Bhatia, R.S., et al, JAMA Intern Med 177(9):1326, September 1, 2017

BACKGROUND: Both the USPSTF and the Choosing Wisely campaign recommend against routine ECG screening in low-risk patients. A routine ECG at the time of an annual physical in this population is considered to be an example of low-value care.

METHODS: The authors, coordinated at Women’s College Hospital in Toronto, examined the frequency of ECGs after annual health examinations in low-risk adults seen in primary care. Scrutiny of provincial databases identified 3,629,859 patients who had an annual exam in 2010-2015, excluding those with a history of cardiac disease or high-risk criteria. The primary outcomes were receipt of an ECG within 30 days after the annual exam and downstream cardiac care (cardiac testing or consultations) within 90 days.

RESULTS: Just over one-fifth of the patients (21.5%) had an ECG following the annual exam. Rates of ECG ordering varied widely among regions (from 0.7% to 24.4%), among the 679 primary care practices (1.8% to 76.1% of patients), and among the 8036 primary care physicians (1.1% to 94.9%). Receipt of an ECG was significantly more likely for older patients with certain comorbidities (cancer, rheumatologic disease) and less likely for rural residents. Physician traits associated with ECG ordering included male sex, medical school in an international program, and practicing for 30 years or more; in fact, practice-level variation explained 22% of the variation in ECG use. Patients having (versus not having) ECGs had significantly higher rates of cardiac consultations (odds ratio [OR] 5.38; 95% CI 5.24- 5.52) and cardiac tests (transthoracic echocardiogram, OR 7.1; stress test, OR 6.5; and nuclear stress test, OR 4.2). Despite this, one-year follow-up was consistent with low rates of cardiac morbidity and mortality in both groups.

CONCLUSIONS: Routine performance of an ECG appears to be relatively common in low-risk patients and increases the likelihood of unnecessary downstream testing. 37 references ([email protected] – no reprints)

Bhatia, R.S., et al, JAMA Intern Med 177(9):1326, September 1, 2017

BACKGROUND: Both the USPSTF and the Choosing Wisely campaign recommend against routine ECG screening in low-risk patients. A routine ECG at the time of an annual physical in this population is considered to be an example of low-value care.

METHODS: The authors, coordinated at Women’s College Hospital in Toronto, examined the frequency of ECGs after annual health examinations in low-risk adults seen in primary care. Scrutiny of provincial databases identified 3,629,859 patients who had an annual exam in 2010-2015, excluding those with a history of cardiac disease or high-risk criteria. The primary outcomes were receipt of an ECG within 30 days after the annual exam and downstream cardiac care (cardiac testing or consultations) within 90 days.

RESULTS: Just over one-fifth of the patients (21.5%) had an ECG following the annual exam. Rates of ECG ordering varied widely among regions (from 0.7% to 24.4%), among the 679 primary care practices (1.8% to 76.1% of patients), and among the 8036 primary care physicians (1.1% to 94.9%). Receipt of an ECG was significantly more likely for older patients with certain comorbidities (cancer, rheumatologic disease) and less likely for rural residents. Physician traits associated with ECG ordering included male sex, medical school in an international program, and practicing for 30 years or more; in fact, practice-level variation explained 22% of the variation in ECG use. Patients having (versus not having) ECGs had significantly higher rates of cardiac consultations (odds ratio [OR] 5.38; 95% CI 5.24- 5.52) and cardiac tests (transthoracic echocardiogram, OR 7.1; stress test, OR 6.5; and nuclear stress test, OR 4.2). Despite this, one-year follow-up was consistent with low rates of cardiac morbidity and mortality in both groups.

CONCLUSIONS: Routine performance of an ECG appears to be relatively common in low-risk patients and increases the likelihood of unnecessary downstream testing. 37 references ([email protected] – no reprints)

Bhatia, R.S., et al, JAMA Intern Med 177(9):1326, September 1, 2017

BACKGROUND: Both the USPSTF and the Choosing Wisely campaign recommend against routine ECG screening in low-risk patients. A routine ECG at the time of an annual physical in this population is considered to be an example of low-value care.

METHODS: The authors, coordinated at Women’s College Hospital in Toronto, examined the frequency of ECGs after annual health examinations in low-risk adults seen in primary care. Scrutiny of provincial databases identified 3,629,859 patients who had an annual exam in 2010-2015, excluding those with a history of cardiac disease or high-risk criteria. The primary outcomes were receipt of an ECG within 30 days after the annual exam and downstream cardiac care (cardiac testing or consultations) within 90 days.

RESULTS: Just over one-fifth of the patients (21.5%) had an ECG following the annual exam. Rates of ECG ordering varied widely among regions (from 0.7% to 24.4%), among the 679 primary care practices (1.8% to 76.1% of patients), and among the 8036 primary care physicians (1.1% to 94.9%). Receipt of an ECG was significantly more likely for older patients with certain comorbidities (cancer, rheumatologic disease) and less likely for rural residents. Physician traits associated with ECG ordering included male sex, medical school in an international program, and practicing for 30 years or more; in fact, practice-level variation explained 22% of the variation in ECG use. Patients having (versus not having) ECGs had significantly higher rates of cardiac consultations (odds ratio [OR] 5.38; 95% CI 5.24- 5.52) and cardiac tests (transthoracic echocardiogram, OR 7.1; stress test, OR 6.5; and nuclear stress test, OR 4.2). Despite this, one-year follow-up was consistent with low rates of cardiac morbidity and mortality in both groups.

CONCLUSIONS: Routine performance of an ECG appears to be relatively common in low-risk patients and increases the likelihood of unnecessary downstream testing. 37 references ([email protected] – no reprints)

LAS VEGAS – Minimally invasive colon surgery has many advantages over an open procedure with respect to complications and patient recovery, but as surgeons are well aware, sometimes conversion cannot and should not be avoided. “It’s going to happen, and if you’re not converting any of your patients, then you’re probably not being aggressive enough,” said Bradley R. Davis, MD, FACS, at a talk he gave on the topic at the Annual Minimally Invasive Surgery Symposium (MISS) 2018 by Global Academy for Medical Education.

Dr. Davis discussed some of the most common reasons for conversion to open surgery and strategies to try to reduce the incidence. He is the chief of general surgery and the chief of rectal and rectal surgery at Carolinas Medical Center, Charlotte, N.C.

A 2017 survey of 41,417 left hemicolectomy and sigmoidectomy procedures revealed that 63.4% were attempted laparoscopically, and the rate of conversion to an open procedure was 13.4% (JSLS. 2017 Jul-Sep;21[3]:e2017.00036). “I think that if your conversation rate is between 5% and 15%, [it’s] perfectly acceptable,” said Dr. Davis.

He suggested that surgeons should be willing to consider an increasing number of cases for minimally invasive surgery, despite the risk of conversion. By taking some precautions and being aware of which cases are most likely to lead to conversion, surgeons can potentially reduce the conversion rate – or at least lessen the effects it can have on patients and on costs.

LAS VEGAS – Minimally invasive colon surgery has many advantages over an open procedure with respect to complications and patient recovery, but as surgeons are well aware, sometimes conversion cannot and should not be avoided. “It’s going to happen, and if you’re not converting any of your patients, then you’re probably not being aggressive enough,” said Bradley R. Davis, MD, FACS, at a talk he gave on the topic at the Annual Minimally Invasive Surgery Symposium (MISS) 2018 by Global Academy for Medical Education.

Dr. Davis discussed some of the most common reasons for conversion to open surgery and strategies to try to reduce the incidence. He is the chief of general surgery and the chief of rectal and rectal surgery at Carolinas Medical Center, Charlotte, N.C.

A 2017 survey of 41,417 left hemicolectomy and sigmoidectomy procedures revealed that 63.4% were attempted laparoscopically, and the rate of conversion to an open procedure was 13.4% (JSLS. 2017 Jul-Sep;21[3]:e2017.00036). “I think that if your conversation rate is between 5% and 15%, [it’s] perfectly acceptable,” said Dr. Davis.

He suggested that surgeons should be willing to consider an increasing number of cases for minimally invasive surgery, despite the risk of conversion. By taking some precautions and being aware of which cases are most likely to lead to conversion, surgeons can potentially reduce the conversion rate – or at least lessen the effects it can have on patients and on costs.

LAS VEGAS – Minimally invasive colon surgery has many advantages over an open procedure with respect to complications and patient recovery, but as surgeons are well aware, sometimes conversion cannot and should not be avoided. “It’s going to happen, and if you’re not converting any of your patients, then you’re probably not being aggressive enough,” said Bradley R. Davis, MD, FACS, at a talk he gave on the topic at the Annual Minimally Invasive Surgery Symposium (MISS) 2018 by Global Academy for Medical Education.

Dr. Davis discussed some of the most common reasons for conversion to open surgery and strategies to try to reduce the incidence. He is the chief of general surgery and the chief of rectal and rectal surgery at Carolinas Medical Center, Charlotte, N.C.

A 2017 survey of 41,417 left hemicolectomy and sigmoidectomy procedures revealed that 63.4% were attempted laparoscopically, and the rate of conversion to an open procedure was 13.4% (JSLS. 2017 Jul-Sep;21[3]:e2017.00036). “I think that if your conversation rate is between 5% and 15%, [it’s] perfectly acceptable,” said Dr. Davis.

He suggested that surgeons should be willing to consider an increasing number of cases for minimally invasive surgery, despite the risk of conversion. By taking some precautions and being aware of which cases are most likely to lead to conversion, surgeons can potentially reduce the conversion rate – or at least lessen the effects it can have on patients and on costs.

When I was a kid, there used to be a radio show by Paul Harvey called “The Rest of the Story.” I loved this show because there was always a big back story behind the happy ending. And that’s how I feel now, it is indeed a happy day, and glad we should be, because the modifier 25 reductions have been rescinded by Anthem. But there is much more to the story, so here is the back story.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

When I was a kid, there used to be a radio show by Paul Harvey called “The Rest of the Story.” I loved this show because there was always a big back story behind the happy ending. And that’s how I feel now, it is indeed a happy day, and glad we should be, because the modifier 25 reductions have been rescinded by Anthem. But there is much more to the story, so here is the back story.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

When I was a kid, there used to be a radio show by Paul Harvey called “The Rest of the Story.” I loved this show because there was always a big back story behind the happy ending. And that’s how I feel now, it is indeed a happy day, and glad we should be, because the modifier 25 reductions have been rescinded by Anthem. But there is much more to the story, so here is the back story.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

Disaster Response

A Natural Disaster Creates Nationwide Threat

Hurricane Maria devastated Puerto Rico in late September 2017, and the lessons learned endure as the storm exposed the vulnerability of an increasingly interconnected and fragile medical community across the continental United States. According to the US Food and Drug Administration (FDA), Puerto Rico manufactures more drug products than any US state and just under 10% of all drugs consumed by Americans, some of which do not have therapeutic alternatives. In addition, certain medical devices are only produced in Puerto Rico. The humanitarian crisis caused by Hurricane Maria consequently created critical medication and medical device shortages across the United States (FDA. https://www.fda.gov/NewsEvents/. Accessed Feb 01, 2018).

The disruption and disorganization caused by Hurricane Maria was perhaps best exemplified by the resultant shortage of small-volume 0.9% saline injection bags, which coincided with a particularly bad flu season. The FDA temporarily allowed import of saline bags from outside the United States while concurrently expediting the approval of IV solutions from new manufacturers. The American Society for Health-System Pharmacists (ASHP), meanwhile, contributed guidance on managing fluid shortages (ASHP. https://www.ashp.org/Drug-Shortages/. Accessed Feb 01, 2018).

Hurricane Maria was a wake-up call for medical professionals across the United States to modernize institutional procedures and to develop contingency plans to deal with medication shortages, particularly IV fluids, since this is a recurring problem across the United States since 2014. Ultimately, the goal of health-care providers across the United States is to manage natural catastrophes, however distant, by effectively planning for and adapting to medical product shortages to ensure patient care is not interrupted and that critical shortages remain invisible to patients themselves.

Cristian Madar, MD
Steering Committee Member

Practice Operations

Are All Regulations Well Thought Out? Point of View!

Current medicine is complex, with patients presenting in the ICU with multiorgan dysfunction. The art and science of medicine is being replaced by protocolized medicine. To help streamline the care, societies and colleges are coming up with guidelines. The guideline, though, changes from year to year what has been practiced in the past has been obsolete, and what is current may not hold true in the future. With increasing health-care costs affecting physician and hospital practices, innovations are being undertaken on a daily basis. The payers, on the other hand, are trying to come up with regulations, whether one likes it or not, that have become the beacon for penalty and reward. Sometimes those regulations conflict with what is sound judgment and prudent care, cornering the providers in the box with unnecessary penalties.

Approximately 250,000 bloodstream infections occur in the United States yearly, mostly attributed to the presence of intravascular devices. The rate of central line-associated blood stream infection (CLABSI) in the United States is 0.8 per 1,000 central line days. The desirable rate is zero rate of CLABSI. The hospitals are being pushed to be prudent with the use of central lines and removal if not needed. The technique and sterile field along with appropriate innovation in dressing technique have been effective in reducing the CLABSI by 46% from 2008 to 2013. The hospitals and ICUs are being very vigilant in trying to avoid CLABSI and are striving to achieve the goal of a zero percentage CLABSI rate, leading to almost a state of paranoia. The efforts are being undertaken in many institutions to get all the cultures on admission to identify the organism on admission so as to be designated as a bloodstream infection (BSI) due to other causes and to avoid the CLABSI attribution. The CLABSI attribution follows a complex algorithm with no waiver for the exception outside the strict definition that is changing (The 2015 definition change resulted in an 83% increase in CLABSI rate.).

Adel Bassily-Marcus, MD, FCCP
Chair

Salim Surani, MD, FCCP
Vice-Chair

References

Grimes L, McMullen KM, Leone C, et al. Impact of 2015 National Healthcare Safety Network (NHSN) Definition Changes on Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection (CLABSI) at a Large Healthcare System. Open Forum Infectious Diseases. 2016;3(suppl1):946-946.

Transplant

Radius of Change: Will Expanding Organ Sharing Beyond Donor Service Area Enhance Access in Lung Transplantation?

In November 2017, the US Department of Health and Human Services (HHS) prompted the United Network for Organ Sharing Organ Procurement and Transplant Network (UNOS/OPTN) to reconsider geographical boundaries of donor allocation. The impetus for change was driven by a recent litigation and data that challenged the current organ allocation algorithm on the premise that it overlooked potential high acuity candidates listed at centers outside the primary DSA (donor service area) of the donor hospital, in favor of less sick local recipients. In response, the UNOS/OPTN Executive Committee recommended the adoption of a 250-nautical mile radius from the donor hospital in lieu of the DSA as the first circle or zone A of distribution for lungs. The putative merits of this change, due to last an experimental year, is intended to provide sicker candidates with access to a broader geographic range of donors. Its impact will then be evaluated by the Thoracic Organ Transplantation Committee to make further recommendations, including possibly extending zone A to 500 miles.

The extended geographical limits have organ-specific implications. In contrast to other organs, constraints of cold ischemia limit the duration within which lungs and hearts must be transplanted. Indeed, this latter point is the basis for using a radius from the donor hospital, rather than the region, as the first circle of distribution. Furthermore, DSAs vary substantially in both size and population and performance, leading to considerable variation in access to organs for candidates based on their region of residence. Currently, more than 50% of the lung allocation in the United States occurs locally to recipients with lung allocation scores (LAS) less than 50 (Iribarne et al. Chest. 2009;135[4]:923). In addition, waiting time mortality remains high and actuarial survival remains low for those with higher LAS (Russo et al. Chest. 2010;137[3]:651). The new recommendations broaden the concentric circle approach and potentially provide enhanced access for the sickest candidates on the waiting list. However, this may increase duration of waitlist time for those with lower LAS, certain disease groups such as COPD and those listed in more conservative centers. It may conversely, however, drive transplantation in the sickest patients and increase the use of bridging strategies in high volume centers and those with ECMO capabilities, as there will now be a greater reassurance of donor offers with the wider catchment area. The implications are unclear at this time, and over the next year, the efficacy and the potential unintended consequences of this newly implemented directive should become more apparent.

Anupam Kumar, MD
Fellow-in-Training Member

J. W. Awori Hayanga, MD, MPH
Steering Committee Member

Women’s Health

Lung Cancer and Steroid Hormones: An Evolving Paradigm

Lung cancer remains to be the second most common cancer and the leading cause of cancer-related mortality in women. The risk for developing lung cancer in women is 1/17 and increases with age and smoking history. Women with stage I NSLC have better prognosis after surgical treatment compared with men (Graham et al. South Med J. 2013;106[10]:582); however. they are less likely to have undergone a low dose screening CT scan, even after meeting high risk criteria (Lamb et al. Chest. 2017;152[suppl]A623). The prognosis in advanced stage lung cancer at diagnosis does not differ among the genders or age groups (Santoro et al. J Bras Pneumol. 2017;43[6]:431).

There is increasing interest in the role of steroid hormones in lung biology in health and disease with estrogen and progesterone receptors identified in both healthy and malignant tissue. The role of hormone receptors as a prognostication tool and a therapeutic target is being actively investigated.

Fidaa Shaib, MD, FCCP
Steering Committee Member

Ali Jiwani, MD
NetWork Member

Disaster Response

A Natural Disaster Creates Nationwide Threat

Hurricane Maria devastated Puerto Rico in late September 2017, and the lessons learned endure as the storm exposed the vulnerability of an increasingly interconnected and fragile medical community across the continental United States. According to the US Food and Drug Administration (FDA), Puerto Rico manufactures more drug products than any US state and just under 10% of all drugs consumed by Americans, some of which do not have therapeutic alternatives. In addition, certain medical devices are only produced in Puerto Rico. The humanitarian crisis caused by Hurricane Maria consequently created critical medication and medical device shortages across the United States (FDA. https://www.fda.gov/NewsEvents/. Accessed Feb 01, 2018).

The disruption and disorganization caused by Hurricane Maria was perhaps best exemplified by the resultant shortage of small-volume 0.9% saline injection bags, which coincided with a particularly bad flu season. The FDA temporarily allowed import of saline bags from outside the United States while concurrently expediting the approval of IV solutions from new manufacturers. The American Society for Health-System Pharmacists (ASHP), meanwhile, contributed guidance on managing fluid shortages (ASHP. https://www.ashp.org/Drug-Shortages/. Accessed Feb 01, 2018).

Hurricane Maria was a wake-up call for medical professionals across the United States to modernize institutional procedures and to develop contingency plans to deal with medication shortages, particularly IV fluids, since this is a recurring problem across the United States since 2014. Ultimately, the goal of health-care providers across the United States is to manage natural catastrophes, however distant, by effectively planning for and adapting to medical product shortages to ensure patient care is not interrupted and that critical shortages remain invisible to patients themselves.

Cristian Madar, MD
Steering Committee Member

Practice Operations

Are All Regulations Well Thought Out? Point of View!

Current medicine is complex, with patients presenting in the ICU with multiorgan dysfunction. The art and science of medicine is being replaced by protocolized medicine. To help streamline the care, societies and colleges are coming up with guidelines. The guideline, though, changes from year to year what has been practiced in the past has been obsolete, and what is current may not hold true in the future. With increasing health-care costs affecting physician and hospital practices, innovations are being undertaken on a daily basis. The payers, on the other hand, are trying to come up with regulations, whether one likes it or not, that have become the beacon for penalty and reward. Sometimes those regulations conflict with what is sound judgment and prudent care, cornering the providers in the box with unnecessary penalties.

Approximately 250,000 bloodstream infections occur in the United States yearly, mostly attributed to the presence of intravascular devices. The rate of central line-associated blood stream infection (CLABSI) in the United States is 0.8 per 1,000 central line days. The desirable rate is zero rate of CLABSI. The hospitals are being pushed to be prudent with the use of central lines and removal if not needed. The technique and sterile field along with appropriate innovation in dressing technique have been effective in reducing the CLABSI by 46% from 2008 to 2013. The hospitals and ICUs are being very vigilant in trying to avoid CLABSI and are striving to achieve the goal of a zero percentage CLABSI rate, leading to almost a state of paranoia. The efforts are being undertaken in many institutions to get all the cultures on admission to identify the organism on admission so as to be designated as a bloodstream infection (BSI) due to other causes and to avoid the CLABSI attribution. The CLABSI attribution follows a complex algorithm with no waiver for the exception outside the strict definition that is changing (The 2015 definition change resulted in an 83% increase in CLABSI rate.).

Adel Bassily-Marcus, MD, FCCP
Chair

Salim Surani, MD, FCCP
Vice-Chair

References

Grimes L, McMullen KM, Leone C, et al. Impact of 2015 National Healthcare Safety Network (NHSN) Definition Changes on Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection (CLABSI) at a Large Healthcare System. Open Forum Infectious Diseases. 2016;3(suppl1):946-946.

Transplant

Radius of Change: Will Expanding Organ Sharing Beyond Donor Service Area Enhance Access in Lung Transplantation?

In November 2017, the US Department of Health and Human Services (HHS) prompted the United Network for Organ Sharing Organ Procurement and Transplant Network (UNOS/OPTN) to reconsider geographical boundaries of donor allocation. The impetus for change was driven by a recent litigation and data that challenged the current organ allocation algorithm on the premise that it overlooked potential high acuity candidates listed at centers outside the primary DSA (donor service area) of the donor hospital, in favor of less sick local recipients. In response, the UNOS/OPTN Executive Committee recommended the adoption of a 250-nautical mile radius from the donor hospital in lieu of the DSA as the first circle or zone A of distribution for lungs. The putative merits of this change, due to last an experimental year, is intended to provide sicker candidates with access to a broader geographic range of donors. Its impact will then be evaluated by the Thoracic Organ Transplantation Committee to make further recommendations, including possibly extending zone A to 500 miles.

The extended geographical limits have organ-specific implications. In contrast to other organs, constraints of cold ischemia limit the duration within which lungs and hearts must be transplanted. Indeed, this latter point is the basis for using a radius from the donor hospital, rather than the region, as the first circle of distribution. Furthermore, DSAs vary substantially in both size and population and performance, leading to considerable variation in access to organs for candidates based on their region of residence. Currently, more than 50% of the lung allocation in the United States occurs locally to recipients with lung allocation scores (LAS) less than 50 (Iribarne et al. Chest. 2009;135[4]:923). In addition, waiting time mortality remains high and actuarial survival remains low for those with higher LAS (Russo et al. Chest. 2010;137[3]:651). The new recommendations broaden the concentric circle approach and potentially provide enhanced access for the sickest candidates on the waiting list. However, this may increase duration of waitlist time for those with lower LAS, certain disease groups such as COPD and those listed in more conservative centers. It may conversely, however, drive transplantation in the sickest patients and increase the use of bridging strategies in high volume centers and those with ECMO capabilities, as there will now be a greater reassurance of donor offers with the wider catchment area. The implications are unclear at this time, and over the next year, the efficacy and the potential unintended consequences of this newly implemented directive should become more apparent.

Anupam Kumar, MD
Fellow-in-Training Member

J. W. Awori Hayanga, MD, MPH
Steering Committee Member

Women’s Health

Lung Cancer and Steroid Hormones: An Evolving Paradigm

Lung cancer remains to be the second most common cancer and the leading cause of cancer-related mortality in women. The risk for developing lung cancer in women is 1/17 and increases with age and smoking history. Women with stage I NSLC have better prognosis after surgical treatment compared with men (Graham et al. South Med J. 2013;106[10]:582); however. they are less likely to have undergone a low dose screening CT scan, even after meeting high risk criteria (Lamb et al. Chest. 2017;152[suppl]A623). The prognosis in advanced stage lung cancer at diagnosis does not differ among the genders or age groups (Santoro et al. J Bras Pneumol. 2017;43[6]:431).

There is increasing interest in the role of steroid hormones in lung biology in health and disease with estrogen and progesterone receptors identified in both healthy and malignant tissue. The role of hormone receptors as a prognostication tool and a therapeutic target is being actively investigated.

Fidaa Shaib, MD, FCCP
Steering Committee Member

Ali Jiwani, MD
NetWork Member

Disaster Response

A Natural Disaster Creates Nationwide Threat

Hurricane Maria devastated Puerto Rico in late September 2017, and the lessons learned endure as the storm exposed the vulnerability of an increasingly interconnected and fragile medical community across the continental United States. According to the US Food and Drug Administration (FDA), Puerto Rico manufactures more drug products than any US state and just under 10% of all drugs consumed by Americans, some of which do not have therapeutic alternatives. In addition, certain medical devices are only produced in Puerto Rico. The humanitarian crisis caused by Hurricane Maria consequently created critical medication and medical device shortages across the United States (FDA. https://www.fda.gov/NewsEvents/. Accessed Feb 01, 2018).

The disruption and disorganization caused by Hurricane Maria was perhaps best exemplified by the resultant shortage of small-volume 0.9% saline injection bags, which coincided with a particularly bad flu season. The FDA temporarily allowed import of saline bags from outside the United States while concurrently expediting the approval of IV solutions from new manufacturers. The American Society for Health-System Pharmacists (ASHP), meanwhile, contributed guidance on managing fluid shortages (ASHP. https://www.ashp.org/Drug-Shortages/. Accessed Feb 01, 2018).

Hurricane Maria was a wake-up call for medical professionals across the United States to modernize institutional procedures and to develop contingency plans to deal with medication shortages, particularly IV fluids, since this is a recurring problem across the United States since 2014. Ultimately, the goal of health-care providers across the United States is to manage natural catastrophes, however distant, by effectively planning for and adapting to medical product shortages to ensure patient care is not interrupted and that critical shortages remain invisible to patients themselves.

Cristian Madar, MD
Steering Committee Member

Practice Operations

Are All Regulations Well Thought Out? Point of View!

Current medicine is complex, with patients presenting in the ICU with multiorgan dysfunction. The art and science of medicine is being replaced by protocolized medicine. To help streamline the care, societies and colleges are coming up with guidelines. The guideline, though, changes from year to year what has been practiced in the past has been obsolete, and what is current may not hold true in the future. With increasing health-care costs affecting physician and hospital practices, innovations are being undertaken on a daily basis. The payers, on the other hand, are trying to come up with regulations, whether one likes it or not, that have become the beacon for penalty and reward. Sometimes those regulations conflict with what is sound judgment and prudent care, cornering the providers in the box with unnecessary penalties.

Approximately 250,000 bloodstream infections occur in the United States yearly, mostly attributed to the presence of intravascular devices. The rate of central line-associated blood stream infection (CLABSI) in the United States is 0.8 per 1,000 central line days. The desirable rate is zero rate of CLABSI. The hospitals are being pushed to be prudent with the use of central lines and removal if not needed. The technique and sterile field along with appropriate innovation in dressing technique have been effective in reducing the CLABSI by 46% from 2008 to 2013. The hospitals and ICUs are being very vigilant in trying to avoid CLABSI and are striving to achieve the goal of a zero percentage CLABSI rate, leading to almost a state of paranoia. The efforts are being undertaken in many institutions to get all the cultures on admission to identify the organism on admission so as to be designated as a bloodstream infection (BSI) due to other causes and to avoid the CLABSI attribution. The CLABSI attribution follows a complex algorithm with no waiver for the exception outside the strict definition that is changing (The 2015 definition change resulted in an 83% increase in CLABSI rate.).

Adel Bassily-Marcus, MD, FCCP
Chair

Salim Surani, MD, FCCP
Vice-Chair

References

Grimes L, McMullen KM, Leone C, et al. Impact of 2015 National Healthcare Safety Network (NHSN) Definition Changes on Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection (CLABSI) at a Large Healthcare System. Open Forum Infectious Diseases. 2016;3(suppl1):946-946.

Transplant

Radius of Change: Will Expanding Organ Sharing Beyond Donor Service Area Enhance Access in Lung Transplantation?

In November 2017, the US Department of Health and Human Services (HHS) prompted the United Network for Organ Sharing Organ Procurement and Transplant Network (UNOS/OPTN) to reconsider geographical boundaries of donor allocation. The impetus for change was driven by a recent litigation and data that challenged the current organ allocation algorithm on the premise that it overlooked potential high acuity candidates listed at centers outside the primary DSA (donor service area) of the donor hospital, in favor of less sick local recipients. In response, the UNOS/OPTN Executive Committee recommended the adoption of a 250-nautical mile radius from the donor hospital in lieu of the DSA as the first circle or zone A of distribution for lungs. The putative merits of this change, due to last an experimental year, is intended to provide sicker candidates with access to a broader geographic range of donors. Its impact will then be evaluated by the Thoracic Organ Transplantation Committee to make further recommendations, including possibly extending zone A to 500 miles.

The extended geographical limits have organ-specific implications. In contrast to other organs, constraints of cold ischemia limit the duration within which lungs and hearts must be transplanted. Indeed, this latter point is the basis for using a radius from the donor hospital, rather than the region, as the first circle of distribution. Furthermore, DSAs vary substantially in both size and population and performance, leading to considerable variation in access to organs for candidates based on their region of residence. Currently, more than 50% of the lung allocation in the United States occurs locally to recipients with lung allocation scores (LAS) less than 50 (Iribarne et al. Chest. 2009;135[4]:923). In addition, waiting time mortality remains high and actuarial survival remains low for those with higher LAS (Russo et al. Chest. 2010;137[3]:651). The new recommendations broaden the concentric circle approach and potentially provide enhanced access for the sickest candidates on the waiting list. However, this may increase duration of waitlist time for those with lower LAS, certain disease groups such as COPD and those listed in more conservative centers. It may conversely, however, drive transplantation in the sickest patients and increase the use of bridging strategies in high volume centers and those with ECMO capabilities, as there will now be a greater reassurance of donor offers with the wider catchment area. The implications are unclear at this time, and over the next year, the efficacy and the potential unintended consequences of this newly implemented directive should become more apparent.

Anupam Kumar, MD
Fellow-in-Training Member

J. W. Awori Hayanga, MD, MPH
Steering Committee Member

Women’s Health

Lung Cancer and Steroid Hormones: An Evolving Paradigm

Lung cancer remains to be the second most common cancer and the leading cause of cancer-related mortality in women. The risk for developing lung cancer in women is 1/17 and increases with age and smoking history. Women with stage I NSLC have better prognosis after surgical treatment compared with men (Graham et al. South Med J. 2013;106[10]:582); however. they are less likely to have undergone a low dose screening CT scan, even after meeting high risk criteria (Lamb et al. Chest. 2017;152[suppl]A623). The prognosis in advanced stage lung cancer at diagnosis does not differ among the genders or age groups (Santoro et al. J Bras Pneumol. 2017;43[6]:431).

There is increasing interest in the role of steroid hormones in lung biology in health and disease with estrogen and progesterone receptors identified in both healthy and malignant tissue. The role of hormone receptors as a prognostication tool and a therapeutic target is being actively investigated.

Fidaa Shaib, MD, FCCP
Steering Committee Member

Ali Jiwani, MD
NetWork Member

There is no change in the core mission of the AGA’s Center for GI Innovation and Technology (CGIT) since two cochairs took over the leadership last year. As always, the goal is to support the development and adoption of new technologies for the treatment of digestive disorders. However, the cochairs want to do more to identify and dismantle the obstacles that slow the process.

“Innovators face challenges at every stage, from attracting investors to refining an idea into a viable clinical tool. Even once a device has obtained regulatory approval, issues of training and reimbursement can keep a good idea from improving patient care,” explained V. Raman Muthusamy, MD, director of interventional endoscopy and general GI endoscopy, at the University of California, Los Angeles. “We want to identify these obstacles and use the CGIT resources to provide solutions.”

One strategy is to expand the presence and activities of CGIT. Established in 2010, the CGIT is best known for the AGA Tech Summit, which has been an important event for bringing together innovators, investors, clinicians, and those involved in navigating regulatory issues, but Dr. Komanduri said that he and Dr. Muthusamy are working to make the summit “more of a launching point” for ideas and projects that follow the meeting.

“The AGA Tech Summit has provided an opportunity to recognize hot areas, and the goal will be to drive new ideas forward after the meeting by facilitating communication and cooperation among those who can contribute to advancing the concepts, ” Dr. Komanduri explained.

To help focus the mission of the CGIT, six areas of concentration have been identified. These are colorectal cancer screening and diagnosis, endoscope reprocessing, weight loss interventions, interventional endoscopy platforms, antireflux devices, and tissue resection technologies, according to Dr. Muthusamy. These focus areas do not preclude CGIT involvement in other types of innovations, but Dr. Muthusamy said this list helps emphasize strengths for those who do not yet consider CGIT a resource.

“We want to intersect better with the AGA members who think CGIT is not relevant to them because they are not involved in the development of new technology,” Dr. Muthusamy said. In drawing attention to these specific areas, Dr. Muthusamy said, “We plan to do more with technology updates and keep the AGA membership aware of how opportunities in clinical medicine are evolving through technological innovation.”

The mission of CGIT begins with the encouragement of new technology but it includes all the steps needed to shepherd innovations into routine clinical application. This includes helping with the strategies that will incentivize clinicians to learn the technology. While this has always been part of the CGIT mission, the cochairs are increasing their attention to eliminating delays in the process, which they recognize as a threat to fulfilling the CGIT mandate.

“There are challenges to bringing new ideas to the marketplace, and we think that pace between idea and product is too slow,” Dr. Komanduri said. “We want to increase the emphasis on finding ways to streamline the process.”

There is no change in the core mission of the AGA’s Center for GI Innovation and Technology (CGIT) since two cochairs took over the leadership last year. As always, the goal is to support the development and adoption of new technologies for the treatment of digestive disorders. However, the cochairs want to do more to identify and dismantle the obstacles that slow the process.

“Innovators face challenges at every stage, from attracting investors to refining an idea into a viable clinical tool. Even once a device has obtained regulatory approval, issues of training and reimbursement can keep a good idea from improving patient care,” explained V. Raman Muthusamy, MD, director of interventional endoscopy and general GI endoscopy, at the University of California, Los Angeles. “We want to identify these obstacles and use the CGIT resources to provide solutions.”

One strategy is to expand the presence and activities of CGIT. Established in 2010, the CGIT is best known for the AGA Tech Summit, which has been an important event for bringing together innovators, investors, clinicians, and those involved in navigating regulatory issues, but Dr. Komanduri said that he and Dr. Muthusamy are working to make the summit “more of a launching point” for ideas and projects that follow the meeting.

“The AGA Tech Summit has provided an opportunity to recognize hot areas, and the goal will be to drive new ideas forward after the meeting by facilitating communication and cooperation among those who can contribute to advancing the concepts, ” Dr. Komanduri explained.

To help focus the mission of the CGIT, six areas of concentration have been identified. These are colorectal cancer screening and diagnosis, endoscope reprocessing, weight loss interventions, interventional endoscopy platforms, antireflux devices, and tissue resection technologies, according to Dr. Muthusamy. These focus areas do not preclude CGIT involvement in other types of innovations, but Dr. Muthusamy said this list helps emphasize strengths for those who do not yet consider CGIT a resource.

“We want to intersect better with the AGA members who think CGIT is not relevant to them because they are not involved in the development of new technology,” Dr. Muthusamy said. In drawing attention to these specific areas, Dr. Muthusamy said, “We plan to do more with technology updates and keep the AGA membership aware of how opportunities in clinical medicine are evolving through technological innovation.”

The mission of CGIT begins with the encouragement of new technology but it includes all the steps needed to shepherd innovations into routine clinical application. This includes helping with the strategies that will incentivize clinicians to learn the technology. While this has always been part of the CGIT mission, the cochairs are increasing their attention to eliminating delays in the process, which they recognize as a threat to fulfilling the CGIT mandate.

“There are challenges to bringing new ideas to the marketplace, and we think that pace between idea and product is too slow,” Dr. Komanduri said. “We want to increase the emphasis on finding ways to streamline the process.”

There is no change in the core mission of the AGA’s Center for GI Innovation and Technology (CGIT) since two cochairs took over the leadership last year. As always, the goal is to support the development and adoption of new technologies for the treatment of digestive disorders. However, the cochairs want to do more to identify and dismantle the obstacles that slow the process.

“Innovators face challenges at every stage, from attracting investors to refining an idea into a viable clinical tool. Even once a device has obtained regulatory approval, issues of training and reimbursement can keep a good idea from improving patient care,” explained V. Raman Muthusamy, MD, director of interventional endoscopy and general GI endoscopy, at the University of California, Los Angeles. “We want to identify these obstacles and use the CGIT resources to provide solutions.”

One strategy is to expand the presence and activities of CGIT. Established in 2010, the CGIT is best known for the AGA Tech Summit, which has been an important event for bringing together innovators, investors, clinicians, and those involved in navigating regulatory issues, but Dr. Komanduri said that he and Dr. Muthusamy are working to make the summit “more of a launching point” for ideas and projects that follow the meeting.

“The AGA Tech Summit has provided an opportunity to recognize hot areas, and the goal will be to drive new ideas forward after the meeting by facilitating communication and cooperation among those who can contribute to advancing the concepts, ” Dr. Komanduri explained.

To help focus the mission of the CGIT, six areas of concentration have been identified. These are colorectal cancer screening and diagnosis, endoscope reprocessing, weight loss interventions, interventional endoscopy platforms, antireflux devices, and tissue resection technologies, according to Dr. Muthusamy. These focus areas do not preclude CGIT involvement in other types of innovations, but Dr. Muthusamy said this list helps emphasize strengths for those who do not yet consider CGIT a resource.

“We want to intersect better with the AGA members who think CGIT is not relevant to them because they are not involved in the development of new technology,” Dr. Muthusamy said. In drawing attention to these specific areas, Dr. Muthusamy said, “We plan to do more with technology updates and keep the AGA membership aware of how opportunities in clinical medicine are evolving through technological innovation.”

The mission of CGIT begins with the encouragement of new technology but it includes all the steps needed to shepherd innovations into routine clinical application. This includes helping with the strategies that will incentivize clinicians to learn the technology. While this has always been part of the CGIT mission, the cochairs are increasing their attention to eliminating delays in the process, which they recognize as a threat to fulfilling the CGIT mandate.

“There are challenges to bringing new ideas to the marketplace, and we think that pace between idea and product is too slow,” Dr. Komanduri said. “We want to increase the emphasis on finding ways to streamline the process.”

Nanotechnology is positioned to bring fundamental changes to the diagnosis and treatment of GI diseases, according to the Vadim Backman, MS, PhD, professor of biomedical engineering at the McCormick School of Engineering, Northwestern University, Chicago.

“The ways in which nanotechnology will change the field are going to be quite significant,” Dr. Backman said. He will give the Keynote Presentation at the 2018 AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology. He described progress toward breakthroughs in diagnostics – particularly early detection of GI cancers – and therapeutics, such as nanocage transport of drugs across cell membranes. Applications have moved beyond the theoretical.

“With nanoscale sensitive optics, it is now possible to detect changes in cell and tissue structure that we have connected to the earliest steps in tumorigenesis,” Dr. Backman said. This work largely derives from progress in defining the topography of chromatin, a term that encompasses the protein, DNA, RNA, and protein composition of chromosomes. The work is relevant to all solid tumors, not just GI cancers. Based on the current status of the science, Dr. Backman foresees not just detection of the earliest events in cancer development but opportunities to tailor epigenetic therapies for personalized medicine.

In regard to other opportunities to improve diagnostics in GI diseases through nanotechnology, Dr. Backman spoke of nanoscale constructs that serve as contrast agents to visualize molecular structures and processes. These can be delivered endoscopically or systemically to provide unprecedented 3-D imaging, allowing such structures as cell receptors to be visualized and labeled.

The potential therapeutic applications of nanotechnology involve new approaches to altering disease progression. In addition to explaining the novel opportunities provided by delivering drugs on a nanoscale to alter cell processes in a way that would not be otherwise possible, Dr. Backman described how nanotechnology can be applied to influence global patterns in gene transcription. This is achieved by altering the chromatin structure.

“It is now understood that chromatin acts like software in mediating gene activities,” Dr. Backman explained. “In the case of cancer, normalization of chromatin structure can predictably modulate global patterns of gene expression. There is now evidence that modulation of chromatin structure with macrogenomic engineering may address cancer as well as other illnesses.”

In most cases, the advances described by Dr. Backman are not speculations based on the potential of the technology but concepts that are actively being developed. Partial-wave spectroscopic microscopy, which was developed in Dr. Backman’s laboratory, is permitting the nuclear nanostructure in live cells to be evaluated in real time, while progress in epigenetics is explaining which processes might be candidates for preventing or treating disease.

“Nanotechnology is positioned to advance personalized medicine and tailored therapeutics,” Dr. Backman said. “We do not yet have applications ready for regulatory approval, but they are coming.”

Nanotechnology is positioned to bring fundamental changes to the diagnosis and treatment of GI diseases, according to the Vadim Backman, MS, PhD, professor of biomedical engineering at the McCormick School of Engineering, Northwestern University, Chicago.

“The ways in which nanotechnology will change the field are going to be quite significant,” Dr. Backman said. He will give the Keynote Presentation at the 2018 AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology. He described progress toward breakthroughs in diagnostics – particularly early detection of GI cancers – and therapeutics, such as nanocage transport of drugs across cell membranes. Applications have moved beyond the theoretical.

“With nanoscale sensitive optics, it is now possible to detect changes in cell and tissue structure that we have connected to the earliest steps in tumorigenesis,” Dr. Backman said. This work largely derives from progress in defining the topography of chromatin, a term that encompasses the protein, DNA, RNA, and protein composition of chromosomes. The work is relevant to all solid tumors, not just GI cancers. Based on the current status of the science, Dr. Backman foresees not just detection of the earliest events in cancer development but opportunities to tailor epigenetic therapies for personalized medicine.

In regard to other opportunities to improve diagnostics in GI diseases through nanotechnology, Dr. Backman spoke of nanoscale constructs that serve as contrast agents to visualize molecular structures and processes. These can be delivered endoscopically or systemically to provide unprecedented 3-D imaging, allowing such structures as cell receptors to be visualized and labeled.

The potential therapeutic applications of nanotechnology involve new approaches to altering disease progression. In addition to explaining the novel opportunities provided by delivering drugs on a nanoscale to alter cell processes in a way that would not be otherwise possible, Dr. Backman described how nanotechnology can be applied to influence global patterns in gene transcription. This is achieved by altering the chromatin structure.

“It is now understood that chromatin acts like software in mediating gene activities,” Dr. Backman explained. “In the case of cancer, normalization of chromatin structure can predictably modulate global patterns of gene expression. There is now evidence that modulation of chromatin structure with macrogenomic engineering may address cancer as well as other illnesses.”

In most cases, the advances described by Dr. Backman are not speculations based on the potential of the technology but concepts that are actively being developed. Partial-wave spectroscopic microscopy, which was developed in Dr. Backman’s laboratory, is permitting the nuclear nanostructure in live cells to be evaluated in real time, while progress in epigenetics is explaining which processes might be candidates for preventing or treating disease.

“Nanotechnology is positioned to advance personalized medicine and tailored therapeutics,” Dr. Backman said. “We do not yet have applications ready for regulatory approval, but they are coming.”

Nanotechnology is positioned to bring fundamental changes to the diagnosis and treatment of GI diseases, according to the Vadim Backman, MS, PhD, professor of biomedical engineering at the McCormick School of Engineering, Northwestern University, Chicago.

“The ways in which nanotechnology will change the field are going to be quite significant,” Dr. Backman said. He will give the Keynote Presentation at the 2018 AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology. He described progress toward breakthroughs in diagnostics – particularly early detection of GI cancers – and therapeutics, such as nanocage transport of drugs across cell membranes. Applications have moved beyond the theoretical.

“With nanoscale sensitive optics, it is now possible to detect changes in cell and tissue structure that we have connected to the earliest steps in tumorigenesis,” Dr. Backman said. This work largely derives from progress in defining the topography of chromatin, a term that encompasses the protein, DNA, RNA, and protein composition of chromosomes. The work is relevant to all solid tumors, not just GI cancers. Based on the current status of the science, Dr. Backman foresees not just detection of the earliest events in cancer development but opportunities to tailor epigenetic therapies for personalized medicine.

In regard to other opportunities to improve diagnostics in GI diseases through nanotechnology, Dr. Backman spoke of nanoscale constructs that serve as contrast agents to visualize molecular structures and processes. These can be delivered endoscopically or systemically to provide unprecedented 3-D imaging, allowing such structures as cell receptors to be visualized and labeled.

The potential therapeutic applications of nanotechnology involve new approaches to altering disease progression. In addition to explaining the novel opportunities provided by delivering drugs on a nanoscale to alter cell processes in a way that would not be otherwise possible, Dr. Backman described how nanotechnology can be applied to influence global patterns in gene transcription. This is achieved by altering the chromatin structure.

“It is now understood that chromatin acts like software in mediating gene activities,” Dr. Backman explained. “In the case of cancer, normalization of chromatin structure can predictably modulate global patterns of gene expression. There is now evidence that modulation of chromatin structure with macrogenomic engineering may address cancer as well as other illnesses.”

In most cases, the advances described by Dr. Backman are not speculations based on the potential of the technology but concepts that are actively being developed. Partial-wave spectroscopic microscopy, which was developed in Dr. Backman’s laboratory, is permitting the nuclear nanostructure in live cells to be evaluated in real time, while progress in epigenetics is explaining which processes might be candidates for preventing or treating disease.

“Nanotechnology is positioned to advance personalized medicine and tailored therapeutics,” Dr. Backman said. “We do not yet have applications ready for regulatory approval, but they are coming.”

Nasal pillows showed equal long-term efficacy as standard nasal masks and both tools were used equally in patients treated with continuous positive airway pressure therapy, according to results of a study.

In a retrospective observational study of 144 patients with obstructive sleep apnea, respiratory measures including apnea-hypopnea index (AHI), oxygen desaturation index, mean oxygen saturation, and Epworth Sleepiness scale scores did not differ between the two treatment groups at baseline and during a 12-month follow-up appointment. Treatment adherence was also similar between the two groups, reported Andrea Lanza of the Sleep Medicine Center at Niguarda Hospital in Milan, Italy, and coauthors in Sleep Medicine.

graustufe/ThinkStock

Patients received continuous positive airway pressure (CPAP) treatment between May 2012 and September 2014, and were assigned to one of two groups based on their choice of treatment. Initially, 102 opted for nasal pillows (Group P), and 42 chose the standard nasal mask (Group N). Patients who either changed masks or added a new one during titration or follow-up were assigned to a third group, Group C.

AHI did not differ significantly between groups at baseline or follow-up. In Group P, mean AHI at titration was 1.2 events per hour, compared with 1.8 in Group N and 1.9 in Group C (P = .109). At follow-up, AHI was 0.7 in Group P, 1.1 in Group N, and 0.9 in Group C (P = .172). Oxygen desaturation index and oxygen saturation also remained similar between the groups at baseline and follow-up, the investigators reported.

Additionally, long-term adherence did not differ significantly between the groups, with mean daily CPAP usage of 5.5 hours per night in Group P, 5.3 in Group N, and 5.6 in Group C. Mean usage was less than 4 hours per night for 11.6% in group P, 18.5% in group N, and 13.9% in group C, the authors added.

The frequency of side effects occurring in patients in two of the groups were similar (49% in Group P, vs. 61% in Group N; P = .212), though the nature of the side effects differed. Nostril pain or burning was reported only by patients in the nasal pillows group, and skin breakdown was reported only in the nasal mask group.

Though nasal pillows have typically been reserved for patients who do not tolerate the standard mask, the results of this study suggest that “nasal pillows could be safely prescribed as first-line interfaces,” the authors wrote. “They seem to be efficacious for CPAP titration and long-term treatment, ensuring a good rate of adherence.”

All of the authors reported having no disclosures.

SOURCE: Lanza A et al. Sleep Med. 2018 Jan;41:94-9

Nasal pillows showed equal long-term efficacy as standard nasal masks and both tools were used equally in patients treated with continuous positive airway pressure therapy, according to results of a study.

In a retrospective observational study of 144 patients with obstructive sleep apnea, respiratory measures including apnea-hypopnea index (AHI), oxygen desaturation index, mean oxygen saturation, and Epworth Sleepiness scale scores did not differ between the two treatment groups at baseline and during a 12-month follow-up appointment. Treatment adherence was also similar between the two groups, reported Andrea Lanza of the Sleep Medicine Center at Niguarda Hospital in Milan, Italy, and coauthors in Sleep Medicine.

graustufe/ThinkStock

Patients received continuous positive airway pressure (CPAP) treatment between May 2012 and September 2014, and were assigned to one of two groups based on their choice of treatment. Initially, 102 opted for nasal pillows (Group P), and 42 chose the standard nasal mask (Group N). Patients who either changed masks or added a new one during titration or follow-up were assigned to a third group, Group C.

AHI did not differ significantly between groups at baseline or follow-up. In Group P, mean AHI at titration was 1.2 events per hour, compared with 1.8 in Group N and 1.9 in Group C (P = .109). At follow-up, AHI was 0.7 in Group P, 1.1 in Group N, and 0.9 in Group C (P = .172). Oxygen desaturation index and oxygen saturation also remained similar between the groups at baseline and follow-up, the investigators reported.

Additionally, long-term adherence did not differ significantly between the groups, with mean daily CPAP usage of 5.5 hours per night in Group P, 5.3 in Group N, and 5.6 in Group C. Mean usage was less than 4 hours per night for 11.6% in group P, 18.5% in group N, and 13.9% in group C, the authors added.

The frequency of side effects occurring in patients in two of the groups were similar (49% in Group P, vs. 61% in Group N; P = .212), though the nature of the side effects differed. Nostril pain or burning was reported only by patients in the nasal pillows group, and skin breakdown was reported only in the nasal mask group.

Though nasal pillows have typically been reserved for patients who do not tolerate the standard mask, the results of this study suggest that “nasal pillows could be safely prescribed as first-line interfaces,” the authors wrote. “They seem to be efficacious for CPAP titration and long-term treatment, ensuring a good rate of adherence.”

All of the authors reported having no disclosures.

SOURCE: Lanza A et al. Sleep Med. 2018 Jan;41:94-9

Nasal pillows showed equal long-term efficacy as standard nasal masks and both tools were used equally in patients treated with continuous positive airway pressure therapy, according to results of a study.

In a retrospective observational study of 144 patients with obstructive sleep apnea, respiratory measures including apnea-hypopnea index (AHI), oxygen desaturation index, mean oxygen saturation, and Epworth Sleepiness scale scores did not differ between the two treatment groups at baseline and during a 12-month follow-up appointment. Treatment adherence was also similar between the two groups, reported Andrea Lanza of the Sleep Medicine Center at Niguarda Hospital in Milan, Italy, and coauthors in Sleep Medicine.

graustufe/ThinkStock

Patients received continuous positive airway pressure (CPAP) treatment between May 2012 and September 2014, and were assigned to one of two groups based on their choice of treatment. Initially, 102 opted for nasal pillows (Group P), and 42 chose the standard nasal mask (Group N). Patients who either changed masks or added a new one during titration or follow-up were assigned to a third group, Group C.

AHI did not differ significantly between groups at baseline or follow-up. In Group P, mean AHI at titration was 1.2 events per hour, compared with 1.8 in Group N and 1.9 in Group C (P = .109). At follow-up, AHI was 0.7 in Group P, 1.1 in Group N, and 0.9 in Group C (P = .172). Oxygen desaturation index and oxygen saturation also remained similar between the groups at baseline and follow-up, the investigators reported.

Additionally, long-term adherence did not differ significantly between the groups, with mean daily CPAP usage of 5.5 hours per night in Group P, 5.3 in Group N, and 5.6 in Group C. Mean usage was less than 4 hours per night for 11.6% in group P, 18.5% in group N, and 13.9% in group C, the authors added.

The frequency of side effects occurring in patients in two of the groups were similar (49% in Group P, vs. 61% in Group N; P = .212), though the nature of the side effects differed. Nostril pain or burning was reported only by patients in the nasal pillows group, and skin breakdown was reported only in the nasal mask group.

Though nasal pillows have typically been reserved for patients who do not tolerate the standard mask, the results of this study suggest that “nasal pillows could be safely prescribed as first-line interfaces,” the authors wrote. “They seem to be efficacious for CPAP titration and long-term treatment, ensuring a good rate of adherence.”

All of the authors reported having no disclosures.

SOURCE: Lanza A et al. Sleep Med. 2018 Jan;41:94-9

Hidradenitis suppurativa (HS) is a chronic, non-contagious skin disease that causes acne-like boils to form in folds of skin, particularly in the axilla and groin areas.

Click here to visit the site

Hidradenitis suppurativa (HS) is a chronic, non-contagious skin disease that causes acne-like boils to form in folds of skin, particularly in the axilla and groin areas.

Click here to visit the site

Hidradenitis suppurativa (HS) is a chronic, non-contagious skin disease that causes acne-like boils to form in folds of skin, particularly in the axilla and groin areas.

Click here to visit the site

ORLANDO – High case volume for surgeons performing minimally invasive hysterectomies in women with large uteri is associated with an increased rate of perioperative adverse events – but also with a decreased rate of conversion to laparotomy – according to a review of 763 procedures.

The minimally invasive hysterectomy (MIH) procedures in the study were performed by 66 surgeons and included 416 total laparoscopic hysterectomies, 196 robotic-assisted laparoscopic hysterectomies, 90 total vaginal hysterectomies, and 61 laparoscopic-assisted vaginal hysterectomies, Carol E. Bretschneider, MD, reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

The mean monthly case volume was 16.4 and mean MIH volume was 23, said Dr. Bretschneider, a fellow at the Cleveland Clinic.

“The rate of postoperative adverse events was 17.8%, the rate of intraoperative adverse events was 4.2%, and the rate of conversion from a minimally invasive approach to a laparotomy was 5.5%,” she said, explaining that adverse events were defined as those greater than grade 2 on the Clavien-Dindo classification scale. “No differences were appreciated across routes [of MIH] in terms of perioperative adverse events or conversion to laparotomy,” she noted.

[email protected]

SOURCE: Bretschneider C et al. SGS 2018, Oral Poster 12.

ORLANDO – High case volume for surgeons performing minimally invasive hysterectomies in women with large uteri is associated with an increased rate of perioperative adverse events – but also with a decreased rate of conversion to laparotomy – according to a review of 763 procedures.

The minimally invasive hysterectomy (MIH) procedures in the study were performed by 66 surgeons and included 416 total laparoscopic hysterectomies, 196 robotic-assisted laparoscopic hysterectomies, 90 total vaginal hysterectomies, and 61 laparoscopic-assisted vaginal hysterectomies, Carol E. Bretschneider, MD, reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

The mean monthly case volume was 16.4 and mean MIH volume was 23, said Dr. Bretschneider, a fellow at the Cleveland Clinic.

“The rate of postoperative adverse events was 17.8%, the rate of intraoperative adverse events was 4.2%, and the rate of conversion from a minimally invasive approach to a laparotomy was 5.5%,” she said, explaining that adverse events were defined as those greater than grade 2 on the Clavien-Dindo classification scale. “No differences were appreciated across routes [of MIH] in terms of perioperative adverse events or conversion to laparotomy,” she noted.

[email protected]

SOURCE: Bretschneider C et al. SGS 2018, Oral Poster 12.

ORLANDO – High case volume for surgeons performing minimally invasive hysterectomies in women with large uteri is associated with an increased rate of perioperative adverse events – but also with a decreased rate of conversion to laparotomy – according to a review of 763 procedures.

The minimally invasive hysterectomy (MIH) procedures in the study were performed by 66 surgeons and included 416 total laparoscopic hysterectomies, 196 robotic-assisted laparoscopic hysterectomies, 90 total vaginal hysterectomies, and 61 laparoscopic-assisted vaginal hysterectomies, Carol E. Bretschneider, MD, reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

The mean monthly case volume was 16.4 and mean MIH volume was 23, said Dr. Bretschneider, a fellow at the Cleveland Clinic.

“The rate of postoperative adverse events was 17.8%, the rate of intraoperative adverse events was 4.2%, and the rate of conversion from a minimally invasive approach to a laparotomy was 5.5%,” she said, explaining that adverse events were defined as those greater than grade 2 on the Clavien-Dindo classification scale. “No differences were appreciated across routes [of MIH] in terms of perioperative adverse events or conversion to laparotomy,” she noted.

[email protected]

SOURCE: Bretschneider C et al. SGS 2018, Oral Poster 12.

Where are they now? What have they been up to? CHEST’s Past Presidents each forged the way for the many successes of the American College of Chest Physicians, leading to enhanced patient care around the globe. Their outstanding leadership and vision are evidenced today in many of CHEST’s strategic initiatives. Let’s check in with W. Michael Alberts.

President 2005 - 2006

My year at the helm began in Montreal in 2005 and ended in Salt Lake City in 2006. The year was a blur and seemed to fly by. The inauguration was very special as my entire immediate family made the effort to attend. It was the final time that my father was able to travel. Travel was definitely one of the highlights of my Presidential year. My wife, Debra, and I made many lasting friendships and very special memories while on the road for the College.

Looking back, it is hard to believe that I have been with the University of South Florida since 1983. I came to Tampa directly from my Pulmonary and Critical Care Fellowship in San Diego. After 16 years attending at the Tampa General Hospital and the James A. Haley VA, I was named the Chief Medical Officer at the Moffitt Cancer Center in 1999. In 2015, I stepped down from that position and have been serving as the Medical Director of Moffitt’s satellite clinical location since that time. I no longer do in-patient rounding, which is a major boon to work-life balance. In addition to administrative duties , however, I continue to see outpatients two half-days a week.

Where are they now? What have they been up to? CHEST’s Past Presidents each forged the way for the many successes of the American College of Chest Physicians, leading to enhanced patient care around the globe. Their outstanding leadership and vision are evidenced today in many of CHEST’s strategic initiatives. Let’s check in with W. Michael Alberts.

President 2005 - 2006

My year at the helm began in Montreal in 2005 and ended in Salt Lake City in 2006. The year was a blur and seemed to fly by. The inauguration was very special as my entire immediate family made the effort to attend. It was the final time that my father was able to travel. Travel was definitely one of the highlights of my Presidential year. My wife, Debra, and I made many lasting friendships and very special memories while on the road for the College.

Looking back, it is hard to believe that I have been with the University of South Florida since 1983. I came to Tampa directly from my Pulmonary and Critical Care Fellowship in San Diego. After 16 years attending at the Tampa General Hospital and the James A. Haley VA, I was named the Chief Medical Officer at the Moffitt Cancer Center in 1999. In 2015, I stepped down from that position and have been serving as the Medical Director of Moffitt’s satellite clinical location since that time. I no longer do in-patient rounding, which is a major boon to work-life balance. In addition to administrative duties , however, I continue to see outpatients two half-days a week.

Where are they now? What have they been up to? CHEST’s Past Presidents each forged the way for the many successes of the American College of Chest Physicians, leading to enhanced patient care around the globe. Their outstanding leadership and vision are evidenced today in many of CHEST’s strategic initiatives. Let’s check in with W. Michael Alberts.

President 2005 - 2006

My year at the helm began in Montreal in 2005 and ended in Salt Lake City in 2006. The year was a blur and seemed to fly by. The inauguration was very special as my entire immediate family made the effort to attend. It was the final time that my father was able to travel. Travel was definitely one of the highlights of my Presidential year. My wife, Debra, and I made many lasting friendships and very special memories while on the road for the College.

Looking back, it is hard to believe that I have been with the University of South Florida since 1983. I came to Tampa directly from my Pulmonary and Critical Care Fellowship in San Diego. After 16 years attending at the Tampa General Hospital and the James A. Haley VA, I was named the Chief Medical Officer at the Moffitt Cancer Center in 1999. In 2015, I stepped down from that position and have been serving as the Medical Director of Moffitt’s satellite clinical location since that time. I no longer do in-patient rounding, which is a major boon to work-life balance. In addition to administrative duties , however, I continue to see outpatients two half-days a week.