Cruising above the earth at 37,000 feet on the way back from vacation, my mind starts wandering. The impending reality of returning to work is setting in, and I can’t help but reflect on how the experience of a weary traveler trying to get home is like that of a weary patient trying to navigate modern health care. As it turns out, there are more than a few similarities, and that is not necessarily a good thing.

The modern airline industry is often cited by experts as a model for safety, efficiency, and innovation, though just a few decades ago this wasn’t the case. Several factors (for example, catastrophic crashes; the events of September 11th, 2001; the economic downturn) forced airlines to make radical improvements in how they operated – many of which I am quite thankful for as I gaze down upon America’s heartland from my window seat. Still, there are many who would say that in spite of (and sometimes because of) these improvements, air travel is the worst it’s ever been; airport lines are longer than ever, costs have steadily increased, and customer service has become little more than a quaint idea from a bygone era.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health.

Cruising above the earth at 37,000 feet on the way back from vacation, my mind starts wandering. The impending reality of returning to work is setting in, and I can’t help but reflect on how the experience of a weary traveler trying to get home is like that of a weary patient trying to navigate modern health care. As it turns out, there are more than a few similarities, and that is not necessarily a good thing.

The modern airline industry is often cited by experts as a model for safety, efficiency, and innovation, though just a few decades ago this wasn’t the case. Several factors (for example, catastrophic crashes; the events of September 11th, 2001; the economic downturn) forced airlines to make radical improvements in how they operated – many of which I am quite thankful for as I gaze down upon America’s heartland from my window seat. Still, there are many who would say that in spite of (and sometimes because of) these improvements, air travel is the worst it’s ever been; airport lines are longer than ever, costs have steadily increased, and customer service has become little more than a quaint idea from a bygone era.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health.

Cruising above the earth at 37,000 feet on the way back from vacation, my mind starts wandering. The impending reality of returning to work is setting in, and I can’t help but reflect on how the experience of a weary traveler trying to get home is like that of a weary patient trying to navigate modern health care. As it turns out, there are more than a few similarities, and that is not necessarily a good thing.

The modern airline industry is often cited by experts as a model for safety, efficiency, and innovation, though just a few decades ago this wasn’t the case. Several factors (for example, catastrophic crashes; the events of September 11th, 2001; the economic downturn) forced airlines to make radical improvements in how they operated – many of which I am quite thankful for as I gaze down upon America’s heartland from my window seat. Still, there are many who would say that in spite of (and sometimes because of) these improvements, air travel is the worst it’s ever been; airport lines are longer than ever, costs have steadily increased, and customer service has become little more than a quaint idea from a bygone era.

Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is also a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and associate director of the family medicine residency program at Abington Jefferson Health.

The Diagnosis: Trichofolliculoma

Microscopic examination revealed a dilated cystic follicle that communicated with the skin surface (Figure). The follicle was lined with squamous epithelium and surrounded by numerous secondary follicles, many of which contained a hair shaft. A diagnosis of trichofolliculoma was made.

Clinically, the differential diagnosis of a flesh-colored papule on the scalp with prominent follicle includes dilated pore of Winer, epidermoid cyst, pilar sheath acanthoma, and trichoepithelioma.^1,2 Multiple hair shafts present in a single follicle may be seen in pili multigemini, tufted folliculitis, trichostasis spinulosa, and trichofolliculoma. On histopathologic examination, a dilated central follicle surrounded with smaller secondary follicles was identified, consistent with trichofolliculoma.

Trichofolliculoma is a rare follicular hamartoma typically occurring on the face, scalp, or trunk as a solitary papule or nodule due to the proliferation of abnormal hair follicle stem cells.^3,4 It may present as a flesh-colored nodule with a central pore that may drain sebum or contain white vellus hairs. Trichofolliculoma is considered a benign entity, despite one case report of malignant transformation.⁵ Biopsy is diagnostic and no further treatment is needed. Recurrence rarely occurs at the primary site after surgical excision, which may be performed for cosmetic purposes or to alleviate functional impairment.

The Diagnosis: Trichofolliculoma

Microscopic examination revealed a dilated cystic follicle that communicated with the skin surface (Figure). The follicle was lined with squamous epithelium and surrounded by numerous secondary follicles, many of which contained a hair shaft. A diagnosis of trichofolliculoma was made.

Clinically, the differential diagnosis of a flesh-colored papule on the scalp with prominent follicle includes dilated pore of Winer, epidermoid cyst, pilar sheath acanthoma, and trichoepithelioma.^1,2 Multiple hair shafts present in a single follicle may be seen in pili multigemini, tufted folliculitis, trichostasis spinulosa, and trichofolliculoma. On histopathologic examination, a dilated central follicle surrounded with smaller secondary follicles was identified, consistent with trichofolliculoma.

Trichofolliculoma is a rare follicular hamartoma typically occurring on the face, scalp, or trunk as a solitary papule or nodule due to the proliferation of abnormal hair follicle stem cells.^3,4 It may present as a flesh-colored nodule with a central pore that may drain sebum or contain white vellus hairs. Trichofolliculoma is considered a benign entity, despite one case report of malignant transformation.⁵ Biopsy is diagnostic and no further treatment is needed. Recurrence rarely occurs at the primary site after surgical excision, which may be performed for cosmetic purposes or to alleviate functional impairment.

The Diagnosis: Trichofolliculoma

Microscopic examination revealed a dilated cystic follicle that communicated with the skin surface (Figure). The follicle was lined with squamous epithelium and surrounded by numerous secondary follicles, many of which contained a hair shaft. A diagnosis of trichofolliculoma was made.

Clinically, the differential diagnosis of a flesh-colored papule on the scalp with prominent follicle includes dilated pore of Winer, epidermoid cyst, pilar sheath acanthoma, and trichoepithelioma.^1,2 Multiple hair shafts present in a single follicle may be seen in pili multigemini, tufted folliculitis, trichostasis spinulosa, and trichofolliculoma. On histopathologic examination, a dilated central follicle surrounded with smaller secondary follicles was identified, consistent with trichofolliculoma.

Trichofolliculoma is a rare follicular hamartoma typically occurring on the face, scalp, or trunk as a solitary papule or nodule due to the proliferation of abnormal hair follicle stem cells.^3,4 It may present as a flesh-colored nodule with a central pore that may drain sebum or contain white vellus hairs. Trichofolliculoma is considered a benign entity, despite one case report of malignant transformation.⁵ Biopsy is diagnostic and no further treatment is needed. Recurrence rarely occurs at the primary site after surgical excision, which may be performed for cosmetic purposes or to alleviate functional impairment.

Incidence of campylobacteriosis increased significantly in the United States from 2004 to 2012, according to Aimee Geissler, PhD, and her associates.

A total of 303,520 cases of campylobacteriosis were reported during the study period, with the average incidence rate growing from 10.5 cases per 100,000 persons during 2004-2006 to 12.7 cases per 100,000 persons during 2010-2012, an increase of 21%. The median number of Camplyobacter outbreaks doubled from 28 during 2004-2006 to 56 during 2010-2012; in total, 347 outbreaks were reported. Campylobacteriosis is the nation’s most common bacterial diarrheal illness.

De Wood, Pooley, USDA, ARS, EMU/Wikimedia Commons/Public domain

[email protected]

Incidence of campylobacteriosis increased significantly in the United States from 2004 to 2012, according to Aimee Geissler, PhD, and her associates.

A total of 303,520 cases of campylobacteriosis were reported during the study period, with the average incidence rate growing from 10.5 cases per 100,000 persons during 2004-2006 to 12.7 cases per 100,000 persons during 2010-2012, an increase of 21%. The median number of Camplyobacter outbreaks doubled from 28 during 2004-2006 to 56 during 2010-2012; in total, 347 outbreaks were reported. Campylobacteriosis is the nation’s most common bacterial diarrheal illness.

De Wood, Pooley, USDA, ARS, EMU/Wikimedia Commons/Public domain

[email protected]

Incidence of campylobacteriosis increased significantly in the United States from 2004 to 2012, according to Aimee Geissler, PhD, and her associates.

A total of 303,520 cases of campylobacteriosis were reported during the study period, with the average incidence rate growing from 10.5 cases per 100,000 persons during 2004-2006 to 12.7 cases per 100,000 persons during 2010-2012, an increase of 21%. The median number of Camplyobacter outbreaks doubled from 28 during 2004-2006 to 56 during 2010-2012; in total, 347 outbreaks were reported. Campylobacteriosis is the nation’s most common bacterial diarrheal illness.

De Wood, Pooley, USDA, ARS, EMU/Wikimedia Commons/Public domain

[email protected]

Lack of access to psychiatric services has been a challenge for decades, resulting in significant delays to treatment with associated consequences in reduced quality of care, low patient satisfaction, poor patient outcomes, and higher costs.

The problem is exacerbated by a growing shortage of psychiatrists, an increased demand for psychiatric services, and inadequate payment rates. The result is a crisis that is resonating throughout the U.S. health care system.

As many know, a few months ago, the Medical Director Institute of the National Council for Behavioral Health, in partnership with the American Psychiatric Association, convened an expert panel to develop a report responding to this evolving quandary. The findings of our 60-page report, “The Psychiatric Shortage: Causes and Solutions,” suggest that psychiatry is uniquely positioned to address the issues that face our specialty.

1. Workforce development

Psychiatrists come out of residency training without the skills they need to practice in today’s rapidly evolving health care environment. We need better preparation in measurement-based care, telepsychiatry, collaborative care, and other methods of efficient team collaboration with primary care.

Funding for graduate medical education and training programs must be expanded with an infusion of new funding – not only for psychiatrists – but also for psychiatric nurse practitioners and psychiatric physician assistants.

2. Improved efficiency of service delivery

Providers of psychiatric services in outpatient psychiatric programs face a cramped daily routine with increasingly briefer appointments scheduled back-to-back that limit in-depth clinical assessment, collaboration with other members of the treatment team, and consultation with primary care providers outside of the program. Such a schedule leads to lower-quality care.

Psychiatrists must have the same level of nurse and paraprofessional assistance and support provided to other medical specialties. In addition, regulations that prevent the broader use of telepsychiatry must be revised. All behavioral health providers should implement open access scheduling, a proven modality for reducing missed appointments.

3. Reducing burdensome regulations and confidentiality restrictions

Excessive documentation requirements, especially necessarily detailed, lengthy assessments and treatment must be revised and 42 CFR Part 2 must be made consistent with HIPAA requirements.

4. Broader implementation of innovative models

The shortage of psychiatrists will only worsen with the integration of primary care and behavioral health, and the shift to Accountable Care Organizations as part of health care reform (which, as of this writing, faces much uncertainty). Thanks to more efficient screening for mental health and substance use disorders now occurring in primary care, there will be growing demand for access to psychiatric services.

The collaborative care model for providing psychiatric services should be implemented throughout primary care. Behavioral health organizations must develop their own version of collaborative care that targets the limited psychiatric resource where it is most needed by using measurement-based care and collaborating more effectively with other team members.

5. Adoption of novel reimbursement methods

Inappropriately low rates limit access to care. Today, 40% of psychiatrists choose cash-only private practices, the second-highest among medical specialties after dermatologists, and 75% of provider organizations employing psychiatrists report that they lose money on their psychiatric services. At the same time, the shrinking number of inpatient psychiatric services has become a significant obstacle to improved access. Beds have been eliminated because of lower rates of reimbursement, compared with other medical-surgical procedures and difficulty in recruiting psychiatrists to staff inpatient units.

Psychiatric service rates must be reset to be consistent with the actual cost of providing care. Prospective payment models like Certified Community Behavioral Health Clinics should be expanded, and bundled payments for services like collaborative care and complex care should be covered by payers.

The Medical Director Institute recommends these solutions so that access to psychiatric services does not remain a barrier to the overall success of health care reform and service delivery improving the health of Americans. Multiple stakeholders – federal and state governments, payers, providers, provider trade associations, and advocates – must take action within their spheres of influence in the design, funding, regulation, and delivery of behavioral health care to improve access to psychiatric services. Such broad collaboration is imperative for our patients to get the care they need.

Dr. Parks is the medical director for the National Council for Behavioral Health. He practices psychiatry on an outpatient basis at Family Health Center, a federally funded community health center established to expand services to uninsured and underinsured patients in central Missouri. He also holds the position of Distinguished Research Professor of Science at the University of Missouri–St. Louis and is a clinical assistant professor of psychiatry at the University of Missouri–Columbia.

Lack of access to psychiatric services has been a challenge for decades, resulting in significant delays to treatment with associated consequences in reduced quality of care, low patient satisfaction, poor patient outcomes, and higher costs.

The problem is exacerbated by a growing shortage of psychiatrists, an increased demand for psychiatric services, and inadequate payment rates. The result is a crisis that is resonating throughout the U.S. health care system.

As many know, a few months ago, the Medical Director Institute of the National Council for Behavioral Health, in partnership with the American Psychiatric Association, convened an expert panel to develop a report responding to this evolving quandary. The findings of our 60-page report, “The Psychiatric Shortage: Causes and Solutions,” suggest that psychiatry is uniquely positioned to address the issues that face our specialty.

1. Workforce development

Psychiatrists come out of residency training without the skills they need to practice in today’s rapidly evolving health care environment. We need better preparation in measurement-based care, telepsychiatry, collaborative care, and other methods of efficient team collaboration with primary care.

Funding for graduate medical education and training programs must be expanded with an infusion of new funding – not only for psychiatrists – but also for psychiatric nurse practitioners and psychiatric physician assistants.

2. Improved efficiency of service delivery

Providers of psychiatric services in outpatient psychiatric programs face a cramped daily routine with increasingly briefer appointments scheduled back-to-back that limit in-depth clinical assessment, collaboration with other members of the treatment team, and consultation with primary care providers outside of the program. Such a schedule leads to lower-quality care.

Psychiatrists must have the same level of nurse and paraprofessional assistance and support provided to other medical specialties. In addition, regulations that prevent the broader use of telepsychiatry must be revised. All behavioral health providers should implement open access scheduling, a proven modality for reducing missed appointments.

3. Reducing burdensome regulations and confidentiality restrictions

Excessive documentation requirements, especially necessarily detailed, lengthy assessments and treatment must be revised and 42 CFR Part 2 must be made consistent with HIPAA requirements.

4. Broader implementation of innovative models

The shortage of psychiatrists will only worsen with the integration of primary care and behavioral health, and the shift to Accountable Care Organizations as part of health care reform (which, as of this writing, faces much uncertainty). Thanks to more efficient screening for mental health and substance use disorders now occurring in primary care, there will be growing demand for access to psychiatric services.

The collaborative care model for providing psychiatric services should be implemented throughout primary care. Behavioral health organizations must develop their own version of collaborative care that targets the limited psychiatric resource where it is most needed by using measurement-based care and collaborating more effectively with other team members.

5. Adoption of novel reimbursement methods

Inappropriately low rates limit access to care. Today, 40% of psychiatrists choose cash-only private practices, the second-highest among medical specialties after dermatologists, and 75% of provider organizations employing psychiatrists report that they lose money on their psychiatric services. At the same time, the shrinking number of inpatient psychiatric services has become a significant obstacle to improved access. Beds have been eliminated because of lower rates of reimbursement, compared with other medical-surgical procedures and difficulty in recruiting psychiatrists to staff inpatient units.

Psychiatric service rates must be reset to be consistent with the actual cost of providing care. Prospective payment models like Certified Community Behavioral Health Clinics should be expanded, and bundled payments for services like collaborative care and complex care should be covered by payers.

The Medical Director Institute recommends these solutions so that access to psychiatric services does not remain a barrier to the overall success of health care reform and service delivery improving the health of Americans. Multiple stakeholders – federal and state governments, payers, providers, provider trade associations, and advocates – must take action within their spheres of influence in the design, funding, regulation, and delivery of behavioral health care to improve access to psychiatric services. Such broad collaboration is imperative for our patients to get the care they need.

Dr. Parks is the medical director for the National Council for Behavioral Health. He practices psychiatry on an outpatient basis at Family Health Center, a federally funded community health center established to expand services to uninsured and underinsured patients in central Missouri. He also holds the position of Distinguished Research Professor of Science at the University of Missouri–St. Louis and is a clinical assistant professor of psychiatry at the University of Missouri–Columbia.

Lack of access to psychiatric services has been a challenge for decades, resulting in significant delays to treatment with associated consequences in reduced quality of care, low patient satisfaction, poor patient outcomes, and higher costs.

The problem is exacerbated by a growing shortage of psychiatrists, an increased demand for psychiatric services, and inadequate payment rates. The result is a crisis that is resonating throughout the U.S. health care system.

As many know, a few months ago, the Medical Director Institute of the National Council for Behavioral Health, in partnership with the American Psychiatric Association, convened an expert panel to develop a report responding to this evolving quandary. The findings of our 60-page report, “The Psychiatric Shortage: Causes and Solutions,” suggest that psychiatry is uniquely positioned to address the issues that face our specialty.

1. Workforce development

Psychiatrists come out of residency training without the skills they need to practice in today’s rapidly evolving health care environment. We need better preparation in measurement-based care, telepsychiatry, collaborative care, and other methods of efficient team collaboration with primary care.

Funding for graduate medical education and training programs must be expanded with an infusion of new funding – not only for psychiatrists – but also for psychiatric nurse practitioners and psychiatric physician assistants.

2. Improved efficiency of service delivery

Providers of psychiatric services in outpatient psychiatric programs face a cramped daily routine with increasingly briefer appointments scheduled back-to-back that limit in-depth clinical assessment, collaboration with other members of the treatment team, and consultation with primary care providers outside of the program. Such a schedule leads to lower-quality care.

Psychiatrists must have the same level of nurse and paraprofessional assistance and support provided to other medical specialties. In addition, regulations that prevent the broader use of telepsychiatry must be revised. All behavioral health providers should implement open access scheduling, a proven modality for reducing missed appointments.

3. Reducing burdensome regulations and confidentiality restrictions

Excessive documentation requirements, especially necessarily detailed, lengthy assessments and treatment must be revised and 42 CFR Part 2 must be made consistent with HIPAA requirements.

4. Broader implementation of innovative models

The shortage of psychiatrists will only worsen with the integration of primary care and behavioral health, and the shift to Accountable Care Organizations as part of health care reform (which, as of this writing, faces much uncertainty). Thanks to more efficient screening for mental health and substance use disorders now occurring in primary care, there will be growing demand for access to psychiatric services.

The collaborative care model for providing psychiatric services should be implemented throughout primary care. Behavioral health organizations must develop their own version of collaborative care that targets the limited psychiatric resource where it is most needed by using measurement-based care and collaborating more effectively with other team members.

5. Adoption of novel reimbursement methods

Inappropriately low rates limit access to care. Today, 40% of psychiatrists choose cash-only private practices, the second-highest among medical specialties after dermatologists, and 75% of provider organizations employing psychiatrists report that they lose money on their psychiatric services. At the same time, the shrinking number of inpatient psychiatric services has become a significant obstacle to improved access. Beds have been eliminated because of lower rates of reimbursement, compared with other medical-surgical procedures and difficulty in recruiting psychiatrists to staff inpatient units.

Psychiatric service rates must be reset to be consistent with the actual cost of providing care. Prospective payment models like Certified Community Behavioral Health Clinics should be expanded, and bundled payments for services like collaborative care and complex care should be covered by payers.

The Medical Director Institute recommends these solutions so that access to psychiatric services does not remain a barrier to the overall success of health care reform and service delivery improving the health of Americans. Multiple stakeholders – federal and state governments, payers, providers, provider trade associations, and advocates – must take action within their spheres of influence in the design, funding, regulation, and delivery of behavioral health care to improve access to psychiatric services. Such broad collaboration is imperative for our patients to get the care they need.

Dr. Parks is the medical director for the National Council for Behavioral Health. He practices psychiatry on an outpatient basis at Family Health Center, a federally funded community health center established to expand services to uninsured and underinsured patients in central Missouri. He also holds the position of Distinguished Research Professor of Science at the University of Missouri–St. Louis and is a clinical assistant professor of psychiatry at the University of Missouri–Columbia.

PARIS – Bailout stenting during percutaneous coronary intervention for coronary bifurcations doubled the risk of major adverse cardiovascular events in the world’s largest registry of patients with these often-challenging lesions treated using bioactive stents, Marco Zimarino, MD, reported at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

Indeed, resort to bailout stenting stood out as the major potentially modifiable risk factor for adverse outcomes among the 4,306 participants in the P2BiTO registry, an international collaboration supported by members of the EuroBifurcation Club. Most of the other independent risk factors identified in a multivariate regression analysis of the P2BiTO database were beyond operator control, including diabetes, advanced age, and presentation with an acute coronary syndrome, according to Dr. Zimarino of the University of Chieti (Italy).

[email protected]

PARIS – Bailout stenting during percutaneous coronary intervention for coronary bifurcations doubled the risk of major adverse cardiovascular events in the world’s largest registry of patients with these often-challenging lesions treated using bioactive stents, Marco Zimarino, MD, reported at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

Indeed, resort to bailout stenting stood out as the major potentially modifiable risk factor for adverse outcomes among the 4,306 participants in the P2BiTO registry, an international collaboration supported by members of the EuroBifurcation Club. Most of the other independent risk factors identified in a multivariate regression analysis of the P2BiTO database were beyond operator control, including diabetes, advanced age, and presentation with an acute coronary syndrome, according to Dr. Zimarino of the University of Chieti (Italy).

[email protected]

PARIS – Bailout stenting during percutaneous coronary intervention for coronary bifurcations doubled the risk of major adverse cardiovascular events in the world’s largest registry of patients with these often-challenging lesions treated using bioactive stents, Marco Zimarino, MD, reported at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

Indeed, resort to bailout stenting stood out as the major potentially modifiable risk factor for adverse outcomes among the 4,306 participants in the P2BiTO registry, an international collaboration supported by members of the EuroBifurcation Club. Most of the other independent risk factors identified in a multivariate regression analysis of the P2BiTO database were beyond operator control, including diabetes, advanced age, and presentation with an acute coronary syndrome, according to Dr. Zimarino of the University of Chieti (Italy).

[email protected]

PARIS – The first randomized clinical trial to evaluate quality of life and clinical symptoms as the primary efficacy outcome in patients with coronary chronic total occlusion (CTO) showed a clear advantage for percutaneous revascularization over optimal medical therapy.

At 12 months’ follow-up in the 26-site, 396-patient EuroCTO trial, patients randomized to PCI with drug-eluting stents had significantly less angina and physical limitations coupled with greater improvement in quality of life than the optimal medical therapy (OMT) group on subscales of the Seattle Angina Questionnaire. On the angina frequency subscale, for example, the PCI group improved from a mean baseline score of 77.2 to 91.4 at 12 months, a significantly better result than the OMT group improvement from 80.6 to 87.5.

The PCI group also experienced greater mobility, better activity status, and less pain and discomfort as assessed by the EuroQOL five dimensions questionnaire (EQ-5D), Gerald S. Werner, MD, reported at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

“PCI of a CTO should be considered as a primary option in symptomatic patients. It is a safe and effective treatment option in expert hands,” said Dr. Werner, director of cardiology and nonsurgical intensive care at the Darmstadt (Ger.) Clinic.

He emphasized the point about “expert hands,” drawing attention to the stellar 86.3% successful revascularization rate in the EuroCTO trial, even though these were often complex procedures. Indeed, in 36% of the CTO PCIs, a retrograde approach was used.

“CTO is a special field. Just like not everybody in every hospital will do a transcatheter aortic valve replacement, not everybody should do a CTO. It can be done safely and to the benefit of the patient, but it needs to be done by someone with expertise,” the cardiologist said.

Study participants were evenly split between those with single- and multivessel disease. Patients with additional nonocclusive disease had those lesions treated by PCI before the 2:1 randomization to CTO PCI or OMT.

The periprocedural complication rate was low at 2.9%, a figure that included a 1.5% incidence of pericardial tamponade as well as vascular repairs. There were no periprocedural MIs or deaths. The 1-year major adverse cardiac event rate was roughly 6% in both study arms.

The PCI group received 6-12 months of dual-antiplatelet therapy with clopidogrel and aspirin. So did roughly 40% of the OMT group because of prior PCI.

Both study arms had comparably high rates of guideline-directed medical therapy, including statins, beta-blockers, and ACE inhibitors. However, the PCI group made significantly less use of nitrates than the OMT group during follow-up, reflecting their greater reduction in angina frequency. The crossover rate from OMT to PCI because of ongoing angina was 7.3%.

The long-term safety and durability of the two treatment strategies will be assessed at 3 years of follow-up.

The EuroCTO trial was originally planned for 600 patients. The investigators eventually settled for less because of slow enrollment. Many interventionalists who are skilled in treating CTOs proved reluctant to randomize the patients.

Dr. Werner contrasted the positive EuroCTO findings regarding clinical symptoms and quality of life to the negative results of the Korean DECISION CTO trial presented at the 2017 meeting of the American College of Cardiology. DECISION CTO found that PCI plus OMT wasn’t superior to OMT alone in reducing MI and other major adverse cardiac events in patients with at least one CTO. In Dr. Werner’s view, the Korean investigators chose the wrong endpoint.

“The quality of life improvement we’ve shown after PCI in EuroCTO is a valid clinical goal in treating stable coronary artery disease. I don’t think we can aim at improving prognosis,” according to Dr. Werner.

The impetus for EuroCTO was a recognition that CTOs are common and seriously undertreated. CTOs account for 16%-18% of all coronary lesions in patients with stable coronary artery disease, yet U.S. national data indicate only 5% of PCIs are performed to treat CTOs.

The EuroCTO trial was sponsored by the Euro CTO Club and supported by research grants from Biosensors and Asahi.

[email protected]

PARIS – The first randomized clinical trial to evaluate quality of life and clinical symptoms as the primary efficacy outcome in patients with coronary chronic total occlusion (CTO) showed a clear advantage for percutaneous revascularization over optimal medical therapy.

At 12 months’ follow-up in the 26-site, 396-patient EuroCTO trial, patients randomized to PCI with drug-eluting stents had significantly less angina and physical limitations coupled with greater improvement in quality of life than the optimal medical therapy (OMT) group on subscales of the Seattle Angina Questionnaire. On the angina frequency subscale, for example, the PCI group improved from a mean baseline score of 77.2 to 91.4 at 12 months, a significantly better result than the OMT group improvement from 80.6 to 87.5.

The PCI group also experienced greater mobility, better activity status, and less pain and discomfort as assessed by the EuroQOL five dimensions questionnaire (EQ-5D), Gerald S. Werner, MD, reported at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

“PCI of a CTO should be considered as a primary option in symptomatic patients. It is a safe and effective treatment option in expert hands,” said Dr. Werner, director of cardiology and nonsurgical intensive care at the Darmstadt (Ger.) Clinic.

He emphasized the point about “expert hands,” drawing attention to the stellar 86.3% successful revascularization rate in the EuroCTO trial, even though these were often complex procedures. Indeed, in 36% of the CTO PCIs, a retrograde approach was used.

“CTO is a special field. Just like not everybody in every hospital will do a transcatheter aortic valve replacement, not everybody should do a CTO. It can be done safely and to the benefit of the patient, but it needs to be done by someone with expertise,” the cardiologist said.

Study participants were evenly split between those with single- and multivessel disease. Patients with additional nonocclusive disease had those lesions treated by PCI before the 2:1 randomization to CTO PCI or OMT.

The periprocedural complication rate was low at 2.9%, a figure that included a 1.5% incidence of pericardial tamponade as well as vascular repairs. There were no periprocedural MIs or deaths. The 1-year major adverse cardiac event rate was roughly 6% in both study arms.

The PCI group received 6-12 months of dual-antiplatelet therapy with clopidogrel and aspirin. So did roughly 40% of the OMT group because of prior PCI.

Both study arms had comparably high rates of guideline-directed medical therapy, including statins, beta-blockers, and ACE inhibitors. However, the PCI group made significantly less use of nitrates than the OMT group during follow-up, reflecting their greater reduction in angina frequency. The crossover rate from OMT to PCI because of ongoing angina was 7.3%.

The long-term safety and durability of the two treatment strategies will be assessed at 3 years of follow-up.

The EuroCTO trial was originally planned for 600 patients. The investigators eventually settled for less because of slow enrollment. Many interventionalists who are skilled in treating CTOs proved reluctant to randomize the patients.

Dr. Werner contrasted the positive EuroCTO findings regarding clinical symptoms and quality of life to the negative results of the Korean DECISION CTO trial presented at the 2017 meeting of the American College of Cardiology. DECISION CTO found that PCI plus OMT wasn’t superior to OMT alone in reducing MI and other major adverse cardiac events in patients with at least one CTO. In Dr. Werner’s view, the Korean investigators chose the wrong endpoint.

“The quality of life improvement we’ve shown after PCI in EuroCTO is a valid clinical goal in treating stable coronary artery disease. I don’t think we can aim at improving prognosis,” according to Dr. Werner.

The impetus for EuroCTO was a recognition that CTOs are common and seriously undertreated. CTOs account for 16%-18% of all coronary lesions in patients with stable coronary artery disease, yet U.S. national data indicate only 5% of PCIs are performed to treat CTOs.

The EuroCTO trial was sponsored by the Euro CTO Club and supported by research grants from Biosensors and Asahi.

[email protected]

PARIS – The first randomized clinical trial to evaluate quality of life and clinical symptoms as the primary efficacy outcome in patients with coronary chronic total occlusion (CTO) showed a clear advantage for percutaneous revascularization over optimal medical therapy.

At 12 months’ follow-up in the 26-site, 396-patient EuroCTO trial, patients randomized to PCI with drug-eluting stents had significantly less angina and physical limitations coupled with greater improvement in quality of life than the optimal medical therapy (OMT) group on subscales of the Seattle Angina Questionnaire. On the angina frequency subscale, for example, the PCI group improved from a mean baseline score of 77.2 to 91.4 at 12 months, a significantly better result than the OMT group improvement from 80.6 to 87.5.

The PCI group also experienced greater mobility, better activity status, and less pain and discomfort as assessed by the EuroQOL five dimensions questionnaire (EQ-5D), Gerald S. Werner, MD, reported at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

“PCI of a CTO should be considered as a primary option in symptomatic patients. It is a safe and effective treatment option in expert hands,” said Dr. Werner, director of cardiology and nonsurgical intensive care at the Darmstadt (Ger.) Clinic.

He emphasized the point about “expert hands,” drawing attention to the stellar 86.3% successful revascularization rate in the EuroCTO trial, even though these were often complex procedures. Indeed, in 36% of the CTO PCIs, a retrograde approach was used.

“CTO is a special field. Just like not everybody in every hospital will do a transcatheter aortic valve replacement, not everybody should do a CTO. It can be done safely and to the benefit of the patient, but it needs to be done by someone with expertise,” the cardiologist said.

Study participants were evenly split between those with single- and multivessel disease. Patients with additional nonocclusive disease had those lesions treated by PCI before the 2:1 randomization to CTO PCI or OMT.

The periprocedural complication rate was low at 2.9%, a figure that included a 1.5% incidence of pericardial tamponade as well as vascular repairs. There were no periprocedural MIs or deaths. The 1-year major adverse cardiac event rate was roughly 6% in both study arms.

The PCI group received 6-12 months of dual-antiplatelet therapy with clopidogrel and aspirin. So did roughly 40% of the OMT group because of prior PCI.

Both study arms had comparably high rates of guideline-directed medical therapy, including statins, beta-blockers, and ACE inhibitors. However, the PCI group made significantly less use of nitrates than the OMT group during follow-up, reflecting their greater reduction in angina frequency. The crossover rate from OMT to PCI because of ongoing angina was 7.3%.

The long-term safety and durability of the two treatment strategies will be assessed at 3 years of follow-up.

The EuroCTO trial was originally planned for 600 patients. The investigators eventually settled for less because of slow enrollment. Many interventionalists who are skilled in treating CTOs proved reluctant to randomize the patients.

Dr. Werner contrasted the positive EuroCTO findings regarding clinical symptoms and quality of life to the negative results of the Korean DECISION CTO trial presented at the 2017 meeting of the American College of Cardiology. DECISION CTO found that PCI plus OMT wasn’t superior to OMT alone in reducing MI and other major adverse cardiac events in patients with at least one CTO. In Dr. Werner’s view, the Korean investigators chose the wrong endpoint.

“The quality of life improvement we’ve shown after PCI in EuroCTO is a valid clinical goal in treating stable coronary artery disease. I don’t think we can aim at improving prognosis,” according to Dr. Werner.

The impetus for EuroCTO was a recognition that CTOs are common and seriously undertreated. CTOs account for 16%-18% of all coronary lesions in patients with stable coronary artery disease, yet U.S. national data indicate only 5% of PCIs are performed to treat CTOs.

The EuroCTO trial was sponsored by the Euro CTO Club and supported by research grants from Biosensors and Asahi.

[email protected]

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 Dr. Goldberg.

I arrived in Toronto in 1998 to start my term as President of the American College of Chest Physicians. (I had always loved Toronto, where I had spent months training in pediatric critical care at “Sick Kids” [Toronto’s Children’s Hospital] and collaborating with Audrey King on disability issues and public policy in Ontario.) CHEST 1998 in Toronto was equally exciting. What I remember - with humility – was that being CHEST President is not about “you.” It is about “The President,” who is honored and revered by all members for what CHEST truly represents … excellence in health-care education, communication, and information. Everyone came up to me to respect and honor the role … including awesome Past Presidents who lovingly shared their insights and experience and others (including many who became future presidents) to volunteer their assistance. I was in awe of these leaders and how they demonstrated selfless service.

And so I began my year of presidential service leadership. What I remember best is the respect all around the world for CHEST and what it does to unite people into actions that improve health globally. The President serves CHEST members to facilitate working together, which makes a difference. My presidential year culminated in the 65th anniversary conference in Chicago in 1999. All year, I had worked with my mentor (C. Everett Koop, MD, FCCP(Hon), to plan an opening ceremony that would be inspirational and unforgettable. For years, we had shared personal/private conversations. This time, we planned to communicate in public to inspire others and help them understand key issues we considered critical for the future of health care and global health.

Soon after my Presidential term, I took 2 years off for sabbatical to work more closely with Dr. Koop (2000-2002). Then, I retired to continue to focus on our work together and as personal caregiver for my wife, Evi Faure, MD, FCCP. Dr. Koop and I met many times and also held more public presentations, including the 2003 Surgeons’ General National Meeting on Overcoming Health Disparities at Howard University arranged with CHEST Past President Dr. Alvin Thomas.

All our joint efforts focused on the importance of Communication in Health Care. We shared the belief that communication of health information would create the “informed patient and family” who would then work together in partnership with health-care professional team members. We thought that this would be the best way to improve and reform health-care delivery. We sought to provide information (the “what”) in ways that it would be trusted, understandable, and easily usable (the “how) for patients and famili

http://www.chestnet.org/News/Blogs/CHEST-Thought-Leaders/2013/06/Dr-Koops-Legacy-Reflections-on-Mentorship

http://www.chestnet.org/News/Blogs/CHEST-Thought-Leaders/2013/08/The-Legacy-of-Dr-Koop-Reflections-on-Our-Fireside-Chat

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 Dr. Goldberg.

I arrived in Toronto in 1998 to start my term as President of the American College of Chest Physicians. (I had always loved Toronto, where I had spent months training in pediatric critical care at “Sick Kids” [Toronto’s Children’s Hospital] and collaborating with Audrey King on disability issues and public policy in Ontario.) CHEST 1998 in Toronto was equally exciting. What I remember - with humility – was that being CHEST President is not about “you.” It is about “The President,” who is honored and revered by all members for what CHEST truly represents … excellence in health-care education, communication, and information. Everyone came up to me to respect and honor the role … including awesome Past Presidents who lovingly shared their insights and experience and others (including many who became future presidents) to volunteer their assistance. I was in awe of these leaders and how they demonstrated selfless service.

And so I began my year of presidential service leadership. What I remember best is the respect all around the world for CHEST and what it does to unite people into actions that improve health globally. The President serves CHEST members to facilitate working together, which makes a difference. My presidential year culminated in the 65th anniversary conference in Chicago in 1999. All year, I had worked with my mentor (C. Everett Koop, MD, FCCP(Hon), to plan an opening ceremony that would be inspirational and unforgettable. For years, we had shared personal/private conversations. This time, we planned to communicate in public to inspire others and help them understand key issues we considered critical for the future of health care and global health.

Soon after my Presidential term, I took 2 years off for sabbatical to work more closely with Dr. Koop (2000-2002). Then, I retired to continue to focus on our work together and as personal caregiver for my wife, Evi Faure, MD, FCCP. Dr. Koop and I met many times and also held more public presentations, including the 2003 Surgeons’ General National Meeting on Overcoming Health Disparities at Howard University arranged with CHEST Past President Dr. Alvin Thomas.

All our joint efforts focused on the importance of Communication in Health Care. We shared the belief that communication of health information would create the “informed patient and family” who would then work together in partnership with health-care professional team members. We thought that this would be the best way to improve and reform health-care delivery. We sought to provide information (the “what”) in ways that it would be trusted, understandable, and easily usable (the “how) for patients and famili

http://www.chestnet.org/News/Blogs/CHEST-Thought-Leaders/2013/06/Dr-Koops-Legacy-Reflections-on-Mentorship

http://www.chestnet.org/News/Blogs/CHEST-Thought-Leaders/2013/08/The-Legacy-of-Dr-Koop-Reflections-on-Our-Fireside-Chat

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 Dr. Goldberg.

I arrived in Toronto in 1998 to start my term as President of the American College of Chest Physicians. (I had always loved Toronto, where I had spent months training in pediatric critical care at “Sick Kids” [Toronto’s Children’s Hospital] and collaborating with Audrey King on disability issues and public policy in Ontario.) CHEST 1998 in Toronto was equally exciting. What I remember - with humility – was that being CHEST President is not about “you.” It is about “The President,” who is honored and revered by all members for what CHEST truly represents … excellence in health-care education, communication, and information. Everyone came up to me to respect and honor the role … including awesome Past Presidents who lovingly shared their insights and experience and others (including many who became future presidents) to volunteer their assistance. I was in awe of these leaders and how they demonstrated selfless service.

And so I began my year of presidential service leadership. What I remember best is the respect all around the world for CHEST and what it does to unite people into actions that improve health globally. The President serves CHEST members to facilitate working together, which makes a difference. My presidential year culminated in the 65th anniversary conference in Chicago in 1999. All year, I had worked with my mentor (C. Everett Koop, MD, FCCP(Hon), to plan an opening ceremony that would be inspirational and unforgettable. For years, we had shared personal/private conversations. This time, we planned to communicate in public to inspire others and help them understand key issues we considered critical for the future of health care and global health.

Soon after my Presidential term, I took 2 years off for sabbatical to work more closely with Dr. Koop (2000-2002). Then, I retired to continue to focus on our work together and as personal caregiver for my wife, Evi Faure, MD, FCCP. Dr. Koop and I met many times and also held more public presentations, including the 2003 Surgeons’ General National Meeting on Overcoming Health Disparities at Howard University arranged with CHEST Past President Dr. Alvin Thomas.

All our joint efforts focused on the importance of Communication in Health Care. We shared the belief that communication of health information would create the “informed patient and family” who would then work together in partnership with health-care professional team members. We thought that this would be the best way to improve and reform health-care delivery. We sought to provide information (the “what”) in ways that it would be trusted, understandable, and easily usable (the “how) for patients and famili

http://www.chestnet.org/News/Blogs/CHEST-Thought-Leaders/2013/06/Dr-Koops-Legacy-Reflections-on-Mentorship

http://www.chestnet.org/News/Blogs/CHEST-Thought-Leaders/2013/08/The-Legacy-of-Dr-Koop-Reflections-on-Our-Fireside-Chat

An age-adjusted version of the Sequential Organ Failure Assessment score for sepsis has been found to be at least as good, if not better than, other pediatric organ dysfunction scores at predicting in-hospital mortality.

Writing in the Aug. 7 online edition of JAMA Pediatrics, researchers reported the outcome of a retrospective observational cohort study in 6,303 critically ill patients aged 21 years or younger, which was used to adapt and validate a pediatric version of the Sequential Organ Failure Assessment (SOFA) score.

“One of the major limitations of the SOFA score is that it was developed for adult patients and contains measures that vary significantly with age, which makes it unsuitable for children,” wrote Travis J. Matics, DO, and L. Nelson Sanchez-Pinto, MD, of the department of pediatrics at the University of Chicago.

Several pediatric organ dysfunction scores exist, but their range, scale, and coverage are different from those of the SOFA score, which makes them difficult to use concurrently (JAMA Pediatr. 2017 Aug 7. doi: 10.1001/jamapediatrics.2017.2352).

“Fundamentally, having different definitions of sepsis for patients above or below the pediatric-adult threshold has no known physiologic justification and should therefore be avoided,” the authors wrote.

In this study, they modified the age-dependent cardiovascular and renal variables of the adult SOFA score by using validated cut-offs from the updated Pediatric Logistic Organ Dysfunction (PELOD-2) scoring system. They also expanded the respiratory subscore to incorporate the SpO₂:FiO₂ ratio as an alternative surrogate of lung injury.

The neurologic subscore, based on the Glasgow Coma Scale, was changed to a pediatric version of the scale. The coagulation and hepatic criteria remained the same as the adult version of the score.

Validating the pediatric version of the SOFA score (pSOFA) score in 8,711 hospital encounters, researchers found that nonsurvivors had a significantly higher median maximum pSOFA score, compared with survivors (13 vs. 2, P less than .001). The area under the curve (AUC) for discriminating in-hospital mortality was 0.94 (95% confidence interval, 0.92-0.95) and remained stable across sex, age groups, and admission types.

The maximum pSOFA score was as good as the PELOD and PELOD-2 scales at discriminating in-hospital mortality and better than the Pediatric Multiple Organ Dysfunction Score. It also showed “excellent” discrimination of in-hospital mortality among the 48.4% of patients who had a confirmed or suspected infection in the pediatric intensive care unit (AUC, 0.92; 95% CI, 0.91-0.94), Dr. Matics and Dr. Sanchez-Pinto reported.

Researchers also looked at the clinical utility of pSOFA on the day of admission, compared with the Pediatric Risk of Mortality (PRISM) III score, and found the two were similar, while the pSOFA outperformed other organ dysfunction scores in this setting.

Overall, 14.1% of the pediatric intensive care population met the sepsis criteria according to the adapted definitions and pSOFA scores, and this group had a mortality of 12.1%. Four percent of the population met the criteria for septic shock, with a mortality of 32.3%.

The SOFA score incorporates respiratory, coagulation, renal, hepatic, cardiovascular, and neurologic variables. The authors, however, argued that it does not account for age-related variability, in particular in renal criteria and the detrimental effects of kidney dysfunction in younger patients.

“In addition, the respiratory subscore criteria – based on the ratio of PaO₂ to the fraction of inspired oxygen (FiO₂) – have not been modified in previous adaptations of the SOFA score even though the decreased use of arterial blood gases in children is a known limitation,” they wrote.

“Having a harmonized definition of sepsis across age groups while recognizing the importance of the age-based variation of its measures can have many benefits, including better design of clinical trials, improved accuracy of reported outcomes, and better translation of the research and clinical strategies in the management of sepsis,” Dr. Matics and Dr. Sanchez-Pinto said.

They acknowledged, however, that their findings were limited because they were generated using retrospective data and needed to be validated in a large multicenter sample of critically ill children. They also pointed out that they did not evaluate the performance of pSOFA as a longitudinal biomarker and suggested that such studies would improve understanding of pSOFA’s clinical utility.

No conflicts of interest were reported.

[email protected]

An age-adjusted version of the Sequential Organ Failure Assessment score for sepsis has been found to be at least as good, if not better than, other pediatric organ dysfunction scores at predicting in-hospital mortality.

Writing in the Aug. 7 online edition of JAMA Pediatrics, researchers reported the outcome of a retrospective observational cohort study in 6,303 critically ill patients aged 21 years or younger, which was used to adapt and validate a pediatric version of the Sequential Organ Failure Assessment (SOFA) score.

“One of the major limitations of the SOFA score is that it was developed for adult patients and contains measures that vary significantly with age, which makes it unsuitable for children,” wrote Travis J. Matics, DO, and L. Nelson Sanchez-Pinto, MD, of the department of pediatrics at the University of Chicago.

Several pediatric organ dysfunction scores exist, but their range, scale, and coverage are different from those of the SOFA score, which makes them difficult to use concurrently (JAMA Pediatr. 2017 Aug 7. doi: 10.1001/jamapediatrics.2017.2352).

“Fundamentally, having different definitions of sepsis for patients above or below the pediatric-adult threshold has no known physiologic justification and should therefore be avoided,” the authors wrote.

In this study, they modified the age-dependent cardiovascular and renal variables of the adult SOFA score by using validated cut-offs from the updated Pediatric Logistic Organ Dysfunction (PELOD-2) scoring system. They also expanded the respiratory subscore to incorporate the SpO₂:FiO₂ ratio as an alternative surrogate of lung injury.

The neurologic subscore, based on the Glasgow Coma Scale, was changed to a pediatric version of the scale. The coagulation and hepatic criteria remained the same as the adult version of the score.

Validating the pediatric version of the SOFA score (pSOFA) score in 8,711 hospital encounters, researchers found that nonsurvivors had a significantly higher median maximum pSOFA score, compared with survivors (13 vs. 2, P less than .001). The area under the curve (AUC) for discriminating in-hospital mortality was 0.94 (95% confidence interval, 0.92-0.95) and remained stable across sex, age groups, and admission types.

The maximum pSOFA score was as good as the PELOD and PELOD-2 scales at discriminating in-hospital mortality and better than the Pediatric Multiple Organ Dysfunction Score. It also showed “excellent” discrimination of in-hospital mortality among the 48.4% of patients who had a confirmed or suspected infection in the pediatric intensive care unit (AUC, 0.92; 95% CI, 0.91-0.94), Dr. Matics and Dr. Sanchez-Pinto reported.

Researchers also looked at the clinical utility of pSOFA on the day of admission, compared with the Pediatric Risk of Mortality (PRISM) III score, and found the two were similar, while the pSOFA outperformed other organ dysfunction scores in this setting.

Overall, 14.1% of the pediatric intensive care population met the sepsis criteria according to the adapted definitions and pSOFA scores, and this group had a mortality of 12.1%. Four percent of the population met the criteria for septic shock, with a mortality of 32.3%.

The SOFA score incorporates respiratory, coagulation, renal, hepatic, cardiovascular, and neurologic variables. The authors, however, argued that it does not account for age-related variability, in particular in renal criteria and the detrimental effects of kidney dysfunction in younger patients.

“In addition, the respiratory subscore criteria – based on the ratio of PaO₂ to the fraction of inspired oxygen (FiO₂) – have not been modified in previous adaptations of the SOFA score even though the decreased use of arterial blood gases in children is a known limitation,” they wrote.

“Having a harmonized definition of sepsis across age groups while recognizing the importance of the age-based variation of its measures can have many benefits, including better design of clinical trials, improved accuracy of reported outcomes, and better translation of the research and clinical strategies in the management of sepsis,” Dr. Matics and Dr. Sanchez-Pinto said.

They acknowledged, however, that their findings were limited because they were generated using retrospective data and needed to be validated in a large multicenter sample of critically ill children. They also pointed out that they did not evaluate the performance of pSOFA as a longitudinal biomarker and suggested that such studies would improve understanding of pSOFA’s clinical utility.

No conflicts of interest were reported.

[email protected]

An age-adjusted version of the Sequential Organ Failure Assessment score for sepsis has been found to be at least as good, if not better than, other pediatric organ dysfunction scores at predicting in-hospital mortality.

Writing in the Aug. 7 online edition of JAMA Pediatrics, researchers reported the outcome of a retrospective observational cohort study in 6,303 critically ill patients aged 21 years or younger, which was used to adapt and validate a pediatric version of the Sequential Organ Failure Assessment (SOFA) score.

“One of the major limitations of the SOFA score is that it was developed for adult patients and contains measures that vary significantly with age, which makes it unsuitable for children,” wrote Travis J. Matics, DO, and L. Nelson Sanchez-Pinto, MD, of the department of pediatrics at the University of Chicago.

Several pediatric organ dysfunction scores exist, but their range, scale, and coverage are different from those of the SOFA score, which makes them difficult to use concurrently (JAMA Pediatr. 2017 Aug 7. doi: 10.1001/jamapediatrics.2017.2352).

“Fundamentally, having different definitions of sepsis for patients above or below the pediatric-adult threshold has no known physiologic justification and should therefore be avoided,” the authors wrote.

In this study, they modified the age-dependent cardiovascular and renal variables of the adult SOFA score by using validated cut-offs from the updated Pediatric Logistic Organ Dysfunction (PELOD-2) scoring system. They also expanded the respiratory subscore to incorporate the SpO₂:FiO₂ ratio as an alternative surrogate of lung injury.

The neurologic subscore, based on the Glasgow Coma Scale, was changed to a pediatric version of the scale. The coagulation and hepatic criteria remained the same as the adult version of the score.

Validating the pediatric version of the SOFA score (pSOFA) score in 8,711 hospital encounters, researchers found that nonsurvivors had a significantly higher median maximum pSOFA score, compared with survivors (13 vs. 2, P less than .001). The area under the curve (AUC) for discriminating in-hospital mortality was 0.94 (95% confidence interval, 0.92-0.95) and remained stable across sex, age groups, and admission types.

The maximum pSOFA score was as good as the PELOD and PELOD-2 scales at discriminating in-hospital mortality and better than the Pediatric Multiple Organ Dysfunction Score. It also showed “excellent” discrimination of in-hospital mortality among the 48.4% of patients who had a confirmed or suspected infection in the pediatric intensive care unit (AUC, 0.92; 95% CI, 0.91-0.94), Dr. Matics and Dr. Sanchez-Pinto reported.

Researchers also looked at the clinical utility of pSOFA on the day of admission, compared with the Pediatric Risk of Mortality (PRISM) III score, and found the two were similar, while the pSOFA outperformed other organ dysfunction scores in this setting.

Overall, 14.1% of the pediatric intensive care population met the sepsis criteria according to the adapted definitions and pSOFA scores, and this group had a mortality of 12.1%. Four percent of the population met the criteria for septic shock, with a mortality of 32.3%.

The SOFA score incorporates respiratory, coagulation, renal, hepatic, cardiovascular, and neurologic variables. The authors, however, argued that it does not account for age-related variability, in particular in renal criteria and the detrimental effects of kidney dysfunction in younger patients.

“In addition, the respiratory subscore criteria – based on the ratio of PaO₂ to the fraction of inspired oxygen (FiO₂) – have not been modified in previous adaptations of the SOFA score even though the decreased use of arterial blood gases in children is a known limitation,” they wrote.

“Having a harmonized definition of sepsis across age groups while recognizing the importance of the age-based variation of its measures can have many benefits, including better design of clinical trials, improved accuracy of reported outcomes, and better translation of the research and clinical strategies in the management of sepsis,” Dr. Matics and Dr. Sanchez-Pinto said.

They acknowledged, however, that their findings were limited because they were generated using retrospective data and needed to be validated in a large multicenter sample of critically ill children. They also pointed out that they did not evaluate the performance of pSOFA as a longitudinal biomarker and suggested that such studies would improve understanding of pSOFA’s clinical utility.

No conflicts of interest were reported.

[email protected]

July 4th was bittersweet for me, this year. Independence days of my childhood were spent grilling, sitting by the campfire on the lakes and rivers of Northern Michigan, watching the fireworks turn the night sky red, white, and blue. These fond memories were a painful reminder that others like me may not have the privilege to experience such joy, secondary to their background.

I don’t remember the first time that I heard the tale of my parents coming to America. They were both medical students from India, who received brightly colored brochures from American hospitals inviting them to come further their medical training. Due to the deficit of physicians in the United States, the hospitals even loaned money to medical students, so they would do their residencies in America. My parents took advantage of this opportunity and embarked on a journey that would define their lives. Often, my mother would talk about my father leaving for the hospital on Friday morning only to return to his wife and two toddlers on Monday afternoon. As a child, I remember my uncles taking bottles of milk to the hospital to make chai to fuel through their grueling overnight calls. These immigrant tales were the backdrop of my childhood, the basis of my understanding of America. I was raised in an immigrant community of physicians who were grateful for the opportunities that America offered them. They worked hard, reaped significant rewards, and substantially contributed to their communities. Maybe, I am just nostalgic for my childhood, but this experience, I believe, is still an integral part of the American dream.

The recent choice to restrict immigration from specific nations is disturbing at best and reminiscent of an America that I have never known. More than 7,000 physicians from Libya, Iran, Somalia, Sudan, Syria, and Yemen are currently working in the United States, providing care for more than 14 million people. An estimated 94% of American communities have at least one doctor from one of the targeted countries. These physicians are more likely to work in rural and underserved communities and provide essential services.¹ They are immigrants who have come to America to better their lives and, in turn, have bettered the lives of those around them. They are my parents. Not all physicians are good people or are worthy of the American dream, but America is a better place for welcoming those who are willing to work hard to make a better life for themselves. An important criticism of the effect of migration of medical professionals to the United States has been the loss of human capital to their respective nations, but never the ill-effect they have had on the nations they have emigrated to.

• Reinstate the Visa Interview Waiver Program, as the suspension of this program increases the risk for significant delays in new and renewal visa processing for trainees from any foreign country;

• Remove entry restrictions of physicians and medical students from the seven designated countries that have been approved for J-1, H-1B or F-1 visas;

• Allow affected physicians to obtain travel visas to visit the United States for medical conferences, as well as other medical and research related events; and

• Prioritize the admission of refugees with urgent medical needs who had already been checked and approved for entry prior to the executive order.

These recommendations were good but not broad enough. The decision to bar immigration for any period of time, from any country, is an affront to the American dream with long-lasting consequences, most importantly, the loss of health-care services to the American populace. My Congressman knows how I feel about this, does yours?

1. Fivethirtyeight.com/features/trumps-new-travel-ban-could-affect-doctors-especially-in-the-rust-belt-and-appalachia/.Accessed July 18, 2017.

2. Masri A, Senussi MH. Trump’s executive order on immigration—detrimental effects on medical training and health care. N Engl J Med. 2017; 376(19): e39.

3. http://www.immigrationresearch-info.org/report/immigrant-learning-center-inc/immigrants-health-care-keeping-americans-healthy-through-care-a.Accessed July 27, 2017.

4. http://www.nfap.com/wp-content/uploads/2015/05/International-Educator.May-June-2015.pdf.Accessed July 27, 2017 (not available on Safari).

July 4th was bittersweet for me, this year. Independence days of my childhood were spent grilling, sitting by the campfire on the lakes and rivers of Northern Michigan, watching the fireworks turn the night sky red, white, and blue. These fond memories were a painful reminder that others like me may not have the privilege to experience such joy, secondary to their background.

I don’t remember the first time that I heard the tale of my parents coming to America. They were both medical students from India, who received brightly colored brochures from American hospitals inviting them to come further their medical training. Due to the deficit of physicians in the United States, the hospitals even loaned money to medical students, so they would do their residencies in America. My parents took advantage of this opportunity and embarked on a journey that would define their lives. Often, my mother would talk about my father leaving for the hospital on Friday morning only to return to his wife and two toddlers on Monday afternoon. As a child, I remember my uncles taking bottles of milk to the hospital to make chai to fuel through their grueling overnight calls. These immigrant tales were the backdrop of my childhood, the basis of my understanding of America. I was raised in an immigrant community of physicians who were grateful for the opportunities that America offered them. They worked hard, reaped significant rewards, and substantially contributed to their communities. Maybe, I am just nostalgic for my childhood, but this experience, I believe, is still an integral part of the American dream.

The recent choice to restrict immigration from specific nations is disturbing at best and reminiscent of an America that I have never known. More than 7,000 physicians from Libya, Iran, Somalia, Sudan, Syria, and Yemen are currently working in the United States, providing care for more than 14 million people. An estimated 94% of American communities have at least one doctor from one of the targeted countries. These physicians are more likely to work in rural and underserved communities and provide essential services.¹ They are immigrants who have come to America to better their lives and, in turn, have bettered the lives of those around them. They are my parents. Not all physicians are good people or are worthy of the American dream, but America is a better place for welcoming those who are willing to work hard to make a better life for themselves. An important criticism of the effect of migration of medical professionals to the United States has been the loss of human capital to their respective nations, but never the ill-effect they have had on the nations they have emigrated to.

• Reinstate the Visa Interview Waiver Program, as the suspension of this program increases the risk for significant delays in new and renewal visa processing for trainees from any foreign country;

• Remove entry restrictions of physicians and medical students from the seven designated countries that have been approved for J-1, H-1B or F-1 visas;

• Allow affected physicians to obtain travel visas to visit the United States for medical conferences, as well as other medical and research related events; and

• Prioritize the admission of refugees with urgent medical needs who had already been checked and approved for entry prior to the executive order.

These recommendations were good but not broad enough. The decision to bar immigration for any period of time, from any country, is an affront to the American dream with long-lasting consequences, most importantly, the loss of health-care services to the American populace. My Congressman knows how I feel about this, does yours?

1. Fivethirtyeight.com/features/trumps-new-travel-ban-could-affect-doctors-especially-in-the-rust-belt-and-appalachia/.Accessed July 18, 2017.

2. Masri A, Senussi MH. Trump’s executive order on immigration—detrimental effects on medical training and health care. N Engl J Med. 2017; 376(19): e39.

3. http://www.immigrationresearch-info.org/report/immigrant-learning-center-inc/immigrants-health-care-keeping-americans-healthy-through-care-a.Accessed July 27, 2017.

4. http://www.nfap.com/wp-content/uploads/2015/05/International-Educator.May-June-2015.pdf.Accessed July 27, 2017 (not available on Safari).

July 4th was bittersweet for me, this year. Independence days of my childhood were spent grilling, sitting by the campfire on the lakes and rivers of Northern Michigan, watching the fireworks turn the night sky red, white, and blue. These fond memories were a painful reminder that others like me may not have the privilege to experience such joy, secondary to their background.

I don’t remember the first time that I heard the tale of my parents coming to America. They were both medical students from India, who received brightly colored brochures from American hospitals inviting them to come further their medical training. Due to the deficit of physicians in the United States, the hospitals even loaned money to medical students, so they would do their residencies in America. My parents took advantage of this opportunity and embarked on a journey that would define their lives. Often, my mother would talk about my father leaving for the hospital on Friday morning only to return to his wife and two toddlers on Monday afternoon. As a child, I remember my uncles taking bottles of milk to the hospital to make chai to fuel through their grueling overnight calls. These immigrant tales were the backdrop of my childhood, the basis of my understanding of America. I was raised in an immigrant community of physicians who were grateful for the opportunities that America offered them. They worked hard, reaped significant rewards, and substantially contributed to their communities. Maybe, I am just nostalgic for my childhood, but this experience, I believe, is still an integral part of the American dream.

The recent choice to restrict immigration from specific nations is disturbing at best and reminiscent of an America that I have never known. More than 7,000 physicians from Libya, Iran, Somalia, Sudan, Syria, and Yemen are currently working in the United States, providing care for more than 14 million people. An estimated 94% of American communities have at least one doctor from one of the targeted countries. These physicians are more likely to work in rural and underserved communities and provide essential services.¹ They are immigrants who have come to America to better their lives and, in turn, have bettered the lives of those around them. They are my parents. Not all physicians are good people or are worthy of the American dream, but America is a better place for welcoming those who are willing to work hard to make a better life for themselves. An important criticism of the effect of migration of medical professionals to the United States has been the loss of human capital to their respective nations, but never the ill-effect they have had on the nations they have emigrated to.

• Reinstate the Visa Interview Waiver Program, as the suspension of this program increases the risk for significant delays in new and renewal visa processing for trainees from any foreign country;

• Remove entry restrictions of physicians and medical students from the seven designated countries that have been approved for J-1, H-1B or F-1 visas;

• Allow affected physicians to obtain travel visas to visit the United States for medical conferences, as well as other medical and research related events; and

• Prioritize the admission of refugees with urgent medical needs who had already been checked and approved for entry prior to the executive order.

These recommendations were good but not broad enough. The decision to bar immigration for any period of time, from any country, is an affront to the American dream with long-lasting consequences, most importantly, the loss of health-care services to the American populace. My Congressman knows how I feel about this, does yours?

1. Fivethirtyeight.com/features/trumps-new-travel-ban-could-affect-doctors-especially-in-the-rust-belt-and-appalachia/.Accessed July 18, 2017.

2. Masri A, Senussi MH. Trump’s executive order on immigration—detrimental effects on medical training and health care. N Engl J Med. 2017; 376(19): e39.

3. http://www.immigrationresearch-info.org/report/immigrant-learning-center-inc/immigrants-health-care-keeping-americans-healthy-through-care-a.Accessed July 27, 2017.

4. http://www.nfap.com/wp-content/uploads/2015/05/International-Educator.May-June-2015.pdf.Accessed July 27, 2017 (not available on Safari).

Dear CHEST Leaders, Members, and Friends:

The Forum of International Respiratory Societies (FIRS) is an organization comprised of the world’s leading international professional respiratory societies presenting a unifying voice to improve lung health globally. Its members are: the American College of Chest Physicians (CHEST), American Thoracic Society (ATS), Asian Pacific Society of Respirology (APSR), Asociación Latino Americana De Tórax (ALAT), European Respiratory Society (ERS), International Union Against Tuberculosis and Lung Diseases (The Union), the Pan African Thoracic Society (PATS), the Global Initiative for Chronic Obstructive Lung Disease (GOLD), and the Global Initiative for Asthma (GINA). FIRS has more than 70,000 professional members; the physicians and patients they serve magnify our efforts, allowing FIRS to speak for lung health on a global scale.

FIRS is working with the World Health Organization and the United Nations to make sure lung health is represented in national health agendas. FIRS’ position paper on electronic nicotine delivery systems was presented at a side-event at the United Nations High-Level Meeting (UNHL) in New York in 2014 and is now a world standard. At the recent World Health Assembly meeting (May 2017) in Geneva, FIRS launched its Global Impact of Lung Disease report that called for a global clean air standard, strong anti-tobacco laws, and better health care for patients with respiratory disease.

FIRS will be reviewing the new WHO Global Air Quality Guidelines and will help promote them globally through advocacy and messaging, as well as by providing air quality expertise. FIRS will be involved at the Coimbra meeting (Sept 26-29) on improving the urban environment, the Montevideo UN High-Level (UNHL) meeting on chronic disease (Oct 18-20), and the UN Ministerial Meeting in Moscow on tuberculosis, and it is preparing for the 2018 UNHL meetings on antibiotic drug resistance, tuberculosis, and chronic diseases.

Gerard Silvestri, MD, MS, FCCP

CHEST President

Darcy Marciniuk, MD, FCCP

CHEST FIRS Liaison

Dear CHEST Leaders, Members, and Friends:

The Forum of International Respiratory Societies (FIRS) is an organization comprised of the world’s leading international professional respiratory societies presenting a unifying voice to improve lung health globally. Its members are: the American College of Chest Physicians (CHEST), American Thoracic Society (ATS), Asian Pacific Society of Respirology (APSR), Asociación Latino Americana De Tórax (ALAT), European Respiratory Society (ERS), International Union Against Tuberculosis and Lung Diseases (The Union), the Pan African Thoracic Society (PATS), the Global Initiative for Chronic Obstructive Lung Disease (GOLD), and the Global Initiative for Asthma (GINA). FIRS has more than 70,000 professional members; the physicians and patients they serve magnify our efforts, allowing FIRS to speak for lung health on a global scale.

FIRS is working with the World Health Organization and the United Nations to make sure lung health is represented in national health agendas. FIRS’ position paper on electronic nicotine delivery systems was presented at a side-event at the United Nations High-Level Meeting (UNHL) in New York in 2014 and is now a world standard. At the recent World Health Assembly meeting (May 2017) in Geneva, FIRS launched its Global Impact of Lung Disease report that called for a global clean air standard, strong anti-tobacco laws, and better health care for patients with respiratory disease.

FIRS will be reviewing the new WHO Global Air Quality Guidelines and will help promote them globally through advocacy and messaging, as well as by providing air quality expertise. FIRS will be involved at the Coimbra meeting (Sept 26-29) on improving the urban environment, the Montevideo UN High-Level (UNHL) meeting on chronic disease (Oct 18-20), and the UN Ministerial Meeting in Moscow on tuberculosis, and it is preparing for the 2018 UNHL meetings on antibiotic drug resistance, tuberculosis, and chronic diseases.

Gerard Silvestri, MD, MS, FCCP

CHEST President

Darcy Marciniuk, MD, FCCP

CHEST FIRS Liaison

Dear CHEST Leaders, Members, and Friends:

The Forum of International Respiratory Societies (FIRS) is an organization comprised of the world’s leading international professional respiratory societies presenting a unifying voice to improve lung health globally. Its members are: the American College of Chest Physicians (CHEST), American Thoracic Society (ATS), Asian Pacific Society of Respirology (APSR), Asociación Latino Americana De Tórax (ALAT), European Respiratory Society (ERS), International Union Against Tuberculosis and Lung Diseases (The Union), the Pan African Thoracic Society (PATS), the Global Initiative for Chronic Obstructive Lung Disease (GOLD), and the Global Initiative for Asthma (GINA). FIRS has more than 70,000 professional members; the physicians and patients they serve magnify our efforts, allowing FIRS to speak for lung health on a global scale.

FIRS is working with the World Health Organization and the United Nations to make sure lung health is represented in national health agendas. FIRS’ position paper on electronic nicotine delivery systems was presented at a side-event at the United Nations High-Level Meeting (UNHL) in New York in 2014 and is now a world standard. At the recent World Health Assembly meeting (May 2017) in Geneva, FIRS launched its Global Impact of Lung Disease report that called for a global clean air standard, strong anti-tobacco laws, and better health care for patients with respiratory disease.

FIRS will be reviewing the new WHO Global Air Quality Guidelines and will help promote them globally through advocacy and messaging, as well as by providing air quality expertise. FIRS will be involved at the Coimbra meeting (Sept 26-29) on improving the urban environment, the Montevideo UN High-Level (UNHL) meeting on chronic disease (Oct 18-20), and the UN Ministerial Meeting in Moscow on tuberculosis, and it is preparing for the 2018 UNHL meetings on antibiotic drug resistance, tuberculosis, and chronic diseases.

Gerard Silvestri, MD, MS, FCCP

CHEST President

Darcy Marciniuk, MD, FCCP

CHEST FIRS Liaison