Stanley Riddell, MD

Photo from Fred Hutchinson

Cancer Research Center

 

Results from a phase 1 study have provided insights that may help researchers optimize treatment with JCAR014, a chimeric antigen receptor (CAR) T-cell therapy, in patients with advanced non-Hodgkin lymphoma (NHL).

Researchers said they identified a lymphodepleting regimen that improved the likelihood of complete response (CR) to JCAR014.

Although the regimen also increased the risk of severe cytokine release syndrome (CRS) and neurotoxicity, the researchers discovered biomarkers that might allow them to identify patients who have a high risk of these events and could potentially benefit from early interventions.

The researchers reported these findings in Science Translational Medicine. The trial (NCT01865617) was funded, in part, by Juno Therapeutics, the company developing JCAR014.

Previous results from this trial, in patients with acute lymphoblastic leukemia, were published in The Journal of Clinical Investigation.

About JCAR014

JCAR014 is a CD19-directed CAR T-cell therapy in which CD4+ and CD8+ cells are administered in equal proportions.

“The idea . . . is that by [controlling the ratio of T cells], we would get more reproducible data around the effects of the cells—both beneficial effects against the cancer and also any side effects they might cause the patient,” said study author Stanley Riddell, MD, of the Fred Hutchinson Cancer Research Center in Seattle, Washington.

“And then, by adjusting the dose, we could improve what we call the therapeutic index—the benefit against the tumor—without too much toxicity.”

Patients and treatment

Dr Riddell and his colleagues reported results with JCAR014, following lymphodepleting chemotherapy, in 32 patients with NHL who had a median age of 58 (range, 36-70).

The patients had de novo large B-cell lymphoma (n=11), transformed de novo large B-cell lymphoma (n=11), mantle cell lymphoma (n=4), and follicular lymphoma (n=6).

They had received a median of 5 prior treatment regimens (range, 2 to 11), including autologous

(n=14) and allogeneic (n=4) transplant. All patients had measurable disease (≥ 2 cm) in the lymph nodes or other extramedullary sites at baseline.

The patients received JCAR014 at 1 of 3 dose levels, given 36 to 96 hours after lymphodepleting chemotherapy.

Twelve patients received cyclophosphamide (Cy) alone or Cy and etoposide (E), and 20 received Cy plus fludarabine (Flu). Five patients received 2 × 10⁵ CAR T cells/kg, 18 received 2 × 10⁶ CAR T cells/kg, and 9 received 2 × 10⁷ CAR T cells/kg.

Efficacy

In the 30 evaluable patients, the overall response rate (ORR) was 63% (n=19), and the CR rate was 33% (n=10).

Among patients who received Cy or Cy/E, the ORR was 50% (n=6), and the CR rate was 8% (n=1). Among patients who received Cy/Flu, the ORR was 72% (n=13), and the CR rate was 50% (n=9).

The patients who received Cy/Flu had better CAR T-cell expansion and persistence than patients who received Cy or Cy/E, which was reflected in the higher response rates.

Higher response rates were also observed in patients who received 2 × 10⁶ CAR T cells/kg rather than the other 2 dose levels.

The researchers noted that, although follow-up is short, patients who received CAR T cells at ≤ 2 × 10⁶/kg after Cy/Flu had better progression-free survival (P=0.008) than patients who received CAR T cells at ≤ 2 × 10⁶/kg after Cy or Cy/E.

Of the 9 patients who achieved a CR after Cy/Flu and JCAR014, 1 has relapsed, with follow-up ranging from 2.3 months to 11.2 months. (Seven of these 9 patients had received 2 × 10⁶ CAR T cells/kg, and 1 patient each had received the other 2 doses.)

“The main message is that you can treat patients with non-Hodgkin’s lymphoma with CAR T cells and get very good response rates with optimization of the CAR T-cell dose and lymphodepletion,” said study author Cameron Turtle, MBBS, PhD, of the Fred Hutchinson Cancer Research Center.

“Strategies like modifying the lymphodepletion in conjunction with suitable CAR T-cell dosing can have a big impact on clinical outcome.”

Safety

Two patients who were treated with the highest CAR T-cell dose (2 × 10⁷ cells/kg) died—1 of pontine hemorrhage and 1 of gastrointestinal hemorrhage associated with a known gastrointestinal invasive lymphomatous mass.

This dose was also associated with an increased risk of severe CRS and neurotoxicity, as was the Cy/Flu regimen.

Twenty patients (62.5%) developed CRS, and 4 (12.5%) had severe CRS. All 4 of these patients had received Cy/Flu.

Nine patients (28%) developed severe neurotoxicity (grade 3 or higher), 7 of whom had received Cy/Flu.

Three of the 6 patients (50%) treated at 2 × 10⁷ CAR-T cells/kg after Cy/Flu developed severe CRS, and 4 of the 6 patients (67%) developed severe neurotoxicity.

The researchers looked for biomarkers of toxicity in serum collected 1 day after CAR T-cell infusion.

They found that high IL-6, IL-8, IL-10, IL-15, and IFN-γ concentrations were associated with subsequent severe CRS and neurotoxicity, and low TGF-Β concentration was associated with neurotoxicity.

The team said these findings provide an opportunity for studying the use of serum cytokine concentrations to identify patients at the highest risk of toxicity who might benefit from early interventions.

 

 

Stanley Riddell, MD

Photo from Fred Hutchinson

Cancer Research Center

 

Results from a phase 1 study have provided insights that may help researchers optimize treatment with JCAR014, a chimeric antigen receptor (CAR) T-cell therapy, in patients with advanced non-Hodgkin lymphoma (NHL).

Researchers said they identified a lymphodepleting regimen that improved the likelihood of complete response (CR) to JCAR014.

Although the regimen also increased the risk of severe cytokine release syndrome (CRS) and neurotoxicity, the researchers discovered biomarkers that might allow them to identify patients who have a high risk of these events and could potentially benefit from early interventions.

The researchers reported these findings in Science Translational Medicine. The trial (NCT01865617) was funded, in part, by Juno Therapeutics, the company developing JCAR014.

Previous results from this trial, in patients with acute lymphoblastic leukemia, were published in The Journal of Clinical Investigation.

About JCAR014

JCAR014 is a CD19-directed CAR T-cell therapy in which CD4+ and CD8+ cells are administered in equal proportions.

“The idea . . . is that by [controlling the ratio of T cells], we would get more reproducible data around the effects of the cells—both beneficial effects against the cancer and also any side effects they might cause the patient,” said study author Stanley Riddell, MD, of the Fred Hutchinson Cancer Research Center in Seattle, Washington.

“And then, by adjusting the dose, we could improve what we call the therapeutic index—the benefit against the tumor—without too much toxicity.”

Patients and treatment

Dr Riddell and his colleagues reported results with JCAR014, following lymphodepleting chemotherapy, in 32 patients with NHL who had a median age of 58 (range, 36-70).

The patients had de novo large B-cell lymphoma (n=11), transformed de novo large B-cell lymphoma (n=11), mantle cell lymphoma (n=4), and follicular lymphoma (n=6).

They had received a median of 5 prior treatment regimens (range, 2 to 11), including autologous

(n=14) and allogeneic (n=4) transplant. All patients had measurable disease (≥ 2 cm) in the lymph nodes or other extramedullary sites at baseline.

The patients received JCAR014 at 1 of 3 dose levels, given 36 to 96 hours after lymphodepleting chemotherapy.

Twelve patients received cyclophosphamide (Cy) alone or Cy and etoposide (E), and 20 received Cy plus fludarabine (Flu). Five patients received 2 × 10⁵ CAR T cells/kg, 18 received 2 × 10⁶ CAR T cells/kg, and 9 received 2 × 10⁷ CAR T cells/kg.

Efficacy

In the 30 evaluable patients, the overall response rate (ORR) was 63% (n=19), and the CR rate was 33% (n=10).

Among patients who received Cy or Cy/E, the ORR was 50% (n=6), and the CR rate was 8% (n=1). Among patients who received Cy/Flu, the ORR was 72% (n=13), and the CR rate was 50% (n=9).

The patients who received Cy/Flu had better CAR T-cell expansion and persistence than patients who received Cy or Cy/E, which was reflected in the higher response rates.

Higher response rates were also observed in patients who received 2 × 10⁶ CAR T cells/kg rather than the other 2 dose levels.

The researchers noted that, although follow-up is short, patients who received CAR T cells at ≤ 2 × 10⁶/kg after Cy/Flu had better progression-free survival (P=0.008) than patients who received CAR T cells at ≤ 2 × 10⁶/kg after Cy or Cy/E.

Of the 9 patients who achieved a CR after Cy/Flu and JCAR014, 1 has relapsed, with follow-up ranging from 2.3 months to 11.2 months. (Seven of these 9 patients had received 2 × 10⁶ CAR T cells/kg, and 1 patient each had received the other 2 doses.)

“The main message is that you can treat patients with non-Hodgkin’s lymphoma with CAR T cells and get very good response rates with optimization of the CAR T-cell dose and lymphodepletion,” said study author Cameron Turtle, MBBS, PhD, of the Fred Hutchinson Cancer Research Center.

“Strategies like modifying the lymphodepletion in conjunction with suitable CAR T-cell dosing can have a big impact on clinical outcome.”

Safety

Two patients who were treated with the highest CAR T-cell dose (2 × 10⁷ cells/kg) died—1 of pontine hemorrhage and 1 of gastrointestinal hemorrhage associated with a known gastrointestinal invasive lymphomatous mass.

This dose was also associated with an increased risk of severe CRS and neurotoxicity, as was the Cy/Flu regimen.

Twenty patients (62.5%) developed CRS, and 4 (12.5%) had severe CRS. All 4 of these patients had received Cy/Flu.

Nine patients (28%) developed severe neurotoxicity (grade 3 or higher), 7 of whom had received Cy/Flu.

Three of the 6 patients (50%) treated at 2 × 10⁷ CAR-T cells/kg after Cy/Flu developed severe CRS, and 4 of the 6 patients (67%) developed severe neurotoxicity.

The researchers looked for biomarkers of toxicity in serum collected 1 day after CAR T-cell infusion.

They found that high IL-6, IL-8, IL-10, IL-15, and IFN-γ concentrations were associated with subsequent severe CRS and neurotoxicity, and low TGF-Β concentration was associated with neurotoxicity.

The team said these findings provide an opportunity for studying the use of serum cytokine concentrations to identify patients at the highest risk of toxicity who might benefit from early interventions.

 

 

Stanley Riddell, MD

Photo from Fred Hutchinson

Cancer Research Center

 

Results from a phase 1 study have provided insights that may help researchers optimize treatment with JCAR014, a chimeric antigen receptor (CAR) T-cell therapy, in patients with advanced non-Hodgkin lymphoma (NHL).

Researchers said they identified a lymphodepleting regimen that improved the likelihood of complete response (CR) to JCAR014.

Although the regimen also increased the risk of severe cytokine release syndrome (CRS) and neurotoxicity, the researchers discovered biomarkers that might allow them to identify patients who have a high risk of these events and could potentially benefit from early interventions.

The researchers reported these findings in Science Translational Medicine. The trial (NCT01865617) was funded, in part, by Juno Therapeutics, the company developing JCAR014.

Previous results from this trial, in patients with acute lymphoblastic leukemia, were published in The Journal of Clinical Investigation.

About JCAR014

JCAR014 is a CD19-directed CAR T-cell therapy in which CD4+ and CD8+ cells are administered in equal proportions.

“The idea . . . is that by [controlling the ratio of T cells], we would get more reproducible data around the effects of the cells—both beneficial effects against the cancer and also any side effects they might cause the patient,” said study author Stanley Riddell, MD, of the Fred Hutchinson Cancer Research Center in Seattle, Washington.

“And then, by adjusting the dose, we could improve what we call the therapeutic index—the benefit against the tumor—without too much toxicity.”

Patients and treatment

Dr Riddell and his colleagues reported results with JCAR014, following lymphodepleting chemotherapy, in 32 patients with NHL who had a median age of 58 (range, 36-70).

The patients had de novo large B-cell lymphoma (n=11), transformed de novo large B-cell lymphoma (n=11), mantle cell lymphoma (n=4), and follicular lymphoma (n=6).

They had received a median of 5 prior treatment regimens (range, 2 to 11), including autologous

(n=14) and allogeneic (n=4) transplant. All patients had measurable disease (≥ 2 cm) in the lymph nodes or other extramedullary sites at baseline.

The patients received JCAR014 at 1 of 3 dose levels, given 36 to 96 hours after lymphodepleting chemotherapy.

Twelve patients received cyclophosphamide (Cy) alone or Cy and etoposide (E), and 20 received Cy plus fludarabine (Flu). Five patients received 2 × 10⁵ CAR T cells/kg, 18 received 2 × 10⁶ CAR T cells/kg, and 9 received 2 × 10⁷ CAR T cells/kg.

Efficacy

In the 30 evaluable patients, the overall response rate (ORR) was 63% (n=19), and the CR rate was 33% (n=10).

Among patients who received Cy or Cy/E, the ORR was 50% (n=6), and the CR rate was 8% (n=1). Among patients who received Cy/Flu, the ORR was 72% (n=13), and the CR rate was 50% (n=9).

The patients who received Cy/Flu had better CAR T-cell expansion and persistence than patients who received Cy or Cy/E, which was reflected in the higher response rates.

Higher response rates were also observed in patients who received 2 × 10⁶ CAR T cells/kg rather than the other 2 dose levels.

The researchers noted that, although follow-up is short, patients who received CAR T cells at ≤ 2 × 10⁶/kg after Cy/Flu had better progression-free survival (P=0.008) than patients who received CAR T cells at ≤ 2 × 10⁶/kg after Cy or Cy/E.

Of the 9 patients who achieved a CR after Cy/Flu and JCAR014, 1 has relapsed, with follow-up ranging from 2.3 months to 11.2 months. (Seven of these 9 patients had received 2 × 10⁶ CAR T cells/kg, and 1 patient each had received the other 2 doses.)

“The main message is that you can treat patients with non-Hodgkin’s lymphoma with CAR T cells and get very good response rates with optimization of the CAR T-cell dose and lymphodepletion,” said study author Cameron Turtle, MBBS, PhD, of the Fred Hutchinson Cancer Research Center.

“Strategies like modifying the lymphodepletion in conjunction with suitable CAR T-cell dosing can have a big impact on clinical outcome.”

Safety

Two patients who were treated with the highest CAR T-cell dose (2 × 10⁷ cells/kg) died—1 of pontine hemorrhage and 1 of gastrointestinal hemorrhage associated with a known gastrointestinal invasive lymphomatous mass.

This dose was also associated with an increased risk of severe CRS and neurotoxicity, as was the Cy/Flu regimen.

Twenty patients (62.5%) developed CRS, and 4 (12.5%) had severe CRS. All 4 of these patients had received Cy/Flu.

Nine patients (28%) developed severe neurotoxicity (grade 3 or higher), 7 of whom had received Cy/Flu.

Three of the 6 patients (50%) treated at 2 × 10⁷ CAR-T cells/kg after Cy/Flu developed severe CRS, and 4 of the 6 patients (67%) developed severe neurotoxicity.

The researchers looked for biomarkers of toxicity in serum collected 1 day after CAR T-cell infusion.

They found that high IL-6, IL-8, IL-10, IL-15, and IFN-γ concentrations were associated with subsequent severe CRS and neurotoxicity, and low TGF-Β concentration was associated with neurotoxicity.

The team said these findings provide an opportunity for studying the use of serum cytokine concentrations to identify patients at the highest risk of toxicity who might benefit from early interventions.

In a genuine very good news, very bad news proposal included in the 2017 hospital outpatient regulations, the Centers for Medicare & Medicaid Services (CMS) has proposed a major payment boost for pulmonary rehab services billed through hospital outpatient departments, but, simultaneously, the Agency proposes to preclude certain programs from utilizing that long- standing payment mechanism.

In November 2015, Congress authorized CMS to take action on the growing trend of hospitals purchasing certain physician practices so that the hospital can bill for certain services at a notably higher rate than the same service when provided in the physician office setting. CMS Section 603 pf P.L. 114-74 authorizes such action, and “These proposals are made in accordance with our belief that section 603… is intended to curb the practice of hospital acquisition of physician practices that result in receiving additional Medicare payment for similar services.” While we recognize that the congressional intent has some level of legitimacy, as is often the case, the CMS approach is too inclusive, especially as it applies to pulmonary rehabilitation services billed through HCPCS code G0424.

This problem has evolved because of two distinctly different formulas for determining payment. The physician fee schedule is based on the concept of RVUs, practice expense, and malpractice expense. Hospital outpatient services that may be virtually identical are based on a formula that includes charge data from Medicare claims forms and the annual hospital cost report identifying overhead.

If adopted as proposed, hospital outpatient programs in place on the date of enactment of P.L. 114-74 (early November 2015) are grandfathered into the hospital outpatient methodology. However, new programs that are not part of the main hospital campus (or within 250 yards of the campus) will only be able to bill at the physician office setting rate. Likewise, an existing program that moves to a new location that is beyond the 250-yard threshold will lose its “grandfather” status and be forced to bill at the physician office setting payment rate.

For practical purposes, the 2017 proposed rate for G0424 in the hospital setting is $160+, while the same service in the physician office setting is $30+.

While there is certainly understandable logic in the Congressional mandate, the CMS approach that includes pulmonary rehab is fraught with basic flaws in logic, strongly supported by CMS data. For example, in 2014 only 231 distinct providers billed for a total of 22,603 services. That translates into an outlay of approximately $535,000. Compare that outlay for 2014 with the outlay for hospital outpatient pulmonary rehab at just under $120 million, billed by 1350 distinct providers.

Those data alone strongly support the contention that a business model of pulmonary rehab in a physician office setting is rarely viable. Space, capital investment, and staffing, coupled with low payment, hardly create an incentive for a hospital to purchase a pulmonary practice because of lucrative pulmonary rehab services.

Other Medicare data also work in our favor. An examination of the physician specialties that actually bill G0424 through the physician fee schedule also punches a large hole in the CMS argument. The top five physician specialties that billed G0424 through the physician office setting include:

2012 2013 2014

TOTAL $688,489 $589,116 $535,512

Pulmonary $340,805 $310,065 $229,832

Family Practice $175,788 $116,681 $183,499

Internal Medicine $79,053 $78,211 $52,943

Crit Care (intensivists) $29,964 $29,139 $18,723

Cardiology $31,947 $17,729 $17,242

Source: Physician Supplier Procedure Summary File (PSPS), 2012-2014

These data speak volumes, or perhaps an absolute lack of volume. How does one support the concept that this proposed action is necessary to stem the tide of hospital acquisition of pulmonary practices when the total volume, notably declining over the past 3 years, of actual billings for pulmonary rehab is valued at under $230,000? The comparison with actual hospital billing in 2014 of just under $120 million is critical. There is no rhyme or reason to the CMS proposal as it applies to pulmonary rehabilitation services.

Unintended consequences are not difficult to imagine. With the new payment rates, hospitals may choose to expand their programs but cannot do so unless that physical location in on the main campus or within 250 yards of the campus. An off-site program that must move to accommodate larger space would be precluded from such a move. Likewise, hospitals that may want to open a new program must do so within the confines of the hospital campus/250-yard perimeter. Otherwise, these programs would be required to bill at the physician fee schedule rate.

In a genuine very good news, very bad news proposal included in the 2017 hospital outpatient regulations, the Centers for Medicare & Medicaid Services (CMS) has proposed a major payment boost for pulmonary rehab services billed through hospital outpatient departments, but, simultaneously, the Agency proposes to preclude certain programs from utilizing that long- standing payment mechanism.

In November 2015, Congress authorized CMS to take action on the growing trend of hospitals purchasing certain physician practices so that the hospital can bill for certain services at a notably higher rate than the same service when provided in the physician office setting. CMS Section 603 pf P.L. 114-74 authorizes such action, and “These proposals are made in accordance with our belief that section 603… is intended to curb the practice of hospital acquisition of physician practices that result in receiving additional Medicare payment for similar services.” While we recognize that the congressional intent has some level of legitimacy, as is often the case, the CMS approach is too inclusive, especially as it applies to pulmonary rehabilitation services billed through HCPCS code G0424.

This problem has evolved because of two distinctly different formulas for determining payment. The physician fee schedule is based on the concept of RVUs, practice expense, and malpractice expense. Hospital outpatient services that may be virtually identical are based on a formula that includes charge data from Medicare claims forms and the annual hospital cost report identifying overhead.

If adopted as proposed, hospital outpatient programs in place on the date of enactment of P.L. 114-74 (early November 2015) are grandfathered into the hospital outpatient methodology. However, new programs that are not part of the main hospital campus (or within 250 yards of the campus) will only be able to bill at the physician office setting rate. Likewise, an existing program that moves to a new location that is beyond the 250-yard threshold will lose its “grandfather” status and be forced to bill at the physician office setting payment rate.

For practical purposes, the 2017 proposed rate for G0424 in the hospital setting is $160+, while the same service in the physician office setting is $30+.

While there is certainly understandable logic in the Congressional mandate, the CMS approach that includes pulmonary rehab is fraught with basic flaws in logic, strongly supported by CMS data. For example, in 2014 only 231 distinct providers billed for a total of 22,603 services. That translates into an outlay of approximately $535,000. Compare that outlay for 2014 with the outlay for hospital outpatient pulmonary rehab at just under $120 million, billed by 1350 distinct providers.

Those data alone strongly support the contention that a business model of pulmonary rehab in a physician office setting is rarely viable. Space, capital investment, and staffing, coupled with low payment, hardly create an incentive for a hospital to purchase a pulmonary practice because of lucrative pulmonary rehab services.

Other Medicare data also work in our favor. An examination of the physician specialties that actually bill G0424 through the physician fee schedule also punches a large hole in the CMS argument. The top five physician specialties that billed G0424 through the physician office setting include:

2012 2013 2014

TOTAL $688,489 $589,116 $535,512

Pulmonary $340,805 $310,065 $229,832

Family Practice $175,788 $116,681 $183,499

Internal Medicine $79,053 $78,211 $52,943

Crit Care (intensivists) $29,964 $29,139 $18,723

Cardiology $31,947 $17,729 $17,242

Source: Physician Supplier Procedure Summary File (PSPS), 2012-2014

These data speak volumes, or perhaps an absolute lack of volume. How does one support the concept that this proposed action is necessary to stem the tide of hospital acquisition of pulmonary practices when the total volume, notably declining over the past 3 years, of actual billings for pulmonary rehab is valued at under $230,000? The comparison with actual hospital billing in 2014 of just under $120 million is critical. There is no rhyme or reason to the CMS proposal as it applies to pulmonary rehabilitation services.

Unintended consequences are not difficult to imagine. With the new payment rates, hospitals may choose to expand their programs but cannot do so unless that physical location in on the main campus or within 250 yards of the campus. An off-site program that must move to accommodate larger space would be precluded from such a move. Likewise, hospitals that may want to open a new program must do so within the confines of the hospital campus/250-yard perimeter. Otherwise, these programs would be required to bill at the physician fee schedule rate.

In a genuine very good news, very bad news proposal included in the 2017 hospital outpatient regulations, the Centers for Medicare & Medicaid Services (CMS) has proposed a major payment boost for pulmonary rehab services billed through hospital outpatient departments, but, simultaneously, the Agency proposes to preclude certain programs from utilizing that long- standing payment mechanism.

In November 2015, Congress authorized CMS to take action on the growing trend of hospitals purchasing certain physician practices so that the hospital can bill for certain services at a notably higher rate than the same service when provided in the physician office setting. CMS Section 603 pf P.L. 114-74 authorizes such action, and “These proposals are made in accordance with our belief that section 603… is intended to curb the practice of hospital acquisition of physician practices that result in receiving additional Medicare payment for similar services.” While we recognize that the congressional intent has some level of legitimacy, as is often the case, the CMS approach is too inclusive, especially as it applies to pulmonary rehabilitation services billed through HCPCS code G0424.

This problem has evolved because of two distinctly different formulas for determining payment. The physician fee schedule is based on the concept of RVUs, practice expense, and malpractice expense. Hospital outpatient services that may be virtually identical are based on a formula that includes charge data from Medicare claims forms and the annual hospital cost report identifying overhead.

If adopted as proposed, hospital outpatient programs in place on the date of enactment of P.L. 114-74 (early November 2015) are grandfathered into the hospital outpatient methodology. However, new programs that are not part of the main hospital campus (or within 250 yards of the campus) will only be able to bill at the physician office setting rate. Likewise, an existing program that moves to a new location that is beyond the 250-yard threshold will lose its “grandfather” status and be forced to bill at the physician office setting payment rate.

For practical purposes, the 2017 proposed rate for G0424 in the hospital setting is $160+, while the same service in the physician office setting is $30+.

While there is certainly understandable logic in the Congressional mandate, the CMS approach that includes pulmonary rehab is fraught with basic flaws in logic, strongly supported by CMS data. For example, in 2014 only 231 distinct providers billed for a total of 22,603 services. That translates into an outlay of approximately $535,000. Compare that outlay for 2014 with the outlay for hospital outpatient pulmonary rehab at just under $120 million, billed by 1350 distinct providers.

Those data alone strongly support the contention that a business model of pulmonary rehab in a physician office setting is rarely viable. Space, capital investment, and staffing, coupled with low payment, hardly create an incentive for a hospital to purchase a pulmonary practice because of lucrative pulmonary rehab services.

Other Medicare data also work in our favor. An examination of the physician specialties that actually bill G0424 through the physician fee schedule also punches a large hole in the CMS argument. The top five physician specialties that billed G0424 through the physician office setting include:

2012 2013 2014

TOTAL $688,489 $589,116 $535,512

Pulmonary $340,805 $310,065 $229,832

Family Practice $175,788 $116,681 $183,499

Internal Medicine $79,053 $78,211 $52,943

Crit Care (intensivists) $29,964 $29,139 $18,723

Cardiology $31,947 $17,729 $17,242

Source: Physician Supplier Procedure Summary File (PSPS), 2012-2014

These data speak volumes, or perhaps an absolute lack of volume. How does one support the concept that this proposed action is necessary to stem the tide of hospital acquisition of pulmonary practices when the total volume, notably declining over the past 3 years, of actual billings for pulmonary rehab is valued at under $230,000? The comparison with actual hospital billing in 2014 of just under $120 million is critical. There is no rhyme or reason to the CMS proposal as it applies to pulmonary rehabilitation services.

Unintended consequences are not difficult to imagine. With the new payment rates, hospitals may choose to expand their programs but cannot do so unless that physical location in on the main campus or within 250 yards of the campus. An off-site program that must move to accommodate larger space would be precluded from such a move. Likewise, hospitals that may want to open a new program must do so within the confines of the hospital campus/250-yard perimeter. Otherwise, these programs would be required to bill at the physician fee schedule rate.

The CHEST staff’s monthly e-newsletter, Staff Matters, recently highlighted two examples that demonstrate the passion, talent, and cooperation exhibited by CHEST staff as colleagues working together to advance CHEST’s mission. As the name of the newsletter indicates, our staff really does matter and continually provides opportunities fostering our mission.

Celebrating a CHEST first

Chad Jackson recently earned a designation as Fellow of the American College of Chest Physicians (FCCP). He’s the first nonphysician member of CHEST staff to earn this designation. In light of this great honor, Chad was asked some questions about what this means to him.

Q: What does this honor mean to you?

A: It means a lot. More than I think I can eloquently describe in a few words ...

I think it is important for the employees to know that CHEST is a HUGE name in the medical space of hospitals and health systems. CHEST also has an excellent reputation with advanced practice professionals who work with our CHEST physicians. When I told people at Florida State College of Medicine that I was coming to work for CHEST, they literally were giving me high fives in the hallways of the college.

I think this is an important perspective for employees to realize. We come to work day in and day out, and it is just a job to a lot of folks. But outside of these walls, CHEST is well-known as a leader in the pulmonary, critical care, and sleep space. It was and still is an honor for me to work here, and I am truly blessed by being able to obtain my FCCP.

Q: Why did you choose to pursue obtaining an FCCP?

A: This is a realization of a dream that I had since coming to CHEST more than 8 years ago. Previously, as a nonphysician advanced professional practitioner, registered respiratory therapists (RRTs) like me could apply for membership only after you obtained a PhD. I was working on my PhD studies and had to take a break from my studies when life “intervened” and I had too much going on. At that point, I thought my dream of obtaining my FCCP was out of reach. When the membership model changed, I don’t think anyone was as excited as I was when the board discussed these changes.

I am the perfect use-case for this new membership model. I wanted a “home” for my practice. For years, I have been a member of the American Association of Respiratory Care (AARC), which many hospital-based RRTs call their home. I have also been a member of the Society of Critical Care Medicine (SCCM) and was even a Fundamentals of Critical Care Skills (FCCS) course instructor. But, my passion was educating physicians and other health care practitioners in pulmonary, critical care, and sleep medicine.

Obtaining my FCCP is the ultimate recognition for me and the work I have been doing in this medical education space.

Q: What does it mean, as a nonphysician, to have the opportunity to be recognized for your commitment to advancing chest medicine?

A: It is HUGE! I think that there are many more folks who would like to receive recognition for their work in this field, who don’t feel that their current “home” organizations appreciate their efforts. For me, again, it was a dream now realized, to be able to be recognized for my efforts along with my physician friends who work so hard to provide the best possible education for our members and attendees.

CHEST Staff in Action

In July, as part of our annual staff appreciation day, CHEST staff members were offered the opportunity to visit the “Feed My Starving Children” facility for a few hours in the morning to prepare food portions for needy children in different parts of the world. The staff’s response was tremendous, and even our incoming President, Dr. Gerard Silvestri, joined us, as we took to different stations portioning out dry ingredients for individual food packets. We soon learned that our packets were destined for Haiti’s children! This community outreach event brought our staff together, volunteering time toward a mutual goal of helping others and advancing CHEST’s mission in our own personal way.

Here is what we achieved that morning:

Large cartons packed: 129

Individual meals filled and packed: 27,864

Children fed for 1 year: 76

In the words of our interim CEO, Steve Welch, “As I looked around at everyone at the event, I was so touched by the enthusiasm that you all showed, and the comments I heard afterward, that I’ve asked HR to look into setting up similar things as a regular opportunity for those staff who wish to participate, in order to continue fostering an environment of volunteerism and giving back. What we do every day is incumbent on our volunteers giving their time for CHEST, and it sets a great example when we are also volunteering for causes that are important to us individually.”

The CHEST staff’s monthly e-newsletter, Staff Matters, recently highlighted two examples that demonstrate the passion, talent, and cooperation exhibited by CHEST staff as colleagues working together to advance CHEST’s mission. As the name of the newsletter indicates, our staff really does matter and continually provides opportunities fostering our mission.

Celebrating a CHEST first

Chad Jackson recently earned a designation as Fellow of the American College of Chest Physicians (FCCP). He’s the first nonphysician member of CHEST staff to earn this designation. In light of this great honor, Chad was asked some questions about what this means to him.

Q: What does this honor mean to you?

A: It means a lot. More than I think I can eloquently describe in a few words ...

I think it is important for the employees to know that CHEST is a HUGE name in the medical space of hospitals and health systems. CHEST also has an excellent reputation with advanced practice professionals who work with our CHEST physicians. When I told people at Florida State College of Medicine that I was coming to work for CHEST, they literally were giving me high fives in the hallways of the college.

I think this is an important perspective for employees to realize. We come to work day in and day out, and it is just a job to a lot of folks. But outside of these walls, CHEST is well-known as a leader in the pulmonary, critical care, and sleep space. It was and still is an honor for me to work here, and I am truly blessed by being able to obtain my FCCP.

Q: Why did you choose to pursue obtaining an FCCP?

A: This is a realization of a dream that I had since coming to CHEST more than 8 years ago. Previously, as a nonphysician advanced professional practitioner, registered respiratory therapists (RRTs) like me could apply for membership only after you obtained a PhD. I was working on my PhD studies and had to take a break from my studies when life “intervened” and I had too much going on. At that point, I thought my dream of obtaining my FCCP was out of reach. When the membership model changed, I don’t think anyone was as excited as I was when the board discussed these changes.

I am the perfect use-case for this new membership model. I wanted a “home” for my practice. For years, I have been a member of the American Association of Respiratory Care (AARC), which many hospital-based RRTs call their home. I have also been a member of the Society of Critical Care Medicine (SCCM) and was even a Fundamentals of Critical Care Skills (FCCS) course instructor. But, my passion was educating physicians and other health care practitioners in pulmonary, critical care, and sleep medicine.

Obtaining my FCCP is the ultimate recognition for me and the work I have been doing in this medical education space.

Q: What does it mean, as a nonphysician, to have the opportunity to be recognized for your commitment to advancing chest medicine?

A: It is HUGE! I think that there are many more folks who would like to receive recognition for their work in this field, who don’t feel that their current “home” organizations appreciate their efforts. For me, again, it was a dream now realized, to be able to be recognized for my efforts along with my physician friends who work so hard to provide the best possible education for our members and attendees.

CHEST Staff in Action

In July, as part of our annual staff appreciation day, CHEST staff members were offered the opportunity to visit the “Feed My Starving Children” facility for a few hours in the morning to prepare food portions for needy children in different parts of the world. The staff’s response was tremendous, and even our incoming President, Dr. Gerard Silvestri, joined us, as we took to different stations portioning out dry ingredients for individual food packets. We soon learned that our packets were destined for Haiti’s children! This community outreach event brought our staff together, volunteering time toward a mutual goal of helping others and advancing CHEST’s mission in our own personal way.

Here is what we achieved that morning:

Large cartons packed: 129

Individual meals filled and packed: 27,864

Children fed for 1 year: 76

In the words of our interim CEO, Steve Welch, “As I looked around at everyone at the event, I was so touched by the enthusiasm that you all showed, and the comments I heard afterward, that I’ve asked HR to look into setting up similar things as a regular opportunity for those staff who wish to participate, in order to continue fostering an environment of volunteerism and giving back. What we do every day is incumbent on our volunteers giving their time for CHEST, and it sets a great example when we are also volunteering for causes that are important to us individually.”

The CHEST staff’s monthly e-newsletter, Staff Matters, recently highlighted two examples that demonstrate the passion, talent, and cooperation exhibited by CHEST staff as colleagues working together to advance CHEST’s mission. As the name of the newsletter indicates, our staff really does matter and continually provides opportunities fostering our mission.

Celebrating a CHEST first

Chad Jackson recently earned a designation as Fellow of the American College of Chest Physicians (FCCP). He’s the first nonphysician member of CHEST staff to earn this designation. In light of this great honor, Chad was asked some questions about what this means to him.

Q: What does this honor mean to you?

A: It means a lot. More than I think I can eloquently describe in a few words ...

I think it is important for the employees to know that CHEST is a HUGE name in the medical space of hospitals and health systems. CHEST also has an excellent reputation with advanced practice professionals who work with our CHEST physicians. When I told people at Florida State College of Medicine that I was coming to work for CHEST, they literally were giving me high fives in the hallways of the college.

I think this is an important perspective for employees to realize. We come to work day in and day out, and it is just a job to a lot of folks. But outside of these walls, CHEST is well-known as a leader in the pulmonary, critical care, and sleep space. It was and still is an honor for me to work here, and I am truly blessed by being able to obtain my FCCP.

Q: Why did you choose to pursue obtaining an FCCP?

A: This is a realization of a dream that I had since coming to CHEST more than 8 years ago. Previously, as a nonphysician advanced professional practitioner, registered respiratory therapists (RRTs) like me could apply for membership only after you obtained a PhD. I was working on my PhD studies and had to take a break from my studies when life “intervened” and I had too much going on. At that point, I thought my dream of obtaining my FCCP was out of reach. When the membership model changed, I don’t think anyone was as excited as I was when the board discussed these changes.

I am the perfect use-case for this new membership model. I wanted a “home” for my practice. For years, I have been a member of the American Association of Respiratory Care (AARC), which many hospital-based RRTs call their home. I have also been a member of the Society of Critical Care Medicine (SCCM) and was even a Fundamentals of Critical Care Skills (FCCS) course instructor. But, my passion was educating physicians and other health care practitioners in pulmonary, critical care, and sleep medicine.

Obtaining my FCCP is the ultimate recognition for me and the work I have been doing in this medical education space.

Q: What does it mean, as a nonphysician, to have the opportunity to be recognized for your commitment to advancing chest medicine?

A: It is HUGE! I think that there are many more folks who would like to receive recognition for their work in this field, who don’t feel that their current “home” organizations appreciate their efforts. For me, again, it was a dream now realized, to be able to be recognized for my efforts along with my physician friends who work so hard to provide the best possible education for our members and attendees.

CHEST Staff in Action

In July, as part of our annual staff appreciation day, CHEST staff members were offered the opportunity to visit the “Feed My Starving Children” facility for a few hours in the morning to prepare food portions for needy children in different parts of the world. The staff’s response was tremendous, and even our incoming President, Dr. Gerard Silvestri, joined us, as we took to different stations portioning out dry ingredients for individual food packets. We soon learned that our packets were destined for Haiti’s children! This community outreach event brought our staff together, volunteering time toward a mutual goal of helping others and advancing CHEST’s mission in our own personal way.

Here is what we achieved that morning:

Large cartons packed: 129

Individual meals filled and packed: 27,864

Children fed for 1 year: 76

In the words of our interim CEO, Steve Welch, “As I looked around at everyone at the event, I was so touched by the enthusiasm that you all showed, and the comments I heard afterward, that I’ve asked HR to look into setting up similar things as a regular opportunity for those staff who wish to participate, in order to continue fostering an environment of volunteerism and giving back. What we do every day is incumbent on our volunteers giving their time for CHEST, and it sets a great example when we are also volunteering for causes that are important to us individually.”

NetWorks Challenge 2016

Which NetWork will champion lung health?

Donate to the CHEST Foundation from now until the CHEST Annual Meeting 2016. Mark your NetWork when making your donation to receive credit. Donate here:

• Online

• By phone: 224/521-9527

• By mail: Download our donation form and mail to CHEST Foundation, 2595 Patriot Boulevard, Glenview, IL 60026

Three ways to win

Round 1

Highest percentage of participation by NetWork Steering Committee

Number of winners: 2

Winning NetWork Steering Committees will receive:

• Additional time at the meeting – 90 minutes total

• Travel grants to CHEST 2016

First Half Winners: Women’s Health NetWork and Occupational and Environmental Health NetWork

Second Half Winners: (announced at the CHEST Annual Meeting)

Round 2

Total amount contributed by NetWork Steering Committee

Number of winners: 2

Winning NetWork Steering Committees will receive:

• One seat (public member) on the CHEST Foundation Awards Committee for the following year

Bonus: The CHEST Foundation will match funds raised by the two winning NetWork Steering Committees that meet a minimum of $15,000, up to $25,000 for a clinical research grant. Winning NetWork Steering Committees will be announced at the CHEST Annual Meeting Monday Opening Session.

Annual Meeting Winners (announced after CHEST Annual Meeting)

Round 3

Highest percentage of participation by a NetWork’s membership

Number of winners: 2 for travel grants, 4 for membership waivers

Winning NetWorks will receive:

• Travel grants to CHEST 2017

• Free CHEST membership for 2017

Note on Rounds 1 and 3: The NetWork Steering Committee will recommend awardee. The recommendations from winning NetWork Steering Committees will be reviewed by the Foundation Awards Committee. In the event of a tie, the NetWork that achieves its percentage of participation earliest will receive the challenge.

NetWorks Challenge 2016

Which NetWork will champion lung health?

Donate to the CHEST Foundation from now until the CHEST Annual Meeting 2016. Mark your NetWork when making your donation to receive credit. Donate here:

• Online

• By phone: 224/521-9527

• By mail: Download our donation form and mail to CHEST Foundation, 2595 Patriot Boulevard, Glenview, IL 60026

Three ways to win

Round 1

Highest percentage of participation by NetWork Steering Committee

Number of winners: 2

Winning NetWork Steering Committees will receive:

• Additional time at the meeting – 90 minutes total

• Travel grants to CHEST 2016

First Half Winners: Women’s Health NetWork and Occupational and Environmental Health NetWork

Second Half Winners: (announced at the CHEST Annual Meeting)

Round 2

Total amount contributed by NetWork Steering Committee

Number of winners: 2

Winning NetWork Steering Committees will receive:

• One seat (public member) on the CHEST Foundation Awards Committee for the following year

Bonus: The CHEST Foundation will match funds raised by the two winning NetWork Steering Committees that meet a minimum of $15,000, up to $25,000 for a clinical research grant. Winning NetWork Steering Committees will be announced at the CHEST Annual Meeting Monday Opening Session.

Annual Meeting Winners (announced after CHEST Annual Meeting)

Round 3

Highest percentage of participation by a NetWork’s membership

Number of winners: 2 for travel grants, 4 for membership waivers

Winning NetWorks will receive:

• Travel grants to CHEST 2017

• Free CHEST membership for 2017

Note on Rounds 1 and 3: The NetWork Steering Committee will recommend awardee. The recommendations from winning NetWork Steering Committees will be reviewed by the Foundation Awards Committee. In the event of a tie, the NetWork that achieves its percentage of participation earliest will receive the challenge.

NetWorks Challenge 2016

Which NetWork will champion lung health?

Donate to the CHEST Foundation from now until the CHEST Annual Meeting 2016. Mark your NetWork when making your donation to receive credit. Donate here:

• Online

• By phone: 224/521-9527

• By mail: Download our donation form and mail to CHEST Foundation, 2595 Patriot Boulevard, Glenview, IL 60026

Three ways to win

Round 1

Highest percentage of participation by NetWork Steering Committee

Number of winners: 2

Winning NetWork Steering Committees will receive:

• Additional time at the meeting – 90 minutes total

• Travel grants to CHEST 2016

First Half Winners: Women’s Health NetWork and Occupational and Environmental Health NetWork

Second Half Winners: (announced at the CHEST Annual Meeting)

Round 2

Total amount contributed by NetWork Steering Committee

Number of winners: 2

Winning NetWork Steering Committees will receive:

• One seat (public member) on the CHEST Foundation Awards Committee for the following year

Bonus: The CHEST Foundation will match funds raised by the two winning NetWork Steering Committees that meet a minimum of $15,000, up to $25,000 for a clinical research grant. Winning NetWork Steering Committees will be announced at the CHEST Annual Meeting Monday Opening Session.

Annual Meeting Winners (announced after CHEST Annual Meeting)

Round 3

Highest percentage of participation by a NetWork’s membership

Number of winners: 2 for travel grants, 4 for membership waivers

Winning NetWorks will receive:

• Travel grants to CHEST 2017

• Free CHEST membership for 2017

Note on Rounds 1 and 3: The NetWork Steering Committee will recommend awardee. The recommendations from winning NetWork Steering Committees will be reviewed by the Foundation Awards Committee. In the event of a tie, the NetWork that achieves its percentage of participation earliest will receive the challenge.

Gerard Silvestri, MD, MS, FCCP, will be inaugurated as the new President of CHEST next month in Los Angeles during CHEST 2016. He is the Hillenbrand Professor of Thoracic Oncology and Vice Chair of Medicine for Faculty Development at the Medical University of South Carolina, Charleston. Dr. Silvestri completed his fellowship training in pulmonary and critical care at Dartmouth, Hanover, N.H. He has an advanced degree in the evaluative clinical sciences, also from Dartmouth. He is a lung cancer and interventional pulmonologist with an interest in health services research, lung cancer screening, nodule evaluation and management, and staging of lung cancer.

After becoming a Fellow of the American College of Chest Physicians in 1998, Dr. Silvestri became active with the NetWorks, serving on the Steering Committees of the Thoracic Oncology and the Interventional Chest/Diagnostic Procedures NetWorks, eventually chairing the Thoracic Oncology NetWork. Dr. Silvestri has also served on the Nominating Committee, the CHEST Scientific Program Committee, the CHEST Foundation Development Committee, as Treasurer and Trustee on the foundation’s Board of Trustees, and as a Regent-at-Large for the American College of Chest Physicians for 3 years. At CHEST 2012, Dr. Silvestri was awarded the Pasquale Ciaglia Memorial Lecture in Interventional Medicine, and at CHEST 2014, he received the Edward C. Rosenow III, MD, Master FCCP/Master Teacher Honor Lecture award. Dr. Silvestri has authored more than 200 scientific articles, book chapters, and editorials, and he currently serves on the editorial board of the journal CHEST.

We asked Dr. Silvestri for some thoughts on his upcoming CHEST presidency.

1. What would you like to accomplish as President of CHEST?

As boring as this may sound, the role of the President is to oversee and carry out the strategic plan set forth by a very capable Board of Regents. It is an ambitious undertaking and among other things, it includes increasing the output of clinical practice guidelines to better serve pulmonologists and their patients, and educating as many physicians as possible through our national meeting, board review courses, our journal CHEST, our SEEK Library app and publication, and the CHEST headquarters, which has a state-of-the art education and simulation center. Our strategic vision aims to provide education to our global colleagues as well as evidenced by our commitment to regional meetings on different continents and our efforts at collaborating with our Chinese colleagues to establish the first pulmonary and critical care fellowships in that populous nation.

In support of these efforts, there are a few other projects we will get off the ground. Because education is our core mission, CHEST has a goal of helping to increase our faculty development offerings culminating in a master educator certification for those who are interested and qualify. We also will be piloting an app for practice guidelines, which will help with the implementation and dissemination of our valuable clinical practice guidelines.

2. What do you consider to be the greatest strength of CHEST, and how will you build upon this during your presidency?

The greatest strength of the College is the amazing staff and physician volunteers who give tirelessly to support the mission of the College, and ultimately, the membership as a whole. We already have begun to take measures to ensure that our most precious resources, our people, are supported in every way possible to better do their work. In the next year, it is my commitment that we continue to provide the resources and recognition so that our faculty and staff can deliver the best educational content to our membership.

Our CHEST Foundation continues to champion lung health by supporting clinical research grants, community service grants, and patient education. CHEST members, their patients, and many others have benefited from the various clinical research and humanitarian projects that the Foundation has supported. This year, we celebrate the 20th anniversary of the CHEST Foundation, and I am sure that the innovative initiatives of our charitable foundation will continue to move forward, making a difference for people throughout the world.

3. What are some challenges facing CHEST, and how will you address these challenges?

In a day in which physicians have limited resources, decisions about which medical society, if any, they should belong to have become increasingly real. Our members are using electronic media to find the tools they need to care for patients and may be less likely to follow the traditional medical association path. The challenge facing CHEST is to provide value, and it is the job of CHEST leadership to be certain that all of our members find that value in this organization. To do that, we must find or expand in creative ways a means to deliver our content in ways that resonate with our membership.

4. And finally, what is your charge to the members and new Fellows of CHEST?

The simple and overused answer would be to get involved. Without question, I believe that, and my start with the American College of Chest Physicians began as a member of the Thoracic Oncology NetWork, but I want to be a bit more specific. I challenge our members to find a niche within the College that they have a passion for, and in turn, they should challenge us to do better for our members and patients within that chosen area of expertise. There are so many ways to get involved, whether it be our NetWorks, the e-communities, practice guidelines, or helping to teach in our simulation center. CHEST is an extremely welcoming organization, and your passion will find a home here and will be nurtured and supported by other like members and the CHEST staff.

Gerard Silvestri, MD, MS, FCCP, will be inaugurated as the new President of CHEST next month in Los Angeles during CHEST 2016. He is the Hillenbrand Professor of Thoracic Oncology and Vice Chair of Medicine for Faculty Development at the Medical University of South Carolina, Charleston. Dr. Silvestri completed his fellowship training in pulmonary and critical care at Dartmouth, Hanover, N.H. He has an advanced degree in the evaluative clinical sciences, also from Dartmouth. He is a lung cancer and interventional pulmonologist with an interest in health services research, lung cancer screening, nodule evaluation and management, and staging of lung cancer.

After becoming a Fellow of the American College of Chest Physicians in 1998, Dr. Silvestri became active with the NetWorks, serving on the Steering Committees of the Thoracic Oncology and the Interventional Chest/Diagnostic Procedures NetWorks, eventually chairing the Thoracic Oncology NetWork. Dr. Silvestri has also served on the Nominating Committee, the CHEST Scientific Program Committee, the CHEST Foundation Development Committee, as Treasurer and Trustee on the foundation’s Board of Trustees, and as a Regent-at-Large for the American College of Chest Physicians for 3 years. At CHEST 2012, Dr. Silvestri was awarded the Pasquale Ciaglia Memorial Lecture in Interventional Medicine, and at CHEST 2014, he received the Edward C. Rosenow III, MD, Master FCCP/Master Teacher Honor Lecture award. Dr. Silvestri has authored more than 200 scientific articles, book chapters, and editorials, and he currently serves on the editorial board of the journal CHEST.

We asked Dr. Silvestri for some thoughts on his upcoming CHEST presidency.

1. What would you like to accomplish as President of CHEST?

As boring as this may sound, the role of the President is to oversee and carry out the strategic plan set forth by a very capable Board of Regents. It is an ambitious undertaking and among other things, it includes increasing the output of clinical practice guidelines to better serve pulmonologists and their patients, and educating as many physicians as possible through our national meeting, board review courses, our journal CHEST, our SEEK Library app and publication, and the CHEST headquarters, which has a state-of-the art education and simulation center. Our strategic vision aims to provide education to our global colleagues as well as evidenced by our commitment to regional meetings on different continents and our efforts at collaborating with our Chinese colleagues to establish the first pulmonary and critical care fellowships in that populous nation.

In support of these efforts, there are a few other projects we will get off the ground. Because education is our core mission, CHEST has a goal of helping to increase our faculty development offerings culminating in a master educator certification for those who are interested and qualify. We also will be piloting an app for practice guidelines, which will help with the implementation and dissemination of our valuable clinical practice guidelines.

2. What do you consider to be the greatest strength of CHEST, and how will you build upon this during your presidency?

The greatest strength of the College is the amazing staff and physician volunteers who give tirelessly to support the mission of the College, and ultimately, the membership as a whole. We already have begun to take measures to ensure that our most precious resources, our people, are supported in every way possible to better do their work. In the next year, it is my commitment that we continue to provide the resources and recognition so that our faculty and staff can deliver the best educational content to our membership.

Our CHEST Foundation continues to champion lung health by supporting clinical research grants, community service grants, and patient education. CHEST members, their patients, and many others have benefited from the various clinical research and humanitarian projects that the Foundation has supported. This year, we celebrate the 20th anniversary of the CHEST Foundation, and I am sure that the innovative initiatives of our charitable foundation will continue to move forward, making a difference for people throughout the world.

3. What are some challenges facing CHEST, and how will you address these challenges?

In a day in which physicians have limited resources, decisions about which medical society, if any, they should belong to have become increasingly real. Our members are using electronic media to find the tools they need to care for patients and may be less likely to follow the traditional medical association path. The challenge facing CHEST is to provide value, and it is the job of CHEST leadership to be certain that all of our members find that value in this organization. To do that, we must find or expand in creative ways a means to deliver our content in ways that resonate with our membership.

4. And finally, what is your charge to the members and new Fellows of CHEST?

The simple and overused answer would be to get involved. Without question, I believe that, and my start with the American College of Chest Physicians began as a member of the Thoracic Oncology NetWork, but I want to be a bit more specific. I challenge our members to find a niche within the College that they have a passion for, and in turn, they should challenge us to do better for our members and patients within that chosen area of expertise. There are so many ways to get involved, whether it be our NetWorks, the e-communities, practice guidelines, or helping to teach in our simulation center. CHEST is an extremely welcoming organization, and your passion will find a home here and will be nurtured and supported by other like members and the CHEST staff.

Gerard Silvestri, MD, MS, FCCP, will be inaugurated as the new President of CHEST next month in Los Angeles during CHEST 2016. He is the Hillenbrand Professor of Thoracic Oncology and Vice Chair of Medicine for Faculty Development at the Medical University of South Carolina, Charleston. Dr. Silvestri completed his fellowship training in pulmonary and critical care at Dartmouth, Hanover, N.H. He has an advanced degree in the evaluative clinical sciences, also from Dartmouth. He is a lung cancer and interventional pulmonologist with an interest in health services research, lung cancer screening, nodule evaluation and management, and staging of lung cancer.

After becoming a Fellow of the American College of Chest Physicians in 1998, Dr. Silvestri became active with the NetWorks, serving on the Steering Committees of the Thoracic Oncology and the Interventional Chest/Diagnostic Procedures NetWorks, eventually chairing the Thoracic Oncology NetWork. Dr. Silvestri has also served on the Nominating Committee, the CHEST Scientific Program Committee, the CHEST Foundation Development Committee, as Treasurer and Trustee on the foundation’s Board of Trustees, and as a Regent-at-Large for the American College of Chest Physicians for 3 years. At CHEST 2012, Dr. Silvestri was awarded the Pasquale Ciaglia Memorial Lecture in Interventional Medicine, and at CHEST 2014, he received the Edward C. Rosenow III, MD, Master FCCP/Master Teacher Honor Lecture award. Dr. Silvestri has authored more than 200 scientific articles, book chapters, and editorials, and he currently serves on the editorial board of the journal CHEST.

We asked Dr. Silvestri for some thoughts on his upcoming CHEST presidency.

1. What would you like to accomplish as President of CHEST?

As boring as this may sound, the role of the President is to oversee and carry out the strategic plan set forth by a very capable Board of Regents. It is an ambitious undertaking and among other things, it includes increasing the output of clinical practice guidelines to better serve pulmonologists and their patients, and educating as many physicians as possible through our national meeting, board review courses, our journal CHEST, our SEEK Library app and publication, and the CHEST headquarters, which has a state-of-the art education and simulation center. Our strategic vision aims to provide education to our global colleagues as well as evidenced by our commitment to regional meetings on different continents and our efforts at collaborating with our Chinese colleagues to establish the first pulmonary and critical care fellowships in that populous nation.

In support of these efforts, there are a few other projects we will get off the ground. Because education is our core mission, CHEST has a goal of helping to increase our faculty development offerings culminating in a master educator certification for those who are interested and qualify. We also will be piloting an app for practice guidelines, which will help with the implementation and dissemination of our valuable clinical practice guidelines.

2. What do you consider to be the greatest strength of CHEST, and how will you build upon this during your presidency?

The greatest strength of the College is the amazing staff and physician volunteers who give tirelessly to support the mission of the College, and ultimately, the membership as a whole. We already have begun to take measures to ensure that our most precious resources, our people, are supported in every way possible to better do their work. In the next year, it is my commitment that we continue to provide the resources and recognition so that our faculty and staff can deliver the best educational content to our membership.

Our CHEST Foundation continues to champion lung health by supporting clinical research grants, community service grants, and patient education. CHEST members, their patients, and many others have benefited from the various clinical research and humanitarian projects that the Foundation has supported. This year, we celebrate the 20th anniversary of the CHEST Foundation, and I am sure that the innovative initiatives of our charitable foundation will continue to move forward, making a difference for people throughout the world.

3. What are some challenges facing CHEST, and how will you address these challenges?

In a day in which physicians have limited resources, decisions about which medical society, if any, they should belong to have become increasingly real. Our members are using electronic media to find the tools they need to care for patients and may be less likely to follow the traditional medical association path. The challenge facing CHEST is to provide value, and it is the job of CHEST leadership to be certain that all of our members find that value in this organization. To do that, we must find or expand in creative ways a means to deliver our content in ways that resonate with our membership.

4. And finally, what is your charge to the members and new Fellows of CHEST?

The simple and overused answer would be to get involved. Without question, I believe that, and my start with the American College of Chest Physicians began as a member of the Thoracic Oncology NetWork, but I want to be a bit more specific. I challenge our members to find a niche within the College that they have a passion for, and in turn, they should challenge us to do better for our members and patients within that chosen area of expertise. There are so many ways to get involved, whether it be our NetWorks, the e-communities, practice guidelines, or helping to teach in our simulation center. CHEST is an extremely welcoming organization, and your passion will find a home here and will be nurtured and supported by other like members and the CHEST staff.

Steven A. Sahn, MD, FCCP, died on August 16, 2016, after an illustrious academic career. Born in Brooklyn, N.Y., he attended Duke University as an undergraduate and subsequently graduated from the University of Louisville School of Medicine. He completed a pulmonary–critical care fellowship at the University of Colorado, where he served the first 12 years of his academic career. As an investigator, Steve’s early pioneering work in weaning from mechanical ventilation and pleural physiology set the stage for almost all subsequent research in these fields. He was recruited in 1983 to the Medical University of South Carolina as Director of the Division of Pulmonary and Critical Care Medicine. During the next 30 years, he built the Division from three physicians to an internationally prominent team of clinicians and investigators. His passion for teaching blended his mentoring style with a love for sports and positive coaching.

He was a master clinician with remarkable diagnostic skills who attracted patients from around the world who valued his exceptional warmth and compassion. Steve’s extensive contributions to the literature resulted in numerous awards, which included CHEST’s Alfred Soffer Award for Editorial Excellence, ATS Trudeau Medal, CHEST Distinguished Lecturer for Pleural Disease, induction into the Colorado Trudeau Society Pulmonary Hall of Fame, and Distinguished University Professor of Medicine at MUSC. He contributed to the American College of Chest Physicians throughout his career serving on editorial boards of CHEST and PCCSU (Editor in Chief), on numerous committees, as co-editor of the CHEST “Pearls” section, and on the Council of Governors representing South Carolina. We extend our heartfelt condolences to his wife, Claire, and the entire Sahn family.

Steven A. Sahn, MD, FCCP, died on August 16, 2016, after an illustrious academic career. Born in Brooklyn, N.Y., he attended Duke University as an undergraduate and subsequently graduated from the University of Louisville School of Medicine. He completed a pulmonary–critical care fellowship at the University of Colorado, where he served the first 12 years of his academic career. As an investigator, Steve’s early pioneering work in weaning from mechanical ventilation and pleural physiology set the stage for almost all subsequent research in these fields. He was recruited in 1983 to the Medical University of South Carolina as Director of the Division of Pulmonary and Critical Care Medicine. During the next 30 years, he built the Division from three physicians to an internationally prominent team of clinicians and investigators. His passion for teaching blended his mentoring style with a love for sports and positive coaching.

He was a master clinician with remarkable diagnostic skills who attracted patients from around the world who valued his exceptional warmth and compassion. Steve’s extensive contributions to the literature resulted in numerous awards, which included CHEST’s Alfred Soffer Award for Editorial Excellence, ATS Trudeau Medal, CHEST Distinguished Lecturer for Pleural Disease, induction into the Colorado Trudeau Society Pulmonary Hall of Fame, and Distinguished University Professor of Medicine at MUSC. He contributed to the American College of Chest Physicians throughout his career serving on editorial boards of CHEST and PCCSU (Editor in Chief), on numerous committees, as co-editor of the CHEST “Pearls” section, and on the Council of Governors representing South Carolina. We extend our heartfelt condolences to his wife, Claire, and the entire Sahn family.

Steven A. Sahn, MD, FCCP, died on August 16, 2016, after an illustrious academic career. Born in Brooklyn, N.Y., he attended Duke University as an undergraduate and subsequently graduated from the University of Louisville School of Medicine. He completed a pulmonary–critical care fellowship at the University of Colorado, where he served the first 12 years of his academic career. As an investigator, Steve’s early pioneering work in weaning from mechanical ventilation and pleural physiology set the stage for almost all subsequent research in these fields. He was recruited in 1983 to the Medical University of South Carolina as Director of the Division of Pulmonary and Critical Care Medicine. During the next 30 years, he built the Division from three physicians to an internationally prominent team of clinicians and investigators. His passion for teaching blended his mentoring style with a love for sports and positive coaching.

He was a master clinician with remarkable diagnostic skills who attracted patients from around the world who valued his exceptional warmth and compassion. Steve’s extensive contributions to the literature resulted in numerous awards, which included CHEST’s Alfred Soffer Award for Editorial Excellence, ATS Trudeau Medal, CHEST Distinguished Lecturer for Pleural Disease, induction into the Colorado Trudeau Society Pulmonary Hall of Fame, and Distinguished University Professor of Medicine at MUSC. He contributed to the American College of Chest Physicians throughout his career serving on editorial boards of CHEST and PCCSU (Editor in Chief), on numerous committees, as co-editor of the CHEST “Pearls” section, and on the Council of Governors representing South Carolina. We extend our heartfelt condolences to his wife, Claire, and the entire Sahn family.

The phenomenon of preconditioning reflects complex adaptive responses by living organisms to stimuli such as ischemia, hypoxia, hypothermia, or starvation. Acute ischemic preconditioning, initially described by Murry in 1986 (Circulation. 1986;74[5]:1124), occurs when multiple brief episodes of ischemia followed by reperfusion elicit a protective effect on the heart from a subsequent prolonged period of ischemia, such as a heart attack. This protective effect from ischemic preconditioning can be in the form of a smaller heart attack, lower chance of cardiac arrhythmias, less myocardial cell death, and lower risk of heart muscle failure. The cardioprotective effect of ischemic preconditioning is dependent on the duration and strength of the preconditioning stimulus. If the preconditioning stimulus is too strong or prolonged, detrimental effects on the heart may be observed.

Like ischemic preconditioning, hypoxic preconditioning represents a complex adaptive response that organisms have developed to offset damage inflicted by oxygen deprivation. The concept of hypoxic preconditioning is familiar to humans; for years, athletes have been using hypoxic training (high altitude and other newer technologies) to boost their performance in sporting events. Additionally, there is evidence dating back to before the breakthrough findings of Murry and colleagues who confirm the cardioprotective effects of hypoxia. In 1973, Meerson and colleagues (Am J Cardiol. 1973;31[1]:30) reported that mice exposed to high-altitude hypoxia have reduced mortality and smaller areas of necrotic myocardium after coronary artery occlusion.

Both of the ischemic and hypoxic preconditioning animal experiments mentioned above involve acute exposure to the preconditioning stimuli, resulting in a cardioprotective response for a limited time period. In order to afford a sustained period of cardioprotection, recurrent hypoxic exposure may be necessary. Indeed, recent studies have concentrated on just that; repeated exposure to intermittent hypoxia over a few weeks (Manukhina et al. Exp Biol Med. 2013;238[12]:1413) results in robust cardioprotection after coronary artery occlusion and reperfusion.

Despite the convincing cardioprotective discoveries from ischemic and hypoxic preconditioning, translation into clinical practice as a therapeutic modality is absent. This is partly because human beings are more complex than animals. They have comorbidities and are affected by aging, both of which may alter the milieu for preconditioning stimuli. Furthermore, the therapeutic range for any given preconditioning stimulus is unknown.

Sleep apnea (SA) is exceedingly prevalent in the United States. In SA, an individual stops breathing either completely (apnea) or partially (hypopnea) during sleep resulting in intermittent hypoxia, with arousal from sleep and resumption of breathing leading to reoxygenation. Hence, SA is characterized by intermittent hypoxia followed by reoxygenation. So, one can speculate that SA could exert cardioprotective effects as seen in hypoxic preconditioning and ischemic preconditioning. It is important to note, however, that SA is associated with hypercapnic intermittent hypoxia, whereas most of the investigations on ischemic preconditioning and intermittent hypoxia are with eucapnia or hypocapnia.

The potentially cardioprotective role of SA is supported by a growing body of complementary research that indicates that coronary collateral flow is higher in patients with SA vs. control subjects (Steiner. Chest. 2010;137[3]:516) and that there is an increased mobilization, proliferation, and angiogenic capacity of endothelial progenitor cells from patients with myocardial infarction and SA as compared with cells from controls subjects without SA (Berger. Am J Respir Crit Care Med. 2013;187[1]:90). Some epidemiologic data support a weaker relationship between SA and coronary ischemic events compared with other cardiovascular events (Gottlieb. Circulation. 2010;122[4]:352). Hypoxic preconditioning may explain the relatively decreased pro-thrombotic influence of SA in the coronary vascular bed. Nevertheless, more research is needed to determine if SA is cardioprotective. If, however, cardioprotection from SA is confirmed, it may contribute to a paradigm shift in how SA is considered in relationship to coronary heart disease. Furthermore, future investigations would need to focus on what dose and duration of SA is needed for cardioprotection to occur. Prospective studies may also provide an opportunity for investigating interindividual variability in the susceptibility of the myocardium to the hypoxic preconditioning stimulus from SA.

This article highlights how complex the relationship between hypoxia and myocardial response is. This is further supported by results from a recent clinical trial, AVOID (Air Versus Oxygen In ST-elevation MyocarDial Infarction) (Stub. Circulation. 2015;131[24]:2143). Results from the AVOID trial report that routine oxygen use in normoxic patients hospitalized with a heart attack was not beneficial and, in fact, was harmful. Patients who received oxygen had more myocardial injury than those who did not. Therefore, even though for decades we thought that oxygen therapy helps hospitalized heart attack patients, results from the AVOID trial have initiated a paradigm shift. It remains to be determined whether such a paradigm shift will follow for sleep apnea.

Dr. Shah is with the department of epidemiology and population health, Albert Einstein College of Medicine, N.Y.

The phenomenon of preconditioning reflects complex adaptive responses by living organisms to stimuli such as ischemia, hypoxia, hypothermia, or starvation. Acute ischemic preconditioning, initially described by Murry in 1986 (Circulation. 1986;74[5]:1124), occurs when multiple brief episodes of ischemia followed by reperfusion elicit a protective effect on the heart from a subsequent prolonged period of ischemia, such as a heart attack. This protective effect from ischemic preconditioning can be in the form of a smaller heart attack, lower chance of cardiac arrhythmias, less myocardial cell death, and lower risk of heart muscle failure. The cardioprotective effect of ischemic preconditioning is dependent on the duration and strength of the preconditioning stimulus. If the preconditioning stimulus is too strong or prolonged, detrimental effects on the heart may be observed.

Like ischemic preconditioning, hypoxic preconditioning represents a complex adaptive response that organisms have developed to offset damage inflicted by oxygen deprivation. The concept of hypoxic preconditioning is familiar to humans; for years, athletes have been using hypoxic training (high altitude and other newer technologies) to boost their performance in sporting events. Additionally, there is evidence dating back to before the breakthrough findings of Murry and colleagues who confirm the cardioprotective effects of hypoxia. In 1973, Meerson and colleagues (Am J Cardiol. 1973;31[1]:30) reported that mice exposed to high-altitude hypoxia have reduced mortality and smaller areas of necrotic myocardium after coronary artery occlusion.

Both of the ischemic and hypoxic preconditioning animal experiments mentioned above involve acute exposure to the preconditioning stimuli, resulting in a cardioprotective response for a limited time period. In order to afford a sustained period of cardioprotection, recurrent hypoxic exposure may be necessary. Indeed, recent studies have concentrated on just that; repeated exposure to intermittent hypoxia over a few weeks (Manukhina et al. Exp Biol Med. 2013;238[12]:1413) results in robust cardioprotection after coronary artery occlusion and reperfusion.

Despite the convincing cardioprotective discoveries from ischemic and hypoxic preconditioning, translation into clinical practice as a therapeutic modality is absent. This is partly because human beings are more complex than animals. They have comorbidities and are affected by aging, both of which may alter the milieu for preconditioning stimuli. Furthermore, the therapeutic range for any given preconditioning stimulus is unknown.

Sleep apnea (SA) is exceedingly prevalent in the United States. In SA, an individual stops breathing either completely (apnea) or partially (hypopnea) during sleep resulting in intermittent hypoxia, with arousal from sleep and resumption of breathing leading to reoxygenation. Hence, SA is characterized by intermittent hypoxia followed by reoxygenation. So, one can speculate that SA could exert cardioprotective effects as seen in hypoxic preconditioning and ischemic preconditioning. It is important to note, however, that SA is associated with hypercapnic intermittent hypoxia, whereas most of the investigations on ischemic preconditioning and intermittent hypoxia are with eucapnia or hypocapnia.

The potentially cardioprotective role of SA is supported by a growing body of complementary research that indicates that coronary collateral flow is higher in patients with SA vs. control subjects (Steiner. Chest. 2010;137[3]:516) and that there is an increased mobilization, proliferation, and angiogenic capacity of endothelial progenitor cells from patients with myocardial infarction and SA as compared with cells from controls subjects without SA (Berger. Am J Respir Crit Care Med. 2013;187[1]:90). Some epidemiologic data support a weaker relationship between SA and coronary ischemic events compared with other cardiovascular events (Gottlieb. Circulation. 2010;122[4]:352). Hypoxic preconditioning may explain the relatively decreased pro-thrombotic influence of SA in the coronary vascular bed. Nevertheless, more research is needed to determine if SA is cardioprotective. If, however, cardioprotection from SA is confirmed, it may contribute to a paradigm shift in how SA is considered in relationship to coronary heart disease. Furthermore, future investigations would need to focus on what dose and duration of SA is needed for cardioprotection to occur. Prospective studies may also provide an opportunity for investigating interindividual variability in the susceptibility of the myocardium to the hypoxic preconditioning stimulus from SA.

This article highlights how complex the relationship between hypoxia and myocardial response is. This is further supported by results from a recent clinical trial, AVOID (Air Versus Oxygen In ST-elevation MyocarDial Infarction) (Stub. Circulation. 2015;131[24]:2143). Results from the AVOID trial report that routine oxygen use in normoxic patients hospitalized with a heart attack was not beneficial and, in fact, was harmful. Patients who received oxygen had more myocardial injury than those who did not. Therefore, even though for decades we thought that oxygen therapy helps hospitalized heart attack patients, results from the AVOID trial have initiated a paradigm shift. It remains to be determined whether such a paradigm shift will follow for sleep apnea.

Dr. Shah is with the department of epidemiology and population health, Albert Einstein College of Medicine, N.Y.

The phenomenon of preconditioning reflects complex adaptive responses by living organisms to stimuli such as ischemia, hypoxia, hypothermia, or starvation. Acute ischemic preconditioning, initially described by Murry in 1986 (Circulation. 1986;74[5]:1124), occurs when multiple brief episodes of ischemia followed by reperfusion elicit a protective effect on the heart from a subsequent prolonged period of ischemia, such as a heart attack. This protective effect from ischemic preconditioning can be in the form of a smaller heart attack, lower chance of cardiac arrhythmias, less myocardial cell death, and lower risk of heart muscle failure. The cardioprotective effect of ischemic preconditioning is dependent on the duration and strength of the preconditioning stimulus. If the preconditioning stimulus is too strong or prolonged, detrimental effects on the heart may be observed.

Like ischemic preconditioning, hypoxic preconditioning represents a complex adaptive response that organisms have developed to offset damage inflicted by oxygen deprivation. The concept of hypoxic preconditioning is familiar to humans; for years, athletes have been using hypoxic training (high altitude and other newer technologies) to boost their performance in sporting events. Additionally, there is evidence dating back to before the breakthrough findings of Murry and colleagues who confirm the cardioprotective effects of hypoxia. In 1973, Meerson and colleagues (Am J Cardiol. 1973;31[1]:30) reported that mice exposed to high-altitude hypoxia have reduced mortality and smaller areas of necrotic myocardium after coronary artery occlusion.

Both of the ischemic and hypoxic preconditioning animal experiments mentioned above involve acute exposure to the preconditioning stimuli, resulting in a cardioprotective response for a limited time period. In order to afford a sustained period of cardioprotection, recurrent hypoxic exposure may be necessary. Indeed, recent studies have concentrated on just that; repeated exposure to intermittent hypoxia over a few weeks (Manukhina et al. Exp Biol Med. 2013;238[12]:1413) results in robust cardioprotection after coronary artery occlusion and reperfusion.

Despite the convincing cardioprotective discoveries from ischemic and hypoxic preconditioning, translation into clinical practice as a therapeutic modality is absent. This is partly because human beings are more complex than animals. They have comorbidities and are affected by aging, both of which may alter the milieu for preconditioning stimuli. Furthermore, the therapeutic range for any given preconditioning stimulus is unknown.

Sleep apnea (SA) is exceedingly prevalent in the United States. In SA, an individual stops breathing either completely (apnea) or partially (hypopnea) during sleep resulting in intermittent hypoxia, with arousal from sleep and resumption of breathing leading to reoxygenation. Hence, SA is characterized by intermittent hypoxia followed by reoxygenation. So, one can speculate that SA could exert cardioprotective effects as seen in hypoxic preconditioning and ischemic preconditioning. It is important to note, however, that SA is associated with hypercapnic intermittent hypoxia, whereas most of the investigations on ischemic preconditioning and intermittent hypoxia are with eucapnia or hypocapnia.

The potentially cardioprotective role of SA is supported by a growing body of complementary research that indicates that coronary collateral flow is higher in patients with SA vs. control subjects (Steiner. Chest. 2010;137[3]:516) and that there is an increased mobilization, proliferation, and angiogenic capacity of endothelial progenitor cells from patients with myocardial infarction and SA as compared with cells from controls subjects without SA (Berger. Am J Respir Crit Care Med. 2013;187[1]:90). Some epidemiologic data support a weaker relationship between SA and coronary ischemic events compared with other cardiovascular events (Gottlieb. Circulation. 2010;122[4]:352). Hypoxic preconditioning may explain the relatively decreased pro-thrombotic influence of SA in the coronary vascular bed. Nevertheless, more research is needed to determine if SA is cardioprotective. If, however, cardioprotection from SA is confirmed, it may contribute to a paradigm shift in how SA is considered in relationship to coronary heart disease. Furthermore, future investigations would need to focus on what dose and duration of SA is needed for cardioprotection to occur. Prospective studies may also provide an opportunity for investigating interindividual variability in the susceptibility of the myocardium to the hypoxic preconditioning stimulus from SA.

This article highlights how complex the relationship between hypoxia and myocardial response is. This is further supported by results from a recent clinical trial, AVOID (Air Versus Oxygen In ST-elevation MyocarDial Infarction) (Stub. Circulation. 2015;131[24]:2143). Results from the AVOID trial report that routine oxygen use in normoxic patients hospitalized with a heart attack was not beneficial and, in fact, was harmful. Patients who received oxygen had more myocardial injury than those who did not. Therefore, even though for decades we thought that oxygen therapy helps hospitalized heart attack patients, results from the AVOID trial have initiated a paradigm shift. It remains to be determined whether such a paradigm shift will follow for sleep apnea.

Dr. Shah is with the department of epidemiology and population health, Albert Einstein College of Medicine, N.Y.

Occupational and Environmental Health

Incident sarcoidosis

The history of sarcoidosis dates back to 1869, when Dr. Jonathan Hutchinson described symmetrical purple skin plaques on the legs and hands of a coal-wharf worker (James and Sharma. Curr Opin Pulm Med. 2002;8[5]:416). However, despite its distant beginning, much remains unknown. It has been hypothesized that environmental factors play a pivotal role in disease onset and course, as is evidenced by the notable exposure in the first historical case.

Research has shown environmental factors, such as wood smoke, tree pollen, insecticides, and mold; as well as occupational exposures, such as flight deck work on aircraft carriers, metalworking, construction, and firefighting, carry increased risk of sarcoidosis (Newman et al. Am J Respir Crit Care Med. 2004;170[12]:1324; Newman and Newman. Curr Opin Allergy Clin Immunol. 2012;12[2]:145). A significantly high annual incidence of sarcoidosis was first demonstrated in FDNY firefighters between 1985 and 1998; 12.9/100,000, as compared with 2.5 to 7.6/100,000 for U.S. white men (Prezant et al. Chest. 1999;116[5]:1183).

Following the attack of the World Trade Center (WTC) on September 11, 2001, a further increase in sarcoidosis incidence was found in FDNY firefighters exposed to WTC “dust” during the collapse and rescue/recovery effort (Izbicki et al. Chest. 2007;131[5]:1414). As of 2015, a total of 75 FDNY firefighters have been identified as having new post-9/11 sarcoidosis.

Since the WTC-exposed FDNY firefighters with new-onset sarcoidosis since September 11, 2001 can be considered to have had a WTC “trigger,” we have a unique opportunity to define the clinical patterns and outcomes of incident sarcoidosis following a distinct exposure. Members of the Occupational and Environmental NetWork Steering Committee are currently investigating this aim and others in a National Institute of Occupational Safety and Health (NIOSH)-granted cohort study. We hypothesize that the patterns of organ involvement, and time course of disease progression or resolution, may significantly differ in this group as compared with the general population. Preliminary results of our study of WTC-exposed FDNY firefighters will be presented at CHEST 2016 in Los Angeles.

Kerry Hena, MD

Physician-in-Training Member

Palliative and End-of-Life Care

Integrated palliative care for mechanical circulatory support

Patients with advanced heart failure (AHF) have well-documented needs for comprehensive supportive care services in the critical care setting. Notable symptom burden, high morbidity and mortality, prognostic uncertainty, and need for care coordination across hospital settings pave the way for palliative care (PC) teams to work symbiotically with advanced heart failure specialists and intensivists. Furthermore, the expanded availability of mechanical circulatory support (MCS) technology extends these clinical and ethical challenges to balancing longevity, quality of life, and resource utilization, most prominently in the ICU.

To date, collaborations between PC, AHF specialists, and critical care have tended to be reactive, not proactive – palliative consultation usually occurs after a medical or surgical crisis (for example, the massive stroke, MCS thrombus, sepsis, and multiorgan failure) or after a prolonged ICU stay without clear improvement in patient function or prognosis. This reactive consult may be misperceived by patient and family as “giving up.”

At our institution, we have worked to develop a model of seamless integration of interdisciplinary palliative care consultation upstream in advanced heart failure patient care that aims to preempt many dilemmas in the ICU around complex medical decision making and end-of-life care. Through development of therapeutic supportive care relationships, preparedness planning, and discussions of goals of care early in treatment pathways involving critical care resources – including MCS evaluation and cardiac transplantation – this model purports to strengthen appropriate critical care delivery for patients with advanced heart failure. This model has evolved to where PC consultation becomes a structured part of the preoperative evaluation of all candidates for left-ventricular assist device as destination therapy (LVAD-DT). The result is a collaborative approach where patients and families see PC as part of the continuum of whole-person AHF care, rather than a negative alternative.

MCS implantation is on the rise. While MCS technology continues to evolve, its recipients remain seriously ill. Normalizing and integrating PC consultation as part of high quality AHF and critical care sends an important message to patients and families: regardless of clinical outcome, relief from suffering matters throughout the trajectory of the illness experience.

Hunter Groninger, MD

Steering Committee Member

Respiratory Care NetWork

Professional relationships in RC

At the 2015 meeting of the American Association for Respiratory Care (AARC) in Tampa, there were more than 20 presentations given by FCCPs! Also, a majority of CHEST’s Respiratory Care NetWork’s steering committee was in attendance at the meeting. To other members of CHEST, that might seem rather unusual. However, many CHEST members have connections with the field of respiratory care. In addition, CHEST as an organization has a professional relationship with the respiratory care field. CHEST has more than 10 official liaisons to respiratory care professional organizations.

Those organizations include: The Commission for Accreditation for Respiratory Care, which credentials all RC educational programs; The National Board for Respiratory Care, which provides the credentialing examinations for all RC practitioners in the United States; The National Association for Medical Direction for Respiratory Care (NAMDRC); the Board of Medical Advisors to the AARC; and the Respiratory Compromise Institute.

The Respiratory Care NetWork has the responsibility of identifying and nominating CHEST members for these liaison positions. These volunteer positions do involve work, yet past and present liaisons have enthusiastically fulfilled their respective roles. As one recently noted, “This work has been some of the most important endeavors of my professional career.”

We are always seeking volunteers for these positions, which vary in time commitment and type of work involved. Please contact the Respiratory Care NetWork ([email protected]) for further information. These organizations accomplish the type of things that made us all want to get into medicine. Be a part of those important efforts!

Thomas Fuhrman, MD, FCCP

Steering Committee Member

Sleep Medicine

Listening to patient voices: Sleep Apnea Patient-Centered Outcomes Network (MyApnea.org)

The US Department of Transportation’s (DOT) Federal Motor Carrier Safety Administration (FMCSA) and Federal Railroad Administration (FRA) recently called for input for obstructive sleep apnea screening and treatment for transportation workers. The DOT (https://www.transportation.gov) encouraged input from the public regarding this important transportation safety issue. This concept of engaging the public (which includes patients) with sleep disorders is gaining momentum as patients are increasingly partnering with researchers, clinicians, and policy makers to improve the delivery of care and research efforts in sleep medicine.

A remarkable example of such an effort is the Sleep Apnea Patient-Centered Outcomes Network (SAPCON; MyApnea.Org) (Redline et al. JCSM. 2016;12[7]:1053). This patient-powered research network was initiated in 2013 to improve the diagnosis and treatment of sleep apnea through the active engagement of patients, families, researchers, and healthcare providers in a virtual community that facilitates patient-centered research. The need for such an initiative reflects the paucity of patient-centric evidence from large populations to inform insurers, public policy makers, medical schools, and clinicians on the best ways to screen, diagnose, and treat patients with sleep apnea.

As of August 2016, over 8,000 individuals across the globe have joined SAPCON. There are approximately 500 unique visitors to the site per day, with over 2,500 posts on over 250 topics, including blogs on a variety of emerging research and public health topics. Among these topics are driving and general transportation safety concerns. Further engagement of patients and key stakeholders through forums and patient-centered networks can promote the “patient voice” in public policy, while linking patient needs for better information with responsive research and policy development.

Neomi Shah, MD, MPH

Steering Committee Member

Occupational and Environmental Health

Incident sarcoidosis

The history of sarcoidosis dates back to 1869, when Dr. Jonathan Hutchinson described symmetrical purple skin plaques on the legs and hands of a coal-wharf worker (James and Sharma. Curr Opin Pulm Med. 2002;8[5]:416). However, despite its distant beginning, much remains unknown. It has been hypothesized that environmental factors play a pivotal role in disease onset and course, as is evidenced by the notable exposure in the first historical case.

Research has shown environmental factors, such as wood smoke, tree pollen, insecticides, and mold; as well as occupational exposures, such as flight deck work on aircraft carriers, metalworking, construction, and firefighting, carry increased risk of sarcoidosis (Newman et al. Am J Respir Crit Care Med. 2004;170[12]:1324; Newman and Newman. Curr Opin Allergy Clin Immunol. 2012;12[2]:145). A significantly high annual incidence of sarcoidosis was first demonstrated in FDNY firefighters between 1985 and 1998; 12.9/100,000, as compared with 2.5 to 7.6/100,000 for U.S. white men (Prezant et al. Chest. 1999;116[5]:1183).

Following the attack of the World Trade Center (WTC) on September 11, 2001, a further increase in sarcoidosis incidence was found in FDNY firefighters exposed to WTC “dust” during the collapse and rescue/recovery effort (Izbicki et al. Chest. 2007;131[5]:1414). As of 2015, a total of 75 FDNY firefighters have been identified as having new post-9/11 sarcoidosis.

Since the WTC-exposed FDNY firefighters with new-onset sarcoidosis since September 11, 2001 can be considered to have had a WTC “trigger,” we have a unique opportunity to define the clinical patterns and outcomes of incident sarcoidosis following a distinct exposure. Members of the Occupational and Environmental NetWork Steering Committee are currently investigating this aim and others in a National Institute of Occupational Safety and Health (NIOSH)-granted cohort study. We hypothesize that the patterns of organ involvement, and time course of disease progression or resolution, may significantly differ in this group as compared with the general population. Preliminary results of our study of WTC-exposed FDNY firefighters will be presented at CHEST 2016 in Los Angeles.

Kerry Hena, MD

Physician-in-Training Member

Palliative and End-of-Life Care

Integrated palliative care for mechanical circulatory support

Patients with advanced heart failure (AHF) have well-documented needs for comprehensive supportive care services in the critical care setting. Notable symptom burden, high morbidity and mortality, prognostic uncertainty, and need for care coordination across hospital settings pave the way for palliative care (PC) teams to work symbiotically with advanced heart failure specialists and intensivists. Furthermore, the expanded availability of mechanical circulatory support (MCS) technology extends these clinical and ethical challenges to balancing longevity, quality of life, and resource utilization, most prominently in the ICU.

To date, collaborations between PC, AHF specialists, and critical care have tended to be reactive, not proactive – palliative consultation usually occurs after a medical or surgical crisis (for example, the massive stroke, MCS thrombus, sepsis, and multiorgan failure) or after a prolonged ICU stay without clear improvement in patient function or prognosis. This reactive consult may be misperceived by patient and family as “giving up.”

At our institution, we have worked to develop a model of seamless integration of interdisciplinary palliative care consultation upstream in advanced heart failure patient care that aims to preempt many dilemmas in the ICU around complex medical decision making and end-of-life care. Through development of therapeutic supportive care relationships, preparedness planning, and discussions of goals of care early in treatment pathways involving critical care resources – including MCS evaluation and cardiac transplantation – this model purports to strengthen appropriate critical care delivery for patients with advanced heart failure. This model has evolved to where PC consultation becomes a structured part of the preoperative evaluation of all candidates for left-ventricular assist device as destination therapy (LVAD-DT). The result is a collaborative approach where patients and families see PC as part of the continuum of whole-person AHF care, rather than a negative alternative.

MCS implantation is on the rise. While MCS technology continues to evolve, its recipients remain seriously ill. Normalizing and integrating PC consultation as part of high quality AHF and critical care sends an important message to patients and families: regardless of clinical outcome, relief from suffering matters throughout the trajectory of the illness experience.

Hunter Groninger, MD

Steering Committee Member

Respiratory Care NetWork

Professional relationships in RC

At the 2015 meeting of the American Association for Respiratory Care (AARC) in Tampa, there were more than 20 presentations given by FCCPs! Also, a majority of CHEST’s Respiratory Care NetWork’s steering committee was in attendance at the meeting. To other members of CHEST, that might seem rather unusual. However, many CHEST members have connections with the field of respiratory care. In addition, CHEST as an organization has a professional relationship with the respiratory care field. CHEST has more than 10 official liaisons to respiratory care professional organizations.

Those organizations include: The Commission for Accreditation for Respiratory Care, which credentials all RC educational programs; The National Board for Respiratory Care, which provides the credentialing examinations for all RC practitioners in the United States; The National Association for Medical Direction for Respiratory Care (NAMDRC); the Board of Medical Advisors to the AARC; and the Respiratory Compromise Institute.

The Respiratory Care NetWork has the responsibility of identifying and nominating CHEST members for these liaison positions. These volunteer positions do involve work, yet past and present liaisons have enthusiastically fulfilled their respective roles. As one recently noted, “This work has been some of the most important endeavors of my professional career.”

We are always seeking volunteers for these positions, which vary in time commitment and type of work involved. Please contact the Respiratory Care NetWork ([email protected]) for further information. These organizations accomplish the type of things that made us all want to get into medicine. Be a part of those important efforts!

Thomas Fuhrman, MD, FCCP

Steering Committee Member

Sleep Medicine

Listening to patient voices: Sleep Apnea Patient-Centered Outcomes Network (MyApnea.org)

The US Department of Transportation’s (DOT) Federal Motor Carrier Safety Administration (FMCSA) and Federal Railroad Administration (FRA) recently called for input for obstructive sleep apnea screening and treatment for transportation workers. The DOT (https://www.transportation.gov) encouraged input from the public regarding this important transportation safety issue. This concept of engaging the public (which includes patients) with sleep disorders is gaining momentum as patients are increasingly partnering with researchers, clinicians, and policy makers to improve the delivery of care and research efforts in sleep medicine.

A remarkable example of such an effort is the Sleep Apnea Patient-Centered Outcomes Network (SAPCON; MyApnea.Org) (Redline et al. JCSM. 2016;12[7]:1053). This patient-powered research network was initiated in 2013 to improve the diagnosis and treatment of sleep apnea through the active engagement of patients, families, researchers, and healthcare providers in a virtual community that facilitates patient-centered research. The need for such an initiative reflects the paucity of patient-centric evidence from large populations to inform insurers, public policy makers, medical schools, and clinicians on the best ways to screen, diagnose, and treat patients with sleep apnea.

As of August 2016, over 8,000 individuals across the globe have joined SAPCON. There are approximately 500 unique visitors to the site per day, with over 2,500 posts on over 250 topics, including blogs on a variety of emerging research and public health topics. Among these topics are driving and general transportation safety concerns. Further engagement of patients and key stakeholders through forums and patient-centered networks can promote the “patient voice” in public policy, while linking patient needs for better information with responsive research and policy development.

Neomi Shah, MD, MPH

Steering Committee Member

Occupational and Environmental Health

Incident sarcoidosis

The history of sarcoidosis dates back to 1869, when Dr. Jonathan Hutchinson described symmetrical purple skin plaques on the legs and hands of a coal-wharf worker (James and Sharma. Curr Opin Pulm Med. 2002;8[5]:416). However, despite its distant beginning, much remains unknown. It has been hypothesized that environmental factors play a pivotal role in disease onset and course, as is evidenced by the notable exposure in the first historical case.

Research has shown environmental factors, such as wood smoke, tree pollen, insecticides, and mold; as well as occupational exposures, such as flight deck work on aircraft carriers, metalworking, construction, and firefighting, carry increased risk of sarcoidosis (Newman et al. Am J Respir Crit Care Med. 2004;170[12]:1324; Newman and Newman. Curr Opin Allergy Clin Immunol. 2012;12[2]:145). A significantly high annual incidence of sarcoidosis was first demonstrated in FDNY firefighters between 1985 and 1998; 12.9/100,000, as compared with 2.5 to 7.6/100,000 for U.S. white men (Prezant et al. Chest. 1999;116[5]:1183).

Following the attack of the World Trade Center (WTC) on September 11, 2001, a further increase in sarcoidosis incidence was found in FDNY firefighters exposed to WTC “dust” during the collapse and rescue/recovery effort (Izbicki et al. Chest. 2007;131[5]:1414). As of 2015, a total of 75 FDNY firefighters have been identified as having new post-9/11 sarcoidosis.

Since the WTC-exposed FDNY firefighters with new-onset sarcoidosis since September 11, 2001 can be considered to have had a WTC “trigger,” we have a unique opportunity to define the clinical patterns and outcomes of incident sarcoidosis following a distinct exposure. Members of the Occupational and Environmental NetWork Steering Committee are currently investigating this aim and others in a National Institute of Occupational Safety and Health (NIOSH)-granted cohort study. We hypothesize that the patterns of organ involvement, and time course of disease progression or resolution, may significantly differ in this group as compared with the general population. Preliminary results of our study of WTC-exposed FDNY firefighters will be presented at CHEST 2016 in Los Angeles.

Kerry Hena, MD

Physician-in-Training Member

Palliative and End-of-Life Care

Integrated palliative care for mechanical circulatory support

Patients with advanced heart failure (AHF) have well-documented needs for comprehensive supportive care services in the critical care setting. Notable symptom burden, high morbidity and mortality, prognostic uncertainty, and need for care coordination across hospital settings pave the way for palliative care (PC) teams to work symbiotically with advanced heart failure specialists and intensivists. Furthermore, the expanded availability of mechanical circulatory support (MCS) technology extends these clinical and ethical challenges to balancing longevity, quality of life, and resource utilization, most prominently in the ICU.

To date, collaborations between PC, AHF specialists, and critical care have tended to be reactive, not proactive – palliative consultation usually occurs after a medical or surgical crisis (for example, the massive stroke, MCS thrombus, sepsis, and multiorgan failure) or after a prolonged ICU stay without clear improvement in patient function or prognosis. This reactive consult may be misperceived by patient and family as “giving up.”

At our institution, we have worked to develop a model of seamless integration of interdisciplinary palliative care consultation upstream in advanced heart failure patient care that aims to preempt many dilemmas in the ICU around complex medical decision making and end-of-life care. Through development of therapeutic supportive care relationships, preparedness planning, and discussions of goals of care early in treatment pathways involving critical care resources – including MCS evaluation and cardiac transplantation – this model purports to strengthen appropriate critical care delivery for patients with advanced heart failure. This model has evolved to where PC consultation becomes a structured part of the preoperative evaluation of all candidates for left-ventricular assist device as destination therapy (LVAD-DT). The result is a collaborative approach where patients and families see PC as part of the continuum of whole-person AHF care, rather than a negative alternative.

MCS implantation is on the rise. While MCS technology continues to evolve, its recipients remain seriously ill. Normalizing and integrating PC consultation as part of high quality AHF and critical care sends an important message to patients and families: regardless of clinical outcome, relief from suffering matters throughout the trajectory of the illness experience.

Hunter Groninger, MD

Steering Committee Member

Respiratory Care NetWork

Professional relationships in RC

At the 2015 meeting of the American Association for Respiratory Care (AARC) in Tampa, there were more than 20 presentations given by FCCPs! Also, a majority of CHEST’s Respiratory Care NetWork’s steering committee was in attendance at the meeting. To other members of CHEST, that might seem rather unusual. However, many CHEST members have connections with the field of respiratory care. In addition, CHEST as an organization has a professional relationship with the respiratory care field. CHEST has more than 10 official liaisons to respiratory care professional organizations.

Those organizations include: The Commission for Accreditation for Respiratory Care, which credentials all RC educational programs; The National Board for Respiratory Care, which provides the credentialing examinations for all RC practitioners in the United States; The National Association for Medical Direction for Respiratory Care (NAMDRC); the Board of Medical Advisors to the AARC; and the Respiratory Compromise Institute.

The Respiratory Care NetWork has the responsibility of identifying and nominating CHEST members for these liaison positions. These volunteer positions do involve work, yet past and present liaisons have enthusiastically fulfilled their respective roles. As one recently noted, “This work has been some of the most important endeavors of my professional career.”

We are always seeking volunteers for these positions, which vary in time commitment and type of work involved. Please contact the Respiratory Care NetWork ([email protected]) for further information. These organizations accomplish the type of things that made us all want to get into medicine. Be a part of those important efforts!

Thomas Fuhrman, MD, FCCP

Steering Committee Member

Sleep Medicine

Listening to patient voices: Sleep Apnea Patient-Centered Outcomes Network (MyApnea.org)

The US Department of Transportation’s (DOT) Federal Motor Carrier Safety Administration (FMCSA) and Federal Railroad Administration (FRA) recently called for input for obstructive sleep apnea screening and treatment for transportation workers. The DOT (https://www.transportation.gov) encouraged input from the public regarding this important transportation safety issue. This concept of engaging the public (which includes patients) with sleep disorders is gaining momentum as patients are increasingly partnering with researchers, clinicians, and policy makers to improve the delivery of care and research efforts in sleep medicine.

A remarkable example of such an effort is the Sleep Apnea Patient-Centered Outcomes Network (SAPCON; MyApnea.Org) (Redline et al. JCSM. 2016;12[7]:1053). This patient-powered research network was initiated in 2013 to improve the diagnosis and treatment of sleep apnea through the active engagement of patients, families, researchers, and healthcare providers in a virtual community that facilitates patient-centered research. The need for such an initiative reflects the paucity of patient-centric evidence from large populations to inform insurers, public policy makers, medical schools, and clinicians on the best ways to screen, diagnose, and treat patients with sleep apnea.

As of August 2016, over 8,000 individuals across the globe have joined SAPCON. There are approximately 500 unique visitors to the site per day, with over 2,500 posts on over 250 topics, including blogs on a variety of emerging research and public health topics. Among these topics are driving and general transportation safety concerns. Further engagement of patients and key stakeholders through forums and patient-centered networks can promote the “patient voice” in public policy, while linking patient needs for better information with responsive research and policy development.

Neomi Shah, MD, MPH

Steering Committee Member

Los Angeles has a flare for the dramatic, and we’re not just talking about Hollywood’s fast-paced, larger-than-life movie industry. When you visit Los Angeles, October 22 – 26, for CHEST 2016, be sure to check out the assortment of arts and culture venues located nearby your home base at CHEST 2016.

Los Angeles has more museums and theaters than any other U.S. city, and we’ll highlight a few local favorites below. For more information on L.A.’s thriving arts and culture scene, check out discoverlosangeles.com.

• The Dorothy Chandler Pavilion – (7-minute drive) – This hall is part of the Los Angeles music center. On October 22 – 23, watch three major U.S. ballet companies share the stage in Celebrate Forsythe. Or, take in The Source, a music-theater production about Chelsea (formerly Bradley) Manning and WikiLeaks.

• The Ahmanson Theatre – (7-minute drive) – This theater is also part of the Los Angeles music center. Be captivated by a 2016 Tony Award–winning play, A View from the Bridge.

• Walt Disney Concert Hall – (6-minute drive) – Home to the Los Angeles Philharmonic Orchestra and the Los Angeles Master Chorale, it is also part of the Los Angeles music center. Listen to the beautiful sounds of Mahler’s Ninth or Hilary Hahn on violin.

• MOCA Grand – (5-minute drive) – The Museum of Contemporary Art has three locations in Los Angeles. The main branch, located on Grand Avenue, is the closest to the convention center. Check out the museum’s main galleries at this location.

• The Getty Center – (30-minute drive) – See spectacular art and architecture at the top of Los Angeles.

Note: all estimated times assume you are starting at the Los Angeles Convention Center.

Los Angeles’ arts and culture scene is sure to inspire you, and CHEST 2016 will move you with the latest clinical information in chest medicine. Join us at CHEST 2016, and you won’t miss a beat with cutting-edge sessions and simulation training designed to update you on the latest patient care strategies. You will be part of an international community of innovative problem solvers. Learn more and register today at chestmeeting.chestnet.org.

Los Angeles has a flare for the dramatic, and we’re not just talking about Hollywood’s fast-paced, larger-than-life movie industry. When you visit Los Angeles, October 22 – 26, for CHEST 2016, be sure to check out the assortment of arts and culture venues located nearby your home base at CHEST 2016.

Los Angeles has more museums and theaters than any other U.S. city, and we’ll highlight a few local favorites below. For more information on L.A.’s thriving arts and culture scene, check out discoverlosangeles.com.

• The Dorothy Chandler Pavilion – (7-minute drive) – This hall is part of the Los Angeles music center. On October 22 – 23, watch three major U.S. ballet companies share the stage in Celebrate Forsythe. Or, take in The Source, a music-theater production about Chelsea (formerly Bradley) Manning and WikiLeaks.

• The Ahmanson Theatre – (7-minute drive) – This theater is also part of the Los Angeles music center. Be captivated by a 2016 Tony Award–winning play, A View from the Bridge.

• Walt Disney Concert Hall – (6-minute drive) – Home to the Los Angeles Philharmonic Orchestra and the Los Angeles Master Chorale, it is also part of the Los Angeles music center. Listen to the beautiful sounds of Mahler’s Ninth or Hilary Hahn on violin.

• MOCA Grand – (5-minute drive) – The Museum of Contemporary Art has three locations in Los Angeles. The main branch, located on Grand Avenue, is the closest to the convention center. Check out the museum’s main galleries at this location.

• The Getty Center – (30-minute drive) – See spectacular art and architecture at the top of Los Angeles.

Note: all estimated times assume you are starting at the Los Angeles Convention Center.

Los Angeles’ arts and culture scene is sure to inspire you, and CHEST 2016 will move you with the latest clinical information in chest medicine. Join us at CHEST 2016, and you won’t miss a beat with cutting-edge sessions and simulation training designed to update you on the latest patient care strategies. You will be part of an international community of innovative problem solvers. Learn more and register today at chestmeeting.chestnet.org.

Los Angeles has a flare for the dramatic, and we’re not just talking about Hollywood’s fast-paced, larger-than-life movie industry. When you visit Los Angeles, October 22 – 26, for CHEST 2016, be sure to check out the assortment of arts and culture venues located nearby your home base at CHEST 2016.

Los Angeles has more museums and theaters than any other U.S. city, and we’ll highlight a few local favorites below. For more information on L.A.’s thriving arts and culture scene, check out discoverlosangeles.com.

• The Dorothy Chandler Pavilion – (7-minute drive) – This hall is part of the Los Angeles music center. On October 22 – 23, watch three major U.S. ballet companies share the stage in Celebrate Forsythe. Or, take in The Source, a music-theater production about Chelsea (formerly Bradley) Manning and WikiLeaks.

• The Ahmanson Theatre – (7-minute drive) – This theater is also part of the Los Angeles music center. Be captivated by a 2016 Tony Award–winning play, A View from the Bridge.

• Walt Disney Concert Hall – (6-minute drive) – Home to the Los Angeles Philharmonic Orchestra and the Los Angeles Master Chorale, it is also part of the Los Angeles music center. Listen to the beautiful sounds of Mahler’s Ninth or Hilary Hahn on violin.

• MOCA Grand – (5-minute drive) – The Museum of Contemporary Art has three locations in Los Angeles. The main branch, located on Grand Avenue, is the closest to the convention center. Check out the museum’s main galleries at this location.

• The Getty Center – (30-minute drive) – See spectacular art and architecture at the top of Los Angeles.

Note: all estimated times assume you are starting at the Los Angeles Convention Center.

Los Angeles’ arts and culture scene is sure to inspire you, and CHEST 2016 will move you with the latest clinical information in chest medicine. Join us at CHEST 2016, and you won’t miss a beat with cutting-edge sessions and simulation training designed to update you on the latest patient care strategies. You will be part of an international community of innovative problem solvers. Learn more and register today at chestmeeting.chestnet.org.

A Novel PF4-Dependent Platelet Activation Assay Identifies Patients Likely to Have

Heparin-Induced Thrombocytopenia/Thrombosis.By Dr. A Padmanabhan et al.

Safety and Tolerability of Alveolar Type II Cell Transplantation in Idiopathic

Pulmonary Fibrosis.By Dr. A. Serrano-Mollar et al.

Hypertension Is Associated With Undiagnosed OSA During Rapid Eye Movement Sleep.By Dr. S. L. Appleton et al.

A Novel PF4-Dependent Platelet Activation Assay Identifies Patients Likely to Have

Heparin-Induced Thrombocytopenia/Thrombosis.By Dr. A Padmanabhan et al.

Safety and Tolerability of Alveolar Type II Cell Transplantation in Idiopathic

Pulmonary Fibrosis.By Dr. A. Serrano-Mollar et al.

Hypertension Is Associated With Undiagnosed OSA During Rapid Eye Movement Sleep.By Dr. S. L. Appleton et al.

A Novel PF4-Dependent Platelet Activation Assay Identifies Patients Likely to Have

Heparin-Induced Thrombocytopenia/Thrombosis.By Dr. A Padmanabhan et al.

Safety and Tolerability of Alveolar Type II Cell Transplantation in Idiopathic

Pulmonary Fibrosis.By Dr. A. Serrano-Mollar et al.

Hypertension Is Associated With Undiagnosed OSA During Rapid Eye Movement Sleep.By Dr. S. L. Appleton et al.