Drs. Simpson, Hogarth, and Moores told Reddit to ask them anything—here’s what happened next.

“Is there an organ or system that sepsis generally targets?”

“If I’m going to be in the back of a cramped car cross country for 16 hours straight, should I take an aspirin beforehand to cut down risk of DVT?”

“Hello Doctor. Does thermoplasty have any application for bronchiectasis patients, like myself?”

Within the science AMA subsection, users have the ability to post a topic or questions about anything and respond to other users. AMA, which stands for “Ask Me Anything,” describes the conversation happening between the user and the host of the topic. Users have the ability to ask questions related to the topic, or even ‘upvote’ particular questions that they would like answered. An ‘upvote’ moves a question or comment to the top of the page to become more visible to the host. AMAs can become trending topics on Reddit through ‘upvotes’, as well.

In an effort to help educate and inform individuals on advancements in chest medicine education, clinical research, and team-based care, CHEST has connected specialists with a deep passion for topics in pulmonary, critical care, and sleep medicine to an audience filled with questions ready to be answered. Some of the topics we’ve covered include:

• Sepsis with Dr. Steven Q. Simpson, FCCP, who is a pulmonologist, intensivist, CHEST board member, and a sepsis researcher and expert. Dr. Simpson discussed the recent consensus statement on sepsis diagnosis. The statement aimed to redefine the diagnostic criteria of sepsis and eliminate the concept of the systemic inflammatory response syndrome (SIRS). Dr. Simpson shared his rebuttal New Sepsis Guidelines: A Change We Should Not Make in the journal CHEST. Dr. Simpson’s statement expressed the concern that widespread application of this new SIRS definition could cost patient lives, and it should not be adopted. This AMA was upvoted 784 times.
• Asthma and bronchial thermoplasty with Dr. D. Kyle Hogarth, FCCP, who is a pulmonologist, member of CHEST, and the first physician in Illinois to perform bronchial thermoplasty, a nonpharmaceutical treatment for severe asthma. This AMA was upvoted 3,112 times.
• DVT with Dr. Lisa K. Moores, FCCP, who is a pulmonologist, member of CHEST, and an expert on thrombosis. Dr. Moores discussed VTE, DVT, and PE. This AMA was upvoted 903 times.

Hosting Reddit AMAs has allowed CHEST to not only reach a more public-facing audience but also health-care providers outside of chest medicine. Stepping into this platform has allowed us to position CHEST as a subject matter expert in topics like asthma, sepsis, and DVT/VTE. These AMAs have helped people to understand the role our members play within health-care by showcasing new and emerging treatments and raising public awareness of health conditions.

If you are interested in sharing your knowledge on a specific topic on Reddit, you can contact CHEST’s New Media Specialist Taylor Pecko-Reid, at [email protected].

Drs. Simpson, Hogarth, and Moores told Reddit to ask them anything—here’s what happened next.

“Is there an organ or system that sepsis generally targets?”

“If I’m going to be in the back of a cramped car cross country for 16 hours straight, should I take an aspirin beforehand to cut down risk of DVT?”

“Hello Doctor. Does thermoplasty have any application for bronchiectasis patients, like myself?”

Within the science AMA subsection, users have the ability to post a topic or questions about anything and respond to other users. AMA, which stands for “Ask Me Anything,” describes the conversation happening between the user and the host of the topic. Users have the ability to ask questions related to the topic, or even ‘upvote’ particular questions that they would like answered. An ‘upvote’ moves a question or comment to the top of the page to become more visible to the host. AMAs can become trending topics on Reddit through ‘upvotes’, as well.

In an effort to help educate and inform individuals on advancements in chest medicine education, clinical research, and team-based care, CHEST has connected specialists with a deep passion for topics in pulmonary, critical care, and sleep medicine to an audience filled with questions ready to be answered. Some of the topics we’ve covered include:

• Sepsis with Dr. Steven Q. Simpson, FCCP, who is a pulmonologist, intensivist, CHEST board member, and a sepsis researcher and expert. Dr. Simpson discussed the recent consensus statement on sepsis diagnosis. The statement aimed to redefine the diagnostic criteria of sepsis and eliminate the concept of the systemic inflammatory response syndrome (SIRS). Dr. Simpson shared his rebuttal New Sepsis Guidelines: A Change We Should Not Make in the journal CHEST. Dr. Simpson’s statement expressed the concern that widespread application of this new SIRS definition could cost patient lives, and it should not be adopted. This AMA was upvoted 784 times.
• Asthma and bronchial thermoplasty with Dr. D. Kyle Hogarth, FCCP, who is a pulmonologist, member of CHEST, and the first physician in Illinois to perform bronchial thermoplasty, a nonpharmaceutical treatment for severe asthma. This AMA was upvoted 3,112 times.
• DVT with Dr. Lisa K. Moores, FCCP, who is a pulmonologist, member of CHEST, and an expert on thrombosis. Dr. Moores discussed VTE, DVT, and PE. This AMA was upvoted 903 times.

Hosting Reddit AMAs has allowed CHEST to not only reach a more public-facing audience but also health-care providers outside of chest medicine. Stepping into this platform has allowed us to position CHEST as a subject matter expert in topics like asthma, sepsis, and DVT/VTE. These AMAs have helped people to understand the role our members play within health-care by showcasing new and emerging treatments and raising public awareness of health conditions.

If you are interested in sharing your knowledge on a specific topic on Reddit, you can contact CHEST’s New Media Specialist Taylor Pecko-Reid, at [email protected].

Drs. Simpson, Hogarth, and Moores told Reddit to ask them anything—here’s what happened next.

“Is there an organ or system that sepsis generally targets?”

“If I’m going to be in the back of a cramped car cross country for 16 hours straight, should I take an aspirin beforehand to cut down risk of DVT?”

“Hello Doctor. Does thermoplasty have any application for bronchiectasis patients, like myself?”

Within the science AMA subsection, users have the ability to post a topic or questions about anything and respond to other users. AMA, which stands for “Ask Me Anything,” describes the conversation happening between the user and the host of the topic. Users have the ability to ask questions related to the topic, or even ‘upvote’ particular questions that they would like answered. An ‘upvote’ moves a question or comment to the top of the page to become more visible to the host. AMAs can become trending topics on Reddit through ‘upvotes’, as well.

In an effort to help educate and inform individuals on advancements in chest medicine education, clinical research, and team-based care, CHEST has connected specialists with a deep passion for topics in pulmonary, critical care, and sleep medicine to an audience filled with questions ready to be answered. Some of the topics we’ve covered include:

• Sepsis with Dr. Steven Q. Simpson, FCCP, who is a pulmonologist, intensivist, CHEST board member, and a sepsis researcher and expert. Dr. Simpson discussed the recent consensus statement on sepsis diagnosis. The statement aimed to redefine the diagnostic criteria of sepsis and eliminate the concept of the systemic inflammatory response syndrome (SIRS). Dr. Simpson shared his rebuttal New Sepsis Guidelines: A Change We Should Not Make in the journal CHEST. Dr. Simpson’s statement expressed the concern that widespread application of this new SIRS definition could cost patient lives, and it should not be adopted. This AMA was upvoted 784 times.
• Asthma and bronchial thermoplasty with Dr. D. Kyle Hogarth, FCCP, who is a pulmonologist, member of CHEST, and the first physician in Illinois to perform bronchial thermoplasty, a nonpharmaceutical treatment for severe asthma. This AMA was upvoted 3,112 times.
• DVT with Dr. Lisa K. Moores, FCCP, who is a pulmonologist, member of CHEST, and an expert on thrombosis. Dr. Moores discussed VTE, DVT, and PE. This AMA was upvoted 903 times.

Hosting Reddit AMAs has allowed CHEST to not only reach a more public-facing audience but also health-care providers outside of chest medicine. Stepping into this platform has allowed us to position CHEST as a subject matter expert in topics like asthma, sepsis, and DVT/VTE. These AMAs have helped people to understand the role our members play within health-care by showcasing new and emerging treatments and raising public awareness of health conditions.

If you are interested in sharing your knowledge on a specific topic on Reddit, you can contact CHEST’s New Media Specialist Taylor Pecko-Reid, at [email protected].

The Board of Regents of the American College of Chest Physicians (CHEST) has finalized the appointment of Stephen J. Welch as Executive Vice President and Chief Executive Officer for CHEST. Welch had been serving as the interim EVP/CEO since May 2016. Prior to this appointment, he served in a senior staff role at CHEST for 22 years, most recently as Publisher and Senior Vice President of Publications and Digital Content, which includes managing the organization’s flagship scientific journal, CHEST^®.

The Board of Regents of the American College of Chest Physicians (CHEST) has finalized the appointment of Stephen J. Welch as Executive Vice President and Chief Executive Officer for CHEST. Welch had been serving as the interim EVP/CEO since May 2016. Prior to this appointment, he served in a senior staff role at CHEST for 22 years, most recently as Publisher and Senior Vice President of Publications and Digital Content, which includes managing the organization’s flagship scientific journal, CHEST^®.

The Board of Regents of the American College of Chest Physicians (CHEST) has finalized the appointment of Stephen J. Welch as Executive Vice President and Chief Executive Officer for CHEST. Welch had been serving as the interim EVP/CEO since May 2016. Prior to this appointment, he served in a senior staff role at CHEST for 22 years, most recently as Publisher and Senior Vice President of Publications and Digital Content, which includes managing the organization’s flagship scientific journal, CHEST^®.

Explore the talent of Canadian artists and the culture of Toronto during CHEST Annual Meeting 2017.

Over the last decade, Toronto’s art scene has moved to the former industrial district, creating a new home for galleries, especially those of contemporary art. While Toronto’s galleries may not be very busy outside of opening nights, they allow you to visit at any time and admire the artwork at your own pace. Along with art galleries, there are many options available to experience music and performance art, as well as family-friendly activities. Here are a few places you’ll want to visit:
 

Art Galleries

• The Power Plant (4-minute drive), one of Toronto’s most established contemporary art galleries, is located within Harbourfront in an actual power plant - one that was in operation for most of the 1900s. If you’re with young family members, a free, hands-on art workshop led by artists with activities designed around the current exhibitions is available called Power Plant: Power Kids.
• Art Metropole (15-minute drive) is a nonprofit organization with an eclectic collection of merchandise, including a huge selection of artist-created books, periodicals,

  

  By Raysonho @ Open Grid Scheduler / Grid Engine (Own work)

  posters, clothing, audio, video, and more. The name is taken from the building’s original tenant, Art Metropole, which operated as one of Toronto’s earliest galleries from 1911 to the 1940s. Art Metropole has always been the leader of Toronto’s artistic community. In 1997, over 13,000 items were transferred to the National Gallery of Canada as the “Art Metropole Collection.” The works of world-renowned artists, such as Yoko Ono, Sol Lewitt, Joseph Beuys, and Marcel Duchamp, are included in the collection.
• Daniel Faria Gallery (18-minute drive) is a bright contemporary art space found in a warehouse that used to be an auto body shop. A number of reputable, mostly Canadian, artists’ works are displayed by owner Daniel Faria, including works by Shannon Bool, Chris Curreri, Kristine Moran, and Coupland. Check out other neighboring galleries within walking distance, including Tomorrow Gallery and the artist-run Mercer Union.

Music and Theatre

• The Rex Jazz & Blues Bar (6-minute drive) has two to three (mostly free) shows every day, about 19 shows a week, jazz jams on Tuesdays, local and international talent, and a fantastic location. This place is truly hard to beat.
• Spend an evening at the Canadian Opera Company (6-minute drive). During the week of CHEST 2017, the COC will be showing The Elixir of Love, a Cinderella story presented with a twist, as a poor and uneducated young man dreams ofwinning the heart of a rich, clever, and beautiful woman.
• For a wide variety of events and visual art, visit the Harbourfront Centre (4-minute drive). During your time at CHEST 2017, you’ll find options for literary arts, like the International Festival of Authors, theatre, music, shopping, and more. You may even get a chance for family skating on the Natrel Rink, which opens in November!

Note: all estimated times assume you are starting at the Metro Toronto Convention Centre.The arts and culture of Toronto are sure to inspire you, as will CHEST 2017. When you visit Toronto, October 28 to November 1, you’ll have access to cutting-edge education on pulmonary, critical care, and sleep medicine topics.

Learn more, and register today at chestmeeting.chestnet.org.

Explore the talent of Canadian artists and the culture of Toronto during CHEST Annual Meeting 2017.

Over the last decade, Toronto’s art scene has moved to the former industrial district, creating a new home for galleries, especially those of contemporary art. While Toronto’s galleries may not be very busy outside of opening nights, they allow you to visit at any time and admire the artwork at your own pace. Along with art galleries, there are many options available to experience music and performance art, as well as family-friendly activities. Here are a few places you’ll want to visit:
 

Art Galleries

• The Power Plant (4-minute drive), one of Toronto’s most established contemporary art galleries, is located within Harbourfront in an actual power plant - one that was in operation for most of the 1900s. If you’re with young family members, a free, hands-on art workshop led by artists with activities designed around the current exhibitions is available called Power Plant: Power Kids.
• Art Metropole (15-minute drive) is a nonprofit organization with an eclectic collection of merchandise, including a huge selection of artist-created books, periodicals,

  

  By Raysonho @ Open Grid Scheduler / Grid Engine (Own work)

  posters, clothing, audio, video, and more. The name is taken from the building’s original tenant, Art Metropole, which operated as one of Toronto’s earliest galleries from 1911 to the 1940s. Art Metropole has always been the leader of Toronto’s artistic community. In 1997, over 13,000 items were transferred to the National Gallery of Canada as the “Art Metropole Collection.” The works of world-renowned artists, such as Yoko Ono, Sol Lewitt, Joseph Beuys, and Marcel Duchamp, are included in the collection.
• Daniel Faria Gallery (18-minute drive) is a bright contemporary art space found in a warehouse that used to be an auto body shop. A number of reputable, mostly Canadian, artists’ works are displayed by owner Daniel Faria, including works by Shannon Bool, Chris Curreri, Kristine Moran, and Coupland. Check out other neighboring galleries within walking distance, including Tomorrow Gallery and the artist-run Mercer Union.

Music and Theatre

• The Rex Jazz & Blues Bar (6-minute drive) has two to three (mostly free) shows every day, about 19 shows a week, jazz jams on Tuesdays, local and international talent, and a fantastic location. This place is truly hard to beat.
• Spend an evening at the Canadian Opera Company (6-minute drive). During the week of CHEST 2017, the COC will be showing The Elixir of Love, a Cinderella story presented with a twist, as a poor and uneducated young man dreams ofwinning the heart of a rich, clever, and beautiful woman.
• For a wide variety of events and visual art, visit the Harbourfront Centre (4-minute drive). During your time at CHEST 2017, you’ll find options for literary arts, like the International Festival of Authors, theatre, music, shopping, and more. You may even get a chance for family skating on the Natrel Rink, which opens in November!

Note: all estimated times assume you are starting at the Metro Toronto Convention Centre.The arts and culture of Toronto are sure to inspire you, as will CHEST 2017. When you visit Toronto, October 28 to November 1, you’ll have access to cutting-edge education on pulmonary, critical care, and sleep medicine topics.

Learn more, and register today at chestmeeting.chestnet.org.

Explore the talent of Canadian artists and the culture of Toronto during CHEST Annual Meeting 2017.

Over the last decade, Toronto’s art scene has moved to the former industrial district, creating a new home for galleries, especially those of contemporary art. While Toronto’s galleries may not be very busy outside of opening nights, they allow you to visit at any time and admire the artwork at your own pace. Along with art galleries, there are many options available to experience music and performance art, as well as family-friendly activities. Here are a few places you’ll want to visit:
 

Art Galleries

• The Power Plant (4-minute drive), one of Toronto’s most established contemporary art galleries, is located within Harbourfront in an actual power plant - one that was in operation for most of the 1900s. If you’re with young family members, a free, hands-on art workshop led by artists with activities designed around the current exhibitions is available called Power Plant: Power Kids.
• Art Metropole (15-minute drive) is a nonprofit organization with an eclectic collection of merchandise, including a huge selection of artist-created books, periodicals,

  

  By Raysonho @ Open Grid Scheduler / Grid Engine (Own work)

  posters, clothing, audio, video, and more. The name is taken from the building’s original tenant, Art Metropole, which operated as one of Toronto’s earliest galleries from 1911 to the 1940s. Art Metropole has always been the leader of Toronto’s artistic community. In 1997, over 13,000 items were transferred to the National Gallery of Canada as the “Art Metropole Collection.” The works of world-renowned artists, such as Yoko Ono, Sol Lewitt, Joseph Beuys, and Marcel Duchamp, are included in the collection.
• Daniel Faria Gallery (18-minute drive) is a bright contemporary art space found in a warehouse that used to be an auto body shop. A number of reputable, mostly Canadian, artists’ works are displayed by owner Daniel Faria, including works by Shannon Bool, Chris Curreri, Kristine Moran, and Coupland. Check out other neighboring galleries within walking distance, including Tomorrow Gallery and the artist-run Mercer Union.

Music and Theatre

• The Rex Jazz & Blues Bar (6-minute drive) has two to three (mostly free) shows every day, about 19 shows a week, jazz jams on Tuesdays, local and international talent, and a fantastic location. This place is truly hard to beat.
• Spend an evening at the Canadian Opera Company (6-minute drive). During the week of CHEST 2017, the COC will be showing The Elixir of Love, a Cinderella story presented with a twist, as a poor and uneducated young man dreams ofwinning the heart of a rich, clever, and beautiful woman.
• For a wide variety of events and visual art, visit the Harbourfront Centre (4-minute drive). During your time at CHEST 2017, you’ll find options for literary arts, like the International Festival of Authors, theatre, music, shopping, and more. You may even get a chance for family skating on the Natrel Rink, which opens in November!

Note: all estimated times assume you are starting at the Metro Toronto Convention Centre.The arts and culture of Toronto are sure to inspire you, as will CHEST 2017. When you visit Toronto, October 28 to November 1, you’ll have access to cutting-edge education on pulmonary, critical care, and sleep medicine topics.

Learn more, and register today at chestmeeting.chestnet.org.

Down syndrome (DS) is the most common chromosomal disorder with an estimated 250,700 children, teens, and adults living with DS in the United States in 2008 (CDC.gov). The life expectancy for individuals with DS has increased due to improved medical care, educational interventions, and identification and management of underlying psychiatric and behavioral problems. This has resulted in increased median age to 49 years, and the life expectancy of a 1-year-old child with DS to more than 60 to 65 years (Bittles et al. Dev Med Child Neurol. 2004;46[4]:282).

Sleep medicine specialists have been very involved in the care of the pediatric DS population but with the improved survival, more adult patients with DS are presenting to sleep clinics for their care. The complexity of caring for adult patients with DS poses a challenge to sleep specialists, especially with the paucity of literature and clinical guidelines.

Dr. Shaib is Associate Professor of Medicine, Medical Director, Baylor St Luke’s Center for Sleep Medicine, Department of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston, Texas.

Down syndrome (DS) is the most common chromosomal disorder with an estimated 250,700 children, teens, and adults living with DS in the United States in 2008 (CDC.gov). The life expectancy for individuals with DS has increased due to improved medical care, educational interventions, and identification and management of underlying psychiatric and behavioral problems. This has resulted in increased median age to 49 years, and the life expectancy of a 1-year-old child with DS to more than 60 to 65 years (Bittles et al. Dev Med Child Neurol. 2004;46[4]:282).

Sleep medicine specialists have been very involved in the care of the pediatric DS population but with the improved survival, more adult patients with DS are presenting to sleep clinics for their care. The complexity of caring for adult patients with DS poses a challenge to sleep specialists, especially with the paucity of literature and clinical guidelines.

Dr. Shaib is Associate Professor of Medicine, Medical Director, Baylor St Luke’s Center for Sleep Medicine, Department of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston, Texas.

Down syndrome (DS) is the most common chromosomal disorder with an estimated 250,700 children, teens, and adults living with DS in the United States in 2008 (CDC.gov). The life expectancy for individuals with DS has increased due to improved medical care, educational interventions, and identification and management of underlying psychiatric and behavioral problems. This has resulted in increased median age to 49 years, and the life expectancy of a 1-year-old child with DS to more than 60 to 65 years (Bittles et al. Dev Med Child Neurol. 2004;46[4]:282).

Sleep medicine specialists have been very involved in the care of the pediatric DS population but with the improved survival, more adult patients with DS are presenting to sleep clinics for their care. The complexity of caring for adult patients with DS poses a challenge to sleep specialists, especially with the paucity of literature and clinical guidelines.

Dr. Shaib is Associate Professor of Medicine, Medical Director, Baylor St Luke’s Center for Sleep Medicine, Department of Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, Houston, Texas.

Original Research

Allogeneic Human Mesenchymal Stem Cells in Patients With Idiopathic Pulmonary Fibrosis via Intravenous Delivery (AETHER): A Phase I Safety Clinical Trial. By Dr. M. K. Glassberg et al.



Adult Patients With Bronchiectasis: A First Look at the US Bronchiectasis Research Registry. By Dr. T. R. Aksamit et al.

Evidence-Based Medicine

Interventional Pulmonology Fellowship Accreditation Standards: Executive Summary of the Multisociety Interventional Pulmonology Fellowship Accreditation Committee. By Dr. J. J. Mullon et al.
 

Giants in Chest Medicine

Talmadge E. King Jr., MD, FCCP. By Dr. Harold R. Collard.

Original Research

Allogeneic Human Mesenchymal Stem Cells in Patients With Idiopathic Pulmonary Fibrosis via Intravenous Delivery (AETHER): A Phase I Safety Clinical Trial. By Dr. M. K. Glassberg et al.



Adult Patients With Bronchiectasis: A First Look at the US Bronchiectasis Research Registry. By Dr. T. R. Aksamit et al.

Evidence-Based Medicine

Interventional Pulmonology Fellowship Accreditation Standards: Executive Summary of the Multisociety Interventional Pulmonology Fellowship Accreditation Committee. By Dr. J. J. Mullon et al.
 

Giants in Chest Medicine

Talmadge E. King Jr., MD, FCCP. By Dr. Harold R. Collard.

Original Research

Allogeneic Human Mesenchymal Stem Cells in Patients With Idiopathic Pulmonary Fibrosis via Intravenous Delivery (AETHER): A Phase I Safety Clinical Trial. By Dr. M. K. Glassberg et al.



Adult Patients With Bronchiectasis: A First Look at the US Bronchiectasis Research Registry. By Dr. T. R. Aksamit et al.

Evidence-Based Medicine

Interventional Pulmonology Fellowship Accreditation Standards: Executive Summary of the Multisociety Interventional Pulmonology Fellowship Accreditation Committee. By Dr. J. J. Mullon et al.
 

Giants in Chest Medicine

Talmadge E. King Jr., MD, FCCP. By Dr. Harold R. Collard.

Interventional Chest/Diagnostic Procedures

Update: 8th ed IASLC lung cancer staging guidelines

The new 8th edition guidelines on the staging of non-small cell lung cancer sponsored by the International Association for the Study of Lung Cancer (IASLC), and developed jointly by the American Joint Committee on Cancer and the Union Internationale Contre le Cancer were enacted January 1, 2017, and provide a methodologically rigorous update to staging nomenclature (Detterbeck et al. Chest. 2017;151[1]:193). The new guidelines were developed using a database comprising 94,708 patients in 16 countries, integrating clinical, pathologic, and survival data with multivariate analysis to establish prognostically significant staging subgroups.

In the new guidelines, tumor size has been divided into 1-cm increments for T classifications with new subcategories of T1a <1 cm, T1b 1-2 cm, and T1c 2-3 cm (Rami-Porta et al. J Thorac Oncol. 2015;10[7]:990). Furthermore, T2 has been broadened to include main bronchus tumors causing lobar or whole lung atelectasis extending to the hilum. Tumors with diaphragmatic involvement have been reclassified as T4. Guidance on heterogeneous nodules has also been provided, with emphasis on measurement of the solid component (based on imaging) or depth of invasion (on pathology) to determine T classification.

The N classification remains unchanged from the 7th edition. Exploratory analysis suggested prognostic significance to the number of involved N1/N2 lymph nodes; however, this requires detailed pathologic assessment and was not adopted as a staging criterion (Asamura et al. J Thorac Oncol. 2015;10[12]:1675).

Classification of metastatic disease has been modified from M1a/M1b to M1a for thoracic metastasis, M1b for single/oligometastatic extrathoracic metastasis, and the new category M1c for multiple/disseminated metastases. M1c involvement now denotes stage IVb disease, with lower survival compared to IVa disease (0% vs 10% 5-year survival (Goldstraw et al. J Thorac Oncol. 2015;11[1]:39). Application in broader cohorts, including patients undergoing bronchoscopic staging, will be needed to further validate the new guidelines.

Vivek Murthy, MD

Fellow-in-Training MemberSteering Committee
 

Pulmonary Physiology, Function, and Rehabilitation

6-minute walk test

The 6-minute walk test (6MWT) is a widely used measure of functional status and exercise capacity. Though it does not diagnose specific etiologies of impairment, the 6MWT provides an assessment of the overall integrated physiologic responses to exercise (Am J Respir Crit Care Med. 2002;166[1]:111). The test is a self-paced, submaximal study. Patients are instructed to “walk as far as possible for 6 minutes” with this distance (6MWD) measured as the primary outcome. 6MWD is associated with clinical outcomes in many cardiopulmonary disorders and is reliable, valid, and responsive to treatment. Normative equations provide predicted and lower limit of normal values (Singh et al. Eur Respir J. 2014;44[6]:1447). In addition to patient comorbidities, several important factors impact 6MWD interpretation. Standardization of the testing course, patient instructions, encouragement, technician assistance, walking aids, and supplemental oxygen use are important in reducing testing variability (Holland et al. Eur Respir J. 2014;44[6]:1428). A significant learning effect exists during the first several walks. An improvement of about 26 m (range 24-29 m) has been reported in patients with COPD, with the majority improving during the second test despite a short time interval lapse. Assessing for longitudinal change in serial testing is based on the minimal clinically important difference (MCID). This represents the difference in 6MWD that is perceived as important to the patient or leads to change in management. Techniques to develop these estimates are based upon statistical analysis of study sample data (distribution-based) or changes in a different, but related, clinical variable that is used as a reference (anchor-based). While minor differences in MCID are reported based on specific disease processes, a European Respiratory Society/American Thoracic Society review based on data from patients with COPD, ILD, and PAH found a MCID value of about 30 m (range 25-33 m) for adults with chronic respiratory disease, independent of specific disease, which is only slightly larger than the short term variability (Puente-Maestu et al. Eur Respir J. 2016;47[2]:429). Knowledge of these factors can assist in proper interpretation of the 6MWT.

Lana Alghothani, MD

NetWork Member

Nitin Bhatt, MD

Steering Committee Member

Pulmonary Vascular Disease

Methamphetamine-associated pulmonary hypertension (MAPAH): “tip of the iceberg”

Pulmonary hypertension (PH) is a devastating condition with serious morbidity and mortality. The Evian Classification and more recent revisions (J Am Coll Cardiol. 2013;62(25 Suppl ):D34) reclassified PH into five subgroups based upon etio-pathogenesis. Group I PH (pulmonary arterial hypertension, PAH) represents a growing list of entities, with Drugs & Toxins (Group 1.3) as a separate subgroup. This subgroup was first recognized following the discovery of an association between PH and the ingestion of the anorexigen aminorex (Gurtner HP. Schweiz Med Wochenschr. 1985;115[24]:818).

Methamphetamine (ME) as a potential etiology for PAH was first reported in 1993 (Schaiberger et al. Chest. 1993;104[2]:614). More recently, Chin et al suggested an association between stimulant use and PAH in 28.9% of their patients diagnosed with idiopathic PAH (Chest. 2006;130[6]:1657). The growing body of evidence linking ME to PAH resulted in upgrading of ME from “Possible” to “Likely” in the latest revision of the PH classification.

Recent gene sequencing data showed carboxylesterase-1, an enzyme that protects against ME-mediated pulmonary vascular injury, may be downregulated in patients with methamphetamine-associated PAH (MAPAH) (Perez et al. Am J Respir Crit Care Med. 193;2016:A2912). Furthermore, amphetamines promote mitochondrial dysfunction and DNA damage in pulmonary hypertension (Chen PI. JCI Insight. 2017;2[2]:e90427). Importantly, Barnett et al demonstrated a poorer prognosis in MAPAH compared with individuals with idiopathic PAH, but they are less likely to be treated with infused prostanoid therapies (Circulation. 2012;126:A13817).

Amphetamine-type stimulants have become the second most widely used class of illicit drugs worldwide (United Nations Office on Drugs & Crime. World Drug Report 2012). An estimated 4.7 million Americans (2.1% of the US population) have tried MA at some time in their lives (J Psychoactive Drugs. 2000;32[2]:137). The true incidence and prevalence of MAPAH remains unknown. One can surmise that with the widespread use of ME, we are only witnessing the “tip of the iceberg.”

Vijay Balasubramanian, MD, FCCP

Steering Committee Member

Franck Rahaghi, MD, FCCP

NetWork Member
 

Thoracic Oncology

Immunotherapy for lung cancer

The management of non-small cell lung cancer has traditionally focused on surgical resection of early and limited stage tumors and radiation and cytotoxic chemotherapy for patients with advanced disease. Recent progress in the management of patients with metastatic lung cancer treatment has concentrated on the precise histologic diagnosis and the characterization of molecular drivers of malignant progression. Distinguishing small cell from non-small cell carcinomas, as well as differentiating adenocarcinoma from squamous cell carcinomas, enables clinicians to more effectively tailor appropriate chemotherapy. The identification of molecular mutations in EGFR (epidermal growth factor receptor) or fusions in ELM4-ALK translocations as drivers of the malignant process has facilitated tumor regression by targeting the molecular pathways with small molecular inhibitors (tyrosine-kinase inhibitors) or synthetic antibodies. Unfortunately, not all lung cancers carry activating mutations, and those that do may develop resistance to this molecular-targeted approach and show tumor progression.

Immunotherapy, an anticancer therapeutic approach that activates the host immune system to target the tumor, has historically been either a broad spectrum management utilizing immune cytokine modifiers to augment host immune activity or a directed adaptive recruitment and stimulation of host lymphocytes to attack targeted tumor cells. More recently, immunotherapy has taken a targeted molecular approach to modify immune checkpoint inhibitory pathways, the “brakes” of the immune system that tumor cells have manipulated to evade immune surveillance. Cancer cells may be attacked by activated T cells through the MHC complex and T cell receptor pathways. However, cancer cells that express a checkpoint ligand can deactivate T cells through its checkpoint pathway. Cancer cells may evade immune recognition by signaling inhibitory checkpoint receptor pathways, such as PD-1/PDL-1, or CTLA-4 receptors. Blocking the checkpoint inhibition may reactivate the immune response and enhance host immune recognition and killing of tumor cells. Infusions containing FDA-approved nivolumab (Opdivo) and pembrolizumab (Keytruda) block the PD-1 receptor checkpoint, whereas atezolizumab (Tecentriq) blocks PD-L1, the ligand that binds PD-1. These immune therapeutic approaches have been successfully utilized in a variety of solid tumors, including lung cancer and malignant melanomas. Impressive clinical results of prolonged tumor regression have been demonstrated in second-line immunotherapy with improvements over chemotherapy; newer immunotherapy trials have demonstrated efficacy in the first-line setting for metastatic disease. Tumors with high PDL-1 expression and high mutational load predict improved immunotherapy outcomes. As expected, blocking checkpoint immune inhibition may lead to autoimmune-like conditions of pneumonitis, hepatitis, colitis, and dermatitis. Tumor tissue markers predictive of a therapeutic immune response are in the research phase. Immunotherapy against lung cancer adds to the therapeutic armamentarium of cancer management and provides an exciting new research arena into the biology and immunology of lung cancer.

Arnold M. Schwartz, MD, PhD, FCCP

Steering Committee Member

References

Cousin-Frankel J. Breakthrough of the year 2013: cancer immunotherapy. Science . 2013;342[6165]:1432.

Sharma P, et al. The future of immune checkpoint therapy. Science . 2015;348[6230]:56.

Garon EB, et al. Pembrolizumab for the treatment of non-small cell lung cancer. N Engl J Med . 2015;372[21]:2018.

Brahmer J, et al. Nivolumab versus docetaxel in advanced squamous cell non-small cell lung cancer. N Engl J Med . 2015;373[2]:123.

Reck M, et al. Pembrolizumab versus chemotherapy for PDL-1 positive non-small cell cancer. N Engl J Med . 2016;375[19]:1823. Herbst RS, et al. Pembrolizumab versus docetaxel for previously treated PDL-1- positive advanced non-small cell lung cancer. Lancet . 2016;387[10027]:1540.

Interventional Chest/Diagnostic Procedures

Update: 8th ed IASLC lung cancer staging guidelines

The new 8th edition guidelines on the staging of non-small cell lung cancer sponsored by the International Association for the Study of Lung Cancer (IASLC), and developed jointly by the American Joint Committee on Cancer and the Union Internationale Contre le Cancer were enacted January 1, 2017, and provide a methodologically rigorous update to staging nomenclature (Detterbeck et al. Chest. 2017;151[1]:193). The new guidelines were developed using a database comprising 94,708 patients in 16 countries, integrating clinical, pathologic, and survival data with multivariate analysis to establish prognostically significant staging subgroups.

In the new guidelines, tumor size has been divided into 1-cm increments for T classifications with new subcategories of T1a <1 cm, T1b 1-2 cm, and T1c 2-3 cm (Rami-Porta et al. J Thorac Oncol. 2015;10[7]:990). Furthermore, T2 has been broadened to include main bronchus tumors causing lobar or whole lung atelectasis extending to the hilum. Tumors with diaphragmatic involvement have been reclassified as T4. Guidance on heterogeneous nodules has also been provided, with emphasis on measurement of the solid component (based on imaging) or depth of invasion (on pathology) to determine T classification.

The N classification remains unchanged from the 7th edition. Exploratory analysis suggested prognostic significance to the number of involved N1/N2 lymph nodes; however, this requires detailed pathologic assessment and was not adopted as a staging criterion (Asamura et al. J Thorac Oncol. 2015;10[12]:1675).

Classification of metastatic disease has been modified from M1a/M1b to M1a for thoracic metastasis, M1b for single/oligometastatic extrathoracic metastasis, and the new category M1c for multiple/disseminated metastases. M1c involvement now denotes stage IVb disease, with lower survival compared to IVa disease (0% vs 10% 5-year survival (Goldstraw et al. J Thorac Oncol. 2015;11[1]:39). Application in broader cohorts, including patients undergoing bronchoscopic staging, will be needed to further validate the new guidelines.

Vivek Murthy, MD

Fellow-in-Training MemberSteering Committee
 

Pulmonary Physiology, Function, and Rehabilitation

6-minute walk test

The 6-minute walk test (6MWT) is a widely used measure of functional status and exercise capacity. Though it does not diagnose specific etiologies of impairment, the 6MWT provides an assessment of the overall integrated physiologic responses to exercise (Am J Respir Crit Care Med. 2002;166[1]:111). The test is a self-paced, submaximal study. Patients are instructed to “walk as far as possible for 6 minutes” with this distance (6MWD) measured as the primary outcome. 6MWD is associated with clinical outcomes in many cardiopulmonary disorders and is reliable, valid, and responsive to treatment. Normative equations provide predicted and lower limit of normal values (Singh et al. Eur Respir J. 2014;44[6]:1447). In addition to patient comorbidities, several important factors impact 6MWD interpretation. Standardization of the testing course, patient instructions, encouragement, technician assistance, walking aids, and supplemental oxygen use are important in reducing testing variability (Holland et al. Eur Respir J. 2014;44[6]:1428). A significant learning effect exists during the first several walks. An improvement of about 26 m (range 24-29 m) has been reported in patients with COPD, with the majority improving during the second test despite a short time interval lapse. Assessing for longitudinal change in serial testing is based on the minimal clinically important difference (MCID). This represents the difference in 6MWD that is perceived as important to the patient or leads to change in management. Techniques to develop these estimates are based upon statistical analysis of study sample data (distribution-based) or changes in a different, but related, clinical variable that is used as a reference (anchor-based). While minor differences in MCID are reported based on specific disease processes, a European Respiratory Society/American Thoracic Society review based on data from patients with COPD, ILD, and PAH found a MCID value of about 30 m (range 25-33 m) for adults with chronic respiratory disease, independent of specific disease, which is only slightly larger than the short term variability (Puente-Maestu et al. Eur Respir J. 2016;47[2]:429). Knowledge of these factors can assist in proper interpretation of the 6MWT.

Lana Alghothani, MD

NetWork Member

Nitin Bhatt, MD

Steering Committee Member

Pulmonary Vascular Disease

Methamphetamine-associated pulmonary hypertension (MAPAH): “tip of the iceberg”

Pulmonary hypertension (PH) is a devastating condition with serious morbidity and mortality. The Evian Classification and more recent revisions (J Am Coll Cardiol. 2013;62(25 Suppl ):D34) reclassified PH into five subgroups based upon etio-pathogenesis. Group I PH (pulmonary arterial hypertension, PAH) represents a growing list of entities, with Drugs & Toxins (Group 1.3) as a separate subgroup. This subgroup was first recognized following the discovery of an association between PH and the ingestion of the anorexigen aminorex (Gurtner HP. Schweiz Med Wochenschr. 1985;115[24]:818).

Methamphetamine (ME) as a potential etiology for PAH was first reported in 1993 (Schaiberger et al. Chest. 1993;104[2]:614). More recently, Chin et al suggested an association between stimulant use and PAH in 28.9% of their patients diagnosed with idiopathic PAH (Chest. 2006;130[6]:1657). The growing body of evidence linking ME to PAH resulted in upgrading of ME from “Possible” to “Likely” in the latest revision of the PH classification.

Recent gene sequencing data showed carboxylesterase-1, an enzyme that protects against ME-mediated pulmonary vascular injury, may be downregulated in patients with methamphetamine-associated PAH (MAPAH) (Perez et al. Am J Respir Crit Care Med. 193;2016:A2912). Furthermore, amphetamines promote mitochondrial dysfunction and DNA damage in pulmonary hypertension (Chen PI. JCI Insight. 2017;2[2]:e90427). Importantly, Barnett et al demonstrated a poorer prognosis in MAPAH compared with individuals with idiopathic PAH, but they are less likely to be treated with infused prostanoid therapies (Circulation. 2012;126:A13817).

Amphetamine-type stimulants have become the second most widely used class of illicit drugs worldwide (United Nations Office on Drugs & Crime. World Drug Report 2012). An estimated 4.7 million Americans (2.1% of the US population) have tried MA at some time in their lives (J Psychoactive Drugs. 2000;32[2]:137). The true incidence and prevalence of MAPAH remains unknown. One can surmise that with the widespread use of ME, we are only witnessing the “tip of the iceberg.”

Vijay Balasubramanian, MD, FCCP

Steering Committee Member

Franck Rahaghi, MD, FCCP

NetWork Member
 

Thoracic Oncology

Immunotherapy for lung cancer

The management of non-small cell lung cancer has traditionally focused on surgical resection of early and limited stage tumors and radiation and cytotoxic chemotherapy for patients with advanced disease. Recent progress in the management of patients with metastatic lung cancer treatment has concentrated on the precise histologic diagnosis and the characterization of molecular drivers of malignant progression. Distinguishing small cell from non-small cell carcinomas, as well as differentiating adenocarcinoma from squamous cell carcinomas, enables clinicians to more effectively tailor appropriate chemotherapy. The identification of molecular mutations in EGFR (epidermal growth factor receptor) or fusions in ELM4-ALK translocations as drivers of the malignant process has facilitated tumor regression by targeting the molecular pathways with small molecular inhibitors (tyrosine-kinase inhibitors) or synthetic antibodies. Unfortunately, not all lung cancers carry activating mutations, and those that do may develop resistance to this molecular-targeted approach and show tumor progression.

Immunotherapy, an anticancer therapeutic approach that activates the host immune system to target the tumor, has historically been either a broad spectrum management utilizing immune cytokine modifiers to augment host immune activity or a directed adaptive recruitment and stimulation of host lymphocytes to attack targeted tumor cells. More recently, immunotherapy has taken a targeted molecular approach to modify immune checkpoint inhibitory pathways, the “brakes” of the immune system that tumor cells have manipulated to evade immune surveillance. Cancer cells may be attacked by activated T cells through the MHC complex and T cell receptor pathways. However, cancer cells that express a checkpoint ligand can deactivate T cells through its checkpoint pathway. Cancer cells may evade immune recognition by signaling inhibitory checkpoint receptor pathways, such as PD-1/PDL-1, or CTLA-4 receptors. Blocking the checkpoint inhibition may reactivate the immune response and enhance host immune recognition and killing of tumor cells. Infusions containing FDA-approved nivolumab (Opdivo) and pembrolizumab (Keytruda) block the PD-1 receptor checkpoint, whereas atezolizumab (Tecentriq) blocks PD-L1, the ligand that binds PD-1. These immune therapeutic approaches have been successfully utilized in a variety of solid tumors, including lung cancer and malignant melanomas. Impressive clinical results of prolonged tumor regression have been demonstrated in second-line immunotherapy with improvements over chemotherapy; newer immunotherapy trials have demonstrated efficacy in the first-line setting for metastatic disease. Tumors with high PDL-1 expression and high mutational load predict improved immunotherapy outcomes. As expected, blocking checkpoint immune inhibition may lead to autoimmune-like conditions of pneumonitis, hepatitis, colitis, and dermatitis. Tumor tissue markers predictive of a therapeutic immune response are in the research phase. Immunotherapy against lung cancer adds to the therapeutic armamentarium of cancer management and provides an exciting new research arena into the biology and immunology of lung cancer.

Arnold M. Schwartz, MD, PhD, FCCP

Steering Committee Member

References

Cousin-Frankel J. Breakthrough of the year 2013: cancer immunotherapy. Science . 2013;342[6165]:1432.

Sharma P, et al. The future of immune checkpoint therapy. Science . 2015;348[6230]:56.

Garon EB, et al. Pembrolizumab for the treatment of non-small cell lung cancer. N Engl J Med . 2015;372[21]:2018.

Brahmer J, et al. Nivolumab versus docetaxel in advanced squamous cell non-small cell lung cancer. N Engl J Med . 2015;373[2]:123.

Reck M, et al. Pembrolizumab versus chemotherapy for PDL-1 positive non-small cell cancer. N Engl J Med . 2016;375[19]:1823. Herbst RS, et al. Pembrolizumab versus docetaxel for previously treated PDL-1- positive advanced non-small cell lung cancer. Lancet . 2016;387[10027]:1540.

Interventional Chest/Diagnostic Procedures

Update: 8th ed IASLC lung cancer staging guidelines

The new 8th edition guidelines on the staging of non-small cell lung cancer sponsored by the International Association for the Study of Lung Cancer (IASLC), and developed jointly by the American Joint Committee on Cancer and the Union Internationale Contre le Cancer were enacted January 1, 2017, and provide a methodologically rigorous update to staging nomenclature (Detterbeck et al. Chest. 2017;151[1]:193). The new guidelines were developed using a database comprising 94,708 patients in 16 countries, integrating clinical, pathologic, and survival data with multivariate analysis to establish prognostically significant staging subgroups.

In the new guidelines, tumor size has been divided into 1-cm increments for T classifications with new subcategories of T1a <1 cm, T1b 1-2 cm, and T1c 2-3 cm (Rami-Porta et al. J Thorac Oncol. 2015;10[7]:990). Furthermore, T2 has been broadened to include main bronchus tumors causing lobar or whole lung atelectasis extending to the hilum. Tumors with diaphragmatic involvement have been reclassified as T4. Guidance on heterogeneous nodules has also been provided, with emphasis on measurement of the solid component (based on imaging) or depth of invasion (on pathology) to determine T classification.

The N classification remains unchanged from the 7th edition. Exploratory analysis suggested prognostic significance to the number of involved N1/N2 lymph nodes; however, this requires detailed pathologic assessment and was not adopted as a staging criterion (Asamura et al. J Thorac Oncol. 2015;10[12]:1675).

Classification of metastatic disease has been modified from M1a/M1b to M1a for thoracic metastasis, M1b for single/oligometastatic extrathoracic metastasis, and the new category M1c for multiple/disseminated metastases. M1c involvement now denotes stage IVb disease, with lower survival compared to IVa disease (0% vs 10% 5-year survival (Goldstraw et al. J Thorac Oncol. 2015;11[1]:39). Application in broader cohorts, including patients undergoing bronchoscopic staging, will be needed to further validate the new guidelines.

Vivek Murthy, MD

Fellow-in-Training MemberSteering Committee
 

Pulmonary Physiology, Function, and Rehabilitation

6-minute walk test

The 6-minute walk test (6MWT) is a widely used measure of functional status and exercise capacity. Though it does not diagnose specific etiologies of impairment, the 6MWT provides an assessment of the overall integrated physiologic responses to exercise (Am J Respir Crit Care Med. 2002;166[1]:111). The test is a self-paced, submaximal study. Patients are instructed to “walk as far as possible for 6 minutes” with this distance (6MWD) measured as the primary outcome. 6MWD is associated with clinical outcomes in many cardiopulmonary disorders and is reliable, valid, and responsive to treatment. Normative equations provide predicted and lower limit of normal values (Singh et al. Eur Respir J. 2014;44[6]:1447). In addition to patient comorbidities, several important factors impact 6MWD interpretation. Standardization of the testing course, patient instructions, encouragement, technician assistance, walking aids, and supplemental oxygen use are important in reducing testing variability (Holland et al. Eur Respir J. 2014;44[6]:1428). A significant learning effect exists during the first several walks. An improvement of about 26 m (range 24-29 m) has been reported in patients with COPD, with the majority improving during the second test despite a short time interval lapse. Assessing for longitudinal change in serial testing is based on the minimal clinically important difference (MCID). This represents the difference in 6MWD that is perceived as important to the patient or leads to change in management. Techniques to develop these estimates are based upon statistical analysis of study sample data (distribution-based) or changes in a different, but related, clinical variable that is used as a reference (anchor-based). While minor differences in MCID are reported based on specific disease processes, a European Respiratory Society/American Thoracic Society review based on data from patients with COPD, ILD, and PAH found a MCID value of about 30 m (range 25-33 m) for adults with chronic respiratory disease, independent of specific disease, which is only slightly larger than the short term variability (Puente-Maestu et al. Eur Respir J. 2016;47[2]:429). Knowledge of these factors can assist in proper interpretation of the 6MWT.

Lana Alghothani, MD

NetWork Member

Nitin Bhatt, MD

Steering Committee Member

Pulmonary Vascular Disease

Methamphetamine-associated pulmonary hypertension (MAPAH): “tip of the iceberg”

Pulmonary hypertension (PH) is a devastating condition with serious morbidity and mortality. The Evian Classification and more recent revisions (J Am Coll Cardiol. 2013;62(25 Suppl ):D34) reclassified PH into five subgroups based upon etio-pathogenesis. Group I PH (pulmonary arterial hypertension, PAH) represents a growing list of entities, with Drugs & Toxins (Group 1.3) as a separate subgroup. This subgroup was first recognized following the discovery of an association between PH and the ingestion of the anorexigen aminorex (Gurtner HP. Schweiz Med Wochenschr. 1985;115[24]:818).

Methamphetamine (ME) as a potential etiology for PAH was first reported in 1993 (Schaiberger et al. Chest. 1993;104[2]:614). More recently, Chin et al suggested an association between stimulant use and PAH in 28.9% of their patients diagnosed with idiopathic PAH (Chest. 2006;130[6]:1657). The growing body of evidence linking ME to PAH resulted in upgrading of ME from “Possible” to “Likely” in the latest revision of the PH classification.

Recent gene sequencing data showed carboxylesterase-1, an enzyme that protects against ME-mediated pulmonary vascular injury, may be downregulated in patients with methamphetamine-associated PAH (MAPAH) (Perez et al. Am J Respir Crit Care Med. 193;2016:A2912). Furthermore, amphetamines promote mitochondrial dysfunction and DNA damage in pulmonary hypertension (Chen PI. JCI Insight. 2017;2[2]:e90427). Importantly, Barnett et al demonstrated a poorer prognosis in MAPAH compared with individuals with idiopathic PAH, but they are less likely to be treated with infused prostanoid therapies (Circulation. 2012;126:A13817).

Amphetamine-type stimulants have become the second most widely used class of illicit drugs worldwide (United Nations Office on Drugs & Crime. World Drug Report 2012). An estimated 4.7 million Americans (2.1% of the US population) have tried MA at some time in their lives (J Psychoactive Drugs. 2000;32[2]:137). The true incidence and prevalence of MAPAH remains unknown. One can surmise that with the widespread use of ME, we are only witnessing the “tip of the iceberg.”

Vijay Balasubramanian, MD, FCCP

Steering Committee Member

Franck Rahaghi, MD, FCCP

NetWork Member
 

Thoracic Oncology

Immunotherapy for lung cancer

The management of non-small cell lung cancer has traditionally focused on surgical resection of early and limited stage tumors and radiation and cytotoxic chemotherapy for patients with advanced disease. Recent progress in the management of patients with metastatic lung cancer treatment has concentrated on the precise histologic diagnosis and the characterization of molecular drivers of malignant progression. Distinguishing small cell from non-small cell carcinomas, as well as differentiating adenocarcinoma from squamous cell carcinomas, enables clinicians to more effectively tailor appropriate chemotherapy. The identification of molecular mutations in EGFR (epidermal growth factor receptor) or fusions in ELM4-ALK translocations as drivers of the malignant process has facilitated tumor regression by targeting the molecular pathways with small molecular inhibitors (tyrosine-kinase inhibitors) or synthetic antibodies. Unfortunately, not all lung cancers carry activating mutations, and those that do may develop resistance to this molecular-targeted approach and show tumor progression.

Immunotherapy, an anticancer therapeutic approach that activates the host immune system to target the tumor, has historically been either a broad spectrum management utilizing immune cytokine modifiers to augment host immune activity or a directed adaptive recruitment and stimulation of host lymphocytes to attack targeted tumor cells. More recently, immunotherapy has taken a targeted molecular approach to modify immune checkpoint inhibitory pathways, the “brakes” of the immune system that tumor cells have manipulated to evade immune surveillance. Cancer cells may be attacked by activated T cells through the MHC complex and T cell receptor pathways. However, cancer cells that express a checkpoint ligand can deactivate T cells through its checkpoint pathway. Cancer cells may evade immune recognition by signaling inhibitory checkpoint receptor pathways, such as PD-1/PDL-1, or CTLA-4 receptors. Blocking the checkpoint inhibition may reactivate the immune response and enhance host immune recognition and killing of tumor cells. Infusions containing FDA-approved nivolumab (Opdivo) and pembrolizumab (Keytruda) block the PD-1 receptor checkpoint, whereas atezolizumab (Tecentriq) blocks PD-L1, the ligand that binds PD-1. These immune therapeutic approaches have been successfully utilized in a variety of solid tumors, including lung cancer and malignant melanomas. Impressive clinical results of prolonged tumor regression have been demonstrated in second-line immunotherapy with improvements over chemotherapy; newer immunotherapy trials have demonstrated efficacy in the first-line setting for metastatic disease. Tumors with high PDL-1 expression and high mutational load predict improved immunotherapy outcomes. As expected, blocking checkpoint immune inhibition may lead to autoimmune-like conditions of pneumonitis, hepatitis, colitis, and dermatitis. Tumor tissue markers predictive of a therapeutic immune response are in the research phase. Immunotherapy against lung cancer adds to the therapeutic armamentarium of cancer management and provides an exciting new research arena into the biology and immunology of lung cancer.

Arnold M. Schwartz, MD, PhD, FCCP

Steering Committee Member

References

Cousin-Frankel J. Breakthrough of the year 2013: cancer immunotherapy. Science . 2013;342[6165]:1432.

Sharma P, et al. The future of immune checkpoint therapy. Science . 2015;348[6230]:56.

Garon EB, et al. Pembrolizumab for the treatment of non-small cell lung cancer. N Engl J Med . 2015;372[21]:2018.

Brahmer J, et al. Nivolumab versus docetaxel in advanced squamous cell non-small cell lung cancer. N Engl J Med . 2015;373[2]:123.

Reck M, et al. Pembrolizumab versus chemotherapy for PDL-1 positive non-small cell cancer. N Engl J Med . 2016;375[19]:1823. Herbst RS, et al. Pembrolizumab versus docetaxel for previously treated PDL-1- positive advanced non-small cell lung cancer. Lancet . 2016;387[10027]:1540.

Two-dose human papillomavirus (HPV) vaccine trials appear to show effective immunological responses in teen girls, said Maddalena D’Addario of the University of Bern, Switzerland, and her associates.

In seven controlled trials in 11 countries that directly compared two-dose and three-dose HPV vaccine schedules, teen girls receiving two doses of HPV vaccine with a 6-month interval between them had noninferior antibody responses to HPV16 and HPV18 for at least 2 years, compared with girls receiving three doses.

BVDC/Fotolia.com

National Cancer Institute

Two-dose human papillomavirus (HPV) vaccine trials appear to show effective immunological responses in teen girls, said Maddalena D’Addario of the University of Bern, Switzerland, and her associates.

In seven controlled trials in 11 countries that directly compared two-dose and three-dose HPV vaccine schedules, teen girls receiving two doses of HPV vaccine with a 6-month interval between them had noninferior antibody responses to HPV16 and HPV18 for at least 2 years, compared with girls receiving three doses.

BVDC/Fotolia.com

National Cancer Institute

Two-dose human papillomavirus (HPV) vaccine trials appear to show effective immunological responses in teen girls, said Maddalena D’Addario of the University of Bern, Switzerland, and her associates.

In seven controlled trials in 11 countries that directly compared two-dose and three-dose HPV vaccine schedules, teen girls receiving two doses of HPV vaccine with a 6-month interval between them had noninferior antibody responses to HPV16 and HPV18 for at least 2 years, compared with girls receiving three doses.

BVDC/Fotolia.com

National Cancer Institute

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 our first woman President, Dr. Deborah Shure.

Deborah Shure, MD, Master FCCP

President 1995-1996

When I began my year as President of the American College of Chest Physicians in 1995 in New York City, I became the first woman to serve in that role in the then 60-year history of the College. One major theme for my presidential year was inclusiveness. With the support of the Regents and the members of the College, we sought to increase the roles of our International Fellows and Affiliate Members, as well as the participation of all of our FCCPs. We also expanded the role of the College in global tobacco control.

With a focus on these goals, the presidential year was truly an exciting and fulfilling one. I was honored to meet so many members worldwide and, through the College, enable the support of regional meetings internationally. Our efforts in the Asia-Pacific area lent essential support to one of the early conferences on tobacco control in the Philippines (Asia Pacific Conference on Control of Tobacco, Subic, Philippines, 1998). My presentation in 1996 in Bangkok was the College’s first International Partnering for World Health Award to H.M. King Bhumibol of Thailand for his work in the prevention and treatment of chest diseases in Thailand, was an unforgettable experience.

My presidential year ended in San Francisco. Since that time, my professional life has been varied and interesting. I was fortunate to continue my academic career encompassing both clinical and basic research. In 2005, I tried a new path and worked for the FDA Center for Devices and Radiological Health, using my background in device development (the angioscope) and clinical trials. Since 2012, I have been using my clinical, academic, and regulatory experience as an independent consultant in clinical trial design.

On a personal note, my partner of many years, Aymarah Robles, MD, FCCP, and I were finally able to marry in January 2015. So, we are now a happy and official two pulmonary, Cuban-American household enjoying the culture of Little Havana and the many outdoor activities of Miami!

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 our first woman President, Dr. Deborah Shure.

Deborah Shure, MD, Master FCCP

President 1995-1996

When I began my year as President of the American College of Chest Physicians in 1995 in New York City, I became the first woman to serve in that role in the then 60-year history of the College. One major theme for my presidential year was inclusiveness. With the support of the Regents and the members of the College, we sought to increase the roles of our International Fellows and Affiliate Members, as well as the participation of all of our FCCPs. We also expanded the role of the College in global tobacco control.

With a focus on these goals, the presidential year was truly an exciting and fulfilling one. I was honored to meet so many members worldwide and, through the College, enable the support of regional meetings internationally. Our efforts in the Asia-Pacific area lent essential support to one of the early conferences on tobacco control in the Philippines (Asia Pacific Conference on Control of Tobacco, Subic, Philippines, 1998). My presentation in 1996 in Bangkok was the College’s first International Partnering for World Health Award to H.M. King Bhumibol of Thailand for his work in the prevention and treatment of chest diseases in Thailand, was an unforgettable experience.

My presidential year ended in San Francisco. Since that time, my professional life has been varied and interesting. I was fortunate to continue my academic career encompassing both clinical and basic research. In 2005, I tried a new path and worked for the FDA Center for Devices and Radiological Health, using my background in device development (the angioscope) and clinical trials. Since 2012, I have been using my clinical, academic, and regulatory experience as an independent consultant in clinical trial design.

On a personal note, my partner of many years, Aymarah Robles, MD, FCCP, and I were finally able to marry in January 2015. So, we are now a happy and official two pulmonary, Cuban-American household enjoying the culture of Little Havana and the many outdoor activities of Miami!

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 our first woman President, Dr. Deborah Shure.

Deborah Shure, MD, Master FCCP

President 1995-1996

When I began my year as President of the American College of Chest Physicians in 1995 in New York City, I became the first woman to serve in that role in the then 60-year history of the College. One major theme for my presidential year was inclusiveness. With the support of the Regents and the members of the College, we sought to increase the roles of our International Fellows and Affiliate Members, as well as the participation of all of our FCCPs. We also expanded the role of the College in global tobacco control.

With a focus on these goals, the presidential year was truly an exciting and fulfilling one. I was honored to meet so many members worldwide and, through the College, enable the support of regional meetings internationally. Our efforts in the Asia-Pacific area lent essential support to one of the early conferences on tobacco control in the Philippines (Asia Pacific Conference on Control of Tobacco, Subic, Philippines, 1998). My presentation in 1996 in Bangkok was the College’s first International Partnering for World Health Award to H.M. King Bhumibol of Thailand for his work in the prevention and treatment of chest diseases in Thailand, was an unforgettable experience.

My presidential year ended in San Francisco. Since that time, my professional life has been varied and interesting. I was fortunate to continue my academic career encompassing both clinical and basic research. In 2005, I tried a new path and worked for the FDA Center for Devices and Radiological Health, using my background in device development (the angioscope) and clinical trials. Since 2012, I have been using my clinical, academic, and regulatory experience as an independent consultant in clinical trial design.

On a personal note, my partner of many years, Aymarah Robles, MD, FCCP, and I were finally able to marry in January 2015. So, we are now a happy and official two pulmonary, Cuban-American household enjoying the culture of Little Havana and the many outdoor activities of Miami!

If you consider yourself a busy pediatrician and haven’t seen a Fidget Spinner, you are either a neonatologist or have been on maternity leave for the last 3 months. Because I no longer see patients, my introduction to Fidget Spinners came via my 10-year-old grandson, Peter. Last week, I was tasked with meeting him after school and accompanying him on his bike ride to our house. Instead of a hi-grampy-smile he shouted, “Look what Jonah gave me!”

Peter held in his hand a collection of stainless steel nuts, a bolt, and a pair of roller blade wheel bearings that had been epoxified together so that they would spin with the flick of a finger. This was a homemade Fidget. This wasn’t a “gadget,” a term that would imply to me that it might have some function. No, this was a Fidget, and its sole purpose was to keep the user’s hands busy, usually by spinning it.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

If you consider yourself a busy pediatrician and haven’t seen a Fidget Spinner, you are either a neonatologist or have been on maternity leave for the last 3 months. Because I no longer see patients, my introduction to Fidget Spinners came via my 10-year-old grandson, Peter. Last week, I was tasked with meeting him after school and accompanying him on his bike ride to our house. Instead of a hi-grampy-smile he shouted, “Look what Jonah gave me!”

Peter held in his hand a collection of stainless steel nuts, a bolt, and a pair of roller blade wheel bearings that had been epoxified together so that they would spin with the flick of a finger. This was a homemade Fidget. This wasn’t a “gadget,” a term that would imply to me that it might have some function. No, this was a Fidget, and its sole purpose was to keep the user’s hands busy, usually by spinning it.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

If you consider yourself a busy pediatrician and haven’t seen a Fidget Spinner, you are either a neonatologist or have been on maternity leave for the last 3 months. Because I no longer see patients, my introduction to Fidget Spinners came via my 10-year-old grandson, Peter. Last week, I was tasked with meeting him after school and accompanying him on his bike ride to our house. Instead of a hi-grampy-smile he shouted, “Look what Jonah gave me!”

Peter held in his hand a collection of stainless steel nuts, a bolt, and a pair of roller blade wheel bearings that had been epoxified together so that they would spin with the flick of a finger. This was a homemade Fidget. This wasn’t a “gadget,” a term that would imply to me that it might have some function. No, this was a Fidget, and its sole purpose was to keep the user’s hands busy, usually by spinning it.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

Coadministration of meningococcal serogroup B (4CMenB) and serogroup C (MenC CRM) vaccines in infants was noninferior to administration of MenC CRM alone against MenC, and it demonstrated adequate immune response to MenB, according to Marco Aurelio P. Safadi, MD, of Santa Casa de São Paulo (Brazil) School of Medical Sciences, and his associates.

Of 117 healthy infants who received 4CMenB concomitantly with MenC CRM and 111 who received MenC CRM alone, 99%-100% of infants had serum bactericidal antibody assay using human complement (hSBA) titres 1:8 or greater against MenC after the second vaccination of the primary series (3 months, 5 months, and 12 months of age), and 100% of infants reached these titres after the booster vaccination.

Courtesy CDC

Steve Mann/Thinkstock

Coadministration of meningococcal serogroup B (4CMenB) and serogroup C (MenC CRM) vaccines in infants was noninferior to administration of MenC CRM alone against MenC, and it demonstrated adequate immune response to MenB, according to Marco Aurelio P. Safadi, MD, of Santa Casa de São Paulo (Brazil) School of Medical Sciences, and his associates.

Of 117 healthy infants who received 4CMenB concomitantly with MenC CRM and 111 who received MenC CRM alone, 99%-100% of infants had serum bactericidal antibody assay using human complement (hSBA) titres 1:8 or greater against MenC after the second vaccination of the primary series (3 months, 5 months, and 12 months of age), and 100% of infants reached these titres after the booster vaccination.

Courtesy CDC

Steve Mann/Thinkstock

Coadministration of meningococcal serogroup B (4CMenB) and serogroup C (MenC CRM) vaccines in infants was noninferior to administration of MenC CRM alone against MenC, and it demonstrated adequate immune response to MenB, according to Marco Aurelio P. Safadi, MD, of Santa Casa de São Paulo (Brazil) School of Medical Sciences, and his associates.

Of 117 healthy infants who received 4CMenB concomitantly with MenC CRM and 111 who received MenC CRM alone, 99%-100% of infants had serum bactericidal antibody assay using human complement (hSBA) titres 1:8 or greater against MenC after the second vaccination of the primary series (3 months, 5 months, and 12 months of age), and 100% of infants reached these titres after the booster vaccination.

Courtesy CDC

Steve Mann/Thinkstock