permit patients to receive AT II until doses greater than or equal to 0.2 ug/kg/min of NE-equivalents were reached. In a recently published case report, AT II was successfully used in a patient with septic shock secondary to a colonic perforation (Chow, et al. Accepted for e-publication: A&A Practice. April 2018.). This individual was in vasodilatory shock despite standard resuscitation, 0.48 ug/kg/min of NE, and 0.04 units/min of vasopressin. Methylene blue and hydroxocobalamin had failed to relieve the vasoplegia, and only after the initiation of AT II at 40 ng/kg/min, the patient could be relieved of vasopressors and survived to be discharged from the hospital. In our opinion, best clinical practices would allow for an early multimodal vasopressor regimen that should include AT II at the earliest sign of rapid clinical decline (Jentzer, et al. Chest. 2018. Jan 9. pii: S0012-3692(18)30072-2. doi: 10.1016/j.chest.2017.12.021. [Epub ahead of print]).

Angiotensin II was recently approved by the FDA in December 2017 and is now available on the market for management of vasodilatory shock. This will undoubtedly have a profound impact on the way clinicians treat vasodilatory shock. Previously, we were confined to agents such methylene blue and hydroxocobalamin to rescue patients from profound vasoplegia. However, none of these agents are supported by robust evidence from randomized control trials.

Now, we can openly welcome a new challenger to the campaign, a new hue to the palette of vasopressor colors. This new class of vasopressor makes complete physiological sense and will provide an invaluable tool in our daily battle against sepsis and vasodilatory shock.

Dr. Chow is Assistant Professor, Division of Critical Care Medicine, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD; Dr. Khana is Assistant Professor of Anesthesiology, Staff Intensivist, Vice-Chief for Research, Center for Critical Care, Department of Outcomes Research & General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH

Editor’s note

For decades, our options to treat patients with profound vasoplegia have been limited to high-dose catecholamines and vasopressin. Clinicians are often faced with the need to initiate multiple catecholamine agents knowing that these drugs stimulate similar receptors. The recent ATHOS-3 trial introduces AT II as a new option for the management of patients with refractory vasodilatory shock. This drug has a distinct mechanism of action that complements the effect of other vasopressors. Moreover, recent data suggest that this new agent is most beneficial in patients who are AT II deficient. Just like cancer therapies have evolved to precision medicine, will we perhaps face the need to better understand and promptly identify patients with AT II deficiency? For now, we have a new player on our vasopressor team.

Angel Coz, MD, FCCP
Section Editor

Hypotension is an often-underestimated adversary. Even brief periods of intraoperative mean arterial pressure (MAP) <65 mm Hg increase the odds of both myocardial ischemia and acute kidney injury in the postoperative period. The threshold may be even higher in the postoperative critically ill population (Khanna, et al. Crit Care Med. 2018;46(1):71). Hypotension that is refractory to high-dose vasopressors is associated with an all-cause mortality of 50% to 80%.

The vasopressor toolbox centers around escalating doses of catecholamines with or without the addition of vasopressin. High-dose catecholamines, albeit a frequent choice, is associated with adverse cardiac events (Schmittinger, et al. Intensive Care Med. 2012;38[6]:950) and is an independent predictor of ICU mortality (Sviri, et al. J Crit Care. 2014;29[1]:157).
 

The evidence behind angiotensin II

Angiotensin II (AT II) is a naturally occurring hormone in the renin-angiotensin-aldosterone (RAA) system that modulates blood pressure through direct arterial vasoconstriction and direct stimulation of the kidneys and adrenal cortex to release vasopressin and aldosterone, respectively.

Positive results from the recent phase 3 trial for AT II have offered hope that this agent would add the needed balance to the current scarcity of vasopressor options (Khanna, et al. N Engl J Med. 2017;377[5]:419). AT II would provide the missing piece in the jigsaw that would allow the intensivist to manage refractory hypotension, while keeping a multimodal vasopressor dosing regimen within therapeutic limits.

Is there a downside?

Appropriate caution is necessary when interpreting these outcomes. One criticism that ATHOS-3 received was the use of a MAP goal of 75 mm Hg, a higher value than currently recommended by clinical guidelines, in the first 3 hours of AT II administration. Because this was a phase 3 trial, both the safety and efficacy of the drug were examined. These goals are difficult to accomplish if simultaneously manipulating other variables. Therefore, to isolate the effects of drug efficacy and safety, a higher MAP goal (75 mm Hg) was established to minimize any effect from varying background vasopressor doses during the first 3 hours of the study.

Furthermore, ATHOS-3 did find an increase in venous and arterial thromboembolic events in patients who received AT II (13% AT II vs 5% placebo). Previously, a systematic review of over 30,000 patients did not report this increased thromboembolic risk (Busse, et al. Crit Care. 2017;21[1]:324). According to the package insert, all patients receiving AT II should receive appropriate thromboembolic prophylaxis if medically indicated.
 

Where does AT II fit in our algorithm for resuscitation and the vasopressor toolbox?

Data from Wunderink et al indicate a potential mortality benefit in populations who are AT II depleted. However, we can only infer who these patients may be, as no commonly available assay can measure AT I and AT II levels. ATHOS and ATHOS-3 used AT II late during resuscitation, as did the Expanded Access Program (EAP) of the FDA, which gave physicians preliminary access to AT II while it was undergoing FDA review. Using similar inclusion criteria as ATHOS-3, the EAP did not permit patients to receive AT II until doses greater than or equal to 0.2 ug/kg/min of NE-equivalents were reached. In a recently published case report, AT II was successfully used in a patient with septic shock secondary to a colonic perforation (Chow, et al. Accepted for e-publication: A&A Practice. April 2018.). This individual was in vasodilatory shock despite standard resuscitation, 0.48 ug/kg/min of NE, and 0.04 units/min of vasopressin. Methylene blue and hydroxocobalamin had failed to relieve the vasoplegia, and only after the initiation of AT II at 40 ng/kg/min, the patient could be relieved of vasopressors and survived to be discharged from the hospital. In our opinion, best clinical practices would allow for an early multimodal vasopressor regimen that should include AT II at the earliest sign of rapid clinical decline (Jentzer, et al. Chest. 2018. Jan 9. pii: S0012-3692(18)30072-2. doi: 10.1016/j.chest.2017.12.021. [Epub ahead of print]).

Angiotensin II was recently approved by the FDA in December 2017 and is now available on the market for management of vasodilatory shock. This will undoubtedly have a profound impact on the way clinicians treat vasodilatory shock. Previously, we were confined to agents such methylene blue and hydroxocobalamin to rescue patients from profound vasoplegia. However, none of these agents are supported by robust evidence from randomized control trials.

Now, we can openly welcome a new challenger to the campaign, a new hue to the palette of vasopressor colors. This new class of vasopressor makes complete physiological sense and will provide an invaluable tool in our daily battle against sepsis and vasodilatory shock.

Dr. Chow is Assistant Professor, Division of Critical Care Medicine, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD; Dr. Khana is Assistant Professor of Anesthesiology, Staff Intensivist, Vice-Chief for Research, Center for Critical Care, Department of Outcomes Research & General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH

Editor’s note

For decades, our options to treat patients with profound vasoplegia have been limited to high-dose catecholamines and vasopressin. Clinicians are often faced with the need to initiate multiple catecholamine agents knowing that these drugs stimulate similar receptors. The recent ATHOS-3 trial introduces AT II as a new option for the management of patients with refractory vasodilatory shock. This drug has a distinct mechanism of action that complements the effect of other vasopressors. Moreover, recent data suggest that this new agent is most beneficial in patients who are AT II deficient. Just like cancer therapies have evolved to precision medicine, will we perhaps face the need to better understand and promptly identify patients with AT II deficiency? For now, we have a new player on our vasopressor team.

Angel Coz, MD, FCCP
Section Editor

Hypotension is an often-underestimated adversary. Even brief periods of intraoperative mean arterial pressure (MAP) <65 mm Hg increase the odds of both myocardial ischemia and acute kidney injury in the postoperative period. The threshold may be even higher in the postoperative critically ill population (Khanna, et al. Crit Care Med. 2018;46(1):71). Hypotension that is refractory to high-dose vasopressors is associated with an all-cause mortality of 50% to 80%.

The vasopressor toolbox centers around escalating doses of catecholamines with or without the addition of vasopressin. High-dose catecholamines, albeit a frequent choice, is associated with adverse cardiac events (Schmittinger, et al. Intensive Care Med. 2012;38[6]:950) and is an independent predictor of ICU mortality (Sviri, et al. J Crit Care. 2014;29[1]:157).
 

The evidence behind angiotensin II

Angiotensin II (AT II) is a naturally occurring hormone in the renin-angiotensin-aldosterone (RAA) system that modulates blood pressure through direct arterial vasoconstriction and direct stimulation of the kidneys and adrenal cortex to release vasopressin and aldosterone, respectively.

Positive results from the recent phase 3 trial for AT II have offered hope that this agent would add the needed balance to the current scarcity of vasopressor options (Khanna, et al. N Engl J Med. 2017;377[5]:419). AT II would provide the missing piece in the jigsaw that would allow the intensivist to manage refractory hypotension, while keeping a multimodal vasopressor dosing regimen within therapeutic limits.

Is there a downside?

Appropriate caution is necessary when interpreting these outcomes. One criticism that ATHOS-3 received was the use of a MAP goal of 75 mm Hg, a higher value than currently recommended by clinical guidelines, in the first 3 hours of AT II administration. Because this was a phase 3 trial, both the safety and efficacy of the drug were examined. These goals are difficult to accomplish if simultaneously manipulating other variables. Therefore, to isolate the effects of drug efficacy and safety, a higher MAP goal (75 mm Hg) was established to minimize any effect from varying background vasopressor doses during the first 3 hours of the study.

Furthermore, ATHOS-3 did find an increase in venous and arterial thromboembolic events in patients who received AT II (13% AT II vs 5% placebo). Previously, a systematic review of over 30,000 patients did not report this increased thromboembolic risk (Busse, et al. Crit Care. 2017;21[1]:324). According to the package insert, all patients receiving AT II should receive appropriate thromboembolic prophylaxis if medically indicated.
 

Where does AT II fit in our algorithm for resuscitation and the vasopressor toolbox?

Data from Wunderink et al indicate a potential mortality benefit in populations who are AT II depleted. However, we can only infer who these patients may be, as no commonly available assay can measure AT I and AT II levels. ATHOS and ATHOS-3 used AT II late during resuscitation, as did the Expanded Access Program (EAP) of the FDA, which gave physicians preliminary access to AT II while it was undergoing FDA review. Using similar inclusion criteria as ATHOS-3, the EAP did not permit patients to receive AT II until doses greater than or equal to 0.2 ug/kg/min of NE-equivalents were reached. In a recently published case report, AT II was successfully used in a patient with septic shock secondary to a colonic perforation (Chow, et al. Accepted for e-publication: A&A Practice. April 2018.). This individual was in vasodilatory shock despite standard resuscitation, 0.48 ug/kg/min of NE, and 0.04 units/min of vasopressin. Methylene blue and hydroxocobalamin had failed to relieve the vasoplegia, and only after the initiation of AT II at 40 ng/kg/min, the patient could be relieved of vasopressors and survived to be discharged from the hospital. In our opinion, best clinical practices would allow for an early multimodal vasopressor regimen that should include AT II at the earliest sign of rapid clinical decline (Jentzer, et al. Chest. 2018. Jan 9. pii: S0012-3692(18)30072-2. doi: 10.1016/j.chest.2017.12.021. [Epub ahead of print]).

Angiotensin II was recently approved by the FDA in December 2017 and is now available on the market for management of vasodilatory shock. This will undoubtedly have a profound impact on the way clinicians treat vasodilatory shock. Previously, we were confined to agents such methylene blue and hydroxocobalamin to rescue patients from profound vasoplegia. However, none of these agents are supported by robust evidence from randomized control trials.

Now, we can openly welcome a new challenger to the campaign, a new hue to the palette of vasopressor colors. This new class of vasopressor makes complete physiological sense and will provide an invaluable tool in our daily battle against sepsis and vasodilatory shock.

Dr. Chow is Assistant Professor, Division of Critical Care Medicine, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD; Dr. Khana is Assistant Professor of Anesthesiology, Staff Intensivist, Vice-Chief for Research, Center for Critical Care, Department of Outcomes Research & General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH

Editor’s note

For decades, our options to treat patients with profound vasoplegia have been limited to high-dose catecholamines and vasopressin. Clinicians are often faced with the need to initiate multiple catecholamine agents knowing that these drugs stimulate similar receptors. The recent ATHOS-3 trial introduces AT II as a new option for the management of patients with refractory vasodilatory shock. This drug has a distinct mechanism of action that complements the effect of other vasopressors. Moreover, recent data suggest that this new agent is most beneficial in patients who are AT II deficient. Just like cancer therapies have evolved to precision medicine, will we perhaps face the need to better understand and promptly identify patients with AT II deficiency? For now, we have a new player on our vasopressor team.

Angel Coz, MD, FCCP
Section Editor

How it all started

The study abroad project was truly a goal and vision that came about after returning to Guyana after approximately 46 years. I was born in Guyana but left as a child and returned later and joined a mission group. In 2015, I began a personal journey of missionary service with the team of Bridge Global Medical Missions (BGMM) in Georgetown, Guyana. I was the first respiratory therapist to join the team.

I remember during the first few days in the hospitals I was told that there was “a lot of wheezing” in the EDs. Treating patients consisted of just administrating short-acting nebulizer treatments, but I remember being very impressed with the ICU at the main public hospital, Georgetown Public Hospital Corporation (GPHC), because they had the ventilators I could use. However, physicians only managed the patients while the nurses were left to monitor the ventilators and equipment, which they did not understand.

Study abroad and respiratory care

Then the vision of my project began, because I needed to show him the scope of the practice of a respiratory therapist. I asked Dr. Heyliger-Thomas of BGMM if she could assist me in promoting a study abroad program in Guyana with the Ministry of Health. It was very important for me to bring my students to Guyana for many reasons, the most important being the profession was needed there, and our students would be excellent representatives.

In 2015, the study “Introduction of spirometry into clinical practice in Georgetown, Guyana: quality and diagnostic outcomes” highlighted increased physician referral to the country’s only COPD/asthma clinic. I wanted to promote the importance of study abroad and international mission work, especially when promoting the care of asthma and the pulmonary patient, which I believe we did. The main project during study abroad was to test the school-aged children in Linden, thereby showing that there was undiagnosed asthma.

The effect of the CHEST Foundation grant

Applying for the CHEST Foundation community service grant was the largest grant I had ever attempted. Having a support system behind you is the most important piece of advice I can give to future grant applicants. I could not have completed my grant without our grant team at Texas State University. They truly had my back; and close to the deadline when it seemed insurmountable, they helped push me through it. The other piece of advice is to have a true vision and stick to that vision. The most difficult part of my project was the budget, prioritizing the things or people that I needed. Honestly, I needed help here, because for me, I needed everything. I had to make choices and leave some things out. I focused on what the actual need was for the many.

My ultimate goal for Guyana is to promote and show the need for respiratory care professionals to have that education offered at the University of Guyana as part of its allied health program and assist those in the application to the International Fellowship Program of the American Association of Respiratory Care—there has never been a fellow from Guyana. I believe that Guyana will have the resources, and with assistance, could achieve the goal. My vision and goal started in 2016, and I want to achieve it in the next 10 years.

How it all started

The study abroad project was truly a goal and vision that came about after returning to Guyana after approximately 46 years. I was born in Guyana but left as a child and returned later and joined a mission group. In 2015, I began a personal journey of missionary service with the team of Bridge Global Medical Missions (BGMM) in Georgetown, Guyana. I was the first respiratory therapist to join the team.

I remember during the first few days in the hospitals I was told that there was “a lot of wheezing” in the EDs. Treating patients consisted of just administrating short-acting nebulizer treatments, but I remember being very impressed with the ICU at the main public hospital, Georgetown Public Hospital Corporation (GPHC), because they had the ventilators I could use. However, physicians only managed the patients while the nurses were left to monitor the ventilators and equipment, which they did not understand.

Study abroad and respiratory care

Then the vision of my project began, because I needed to show him the scope of the practice of a respiratory therapist. I asked Dr. Heyliger-Thomas of BGMM if she could assist me in promoting a study abroad program in Guyana with the Ministry of Health. It was very important for me to bring my students to Guyana for many reasons, the most important being the profession was needed there, and our students would be excellent representatives.

In 2015, the study “Introduction of spirometry into clinical practice in Georgetown, Guyana: quality and diagnostic outcomes” highlighted increased physician referral to the country’s only COPD/asthma clinic. I wanted to promote the importance of study abroad and international mission work, especially when promoting the care of asthma and the pulmonary patient, which I believe we did. The main project during study abroad was to test the school-aged children in Linden, thereby showing that there was undiagnosed asthma.

The effect of the CHEST Foundation grant

Applying for the CHEST Foundation community service grant was the largest grant I had ever attempted. Having a support system behind you is the most important piece of advice I can give to future grant applicants. I could not have completed my grant without our grant team at Texas State University. They truly had my back; and close to the deadline when it seemed insurmountable, they helped push me through it. The other piece of advice is to have a true vision and stick to that vision. The most difficult part of my project was the budget, prioritizing the things or people that I needed. Honestly, I needed help here, because for me, I needed everything. I had to make choices and leave some things out. I focused on what the actual need was for the many.

My ultimate goal for Guyana is to promote and show the need for respiratory care professionals to have that education offered at the University of Guyana as part of its allied health program and assist those in the application to the International Fellowship Program of the American Association of Respiratory Care—there has never been a fellow from Guyana. I believe that Guyana will have the resources, and with assistance, could achieve the goal. My vision and goal started in 2016, and I want to achieve it in the next 10 years.

How it all started

The study abroad project was truly a goal and vision that came about after returning to Guyana after approximately 46 years. I was born in Guyana but left as a child and returned later and joined a mission group. In 2015, I began a personal journey of missionary service with the team of Bridge Global Medical Missions (BGMM) in Georgetown, Guyana. I was the first respiratory therapist to join the team.

I remember during the first few days in the hospitals I was told that there was “a lot of wheezing” in the EDs. Treating patients consisted of just administrating short-acting nebulizer treatments, but I remember being very impressed with the ICU at the main public hospital, Georgetown Public Hospital Corporation (GPHC), because they had the ventilators I could use. However, physicians only managed the patients while the nurses were left to monitor the ventilators and equipment, which they did not understand.

Study abroad and respiratory care

Then the vision of my project began, because I needed to show him the scope of the practice of a respiratory therapist. I asked Dr. Heyliger-Thomas of BGMM if she could assist me in promoting a study abroad program in Guyana with the Ministry of Health. It was very important for me to bring my students to Guyana for many reasons, the most important being the profession was needed there, and our students would be excellent representatives.

In 2015, the study “Introduction of spirometry into clinical practice in Georgetown, Guyana: quality and diagnostic outcomes” highlighted increased physician referral to the country’s only COPD/asthma clinic. I wanted to promote the importance of study abroad and international mission work, especially when promoting the care of asthma and the pulmonary patient, which I believe we did. The main project during study abroad was to test the school-aged children in Linden, thereby showing that there was undiagnosed asthma.

The effect of the CHEST Foundation grant

Applying for the CHEST Foundation community service grant was the largest grant I had ever attempted. Having a support system behind you is the most important piece of advice I can give to future grant applicants. I could not have completed my grant without our grant team at Texas State University. They truly had my back; and close to the deadline when it seemed insurmountable, they helped push me through it. The other piece of advice is to have a true vision and stick to that vision. The most difficult part of my project was the budget, prioritizing the things or people that I needed. Honestly, I needed help here, because for me, I needed everything. I had to make choices and leave some things out. I focused on what the actual need was for the many.

My ultimate goal for Guyana is to promote and show the need for respiratory care professionals to have that education offered at the University of Guyana as part of its allied health program and assist those in the application to the International Fellowship Program of the American Association of Respiratory Care—there has never been a fellow from Guyana. I believe that Guyana will have the resources, and with assistance, could achieve the goal. My vision and goal started in 2016, and I want to achieve it in the next 10 years.

You are invited to attend this open meeting on April 16, held at the FDA White Oak Campus in Silver Spring, Md. (https://www.fda.gov/MedicalDevices/NewsEvents/WorkshopsConferences/ucm596147.htm). The FDA is soliciting ideas or opinions about criteria or processes for FDA review of medical devices to diagnose or treat sleep apnea. CHEST is represented by Dr. Neil Freedman ([email protected]) and Dr. Barbara Phillips ([email protected]) who also welcome your input by email prior to the meeting. Home testing, “apps,” and the criteria to diagnose sleep apnea and/or its resolution are among the topics to be discussed.

You are invited to attend this open meeting on April 16, held at the FDA White Oak Campus in Silver Spring, Md. (https://www.fda.gov/MedicalDevices/NewsEvents/WorkshopsConferences/ucm596147.htm). The FDA is soliciting ideas or opinions about criteria or processes for FDA review of medical devices to diagnose or treat sleep apnea. CHEST is represented by Dr. Neil Freedman ([email protected]) and Dr. Barbara Phillips ([email protected]) who also welcome your input by email prior to the meeting. Home testing, “apps,” and the criteria to diagnose sleep apnea and/or its resolution are among the topics to be discussed.

You are invited to attend this open meeting on April 16, held at the FDA White Oak Campus in Silver Spring, Md. (https://www.fda.gov/MedicalDevices/NewsEvents/WorkshopsConferences/ucm596147.htm). The FDA is soliciting ideas or opinions about criteria or processes for FDA review of medical devices to diagnose or treat sleep apnea. CHEST is represented by Dr. Neil Freedman ([email protected]) and Dr. Barbara Phillips ([email protected]) who also welcome your input by email prior to the meeting. Home testing, “apps,” and the criteria to diagnose sleep apnea and/or its resolution are among the topics to be discussed.

In 2018, ABIM is introducing the new Knowledge Check-In assessment option, an every-2-year assessment option serving as an alternative to the 10-year assessment model. Initially, for 2018, this option will be piloted for both Internal Medicine and Nephrology. In 2019, the Knowledge Check-In will expand to several additional specialties, including Pulmonary Disease. The remaining specialties, including Critical Care Medicine, will become available in 2020.

Previously, ABIM announced that physicians taking the Knowledge Check-In in 2018—the initial year it is offered in Internal Medicine or Nephrology—would have another chance to take it again 2 years later if they were unsuccessful, even if they were due to pass the exam that year. Based on feedback ABIM received from the physician community, this feature is now being extended to include all other Internal Medicine subspecialties in the future. Therefore, if a physician opts to take the Knowledge Check-In the first year it is offered in their subspecialty and is unsuccessful, they will get at least one additional opportunity to take it 2 years later.

For more information visit www.abim.org/checkin.

In 2018, ABIM is introducing the new Knowledge Check-In assessment option, an every-2-year assessment option serving as an alternative to the 10-year assessment model. Initially, for 2018, this option will be piloted for both Internal Medicine and Nephrology. In 2019, the Knowledge Check-In will expand to several additional specialties, including Pulmonary Disease. The remaining specialties, including Critical Care Medicine, will become available in 2020.

Previously, ABIM announced that physicians taking the Knowledge Check-In in 2018—the initial year it is offered in Internal Medicine or Nephrology—would have another chance to take it again 2 years later if they were unsuccessful, even if they were due to pass the exam that year. Based on feedback ABIM received from the physician community, this feature is now being extended to include all other Internal Medicine subspecialties in the future. Therefore, if a physician opts to take the Knowledge Check-In the first year it is offered in their subspecialty and is unsuccessful, they will get at least one additional opportunity to take it 2 years later.

For more information visit www.abim.org/checkin.

In 2018, ABIM is introducing the new Knowledge Check-In assessment option, an every-2-year assessment option serving as an alternative to the 10-year assessment model. Initially, for 2018, this option will be piloted for both Internal Medicine and Nephrology. In 2019, the Knowledge Check-In will expand to several additional specialties, including Pulmonary Disease. The remaining specialties, including Critical Care Medicine, will become available in 2020.

Previously, ABIM announced that physicians taking the Knowledge Check-In in 2018—the initial year it is offered in Internal Medicine or Nephrology—would have another chance to take it again 2 years later if they were unsuccessful, even if they were due to pass the exam that year. Based on feedback ABIM received from the physician community, this feature is now being extended to include all other Internal Medicine subspecialties in the future. Therefore, if a physician opts to take the Knowledge Check-In the first year it is offered in their subspecialty and is unsuccessful, they will get at least one additional opportunity to take it 2 years later.

For more information visit www.abim.org/checkin.

We are pleased to announce the completion of a new, multiyear strategic plan for CHEST. Over the past few years, key stakeholders have provided essential input, resulting in a plan that identifies a very focused set of priorities we’ll pursue to help achieve our overarching strategy. Having selected these priorities, which leverage our strengths and strategic advantages, we are committed to dedicating sufficient resources toward their accomplishment over the next several years.

Each year, the plan will be reviewed and modified to reflect changes to CHEST priorities.

A strategic plan is an important tool for our organization because it truly does focus and direct our efforts and resources. Guided by our 2013-2017 strategic plan, we were able to accomplish the following:

• Developed events, products, and services that produced meaningful education for the CHEST community and generated positive financial margins;
• Optimized our membership model to increase engagement of all clinicians on the health-care team;
• Enhanced our global presence through guideline development and increased educational offerings;
• Launched a new Association Management System (AMS) and made strides to becoming a data-driven organization;
• Built and moved into a new building that enhanced our ability to develop and host courses in the CHEST Innovation, Simulation, and Training Center;
• Increased our visibility through our rebrand as “CHEST”;
• Fostered relationships and collaborated with other organizations to promote lung health through the CHEST Foundation; and
• Met our budget goals and financial covenants with our bank, and increased the CHEST Foundation’s corpus for grants and awards.

This new strategic plan can be found on chestnet.org under the “About” section. As members of CHEST, we invite you to review what’s outlined and become familiar with what the plan encompasses. This plan provides details to help you understand the future direction of CHEST, and we know you’ll support us in these important endeavors.

We are pleased to announce the completion of a new, multiyear strategic plan for CHEST. Over the past few years, key stakeholders have provided essential input, resulting in a plan that identifies a very focused set of priorities we’ll pursue to help achieve our overarching strategy. Having selected these priorities, which leverage our strengths and strategic advantages, we are committed to dedicating sufficient resources toward their accomplishment over the next several years.

Each year, the plan will be reviewed and modified to reflect changes to CHEST priorities.

A strategic plan is an important tool for our organization because it truly does focus and direct our efforts and resources. Guided by our 2013-2017 strategic plan, we were able to accomplish the following:

• Developed events, products, and services that produced meaningful education for the CHEST community and generated positive financial margins;
• Optimized our membership model to increase engagement of all clinicians on the health-care team;
• Enhanced our global presence through guideline development and increased educational offerings;
• Launched a new Association Management System (AMS) and made strides to becoming a data-driven organization;
• Built and moved into a new building that enhanced our ability to develop and host courses in the CHEST Innovation, Simulation, and Training Center;
• Increased our visibility through our rebrand as “CHEST”;
• Fostered relationships and collaborated with other organizations to promote lung health through the CHEST Foundation; and
• Met our budget goals and financial covenants with our bank, and increased the CHEST Foundation’s corpus for grants and awards.

This new strategic plan can be found on chestnet.org under the “About” section. As members of CHEST, we invite you to review what’s outlined and become familiar with what the plan encompasses. This plan provides details to help you understand the future direction of CHEST, and we know you’ll support us in these important endeavors.

We are pleased to announce the completion of a new, multiyear strategic plan for CHEST. Over the past few years, key stakeholders have provided essential input, resulting in a plan that identifies a very focused set of priorities we’ll pursue to help achieve our overarching strategy. Having selected these priorities, which leverage our strengths and strategic advantages, we are committed to dedicating sufficient resources toward their accomplishment over the next several years.

Each year, the plan will be reviewed and modified to reflect changes to CHEST priorities.

A strategic plan is an important tool for our organization because it truly does focus and direct our efforts and resources. Guided by our 2013-2017 strategic plan, we were able to accomplish the following:

• Developed events, products, and services that produced meaningful education for the CHEST community and generated positive financial margins;
• Optimized our membership model to increase engagement of all clinicians on the health-care team;
• Enhanced our global presence through guideline development and increased educational offerings;
• Launched a new Association Management System (AMS) and made strides to becoming a data-driven organization;
• Built and moved into a new building that enhanced our ability to develop and host courses in the CHEST Innovation, Simulation, and Training Center;
• Increased our visibility through our rebrand as “CHEST”;
• Fostered relationships and collaborated with other organizations to promote lung health through the CHEST Foundation; and
• Met our budget goals and financial covenants with our bank, and increased the CHEST Foundation’s corpus for grants and awards.

This new strategic plan can be found on chestnet.org under the “About” section. As members of CHEST, we invite you to review what’s outlined and become familiar with what the plan encompasses. This plan provides details to help you understand the future direction of CHEST, and we know you’ll support us in these important endeavors.

ORLANDO – Preoperative electrocardiograms (EKGs) had no effect on management or perioperative complications in women undergoing benign hysterectomy over a 12-month period at a single medical center, according to a review of records.

Of 587 patients included in the review, 182 (31%) underwent EKG as part of their preoperative evaluation, and the majority of those were indicated according to institutional criteria (166; 28%) or National Institute for Health Care Excellence (NICE) guidelines (177; 30%), Nemi M. Shah, MD, reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

“EKG was indicated in 91% of these patients according to institutional criteria, and in 97% of patients per NICE criteria,” said Dr. Shah, a third-year resident at the University of Texas Southwestern Medical Center, Dallas.

By institutional criteria, hypertension was the most common indication (68% of cases), and by NICE criteria, American Society of Anesthesia class 2 physical status was the most common indication (80% of cases), she noted, adding that obesity, which was present in 70% of patients, was the most common comorbidity classifying patients with American Society of Anesthesia class 2 or above.

Of the 182 EKGs performed, findings were abnormal in 89, but further workup was pursued in only 16 patients, and included repeat EKG, echocardiogram, and/or stress testing and cardiology consultation. Surgical delays of 1 and 4 months occurred in 2 patients as a result of the additional workup, and ultimately, all planned hysterectomies were completed by the primary surgical team without changes in management, she said.

Perioperative complications occurred in two patients, and included nonspecific postinduction EKG changes that led to surgery being aborted in one patient who had left ventricular hypertrophy on the preoperative EKG, and failed extubation in a patient with airway edema whose preoperative EKG showed a nonacute inferior infarct.

For the first, cardiology was consulted and determined the findings to be benign; the patient underwent hysterectomy at a later date without complications. The second patient was taken to the surgical intensive care unit for management, Dr. Shah said.

[email protected]

SOURCE: Shah N et al. SGS 2018 Oral Poster 3.

ORLANDO – Preoperative electrocardiograms (EKGs) had no effect on management or perioperative complications in women undergoing benign hysterectomy over a 12-month period at a single medical center, according to a review of records.

Of 587 patients included in the review, 182 (31%) underwent EKG as part of their preoperative evaluation, and the majority of those were indicated according to institutional criteria (166; 28%) or National Institute for Health Care Excellence (NICE) guidelines (177; 30%), Nemi M. Shah, MD, reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

“EKG was indicated in 91% of these patients according to institutional criteria, and in 97% of patients per NICE criteria,” said Dr. Shah, a third-year resident at the University of Texas Southwestern Medical Center, Dallas.

By institutional criteria, hypertension was the most common indication (68% of cases), and by NICE criteria, American Society of Anesthesia class 2 physical status was the most common indication (80% of cases), she noted, adding that obesity, which was present in 70% of patients, was the most common comorbidity classifying patients with American Society of Anesthesia class 2 or above.

Of the 182 EKGs performed, findings were abnormal in 89, but further workup was pursued in only 16 patients, and included repeat EKG, echocardiogram, and/or stress testing and cardiology consultation. Surgical delays of 1 and 4 months occurred in 2 patients as a result of the additional workup, and ultimately, all planned hysterectomies were completed by the primary surgical team without changes in management, she said.

Perioperative complications occurred in two patients, and included nonspecific postinduction EKG changes that led to surgery being aborted in one patient who had left ventricular hypertrophy on the preoperative EKG, and failed extubation in a patient with airway edema whose preoperative EKG showed a nonacute inferior infarct.

For the first, cardiology was consulted and determined the findings to be benign; the patient underwent hysterectomy at a later date without complications. The second patient was taken to the surgical intensive care unit for management, Dr. Shah said.

[email protected]

SOURCE: Shah N et al. SGS 2018 Oral Poster 3.

ORLANDO – Preoperative electrocardiograms (EKGs) had no effect on management or perioperative complications in women undergoing benign hysterectomy over a 12-month period at a single medical center, according to a review of records.

Of 587 patients included in the review, 182 (31%) underwent EKG as part of their preoperative evaluation, and the majority of those were indicated according to institutional criteria (166; 28%) or National Institute for Health Care Excellence (NICE) guidelines (177; 30%), Nemi M. Shah, MD, reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

“EKG was indicated in 91% of these patients according to institutional criteria, and in 97% of patients per NICE criteria,” said Dr. Shah, a third-year resident at the University of Texas Southwestern Medical Center, Dallas.

By institutional criteria, hypertension was the most common indication (68% of cases), and by NICE criteria, American Society of Anesthesia class 2 physical status was the most common indication (80% of cases), she noted, adding that obesity, which was present in 70% of patients, was the most common comorbidity classifying patients with American Society of Anesthesia class 2 or above.

Of the 182 EKGs performed, findings were abnormal in 89, but further workup was pursued in only 16 patients, and included repeat EKG, echocardiogram, and/or stress testing and cardiology consultation. Surgical delays of 1 and 4 months occurred in 2 patients as a result of the additional workup, and ultimately, all planned hysterectomies were completed by the primary surgical team without changes in management, she said.

Perioperative complications occurred in two patients, and included nonspecific postinduction EKG changes that led to surgery being aborted in one patient who had left ventricular hypertrophy on the preoperative EKG, and failed extubation in a patient with airway edema whose preoperative EKG showed a nonacute inferior infarct.

For the first, cardiology was consulted and determined the findings to be benign; the patient underwent hysterectomy at a later date without complications. The second patient was taken to the surgical intensive care unit for management, Dr. Shah said.

[email protected]

SOURCE: Shah N et al. SGS 2018 Oral Poster 3.

NEW ORLEANS – Adding the anti-HER2 antibody trastuzumab to a standard chemotherapy regimen produced markedly improved responses among patients with an advanced stage or recurrent uterine serous carcinoma that also overexpressed the HER2/neu cell receptor protein in a controlled, multicenter, phase 2 study with 58 evaluable patients.

The 30 patients who received trastuzumab along with carboplatin plus paclitaxel had a median progression-free survival of 12.6 months compared with 8.0 months among the 28 control patients who received only carboplatin plus paclitaxel, a hazard reduction of 56% with trastuzumab that was statistically significant (P = .0052), Alessandro D. Santin, MD, said at the annual meeting of the Society of Gynecologic Oncology.

In the subgroup of 41 patients with advanced (not recurrent) uterine serous carcinoma (USC) the incremental difference in median progression-free survival among patients treated with trastuzumab was 8.6 months, based on a 17.9-month duration in the 20 patients who received trastuzumab and 9.3 months in 20 control patients on chemotherapy only (P = .013).

Mitchel L. Zoler/MDedge News

[email protected]

SOURCE: Fader A et al. Abstract 22. J Clin Oncol. 2018 Mar 27. doi: 10.1200/JCO.2017.76.5966.

NEW ORLEANS – Adding the anti-HER2 antibody trastuzumab to a standard chemotherapy regimen produced markedly improved responses among patients with an advanced stage or recurrent uterine serous carcinoma that also overexpressed the HER2/neu cell receptor protein in a controlled, multicenter, phase 2 study with 58 evaluable patients.

The 30 patients who received trastuzumab along with carboplatin plus paclitaxel had a median progression-free survival of 12.6 months compared with 8.0 months among the 28 control patients who received only carboplatin plus paclitaxel, a hazard reduction of 56% with trastuzumab that was statistically significant (P = .0052), Alessandro D. Santin, MD, said at the annual meeting of the Society of Gynecologic Oncology.

In the subgroup of 41 patients with advanced (not recurrent) uterine serous carcinoma (USC) the incremental difference in median progression-free survival among patients treated with trastuzumab was 8.6 months, based on a 17.9-month duration in the 20 patients who received trastuzumab and 9.3 months in 20 control patients on chemotherapy only (P = .013).

Mitchel L. Zoler/MDedge News

[email protected]

SOURCE: Fader A et al. Abstract 22. J Clin Oncol. 2018 Mar 27. doi: 10.1200/JCO.2017.76.5966.

NEW ORLEANS – Adding the anti-HER2 antibody trastuzumab to a standard chemotherapy regimen produced markedly improved responses among patients with an advanced stage or recurrent uterine serous carcinoma that also overexpressed the HER2/neu cell receptor protein in a controlled, multicenter, phase 2 study with 58 evaluable patients.

The 30 patients who received trastuzumab along with carboplatin plus paclitaxel had a median progression-free survival of 12.6 months compared with 8.0 months among the 28 control patients who received only carboplatin plus paclitaxel, a hazard reduction of 56% with trastuzumab that was statistically significant (P = .0052), Alessandro D. Santin, MD, said at the annual meeting of the Society of Gynecologic Oncology.

In the subgroup of 41 patients with advanced (not recurrent) uterine serous carcinoma (USC) the incremental difference in median progression-free survival among patients treated with trastuzumab was 8.6 months, based on a 17.9-month duration in the 20 patients who received trastuzumab and 9.3 months in 20 control patients on chemotherapy only (P = .013).

Mitchel L. Zoler/MDedge News

[email protected]

SOURCE: Fader A et al. Abstract 22. J Clin Oncol. 2018 Mar 27. doi: 10.1200/JCO.2017.76.5966.

In this interview, Dr David Henry, MD, the Editor-in-Chief of JCSO, and David Steensma, MD, of the Dana-Farber Cancer Institute in Boston, talk about myelodysplasic syndromes, from diagnosis, evaluation, and etiologies, to therapy options and molecular sequencing.

Listen to the podcast below, or click on the PDF icon at the top of this introduction to read a transcript of the interview.​

In this interview, Dr David Henry, MD, the Editor-in-Chief of JCSO, and David Steensma, MD, of the Dana-Farber Cancer Institute in Boston, talk about myelodysplasic syndromes, from diagnosis, evaluation, and etiologies, to therapy options and molecular sequencing.

Listen to the podcast below, or click on the PDF icon at the top of this introduction to read a transcript of the interview.​

In this interview, Dr David Henry, MD, the Editor-in-Chief of JCSO, and David Steensma, MD, of the Dana-Farber Cancer Institute in Boston, talk about myelodysplasic syndromes, from diagnosis, evaluation, and etiologies, to therapy options and molecular sequencing.

Listen to the podcast below, or click on the PDF icon at the top of this introduction to read a transcript of the interview.​

CHICAGO – It’s a good idea to look for eating disorders in young, athletic women who present with oligomenorrhea; they are at high risk for them and can be helped with estrogen replacement, especially with a patch, according to investigators from Massachusetts General Hospital, Boston.

Estrogen replacement will also help with stress fractures and other bone problems, but young, athletic women might resist the idea. They worry that it might hurt their performance and are often proud that they work out hard enough to stop their periods, according to investigator Vibha Singhal, MD, a pediatric endocrinologist and eating disorder specialist at the hospital.

M. Alexander Otto/MDedge News

Seventy OA women were then randomized to three groups: 25 to physiological estrogen replacement with an estradiol patch and cyclic progesterone for 12 days/month; 19 to replacement with contraceptive pills on the standard monthly schedule; and 26 to no replacement.

Over 12 months, women on the patch dropped their drive for thinness, body dissatisfaction, and uncontrolled eating scores. Body dissatisfaction scores on the Eating Disorder Inventory–2, for example, fell about two points, compared with staying about the same in the pill group and increasing by about two points in the no-estrogen group.

The pill seemed to help a bit on some measures, too, but the benefit of the pill versus that of no estrogen wasn’t generally statistically significant. Meanwhile, symptoms worsened in women who didn’t get estrogen. “The practice right now is the pill. We are shifting our practice with these data to the patch,” Dr. Singhal said.

Overall, “these findings emphasize the importance of normalizing estrogen levels in this population,” she and her colleagues concluded.

It’s a mystery why estrogen helps with eating disorders. Maybe it has something to do with the estrogen receptors in the appetite centers of the brain. Maybe the patch works better than the pill because there’s no first-pass through the liver, Dr. Singhal said.

Subjects were aged about 20 years, on average. OA women had a mean body mass index of 20.6 kg/m² and a mean estradiol level of 45 pg/mL. Subjects with regular periods had mean BMIs of about 22 kg/m²; mean estradiol levels were 70.2 pg/mL in eumenorrheic athletes and 83.6 pg/mL in nonathletic women.

The work was funded by the National Institutes of Health. The investigators didn’t have any relevant disclosures.

SOURCE: Plessow F et al. ENDO 2018, Abstract SAT-290.

CHICAGO – It’s a good idea to look for eating disorders in young, athletic women who present with oligomenorrhea; they are at high risk for them and can be helped with estrogen replacement, especially with a patch, according to investigators from Massachusetts General Hospital, Boston.

Estrogen replacement will also help with stress fractures and other bone problems, but young, athletic women might resist the idea. They worry that it might hurt their performance and are often proud that they work out hard enough to stop their periods, according to investigator Vibha Singhal, MD, a pediatric endocrinologist and eating disorder specialist at the hospital.

M. Alexander Otto/MDedge News

Seventy OA women were then randomized to three groups: 25 to physiological estrogen replacement with an estradiol patch and cyclic progesterone for 12 days/month; 19 to replacement with contraceptive pills on the standard monthly schedule; and 26 to no replacement.

Over 12 months, women on the patch dropped their drive for thinness, body dissatisfaction, and uncontrolled eating scores. Body dissatisfaction scores on the Eating Disorder Inventory–2, for example, fell about two points, compared with staying about the same in the pill group and increasing by about two points in the no-estrogen group.

The pill seemed to help a bit on some measures, too, but the benefit of the pill versus that of no estrogen wasn’t generally statistically significant. Meanwhile, symptoms worsened in women who didn’t get estrogen. “The practice right now is the pill. We are shifting our practice with these data to the patch,” Dr. Singhal said.

Overall, “these findings emphasize the importance of normalizing estrogen levels in this population,” she and her colleagues concluded.

It’s a mystery why estrogen helps with eating disorders. Maybe it has something to do with the estrogen receptors in the appetite centers of the brain. Maybe the patch works better than the pill because there’s no first-pass through the liver, Dr. Singhal said.

Subjects were aged about 20 years, on average. OA women had a mean body mass index of 20.6 kg/m² and a mean estradiol level of 45 pg/mL. Subjects with regular periods had mean BMIs of about 22 kg/m²; mean estradiol levels were 70.2 pg/mL in eumenorrheic athletes and 83.6 pg/mL in nonathletic women.

The work was funded by the National Institutes of Health. The investigators didn’t have any relevant disclosures.

SOURCE: Plessow F et al. ENDO 2018, Abstract SAT-290.

CHICAGO – It’s a good idea to look for eating disorders in young, athletic women who present with oligomenorrhea; they are at high risk for them and can be helped with estrogen replacement, especially with a patch, according to investigators from Massachusetts General Hospital, Boston.

Estrogen replacement will also help with stress fractures and other bone problems, but young, athletic women might resist the idea. They worry that it might hurt their performance and are often proud that they work out hard enough to stop their periods, according to investigator Vibha Singhal, MD, a pediatric endocrinologist and eating disorder specialist at the hospital.

M. Alexander Otto/MDedge News

Seventy OA women were then randomized to three groups: 25 to physiological estrogen replacement with an estradiol patch and cyclic progesterone for 12 days/month; 19 to replacement with contraceptive pills on the standard monthly schedule; and 26 to no replacement.

Over 12 months, women on the patch dropped their drive for thinness, body dissatisfaction, and uncontrolled eating scores. Body dissatisfaction scores on the Eating Disorder Inventory–2, for example, fell about two points, compared with staying about the same in the pill group and increasing by about two points in the no-estrogen group.

The pill seemed to help a bit on some measures, too, but the benefit of the pill versus that of no estrogen wasn’t generally statistically significant. Meanwhile, symptoms worsened in women who didn’t get estrogen. “The practice right now is the pill. We are shifting our practice with these data to the patch,” Dr. Singhal said.

Overall, “these findings emphasize the importance of normalizing estrogen levels in this population,” she and her colleagues concluded.

It’s a mystery why estrogen helps with eating disorders. Maybe it has something to do with the estrogen receptors in the appetite centers of the brain. Maybe the patch works better than the pill because there’s no first-pass through the liver, Dr. Singhal said.

Subjects were aged about 20 years, on average. OA women had a mean body mass index of 20.6 kg/m² and a mean estradiol level of 45 pg/mL. Subjects with regular periods had mean BMIs of about 22 kg/m²; mean estradiol levels were 70.2 pg/mL in eumenorrheic athletes and 83.6 pg/mL in nonathletic women.

The work was funded by the National Institutes of Health. The investigators didn’t have any relevant disclosures.

SOURCE: Plessow F et al. ENDO 2018, Abstract SAT-290.