On-call specialist incurred a clear ‘duty of care,’ court rules

An Illinois doctor who consulted with a patient’s treating physician but never actually saw the patient himself can’t escape a medical malpractice claim, a state appeals court ruled late in January.

The appeals decision is the result of a case involving the late Dennis Blagden.

On July 26, 2017, Mr. Blagden arrived at the Graham Hospital ED, in Canton, Ill., complaining of neck pain and an insect bite that had resulted in a swollen elbow. His ED doctor, Matthew McMillin, MD, who worked for Coleman Medical Associates, ordered tests and prescribed an anti-inflammatory pain medication and a muscle relaxant.

Dr. McMillin consulted via telephone with Kenneth Krock, MD, an internal medicine specialist and pediatrician, who was on call that day and who enjoyed admitting privileges at Graham. (Krock was also an employee of Coleman Medical Associates, which provided clinical staffing for the hospital.)

Dr. Krock had final admitting authority in this instance. Court records show that Dr. McMillin and he agreed that the patient could be discharged from the ED, despite Krock’s differential diagnosis indicating a possible infection.

Three days later, now with “hypercapnic respiratory failure, sepsis, and an altered mental state,” Mr. Blagden was again seen at the Graham Hospital ED. Mr. Blagden underwent intubation by Dr. McMillin, his original ED doctor, and was airlifted to Methodist Medical Center, in Peoria, 30 miles away. There, an MRI showed that he’d developed a spinal epidural abscess. On Aug. 7, 2017, a little over a week after his admission to Methodist, Mr. Blagden died from complications of his infection.

In January 2019, Mr. Blagden’s wife, Judy, filed a suit against Dr. McMillin, his practice, and Graham Hospital, which is a part of Graham Health System. Her suit alleged medical negligence in the death of her husband.

About 6 months later, Mr.s Blagden amended her original complaint, adding a second count of medical negligence against Dr. Krock; his practice and employer, Coleman Medical Associates; and Graham Hospital. In her amended complaint, Mrs. Blagden alleged that although Krock hadn’t actually seen her husband Dennis, his consultation with Dr. McMillin was sufficient to establish a doctor-patient relationship and thus a legal duty of care. That duty, Mrs. Blagden further alleged, was breached when Dr. Krock failed both to rule out her husband’s “infectious process” and to admit him for proper follow-up monitoring.

In July 2021, after the case had been transferred from Peoria County to Fulton County, Dr. Krock cried foul. In a motion to the court for summary judgment – that is, a ruling prior to an actual trial – he and his practice put forth the following argument: As a mere on-call consultant that day in 2017, he had neither seen the patient nor established a relationship with him, thereby precluding his legal duty of care.

The trial court judge agreed and granted both Dr. Krock and Dr. Coleman the summary judgment they had sought.

Mrs. Blagden then appealed to the Appellate Court of Illinois, Fourth District, which is located in Springfield.

In its unanimous decision, the three-judge panel reversed the lower court’s ruling. Taking direct aim at Dr. Krock’s earlier motion, Justice Eugene Doherty, who wrote the panel’s opinion, said that state law had long established that “the special relationship giving rise to a duty of care may exist even in the absence of any meeting between the physician and the patient where the physician performs specific services for the benefit of the patient.”

As Justice Doherty explained, Dr. Krock’s status that day as both the on-call doctor and the one with final admitting authority undermined his argument for summary judgment. Also undermining it, Justice Doherty added, was the fact that the conversation between the two doctors that day in 2017 was a formal exchange “contemplated by hospital bylaws.”

“While public policy should encourage informal consultations between physicians,” the justice continued, “it must not ignore actual physician involvement in decisions that directly affect a patient’s care.”

Following the Fourth District decision, the suit against Dr. McMillin, Dr. Krock, and the other defendants has now been tossed back to the trial court for further proceedings. At press time, no trial date had been set.
 

Will this proposed damages cap help retain more physicians?

Fear of a doctor shortage, triggered in part by a recent history of large payouts, has prompted Iowa lawmakers to push for new state caps on medical malpractice awards, as a story in the Des Moines Register reports.

Currently, Iowa caps most noneconomic damages – including those for pain and suffering – at $250,000, which is among the lowest such caps in the nation.

Under existing Iowa law, however, the limit doesn’t apply in extraordinary cases – that is, those involving “substantial or permanent loss of body function, substantial disfigurement, or death.” It also isn’t applicable in cases in which a jury decides that a defendant acted with intentional malice.

Lawmakers and Iowa Gov. Kim Reynolds would like to change this.

Under a Senate bill that has now passed out of committee and is awaiting debate on the Senate floor, even plaintiffs involved in extreme cases would receive no more than $1 million to compensate for their pain, suffering, or emotional distress. (The bill also includes a 2.1% annual hike to compensate for inflation. A similar bill, which adds “loss of pregnancy” to the list of extreme cases, has advanced to the House floor.)

Supporters say the proposed cap would help to limit mega awards. In Johnson County in March 2022, for instance, a jury awarded $97.4 million to the parents of a young boy who sustained severe brain injuries during his delivery, causing the clinic that had been involved in the case to file for bankruptcy. This award was nearly three times the total payouts ($35 million) in the entire state of Iowa in all of 2021, a year in which there were 192 closed claims, including at least a dozen that resulted in payouts of $1 million or more.

Supporters also think the proposed cap will mitigate what they see as a looming doctor shortage, especially among ob.gyns. in eastern Iowa. “I just cannot overstate how much this is affecting our workforce, and that turns into effects for the women and the children, the babies, in our state,” Shannon Leveridge, MD, an obstetrician in Davenport said. “In order to keep these women and their babies safe, we need doctors.”

But critics of the bill, including some lawmakers and the trial bar, say it overreaches, even in the case of the $97.4 million award.

“They don’t want to talk about the actual damages that are caused by medical negligence,” explained a spokesman for the trial lawyers. “So, you don’t hear about the fact that, of the $50 million of economic damages ... most of that is going to go to the 24/7 care for this child for the rest of his life.”

A version of this article first appeared on Medscape.com.

On-call specialist incurred a clear ‘duty of care,’ court rules

An Illinois doctor who consulted with a patient’s treating physician but never actually saw the patient himself can’t escape a medical malpractice claim, a state appeals court ruled late in January.

The appeals decision is the result of a case involving the late Dennis Blagden.

On July 26, 2017, Mr. Blagden arrived at the Graham Hospital ED, in Canton, Ill., complaining of neck pain and an insect bite that had resulted in a swollen elbow. His ED doctor, Matthew McMillin, MD, who worked for Coleman Medical Associates, ordered tests and prescribed an anti-inflammatory pain medication and a muscle relaxant.

Dr. McMillin consulted via telephone with Kenneth Krock, MD, an internal medicine specialist and pediatrician, who was on call that day and who enjoyed admitting privileges at Graham. (Krock was also an employee of Coleman Medical Associates, which provided clinical staffing for the hospital.)

Dr. Krock had final admitting authority in this instance. Court records show that Dr. McMillin and he agreed that the patient could be discharged from the ED, despite Krock’s differential diagnosis indicating a possible infection.

Three days later, now with “hypercapnic respiratory failure, sepsis, and an altered mental state,” Mr. Blagden was again seen at the Graham Hospital ED. Mr. Blagden underwent intubation by Dr. McMillin, his original ED doctor, and was airlifted to Methodist Medical Center, in Peoria, 30 miles away. There, an MRI showed that he’d developed a spinal epidural abscess. On Aug. 7, 2017, a little over a week after his admission to Methodist, Mr. Blagden died from complications of his infection.

In January 2019, Mr. Blagden’s wife, Judy, filed a suit against Dr. McMillin, his practice, and Graham Hospital, which is a part of Graham Health System. Her suit alleged medical negligence in the death of her husband.

About 6 months later, Mr.s Blagden amended her original complaint, adding a second count of medical negligence against Dr. Krock; his practice and employer, Coleman Medical Associates; and Graham Hospital. In her amended complaint, Mrs. Blagden alleged that although Krock hadn’t actually seen her husband Dennis, his consultation with Dr. McMillin was sufficient to establish a doctor-patient relationship and thus a legal duty of care. That duty, Mrs. Blagden further alleged, was breached when Dr. Krock failed both to rule out her husband’s “infectious process” and to admit him for proper follow-up monitoring.

In July 2021, after the case had been transferred from Peoria County to Fulton County, Dr. Krock cried foul. In a motion to the court for summary judgment – that is, a ruling prior to an actual trial – he and his practice put forth the following argument: As a mere on-call consultant that day in 2017, he had neither seen the patient nor established a relationship with him, thereby precluding his legal duty of care.

The trial court judge agreed and granted both Dr. Krock and Dr. Coleman the summary judgment they had sought.

Mrs. Blagden then appealed to the Appellate Court of Illinois, Fourth District, which is located in Springfield.

In its unanimous decision, the three-judge panel reversed the lower court’s ruling. Taking direct aim at Dr. Krock’s earlier motion, Justice Eugene Doherty, who wrote the panel’s opinion, said that state law had long established that “the special relationship giving rise to a duty of care may exist even in the absence of any meeting between the physician and the patient where the physician performs specific services for the benefit of the patient.”

As Justice Doherty explained, Dr. Krock’s status that day as both the on-call doctor and the one with final admitting authority undermined his argument for summary judgment. Also undermining it, Justice Doherty added, was the fact that the conversation between the two doctors that day in 2017 was a formal exchange “contemplated by hospital bylaws.”

“While public policy should encourage informal consultations between physicians,” the justice continued, “it must not ignore actual physician involvement in decisions that directly affect a patient’s care.”

Following the Fourth District decision, the suit against Dr. McMillin, Dr. Krock, and the other defendants has now been tossed back to the trial court for further proceedings. At press time, no trial date had been set.
 

Will this proposed damages cap help retain more physicians?

Fear of a doctor shortage, triggered in part by a recent history of large payouts, has prompted Iowa lawmakers to push for new state caps on medical malpractice awards, as a story in the Des Moines Register reports.

Currently, Iowa caps most noneconomic damages – including those for pain and suffering – at $250,000, which is among the lowest such caps in the nation.

Under existing Iowa law, however, the limit doesn’t apply in extraordinary cases – that is, those involving “substantial or permanent loss of body function, substantial disfigurement, or death.” It also isn’t applicable in cases in which a jury decides that a defendant acted with intentional malice.

Lawmakers and Iowa Gov. Kim Reynolds would like to change this.

Under a Senate bill that has now passed out of committee and is awaiting debate on the Senate floor, even plaintiffs involved in extreme cases would receive no more than $1 million to compensate for their pain, suffering, or emotional distress. (The bill also includes a 2.1% annual hike to compensate for inflation. A similar bill, which adds “loss of pregnancy” to the list of extreme cases, has advanced to the House floor.)

Supporters say the proposed cap would help to limit mega awards. In Johnson County in March 2022, for instance, a jury awarded $97.4 million to the parents of a young boy who sustained severe brain injuries during his delivery, causing the clinic that had been involved in the case to file for bankruptcy. This award was nearly three times the total payouts ($35 million) in the entire state of Iowa in all of 2021, a year in which there were 192 closed claims, including at least a dozen that resulted in payouts of $1 million or more.

Supporters also think the proposed cap will mitigate what they see as a looming doctor shortage, especially among ob.gyns. in eastern Iowa. “I just cannot overstate how much this is affecting our workforce, and that turns into effects for the women and the children, the babies, in our state,” Shannon Leveridge, MD, an obstetrician in Davenport said. “In order to keep these women and their babies safe, we need doctors.”

But critics of the bill, including some lawmakers and the trial bar, say it overreaches, even in the case of the $97.4 million award.

“They don’t want to talk about the actual damages that are caused by medical negligence,” explained a spokesman for the trial lawyers. “So, you don’t hear about the fact that, of the $50 million of economic damages ... most of that is going to go to the 24/7 care for this child for the rest of his life.”

A version of this article first appeared on Medscape.com.

On-call specialist incurred a clear ‘duty of care,’ court rules

An Illinois doctor who consulted with a patient’s treating physician but never actually saw the patient himself can’t escape a medical malpractice claim, a state appeals court ruled late in January.

The appeals decision is the result of a case involving the late Dennis Blagden.

On July 26, 2017, Mr. Blagden arrived at the Graham Hospital ED, in Canton, Ill., complaining of neck pain and an insect bite that had resulted in a swollen elbow. His ED doctor, Matthew McMillin, MD, who worked for Coleman Medical Associates, ordered tests and prescribed an anti-inflammatory pain medication and a muscle relaxant.

Dr. McMillin consulted via telephone with Kenneth Krock, MD, an internal medicine specialist and pediatrician, who was on call that day and who enjoyed admitting privileges at Graham. (Krock was also an employee of Coleman Medical Associates, which provided clinical staffing for the hospital.)

Dr. Krock had final admitting authority in this instance. Court records show that Dr. McMillin and he agreed that the patient could be discharged from the ED, despite Krock’s differential diagnosis indicating a possible infection.

Three days later, now with “hypercapnic respiratory failure, sepsis, and an altered mental state,” Mr. Blagden was again seen at the Graham Hospital ED. Mr. Blagden underwent intubation by Dr. McMillin, his original ED doctor, and was airlifted to Methodist Medical Center, in Peoria, 30 miles away. There, an MRI showed that he’d developed a spinal epidural abscess. On Aug. 7, 2017, a little over a week after his admission to Methodist, Mr. Blagden died from complications of his infection.

In January 2019, Mr. Blagden’s wife, Judy, filed a suit against Dr. McMillin, his practice, and Graham Hospital, which is a part of Graham Health System. Her suit alleged medical negligence in the death of her husband.

About 6 months later, Mr.s Blagden amended her original complaint, adding a second count of medical negligence against Dr. Krock; his practice and employer, Coleman Medical Associates; and Graham Hospital. In her amended complaint, Mrs. Blagden alleged that although Krock hadn’t actually seen her husband Dennis, his consultation with Dr. McMillin was sufficient to establish a doctor-patient relationship and thus a legal duty of care. That duty, Mrs. Blagden further alleged, was breached when Dr. Krock failed both to rule out her husband’s “infectious process” and to admit him for proper follow-up monitoring.

In July 2021, after the case had been transferred from Peoria County to Fulton County, Dr. Krock cried foul. In a motion to the court for summary judgment – that is, a ruling prior to an actual trial – he and his practice put forth the following argument: As a mere on-call consultant that day in 2017, he had neither seen the patient nor established a relationship with him, thereby precluding his legal duty of care.

The trial court judge agreed and granted both Dr. Krock and Dr. Coleman the summary judgment they had sought.

Mrs. Blagden then appealed to the Appellate Court of Illinois, Fourth District, which is located in Springfield.

In its unanimous decision, the three-judge panel reversed the lower court’s ruling. Taking direct aim at Dr. Krock’s earlier motion, Justice Eugene Doherty, who wrote the panel’s opinion, said that state law had long established that “the special relationship giving rise to a duty of care may exist even in the absence of any meeting between the physician and the patient where the physician performs specific services for the benefit of the patient.”

As Justice Doherty explained, Dr. Krock’s status that day as both the on-call doctor and the one with final admitting authority undermined his argument for summary judgment. Also undermining it, Justice Doherty added, was the fact that the conversation between the two doctors that day in 2017 was a formal exchange “contemplated by hospital bylaws.”

“While public policy should encourage informal consultations between physicians,” the justice continued, “it must not ignore actual physician involvement in decisions that directly affect a patient’s care.”

Following the Fourth District decision, the suit against Dr. McMillin, Dr. Krock, and the other defendants has now been tossed back to the trial court for further proceedings. At press time, no trial date had been set.
 

Will this proposed damages cap help retain more physicians?

Fear of a doctor shortage, triggered in part by a recent history of large payouts, has prompted Iowa lawmakers to push for new state caps on medical malpractice awards, as a story in the Des Moines Register reports.

Currently, Iowa caps most noneconomic damages – including those for pain and suffering – at $250,000, which is among the lowest such caps in the nation.

Under existing Iowa law, however, the limit doesn’t apply in extraordinary cases – that is, those involving “substantial or permanent loss of body function, substantial disfigurement, or death.” It also isn’t applicable in cases in which a jury decides that a defendant acted with intentional malice.

Lawmakers and Iowa Gov. Kim Reynolds would like to change this.

Under a Senate bill that has now passed out of committee and is awaiting debate on the Senate floor, even plaintiffs involved in extreme cases would receive no more than $1 million to compensate for their pain, suffering, or emotional distress. (The bill also includes a 2.1% annual hike to compensate for inflation. A similar bill, which adds “loss of pregnancy” to the list of extreme cases, has advanced to the House floor.)

Supporters say the proposed cap would help to limit mega awards. In Johnson County in March 2022, for instance, a jury awarded $97.4 million to the parents of a young boy who sustained severe brain injuries during his delivery, causing the clinic that had been involved in the case to file for bankruptcy. This award was nearly three times the total payouts ($35 million) in the entire state of Iowa in all of 2021, a year in which there were 192 closed claims, including at least a dozen that resulted in payouts of $1 million or more.

Supporters also think the proposed cap will mitigate what they see as a looming doctor shortage, especially among ob.gyns. in eastern Iowa. “I just cannot overstate how much this is affecting our workforce, and that turns into effects for the women and the children, the babies, in our state,” Shannon Leveridge, MD, an obstetrician in Davenport said. “In order to keep these women and their babies safe, we need doctors.”

But critics of the bill, including some lawmakers and the trial bar, say it overreaches, even in the case of the $97.4 million award.

“They don’t want to talk about the actual damages that are caused by medical negligence,” explained a spokesman for the trial lawyers. “So, you don’t hear about the fact that, of the $50 million of economic damages ... most of that is going to go to the 24/7 care for this child for the rest of his life.”

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity.

Hello. I’m Dr Sandra Fryhofer. Welcome to Medicine Matters. The topic is highlights from ACIP’s new adult schedule for 2023, published in the Annals of Internal Medicine, and why this new schedule may be a collector’s item.

It’s a new year, which means a new ACIP adult immunization schedule – a valuable resource collating ACIP’s most up-to-date vaccination recommendations.

Here are this year’s five most important changes:

• COVID vaccines now front and center
• New emphasis on polio vaccination
• Inclusion of some nonvaccine products (such as monoclonal antibody products)
• Pharmacists group has approved the schedule for the first time
• New shared clinical decision-making option for pneumococcal vaccines

The schedule’s organization remains the same. It still has four sections:

• Table 1: vaccinations by age
• Table 2: vaccinations by medical condition and other indications
• The Notes section (alphabetically ordered by vaccine type)
• Appendix listing of vaccine-specific contraindications and precautions

But what’s unique this year is that some of the abbreviations have historical implications. The first change is no big surprise in light of what we’ve gone through in the past few years. COVID vaccines are listed first on the cover page by brand name for those authorized and by company name for those still under US emergency use authorization. They’re also listed first on the graphics and in the notes.

COVID and mRNA and protein-based vaccines have now been assigned official abbreviations based on vaccine platform and valency.

• 1vCOV-mRNA: Comirnaty/Pfizer-BioNTech and Spikevax Moderna COVID-19 vaccines
• 2vCOV-mRNA: Pfizer-BioNTech and Moderna bivalent COVID-19 vaccines
• 1vCOV-aPS: Novavax COVID-19 vaccine

Also remarkable is the absence of COVID viral vector vaccines on the list. However, the viral vector COVID vaccine (which has been available but is not preferred) does have a CDC website link in the Notes section.

A sad but necessary inclusion was triggered by recent polio cases in New York. Polio was believed to be eradicated, and we thought adults no longer needed to be vaccinated against polio. In the new schedule, the polio vaccine is listed on the cover page but is not included in the tables. Current polio vaccination recommendations are now in the Notes section.

Also of historical significance and something that may set a precedent is the inclusion of nonvaccine products. The value of COVID preexposure prophylaxis with products including monoclonal antibodies (such as Evusheld) for people who are moderately or severely immunocompromised is mentioned in the Notes section.

For the first time ever, the schedule has been approved by the American Pharmacists Association, which validates pharmacists as established partners in vaccine administration.
 

Color-code key

One aspect of the schedule that has not changed is the color-code key:

• Yellow: Recommended if the patient meets the age requirement
• Purple: Indicated for those with additional risk factors or another indication
• Blue: Recommended based on shared clinical decision-making
• Orange: Precaution
• Red: Contraindicated or not recommended; the vaccine should not be administered. Overlays on the red more precisely clarify whether a vaccine is really contraindicated or just not recommended. An asterisk on red means vaccinate after pregnancy if indicated.
• Gray: No recommendation or not applicable

Vaccinations by age

Table 1 lists recommended vaccinations by age. There is one major change. COVID vaccines are on the first row of the graphic, with the need for both a primary series and boosters emphasized on the overlay. The notes have hyperlinks to the most up-to-date COVID vaccination recommendations.

Pneumococcal vaccination. Pneumococcal vaccination is routinely recommended starting at age 65. Current recommendations for those not previously vaccinated have not changed since last year. But on Table 1, the bottom half of the row for those 65 or older is now blue (and that’s new). This new color blue means shared clinical decision-making and applies to people who were previously considered fully vaccinated with the now extinct combination of PCV13 and PPSV23. These patients now have the option of getting a dose of PCV20 five years after completing their PCV13-PPSV23 combo series. This option is blue because the decision is up to you and your patient.

Check the notes for more pneumococcal vaccination details. For example, for those partially vaccinated using lower valency vaccines, there’s an option of substituting PCV20 for PPSV23 to broaden and increase durability of protection.

The pneumococcal vaccination recommendation options are complicated. A new pneumococcal vaccination app can help.

Hepatitis B. For adults under age 60, the color code for the hepatitis B vaccine is yellow, meaning it’s indicated for all. For older patients, the color code is purple. If a patient who is age 60 or older wants the hepatitis B vaccine, they can have it even in the absence of additional risk indications.
 

Vaccinations by medical condition or other indications

Other than a few minor word changes on the overlay, the only thing that’s new is the COVID vaccine row.

This table is helpful for matching vaccine recommendations with specific medical conditions, including pregnancy, immunocompromise, HIV (with specifics according to CD4 count), asplenia, complement deficiencies, heart disease, lung disease, alcoholism, chronic liver disease, diabetes, health care personnel, and men who have sex with men.

Use this table to dot the i’s and cross the t’s when it comes to vaccination recommendations. For example, take a look at the pregnancy column. Live virus vaccines, including LAIV, MMR, and varicella, are contraindicated and color-coded red. MMR and varicella also have an asterisk, meaning vaccinate after pregnancy if indicated. HPV vaccines are not live virus vaccines, but the overlay says they are not recommended during pregnancy. The asterisk indicates that you can vaccinate after pregnancy.
 

Vaccine notes

The notes are in alphabetical order, and their organization (routine, special situations, and shared clinical decision-making when indicated) has not changed. They are concise and succinct, but sometimes they’re not enough. That’s why vaccine-specific links to more complete recommendations are so convenient.

Notes for hepatitis B contain nuances on specific dosing for vaccinating patients on dialysis, as well as a reminder that newer hepatitis C vaccines such as Heplisav and PreHevbrio are not recommended during pregnancy due to lack of safety data.

For influenza, everyone 6 months or older still needs yearly flu vaccination with an age- and health-appropriate flu vaccine. But for those aged 65 or older, the notes specify the three vaccine versions now preferred: high-dose, recombinant, or adjuvanted versions. However, if these aren’t available, it’s better to get any flu vaccine than to go without.

Under meningococcal vaccines, the notes for MenACWY and MenB are combined. For MenB, trade names Bexsero and Trumenba are specified because the products are not interchangeable. Booster intervals for those still at risk are different for each vaccine type: every 5 years for MenACWY boosters, and every 2-3 years for boosts of MenB.

The recent polio cases in New York have put polio vaccination in the spotlight. ACIP has now reinstated its Polio Vaccine Work Group. The new schedule lists polio vaccines on the cover page. Current recommendations have been added to the notes section. Routine vaccination for adults is not necessary, at least for now. However, those at increased risk for exposure to polio fall in the special-situation category. For those at increased risk who have completed a polio vaccine series, a single lifetime IPV booster can be given. For those at increased risk who have not completed their polio vaccine series, now would be the time to finish the series.
 

Appendix

The final step in using the new schedule is checking the appendix and its list of vaccine-specific contraindications and precautions.

I hope this review of the new ACIP adult immunization schedule has been helpful. For Medicine Matters, I’m Dr. Sandra Fryhofer.

Dr. Fryhofer is clinical associate professor of medicine, Emory University, Atlanta. She reported numerous conflicts of interest.

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity.

Hello. I’m Dr Sandra Fryhofer. Welcome to Medicine Matters. The topic is highlights from ACIP’s new adult schedule for 2023, published in the Annals of Internal Medicine, and why this new schedule may be a collector’s item.

It’s a new year, which means a new ACIP adult immunization schedule – a valuable resource collating ACIP’s most up-to-date vaccination recommendations.

Here are this year’s five most important changes:

• COVID vaccines now front and center
• New emphasis on polio vaccination
• Inclusion of some nonvaccine products (such as monoclonal antibody products)
• Pharmacists group has approved the schedule for the first time
• New shared clinical decision-making option for pneumococcal vaccines

The schedule’s organization remains the same. It still has four sections:

• Table 1: vaccinations by age
• Table 2: vaccinations by medical condition and other indications
• The Notes section (alphabetically ordered by vaccine type)
• Appendix listing of vaccine-specific contraindications and precautions

But what’s unique this year is that some of the abbreviations have historical implications. The first change is no big surprise in light of what we’ve gone through in the past few years. COVID vaccines are listed first on the cover page by brand name for those authorized and by company name for those still under US emergency use authorization. They’re also listed first on the graphics and in the notes.

COVID and mRNA and protein-based vaccines have now been assigned official abbreviations based on vaccine platform and valency.

• 1vCOV-mRNA: Comirnaty/Pfizer-BioNTech and Spikevax Moderna COVID-19 vaccines
• 2vCOV-mRNA: Pfizer-BioNTech and Moderna bivalent COVID-19 vaccines
• 1vCOV-aPS: Novavax COVID-19 vaccine

Also remarkable is the absence of COVID viral vector vaccines on the list. However, the viral vector COVID vaccine (which has been available but is not preferred) does have a CDC website link in the Notes section.

A sad but necessary inclusion was triggered by recent polio cases in New York. Polio was believed to be eradicated, and we thought adults no longer needed to be vaccinated against polio. In the new schedule, the polio vaccine is listed on the cover page but is not included in the tables. Current polio vaccination recommendations are now in the Notes section.

Also of historical significance and something that may set a precedent is the inclusion of nonvaccine products. The value of COVID preexposure prophylaxis with products including monoclonal antibodies (such as Evusheld) for people who are moderately or severely immunocompromised is mentioned in the Notes section.

For the first time ever, the schedule has been approved by the American Pharmacists Association, which validates pharmacists as established partners in vaccine administration.
 

Color-code key

One aspect of the schedule that has not changed is the color-code key:

• Yellow: Recommended if the patient meets the age requirement
• Purple: Indicated for those with additional risk factors or another indication
• Blue: Recommended based on shared clinical decision-making
• Orange: Precaution
• Red: Contraindicated or not recommended; the vaccine should not be administered. Overlays on the red more precisely clarify whether a vaccine is really contraindicated or just not recommended. An asterisk on red means vaccinate after pregnancy if indicated.
• Gray: No recommendation or not applicable

Vaccinations by age

Table 1 lists recommended vaccinations by age. There is one major change. COVID vaccines are on the first row of the graphic, with the need for both a primary series and boosters emphasized on the overlay. The notes have hyperlinks to the most up-to-date COVID vaccination recommendations.

Pneumococcal vaccination. Pneumococcal vaccination is routinely recommended starting at age 65. Current recommendations for those not previously vaccinated have not changed since last year. But on Table 1, the bottom half of the row for those 65 or older is now blue (and that’s new). This new color blue means shared clinical decision-making and applies to people who were previously considered fully vaccinated with the now extinct combination of PCV13 and PPSV23. These patients now have the option of getting a dose of PCV20 five years after completing their PCV13-PPSV23 combo series. This option is blue because the decision is up to you and your patient.

Check the notes for more pneumococcal vaccination details. For example, for those partially vaccinated using lower valency vaccines, there’s an option of substituting PCV20 for PPSV23 to broaden and increase durability of protection.

The pneumococcal vaccination recommendation options are complicated. A new pneumococcal vaccination app can help.

Hepatitis B. For adults under age 60, the color code for the hepatitis B vaccine is yellow, meaning it’s indicated for all. For older patients, the color code is purple. If a patient who is age 60 or older wants the hepatitis B vaccine, they can have it even in the absence of additional risk indications.
 

Vaccinations by medical condition or other indications

Other than a few minor word changes on the overlay, the only thing that’s new is the COVID vaccine row.

This table is helpful for matching vaccine recommendations with specific medical conditions, including pregnancy, immunocompromise, HIV (with specifics according to CD4 count), asplenia, complement deficiencies, heart disease, lung disease, alcoholism, chronic liver disease, diabetes, health care personnel, and men who have sex with men.

Use this table to dot the i’s and cross the t’s when it comes to vaccination recommendations. For example, take a look at the pregnancy column. Live virus vaccines, including LAIV, MMR, and varicella, are contraindicated and color-coded red. MMR and varicella also have an asterisk, meaning vaccinate after pregnancy if indicated. HPV vaccines are not live virus vaccines, but the overlay says they are not recommended during pregnancy. The asterisk indicates that you can vaccinate after pregnancy.
 

Vaccine notes

The notes are in alphabetical order, and their organization (routine, special situations, and shared clinical decision-making when indicated) has not changed. They are concise and succinct, but sometimes they’re not enough. That’s why vaccine-specific links to more complete recommendations are so convenient.

Notes for hepatitis B contain nuances on specific dosing for vaccinating patients on dialysis, as well as a reminder that newer hepatitis C vaccines such as Heplisav and PreHevbrio are not recommended during pregnancy due to lack of safety data.

For influenza, everyone 6 months or older still needs yearly flu vaccination with an age- and health-appropriate flu vaccine. But for those aged 65 or older, the notes specify the three vaccine versions now preferred: high-dose, recombinant, or adjuvanted versions. However, if these aren’t available, it’s better to get any flu vaccine than to go without.

Under meningococcal vaccines, the notes for MenACWY and MenB are combined. For MenB, trade names Bexsero and Trumenba are specified because the products are not interchangeable. Booster intervals for those still at risk are different for each vaccine type: every 5 years for MenACWY boosters, and every 2-3 years for boosts of MenB.

The recent polio cases in New York have put polio vaccination in the spotlight. ACIP has now reinstated its Polio Vaccine Work Group. The new schedule lists polio vaccines on the cover page. Current recommendations have been added to the notes section. Routine vaccination for adults is not necessary, at least for now. However, those at increased risk for exposure to polio fall in the special-situation category. For those at increased risk who have completed a polio vaccine series, a single lifetime IPV booster can be given. For those at increased risk who have not completed their polio vaccine series, now would be the time to finish the series.
 

Appendix

The final step in using the new schedule is checking the appendix and its list of vaccine-specific contraindications and precautions.

I hope this review of the new ACIP adult immunization schedule has been helpful. For Medicine Matters, I’m Dr. Sandra Fryhofer.

Dr. Fryhofer is clinical associate professor of medicine, Emory University, Atlanta. She reported numerous conflicts of interest.

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity.

Hello. I’m Dr Sandra Fryhofer. Welcome to Medicine Matters. The topic is highlights from ACIP’s new adult schedule for 2023, published in the Annals of Internal Medicine, and why this new schedule may be a collector’s item.

It’s a new year, which means a new ACIP adult immunization schedule – a valuable resource collating ACIP’s most up-to-date vaccination recommendations.

Here are this year’s five most important changes:

• COVID vaccines now front and center
• New emphasis on polio vaccination
• Inclusion of some nonvaccine products (such as monoclonal antibody products)
• Pharmacists group has approved the schedule for the first time
• New shared clinical decision-making option for pneumococcal vaccines

The schedule’s organization remains the same. It still has four sections:

• Table 1: vaccinations by age
• Table 2: vaccinations by medical condition and other indications
• The Notes section (alphabetically ordered by vaccine type)
• Appendix listing of vaccine-specific contraindications and precautions

But what’s unique this year is that some of the abbreviations have historical implications. The first change is no big surprise in light of what we’ve gone through in the past few years. COVID vaccines are listed first on the cover page by brand name for those authorized and by company name for those still under US emergency use authorization. They’re also listed first on the graphics and in the notes.

COVID and mRNA and protein-based vaccines have now been assigned official abbreviations based on vaccine platform and valency.

• 1vCOV-mRNA: Comirnaty/Pfizer-BioNTech and Spikevax Moderna COVID-19 vaccines
• 2vCOV-mRNA: Pfizer-BioNTech and Moderna bivalent COVID-19 vaccines
• 1vCOV-aPS: Novavax COVID-19 vaccine

Also remarkable is the absence of COVID viral vector vaccines on the list. However, the viral vector COVID vaccine (which has been available but is not preferred) does have a CDC website link in the Notes section.

A sad but necessary inclusion was triggered by recent polio cases in New York. Polio was believed to be eradicated, and we thought adults no longer needed to be vaccinated against polio. In the new schedule, the polio vaccine is listed on the cover page but is not included in the tables. Current polio vaccination recommendations are now in the Notes section.

Also of historical significance and something that may set a precedent is the inclusion of nonvaccine products. The value of COVID preexposure prophylaxis with products including monoclonal antibodies (such as Evusheld) for people who are moderately or severely immunocompromised is mentioned in the Notes section.

For the first time ever, the schedule has been approved by the American Pharmacists Association, which validates pharmacists as established partners in vaccine administration.
 

Color-code key

One aspect of the schedule that has not changed is the color-code key:

• Yellow: Recommended if the patient meets the age requirement
• Purple: Indicated for those with additional risk factors or another indication
• Blue: Recommended based on shared clinical decision-making
• Orange: Precaution
• Red: Contraindicated or not recommended; the vaccine should not be administered. Overlays on the red more precisely clarify whether a vaccine is really contraindicated or just not recommended. An asterisk on red means vaccinate after pregnancy if indicated.
• Gray: No recommendation or not applicable

Vaccinations by age

Table 1 lists recommended vaccinations by age. There is one major change. COVID vaccines are on the first row of the graphic, with the need for both a primary series and boosters emphasized on the overlay. The notes have hyperlinks to the most up-to-date COVID vaccination recommendations.

Pneumococcal vaccination. Pneumococcal vaccination is routinely recommended starting at age 65. Current recommendations for those not previously vaccinated have not changed since last year. But on Table 1, the bottom half of the row for those 65 or older is now blue (and that’s new). This new color blue means shared clinical decision-making and applies to people who were previously considered fully vaccinated with the now extinct combination of PCV13 and PPSV23. These patients now have the option of getting a dose of PCV20 five years after completing their PCV13-PPSV23 combo series. This option is blue because the decision is up to you and your patient.

Check the notes for more pneumococcal vaccination details. For example, for those partially vaccinated using lower valency vaccines, there’s an option of substituting PCV20 for PPSV23 to broaden and increase durability of protection.

The pneumococcal vaccination recommendation options are complicated. A new pneumococcal vaccination app can help.

Hepatitis B. For adults under age 60, the color code for the hepatitis B vaccine is yellow, meaning it’s indicated for all. For older patients, the color code is purple. If a patient who is age 60 or older wants the hepatitis B vaccine, they can have it even in the absence of additional risk indications.
 

Vaccinations by medical condition or other indications

Other than a few minor word changes on the overlay, the only thing that’s new is the COVID vaccine row.

This table is helpful for matching vaccine recommendations with specific medical conditions, including pregnancy, immunocompromise, HIV (with specifics according to CD4 count), asplenia, complement deficiencies, heart disease, lung disease, alcoholism, chronic liver disease, diabetes, health care personnel, and men who have sex with men.

Use this table to dot the i’s and cross the t’s when it comes to vaccination recommendations. For example, take a look at the pregnancy column. Live virus vaccines, including LAIV, MMR, and varicella, are contraindicated and color-coded red. MMR and varicella also have an asterisk, meaning vaccinate after pregnancy if indicated. HPV vaccines are not live virus vaccines, but the overlay says they are not recommended during pregnancy. The asterisk indicates that you can vaccinate after pregnancy.
 

Vaccine notes

The notes are in alphabetical order, and their organization (routine, special situations, and shared clinical decision-making when indicated) has not changed. They are concise and succinct, but sometimes they’re not enough. That’s why vaccine-specific links to more complete recommendations are so convenient.

Notes for hepatitis B contain nuances on specific dosing for vaccinating patients on dialysis, as well as a reminder that newer hepatitis C vaccines such as Heplisav and PreHevbrio are not recommended during pregnancy due to lack of safety data.

For influenza, everyone 6 months or older still needs yearly flu vaccination with an age- and health-appropriate flu vaccine. But for those aged 65 or older, the notes specify the three vaccine versions now preferred: high-dose, recombinant, or adjuvanted versions. However, if these aren’t available, it’s better to get any flu vaccine than to go without.

Under meningococcal vaccines, the notes for MenACWY and MenB are combined. For MenB, trade names Bexsero and Trumenba are specified because the products are not interchangeable. Booster intervals for those still at risk are different for each vaccine type: every 5 years for MenACWY boosters, and every 2-3 years for boosts of MenB.

The recent polio cases in New York have put polio vaccination in the spotlight. ACIP has now reinstated its Polio Vaccine Work Group. The new schedule lists polio vaccines on the cover page. Current recommendations have been added to the notes section. Routine vaccination for adults is not necessary, at least for now. However, those at increased risk for exposure to polio fall in the special-situation category. For those at increased risk who have completed a polio vaccine series, a single lifetime IPV booster can be given. For those at increased risk who have not completed their polio vaccine series, now would be the time to finish the series.
 

Appendix

The final step in using the new schedule is checking the appendix and its list of vaccine-specific contraindications and precautions.

I hope this review of the new ACIP adult immunization schedule has been helpful. For Medicine Matters, I’m Dr. Sandra Fryhofer.

Dr. Fryhofer is clinical associate professor of medicine, Emory University, Atlanta. She reported numerous conflicts of interest.

A version of this article first appeared on Medscape.com.

Postpartum hemorrhage is the leading cause of maternal mortality worldwide, accounting for 25% of deaths from obstetric causes. Although balloon tamponade has been widely used to manage uncontrolled postpartum bleeding, a recent evaluation of an intrauterine vacuum-induced hemorrhage control device demonstrated impressive safety and effectiveness, researchers reported at the meeting sponsored by the Society for Maternal-Fetal Medicine.

“It’s exciting to see new technology and new potential treatment modalities. We just don’t have that many tools in our toolkit right now,” said Dena Goffman, MD, professor of women’s health and obstetrics and gynecology and vice chair of quality and patient safety at Columbia University’s Irving Medical Center, in New York, who presented the findings.

Dr. Goffman led an earlier multicenter prospective single-arm treatment study of the Jada System, a vacuum device marketed by Organon. The U.S. Food and Drug Administration approved use of the Jada System in October 2020.

Dr. Goffman said she and her colleagues felt “a next logical step would be to see what happens with real-world use.” In the new study, researchers at 16 U.S. medical centers reviewed medical charts of 800 women who underwent treatment with the Jada System between October 2020 and April 2022.

Treatment was successful in 92.5% of the vaginal births (n = 530) and 83.7% of the cesarean births (n = 270), similar to the results of the initial treatment trial that led to FDA approval, according to the researchers. For both types of delivery, bleeding was controlled in less than 5 minutes for most patients. Three serious adverse events were identified that could have been related to use of the device (two in vaginal births, one in cesarean birth), they reported.

Although the study was not designed to directly compare the Jada System with balloon tamponade, in a recent meta-analysis, it was estimated that tamponade controls postpartum hemorrhage in roughly 87% of cases, with complication rates in as many as 6.5% among women who undergo the procedure.

Dr. Goffman pointed out additional benefits. The vacuum device typically must stay in place for less time (3.1 hours for vaginal birth and 4.6 hours for cesarean birth) than balloon tamponade, allowing women to recover more quickly. In the initial trial, which Dr. Goffman helped conduct, 98% of clinicians reported that the device was easy to use, which increases its attractiveness in lower-income countries. Dr. Goffman felt that the device “has potential for huge impact” in those countries, given the high rates of maternal morbidity and mortality in these areas.

Amber Samuel, MD, medical director of OBSETRIX Maternal Fetal Medicine Specialists of Houston, said the device recently became available in the hospitals in which she works, and she has used the Jada System several times. Like Dr. Goffman, she was excited to have a new tool for treating a life-threatening condition.

Although the device has been on the market for more than 2 years, Dr. Samuel felt clinicians who were reluctant to adopt a new technology would be reassured by the findings.

“We should make sure that it’s effective, and we should know what the safety profile is,” said Dr. Samuel, adding that “the more data we have, the more we’re able to counsel patients and work this into our protocols for what is a really common obstetric problem.”

Both Dr. Goffman and Dr. Samuel agreed that more data, ideally from randomized clinical trials, are needed to convince professional groups such as the American College of Obstetricians and Gynecologists to state a clear preference for use of vacuum-induced hemorrhage control devices over balloon tamponade.

“We should be supporting further investigation,” Dr. Goffman said, “but for people who have this tool available to them now, I think they can feel confident in using it.”

The study was funded by Alydia Health, the manufacturer of the Jada System. Alydia Health was acquired by Organon in 2021. Study sites received research-related financial support, but none of the authors received direct payments from Alydia Health/Organon. Dr. Goffman serves on the scientific advisory board of Alydia Health/Organon. Dr. Samuel has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Postpartum hemorrhage is the leading cause of maternal mortality worldwide, accounting for 25% of deaths from obstetric causes. Although balloon tamponade has been widely used to manage uncontrolled postpartum bleeding, a recent evaluation of an intrauterine vacuum-induced hemorrhage control device demonstrated impressive safety and effectiveness, researchers reported at the meeting sponsored by the Society for Maternal-Fetal Medicine.

“It’s exciting to see new technology and new potential treatment modalities. We just don’t have that many tools in our toolkit right now,” said Dena Goffman, MD, professor of women’s health and obstetrics and gynecology and vice chair of quality and patient safety at Columbia University’s Irving Medical Center, in New York, who presented the findings.

Dr. Goffman led an earlier multicenter prospective single-arm treatment study of the Jada System, a vacuum device marketed by Organon. The U.S. Food and Drug Administration approved use of the Jada System in October 2020.

Dr. Goffman said she and her colleagues felt “a next logical step would be to see what happens with real-world use.” In the new study, researchers at 16 U.S. medical centers reviewed medical charts of 800 women who underwent treatment with the Jada System between October 2020 and April 2022.

Treatment was successful in 92.5% of the vaginal births (n = 530) and 83.7% of the cesarean births (n = 270), similar to the results of the initial treatment trial that led to FDA approval, according to the researchers. For both types of delivery, bleeding was controlled in less than 5 minutes for most patients. Three serious adverse events were identified that could have been related to use of the device (two in vaginal births, one in cesarean birth), they reported.

Although the study was not designed to directly compare the Jada System with balloon tamponade, in a recent meta-analysis, it was estimated that tamponade controls postpartum hemorrhage in roughly 87% of cases, with complication rates in as many as 6.5% among women who undergo the procedure.

Dr. Goffman pointed out additional benefits. The vacuum device typically must stay in place for less time (3.1 hours for vaginal birth and 4.6 hours for cesarean birth) than balloon tamponade, allowing women to recover more quickly. In the initial trial, which Dr. Goffman helped conduct, 98% of clinicians reported that the device was easy to use, which increases its attractiveness in lower-income countries. Dr. Goffman felt that the device “has potential for huge impact” in those countries, given the high rates of maternal morbidity and mortality in these areas.

Amber Samuel, MD, medical director of OBSETRIX Maternal Fetal Medicine Specialists of Houston, said the device recently became available in the hospitals in which she works, and she has used the Jada System several times. Like Dr. Goffman, she was excited to have a new tool for treating a life-threatening condition.

Although the device has been on the market for more than 2 years, Dr. Samuel felt clinicians who were reluctant to adopt a new technology would be reassured by the findings.

“We should make sure that it’s effective, and we should know what the safety profile is,” said Dr. Samuel, adding that “the more data we have, the more we’re able to counsel patients and work this into our protocols for what is a really common obstetric problem.”

Both Dr. Goffman and Dr. Samuel agreed that more data, ideally from randomized clinical trials, are needed to convince professional groups such as the American College of Obstetricians and Gynecologists to state a clear preference for use of vacuum-induced hemorrhage control devices over balloon tamponade.

“We should be supporting further investigation,” Dr. Goffman said, “but for people who have this tool available to them now, I think they can feel confident in using it.”

The study was funded by Alydia Health, the manufacturer of the Jada System. Alydia Health was acquired by Organon in 2021. Study sites received research-related financial support, but none of the authors received direct payments from Alydia Health/Organon. Dr. Goffman serves on the scientific advisory board of Alydia Health/Organon. Dr. Samuel has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Postpartum hemorrhage is the leading cause of maternal mortality worldwide, accounting for 25% of deaths from obstetric causes. Although balloon tamponade has been widely used to manage uncontrolled postpartum bleeding, a recent evaluation of an intrauterine vacuum-induced hemorrhage control device demonstrated impressive safety and effectiveness, researchers reported at the meeting sponsored by the Society for Maternal-Fetal Medicine.

“It’s exciting to see new technology and new potential treatment modalities. We just don’t have that many tools in our toolkit right now,” said Dena Goffman, MD, professor of women’s health and obstetrics and gynecology and vice chair of quality and patient safety at Columbia University’s Irving Medical Center, in New York, who presented the findings.

Dr. Goffman led an earlier multicenter prospective single-arm treatment study of the Jada System, a vacuum device marketed by Organon. The U.S. Food and Drug Administration approved use of the Jada System in October 2020.

Dr. Goffman said she and her colleagues felt “a next logical step would be to see what happens with real-world use.” In the new study, researchers at 16 U.S. medical centers reviewed medical charts of 800 women who underwent treatment with the Jada System between October 2020 and April 2022.

Treatment was successful in 92.5% of the vaginal births (n = 530) and 83.7% of the cesarean births (n = 270), similar to the results of the initial treatment trial that led to FDA approval, according to the researchers. For both types of delivery, bleeding was controlled in less than 5 minutes for most patients. Three serious adverse events were identified that could have been related to use of the device (two in vaginal births, one in cesarean birth), they reported.

Although the study was not designed to directly compare the Jada System with balloon tamponade, in a recent meta-analysis, it was estimated that tamponade controls postpartum hemorrhage in roughly 87% of cases, with complication rates in as many as 6.5% among women who undergo the procedure.

Dr. Goffman pointed out additional benefits. The vacuum device typically must stay in place for less time (3.1 hours for vaginal birth and 4.6 hours for cesarean birth) than balloon tamponade, allowing women to recover more quickly. In the initial trial, which Dr. Goffman helped conduct, 98% of clinicians reported that the device was easy to use, which increases its attractiveness in lower-income countries. Dr. Goffman felt that the device “has potential for huge impact” in those countries, given the high rates of maternal morbidity and mortality in these areas.

Amber Samuel, MD, medical director of OBSETRIX Maternal Fetal Medicine Specialists of Houston, said the device recently became available in the hospitals in which she works, and she has used the Jada System several times. Like Dr. Goffman, she was excited to have a new tool for treating a life-threatening condition.

Although the device has been on the market for more than 2 years, Dr. Samuel felt clinicians who were reluctant to adopt a new technology would be reassured by the findings.

“We should make sure that it’s effective, and we should know what the safety profile is,” said Dr. Samuel, adding that “the more data we have, the more we’re able to counsel patients and work this into our protocols for what is a really common obstetric problem.”

Both Dr. Goffman and Dr. Samuel agreed that more data, ideally from randomized clinical trials, are needed to convince professional groups such as the American College of Obstetricians and Gynecologists to state a clear preference for use of vacuum-induced hemorrhage control devices over balloon tamponade.

“We should be supporting further investigation,” Dr. Goffman said, “but for people who have this tool available to them now, I think they can feel confident in using it.”

The study was funded by Alydia Health, the manufacturer of the Jada System. Alydia Health was acquired by Organon in 2021. Study sites received research-related financial support, but none of the authors received direct payments from Alydia Health/Organon. Dr. Goffman serves on the scientific advisory board of Alydia Health/Organon. Dr. Samuel has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The American Academy of Pediatrics said it supports the Recommended Childhood and Adolescent Immunization Schedule: United States, 2023.

In a policy statement published online in the journal Pediatrics, the AAP said the updated recommendations do not include major changes from those released in 2022 by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.

In one small shift, COVID-19 is now addressed in the main text instead of being relegated to the notes section.

“And a new vaccine – Priorix [GlaxoSmithKline] – has been added for MMR [measles, mumps, rubella], so now there are two available,” Sean T. O’Leary, MD, MPH, chair of the AAP’s Committee on Infectious Diseases, told this news organization. “There’s also a second pneumococcal conjugate vaccine listed, PCV15, and this and PCV13 can essentially be used interchangeably.”

Minor updates to the schedule, reflected on the cover page, relate to vaccines for COVID-19, dengue fever, and pneumococcal disease, added Dr. O’Leary, a professor of pediatrics at the University of Colorado Anschutz Medical Campus and Children’s Hospital Colorado, Aurora.

The committee also changed layouts to improve the usability of the schedule. Updated annually, the guidance provides a table on recommended pediatric immunizations from birth to age 18 years, and catch-up recommendations for children aged 4 months to 18 years who start their vaccinations late or are more than 1 month behind the recommended age for vaccine administration.

“We hope this annual update will encourage clinicians to make sure all their patients are up to date on their routine vaccinations,” Dr. O’Leary said. “It’s an opportunity to develop strategies to improve vaccination rates.”

The 2023 schedule follows news from the CDC that kindergarten vaccination rates declined during the 2021-2022 school year. Only 93% of kindergarteners obtained full vaccinations, representing a drop of 1 percentage point from the year before and 2 percentage points from the 2019-2020 school year.

The dip in coverage has been attributed to disruptions caused by the COVID-19 pandemic. AAP advises health care professionals to urge families to make sure their child’s vaccines are current.

Among other additions:
 

In Table 1

• MMR: Second vaccine added (Priorix, GlaxoSmithKline Biologicals)
• Pneumococcal disease: second conjugate vaccine, PCV15, added (Vaxneuvance, Merck Sharp & Dohme).
• COVID-19: New row added.
• Dengue: Text changed from “Seropositive in endemic areas only” to “Seropositive in endemic dengue areas.”
• Inactivated polio vaccine: “See Notes” added to the column for children aged 18 years.

In Table 2

• PCV: Dose 3 to dose 4 interval revised to align with ACIP’s recommendation for dose 4. This dose is necessary only for children ages 12-59 months regardless of risk, or age 60-71 months with any risk who received three doses before age 12 months.

A parent-friendly vaccine schedule for children and adolescents is available on the CDC’s website.

“Vaccines are essential for the health of our whole society, including children and adolescents,” Dr. O’Leary said in a press release from AAP. “These schedules provide a road map [that] parents and pediatricians can follow to help children get the vaccines they need so their immune systems will be ready to recognize and resist diseases.”

As previously, the 2023 schedule was adjusted to ensure consistency between the formats of the childhood/adolescent and adult immunization guidance. A meeting of stakeholder organizations in October 2022 harmonized the two formats.

A version of this article first appeared on Medscape.com.

The American Academy of Pediatrics said it supports the Recommended Childhood and Adolescent Immunization Schedule: United States, 2023.

In a policy statement published online in the journal Pediatrics, the AAP said the updated recommendations do not include major changes from those released in 2022 by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.

In one small shift, COVID-19 is now addressed in the main text instead of being relegated to the notes section.

“And a new vaccine – Priorix [GlaxoSmithKline] – has been added for MMR [measles, mumps, rubella], so now there are two available,” Sean T. O’Leary, MD, MPH, chair of the AAP’s Committee on Infectious Diseases, told this news organization. “There’s also a second pneumococcal conjugate vaccine listed, PCV15, and this and PCV13 can essentially be used interchangeably.”

Minor updates to the schedule, reflected on the cover page, relate to vaccines for COVID-19, dengue fever, and pneumococcal disease, added Dr. O’Leary, a professor of pediatrics at the University of Colorado Anschutz Medical Campus and Children’s Hospital Colorado, Aurora.

The committee also changed layouts to improve the usability of the schedule. Updated annually, the guidance provides a table on recommended pediatric immunizations from birth to age 18 years, and catch-up recommendations for children aged 4 months to 18 years who start their vaccinations late or are more than 1 month behind the recommended age for vaccine administration.

“We hope this annual update will encourage clinicians to make sure all their patients are up to date on their routine vaccinations,” Dr. O’Leary said. “It’s an opportunity to develop strategies to improve vaccination rates.”

The 2023 schedule follows news from the CDC that kindergarten vaccination rates declined during the 2021-2022 school year. Only 93% of kindergarteners obtained full vaccinations, representing a drop of 1 percentage point from the year before and 2 percentage points from the 2019-2020 school year.

The dip in coverage has been attributed to disruptions caused by the COVID-19 pandemic. AAP advises health care professionals to urge families to make sure their child’s vaccines are current.

Among other additions:
 

In Table 1

• MMR: Second vaccine added (Priorix, GlaxoSmithKline Biologicals)
• Pneumococcal disease: second conjugate vaccine, PCV15, added (Vaxneuvance, Merck Sharp & Dohme).
• COVID-19: New row added.
• Dengue: Text changed from “Seropositive in endemic areas only” to “Seropositive in endemic dengue areas.”
• Inactivated polio vaccine: “See Notes” added to the column for children aged 18 years.

In Table 2

• PCV: Dose 3 to dose 4 interval revised to align with ACIP’s recommendation for dose 4. This dose is necessary only for children ages 12-59 months regardless of risk, or age 60-71 months with any risk who received three doses before age 12 months.

A parent-friendly vaccine schedule for children and adolescents is available on the CDC’s website.

“Vaccines are essential for the health of our whole society, including children and adolescents,” Dr. O’Leary said in a press release from AAP. “These schedules provide a road map [that] parents and pediatricians can follow to help children get the vaccines they need so their immune systems will be ready to recognize and resist diseases.”

As previously, the 2023 schedule was adjusted to ensure consistency between the formats of the childhood/adolescent and adult immunization guidance. A meeting of stakeholder organizations in October 2022 harmonized the two formats.

A version of this article first appeared on Medscape.com.

The American Academy of Pediatrics said it supports the Recommended Childhood and Adolescent Immunization Schedule: United States, 2023.

In a policy statement published online in the journal Pediatrics, the AAP said the updated recommendations do not include major changes from those released in 2022 by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.

In one small shift, COVID-19 is now addressed in the main text instead of being relegated to the notes section.

“And a new vaccine – Priorix [GlaxoSmithKline] – has been added for MMR [measles, mumps, rubella], so now there are two available,” Sean T. O’Leary, MD, MPH, chair of the AAP’s Committee on Infectious Diseases, told this news organization. “There’s also a second pneumococcal conjugate vaccine listed, PCV15, and this and PCV13 can essentially be used interchangeably.”

Minor updates to the schedule, reflected on the cover page, relate to vaccines for COVID-19, dengue fever, and pneumococcal disease, added Dr. O’Leary, a professor of pediatrics at the University of Colorado Anschutz Medical Campus and Children’s Hospital Colorado, Aurora.

The committee also changed layouts to improve the usability of the schedule. Updated annually, the guidance provides a table on recommended pediatric immunizations from birth to age 18 years, and catch-up recommendations for children aged 4 months to 18 years who start their vaccinations late or are more than 1 month behind the recommended age for vaccine administration.

“We hope this annual update will encourage clinicians to make sure all their patients are up to date on their routine vaccinations,” Dr. O’Leary said. “It’s an opportunity to develop strategies to improve vaccination rates.”

The 2023 schedule follows news from the CDC that kindergarten vaccination rates declined during the 2021-2022 school year. Only 93% of kindergarteners obtained full vaccinations, representing a drop of 1 percentage point from the year before and 2 percentage points from the 2019-2020 school year.

The dip in coverage has been attributed to disruptions caused by the COVID-19 pandemic. AAP advises health care professionals to urge families to make sure their child’s vaccines are current.

Among other additions:
 

In Table 1

• MMR: Second vaccine added (Priorix, GlaxoSmithKline Biologicals)
• Pneumococcal disease: second conjugate vaccine, PCV15, added (Vaxneuvance, Merck Sharp & Dohme).
• COVID-19: New row added.
• Dengue: Text changed from “Seropositive in endemic areas only” to “Seropositive in endemic dengue areas.”
• Inactivated polio vaccine: “See Notes” added to the column for children aged 18 years.

In Table 2

• PCV: Dose 3 to dose 4 interval revised to align with ACIP’s recommendation for dose 4. This dose is necessary only for children ages 12-59 months regardless of risk, or age 60-71 months with any risk who received three doses before age 12 months.

A parent-friendly vaccine schedule for children and adolescents is available on the CDC’s website.

“Vaccines are essential for the health of our whole society, including children and adolescents,” Dr. O’Leary said in a press release from AAP. “These schedules provide a road map [that] parents and pediatricians can follow to help children get the vaccines they need so their immune systems will be ready to recognize and resist diseases.”

As previously, the 2023 schedule was adjusted to ensure consistency between the formats of the childhood/adolescent and adult immunization guidance. A meeting of stakeholder organizations in October 2022 harmonized the two formats.

A version of this article first appeared on Medscape.com.

For patients with early stage non–small cell lung cancer (NSCLC), the survival outcomes can be just as good with sublobar resection as with the more invasive lobar resection, suggest results from the CALGB 140503 trial, although strict patient selection remains key.

These new results contrast with those from a previous study from 1995, which found that local recurrence was three times higher and cancer mortality was twice as high with the less invasive procedure.

Those results from nearly 30 years ago established lobectomy as the standard of surgical care in this patient population, but since then advances in imaging and staging have allowed the detection of smaller and earlier tumors, which has “rekindled interest in sublobar resection,” the authors comment.

Hence, they conducted the new trial, which involved almost 700 U.S. patients with clinical T1aN0 NSCLC and a tumor size up to 2 cm, who were randomly assigned to lobar or sublobar tumor resection, and followed for 7 years.

The rates of both disease-free and overall survival were similar between the two groups, with no significant differences observed. There were also no substantial differences in rates of distant and locoregional recurrence.

In addition, there was a suggestion of less reduction in pulmonary function following the less invasive procedure.

“These findings affirm that sublobar resection ... is an effective management approach for this subgroup of patients with NSCLC,” says lead author Nasser Altorki, MD, Weill Cornell Medicine, NewYork–Presbyterian Hospital, New York.

“It is important that these results are interpreted strictly within the constraints of the eligibility criteria mandated by the trial, he emphasizes. “Specifically, the results are applicable only to a highly selected group of patients ... in whom the absence of metastases to hilar and mediastinal lymph nodes is pathologically confirmed.”

Nevertheless, Dr. Altorki said that “these results will become increasingly relevant as the proportion of patients with early-stage lung cancer increases with expanded implementation of lung cancer screening, and as the number of older persons with early-stage disease in whom sublobar resection may be the preferred surgical option increases.”

The study was published online in the New England Journal of Medicine.

In an accompanying editorial, Valerie W. Rusch, MD, Thoracic Service, Memorial Sloan Kettering Cancer Center, New York, agrees. “As CT screening becomes more widespread, this patient population will increase in clinical practice,” she explains.

However, Dr. Rusch also urges caution around patient selection, underlining that the results do not “provide a license for suboptimal surgical care.”

She says that “safeguards” such as the meticulous and strict patient criteria used in the trial “must be preserved in routine practice.”

“Thoracic surgeons will need to expand their expertise in sublobar resections, especially complex segmentectomies, and will need to collaborate closely with pathologists in assessing margins of resection, adequacy of lymph-node staging, and tumor characteristics that may predict recurrence.”

While emphasizing that lobectomy should still be performed when appropriate, Dr. Rusch nevertheless says: “The era of ‘precision’ surgery for NSCLC has arrived.”


 

Consistent with Japanese results

The investigators also point out that their findings are “consistent” with those of a recent Japanese study that compared lobectomy with anatomical segmentectomy, which found that the 5-year overall survival was 91.1% for lobectomy and 94.3% for segmentectomy.

The authors suggest that the difference in overall survival rates between the two trials might be due to anatomical segmentectomy being “considered by most surgeons to be more oncologically sound than wedge resection.”

In the current trial, wedge resection was allowed, however, “because it is the most frequently practiced method of sublobar resection in North America and Europe; thus, its inclusion would make the trial more representative of a ‘real world’ setting.”

Another important difference could be that more than 90% of the patients in the Japanese trial had adenocarcinoma, 45% with an associated ground-glass component, which is associated with better survival than a completely solid adenocarcinoma.

Dr. Rusch agrees that there are likely to be various factors related to the survival differences between the two trials, including patient selection, intraoperative management, and tumor characteristics.

“However, these two landmark trials are practice-changing because they establish sublobar resection as the standard of care for a select group of patients with NSCLC,” Dr. Rusch concluded.
 

Study details

Dr. Altorki and colleagues conducted the multicenter, international, randomized, noninferiority, phase 3 trial in patients with clinically staged T1aN0 NSCLC from 83 academic and community-based institutions in the United States, Canada, and Australia.

Patients were required to have a peripheral lung nodule with a solid component of up to 2 cm on preoperative CT, a tumor center in the outer third of the lung, and a tumor location amenable to sublobar resection, whether wedge or segment, or lobar resection, among other criteria.

In all, 697 patients were randomly assigned to undergo either lobar resection or sublobar resection, of whom 59.1% had wedge resection and 37.9% anatomical segmental resection. The median age was 67.9 years, and 57.4% were female. The vast majority (90%) were White.

After a median follow-up of 7 years, the 5-year disease-free survival was 63.6% with sublobar resection and 64.1% following lobar resection.

The team found that sublobar resection was not inferior to lobectomy for disease-free survival, at a hazard ratio for disease recurrence or death of 1.01 (90% confidence interval, 0.83-1.24), which adjusted to 0.99 after taking into account the site where the patient was treated.

The 5-year overall survival rate was 80.3% after sublobar resection, and 78.9% following lobar resection, at a hazard ratio for death of 0.95 (95% CI, 0.72-1.26).

The results were “generally consistent” when accounting for factors such as age group, sex, tumor location, histologic type, smoking history, tumor size, and ECOG performance status, the team says.

Turning to recurrence, they showed that, among 687 patients eligible for assessment, 30.4% of those in the sublobar resection group and 29.3% of those assigned to lobar resection experienced disease recurrence, with 13.4% and 10%, respectively, having locoregional recurrence.

An exploratory analysis indicated that 5-year recurrence-free survival was similar in the two groups, at 70.2% vs. 71.2% or a hazard ratio for recurrence of 1.05 (95% CI, 0.80-1.39). The cumulative incidence of death was also similar.

It was also notable that reduction in predictive forced expiratory volume in 1 second from baseline was lower with sublobar than lobar resection, at –4.0 vs. –6.0, as was the reduction in predicted forced vital capacity, at –3.0 vs. –5.0.

“Although this difference is arguably not clinically meaningful in this patient population with normal baseline pulmonary functions,” the team writes, “it may be more clinically relevant in patients with compromised pulmonary functions, or in those with lower-lobe disease in whom lobar resection may be associated with greater impairment of pulmonary function.”

Dr. Rusch suggests that “more sensitive or functional assessments” of pulmonary function might include “diffusion capacity and 6-minute walk tests,” although she noted that even short-term differences in pulmonary function “may affect perioperative and functional outcomes, especially for tumors in the lower lobe.”

The study was supported by the National Cancer Institute of the National Institutes of Health, including via grants to the Alliance for Clinical Trials in Oncology and the Canadian Cancer Trials Group, and supported in part by Covidien and Ethicon.

Dr. Altorki reports relationships with AstraZeneca, Genentech, Johnson & Johnson, and Regeneron. Dr. Rusch reports relationships with Cancer Research UK, Genentech, and the National Cancer Institute.

A version of this article first appeared on Medscape.com.

For patients with early stage non–small cell lung cancer (NSCLC), the survival outcomes can be just as good with sublobar resection as with the more invasive lobar resection, suggest results from the CALGB 140503 trial, although strict patient selection remains key.

These new results contrast with those from a previous study from 1995, which found that local recurrence was three times higher and cancer mortality was twice as high with the less invasive procedure.

Those results from nearly 30 years ago established lobectomy as the standard of surgical care in this patient population, but since then advances in imaging and staging have allowed the detection of smaller and earlier tumors, which has “rekindled interest in sublobar resection,” the authors comment.

Hence, they conducted the new trial, which involved almost 700 U.S. patients with clinical T1aN0 NSCLC and a tumor size up to 2 cm, who were randomly assigned to lobar or sublobar tumor resection, and followed for 7 years.

The rates of both disease-free and overall survival were similar between the two groups, with no significant differences observed. There were also no substantial differences in rates of distant and locoregional recurrence.

In addition, there was a suggestion of less reduction in pulmonary function following the less invasive procedure.

“These findings affirm that sublobar resection ... is an effective management approach for this subgroup of patients with NSCLC,” says lead author Nasser Altorki, MD, Weill Cornell Medicine, NewYork–Presbyterian Hospital, New York.

“It is important that these results are interpreted strictly within the constraints of the eligibility criteria mandated by the trial, he emphasizes. “Specifically, the results are applicable only to a highly selected group of patients ... in whom the absence of metastases to hilar and mediastinal lymph nodes is pathologically confirmed.”

Nevertheless, Dr. Altorki said that “these results will become increasingly relevant as the proportion of patients with early-stage lung cancer increases with expanded implementation of lung cancer screening, and as the number of older persons with early-stage disease in whom sublobar resection may be the preferred surgical option increases.”

The study was published online in the New England Journal of Medicine.

In an accompanying editorial, Valerie W. Rusch, MD, Thoracic Service, Memorial Sloan Kettering Cancer Center, New York, agrees. “As CT screening becomes more widespread, this patient population will increase in clinical practice,” she explains.

However, Dr. Rusch also urges caution around patient selection, underlining that the results do not “provide a license for suboptimal surgical care.”

She says that “safeguards” such as the meticulous and strict patient criteria used in the trial “must be preserved in routine practice.”

“Thoracic surgeons will need to expand their expertise in sublobar resections, especially complex segmentectomies, and will need to collaborate closely with pathologists in assessing margins of resection, adequacy of lymph-node staging, and tumor characteristics that may predict recurrence.”

While emphasizing that lobectomy should still be performed when appropriate, Dr. Rusch nevertheless says: “The era of ‘precision’ surgery for NSCLC has arrived.”


 

Consistent with Japanese results

The investigators also point out that their findings are “consistent” with those of a recent Japanese study that compared lobectomy with anatomical segmentectomy, which found that the 5-year overall survival was 91.1% for lobectomy and 94.3% for segmentectomy.

The authors suggest that the difference in overall survival rates between the two trials might be due to anatomical segmentectomy being “considered by most surgeons to be more oncologically sound than wedge resection.”

In the current trial, wedge resection was allowed, however, “because it is the most frequently practiced method of sublobar resection in North America and Europe; thus, its inclusion would make the trial more representative of a ‘real world’ setting.”

Another important difference could be that more than 90% of the patients in the Japanese trial had adenocarcinoma, 45% with an associated ground-glass component, which is associated with better survival than a completely solid adenocarcinoma.

Dr. Rusch agrees that there are likely to be various factors related to the survival differences between the two trials, including patient selection, intraoperative management, and tumor characteristics.

“However, these two landmark trials are practice-changing because they establish sublobar resection as the standard of care for a select group of patients with NSCLC,” Dr. Rusch concluded.
 

Study details

Dr. Altorki and colleagues conducted the multicenter, international, randomized, noninferiority, phase 3 trial in patients with clinically staged T1aN0 NSCLC from 83 academic and community-based institutions in the United States, Canada, and Australia.

Patients were required to have a peripheral lung nodule with a solid component of up to 2 cm on preoperative CT, a tumor center in the outer third of the lung, and a tumor location amenable to sublobar resection, whether wedge or segment, or lobar resection, among other criteria.

In all, 697 patients were randomly assigned to undergo either lobar resection or sublobar resection, of whom 59.1% had wedge resection and 37.9% anatomical segmental resection. The median age was 67.9 years, and 57.4% were female. The vast majority (90%) were White.

After a median follow-up of 7 years, the 5-year disease-free survival was 63.6% with sublobar resection and 64.1% following lobar resection.

The team found that sublobar resection was not inferior to lobectomy for disease-free survival, at a hazard ratio for disease recurrence or death of 1.01 (90% confidence interval, 0.83-1.24), which adjusted to 0.99 after taking into account the site where the patient was treated.

The 5-year overall survival rate was 80.3% after sublobar resection, and 78.9% following lobar resection, at a hazard ratio for death of 0.95 (95% CI, 0.72-1.26).

The results were “generally consistent” when accounting for factors such as age group, sex, tumor location, histologic type, smoking history, tumor size, and ECOG performance status, the team says.

Turning to recurrence, they showed that, among 687 patients eligible for assessment, 30.4% of those in the sublobar resection group and 29.3% of those assigned to lobar resection experienced disease recurrence, with 13.4% and 10%, respectively, having locoregional recurrence.

An exploratory analysis indicated that 5-year recurrence-free survival was similar in the two groups, at 70.2% vs. 71.2% or a hazard ratio for recurrence of 1.05 (95% CI, 0.80-1.39). The cumulative incidence of death was also similar.

It was also notable that reduction in predictive forced expiratory volume in 1 second from baseline was lower with sublobar than lobar resection, at –4.0 vs. –6.0, as was the reduction in predicted forced vital capacity, at –3.0 vs. –5.0.

“Although this difference is arguably not clinically meaningful in this patient population with normal baseline pulmonary functions,” the team writes, “it may be more clinically relevant in patients with compromised pulmonary functions, or in those with lower-lobe disease in whom lobar resection may be associated with greater impairment of pulmonary function.”

Dr. Rusch suggests that “more sensitive or functional assessments” of pulmonary function might include “diffusion capacity and 6-minute walk tests,” although she noted that even short-term differences in pulmonary function “may affect perioperative and functional outcomes, especially for tumors in the lower lobe.”

The study was supported by the National Cancer Institute of the National Institutes of Health, including via grants to the Alliance for Clinical Trials in Oncology and the Canadian Cancer Trials Group, and supported in part by Covidien and Ethicon.

Dr. Altorki reports relationships with AstraZeneca, Genentech, Johnson & Johnson, and Regeneron. Dr. Rusch reports relationships with Cancer Research UK, Genentech, and the National Cancer Institute.

A version of this article first appeared on Medscape.com.

For patients with early stage non–small cell lung cancer (NSCLC), the survival outcomes can be just as good with sublobar resection as with the more invasive lobar resection, suggest results from the CALGB 140503 trial, although strict patient selection remains key.

These new results contrast with those from a previous study from 1995, which found that local recurrence was three times higher and cancer mortality was twice as high with the less invasive procedure.

Those results from nearly 30 years ago established lobectomy as the standard of surgical care in this patient population, but since then advances in imaging and staging have allowed the detection of smaller and earlier tumors, which has “rekindled interest in sublobar resection,” the authors comment.

Hence, they conducted the new trial, which involved almost 700 U.S. patients with clinical T1aN0 NSCLC and a tumor size up to 2 cm, who were randomly assigned to lobar or sublobar tumor resection, and followed for 7 years.

The rates of both disease-free and overall survival were similar between the two groups, with no significant differences observed. There were also no substantial differences in rates of distant and locoregional recurrence.

In addition, there was a suggestion of less reduction in pulmonary function following the less invasive procedure.

“These findings affirm that sublobar resection ... is an effective management approach for this subgroup of patients with NSCLC,” says lead author Nasser Altorki, MD, Weill Cornell Medicine, NewYork–Presbyterian Hospital, New York.

“It is important that these results are interpreted strictly within the constraints of the eligibility criteria mandated by the trial, he emphasizes. “Specifically, the results are applicable only to a highly selected group of patients ... in whom the absence of metastases to hilar and mediastinal lymph nodes is pathologically confirmed.”

Nevertheless, Dr. Altorki said that “these results will become increasingly relevant as the proportion of patients with early-stage lung cancer increases with expanded implementation of lung cancer screening, and as the number of older persons with early-stage disease in whom sublobar resection may be the preferred surgical option increases.”

The study was published online in the New England Journal of Medicine.

In an accompanying editorial, Valerie W. Rusch, MD, Thoracic Service, Memorial Sloan Kettering Cancer Center, New York, agrees. “As CT screening becomes more widespread, this patient population will increase in clinical practice,” she explains.

However, Dr. Rusch also urges caution around patient selection, underlining that the results do not “provide a license for suboptimal surgical care.”

She says that “safeguards” such as the meticulous and strict patient criteria used in the trial “must be preserved in routine practice.”

“Thoracic surgeons will need to expand their expertise in sublobar resections, especially complex segmentectomies, and will need to collaborate closely with pathologists in assessing margins of resection, adequacy of lymph-node staging, and tumor characteristics that may predict recurrence.”

While emphasizing that lobectomy should still be performed when appropriate, Dr. Rusch nevertheless says: “The era of ‘precision’ surgery for NSCLC has arrived.”


 

Consistent with Japanese results

The investigators also point out that their findings are “consistent” with those of a recent Japanese study that compared lobectomy with anatomical segmentectomy, which found that the 5-year overall survival was 91.1% for lobectomy and 94.3% for segmentectomy.

The authors suggest that the difference in overall survival rates between the two trials might be due to anatomical segmentectomy being “considered by most surgeons to be more oncologically sound than wedge resection.”

In the current trial, wedge resection was allowed, however, “because it is the most frequently practiced method of sublobar resection in North America and Europe; thus, its inclusion would make the trial more representative of a ‘real world’ setting.”

Another important difference could be that more than 90% of the patients in the Japanese trial had adenocarcinoma, 45% with an associated ground-glass component, which is associated with better survival than a completely solid adenocarcinoma.

Dr. Rusch agrees that there are likely to be various factors related to the survival differences between the two trials, including patient selection, intraoperative management, and tumor characteristics.

“However, these two landmark trials are practice-changing because they establish sublobar resection as the standard of care for a select group of patients with NSCLC,” Dr. Rusch concluded.
 

Study details

Dr. Altorki and colleagues conducted the multicenter, international, randomized, noninferiority, phase 3 trial in patients with clinically staged T1aN0 NSCLC from 83 academic and community-based institutions in the United States, Canada, and Australia.

Patients were required to have a peripheral lung nodule with a solid component of up to 2 cm on preoperative CT, a tumor center in the outer third of the lung, and a tumor location amenable to sublobar resection, whether wedge or segment, or lobar resection, among other criteria.

In all, 697 patients were randomly assigned to undergo either lobar resection or sublobar resection, of whom 59.1% had wedge resection and 37.9% anatomical segmental resection. The median age was 67.9 years, and 57.4% were female. The vast majority (90%) were White.

After a median follow-up of 7 years, the 5-year disease-free survival was 63.6% with sublobar resection and 64.1% following lobar resection.

The team found that sublobar resection was not inferior to lobectomy for disease-free survival, at a hazard ratio for disease recurrence or death of 1.01 (90% confidence interval, 0.83-1.24), which adjusted to 0.99 after taking into account the site where the patient was treated.

The 5-year overall survival rate was 80.3% after sublobar resection, and 78.9% following lobar resection, at a hazard ratio for death of 0.95 (95% CI, 0.72-1.26).

The results were “generally consistent” when accounting for factors such as age group, sex, tumor location, histologic type, smoking history, tumor size, and ECOG performance status, the team says.

Turning to recurrence, they showed that, among 687 patients eligible for assessment, 30.4% of those in the sublobar resection group and 29.3% of those assigned to lobar resection experienced disease recurrence, with 13.4% and 10%, respectively, having locoregional recurrence.

An exploratory analysis indicated that 5-year recurrence-free survival was similar in the two groups, at 70.2% vs. 71.2% or a hazard ratio for recurrence of 1.05 (95% CI, 0.80-1.39). The cumulative incidence of death was also similar.

It was also notable that reduction in predictive forced expiratory volume in 1 second from baseline was lower with sublobar than lobar resection, at –4.0 vs. –6.0, as was the reduction in predicted forced vital capacity, at –3.0 vs. –5.0.

“Although this difference is arguably not clinically meaningful in this patient population with normal baseline pulmonary functions,” the team writes, “it may be more clinically relevant in patients with compromised pulmonary functions, or in those with lower-lobe disease in whom lobar resection may be associated with greater impairment of pulmonary function.”

Dr. Rusch suggests that “more sensitive or functional assessments” of pulmonary function might include “diffusion capacity and 6-minute walk tests,” although she noted that even short-term differences in pulmonary function “may affect perioperative and functional outcomes, especially for tumors in the lower lobe.”

The study was supported by the National Cancer Institute of the National Institutes of Health, including via grants to the Alliance for Clinical Trials in Oncology and the Canadian Cancer Trials Group, and supported in part by Covidien and Ethicon.

Dr. Altorki reports relationships with AstraZeneca, Genentech, Johnson & Johnson, and Regeneron. Dr. Rusch reports relationships with Cancer Research UK, Genentech, and the National Cancer Institute.

A version of this article first appeared on Medscape.com.

The SARS-CoV-2 pandemic changed the way intensivists approach extracorporeal membrane oxygenation (ECMO). Patients with COVID-19 acute respiratory distress syndrome (ARDS) placed on ECMO have a high prevalence of right ventricular (RV) failure, which is associated with reduced survival (Maharaj V et al. ASAIO Journal. 2022;68[6]:772). In 2021, our institution supported 51 patients with COVID-19 ARDS with ECMO: 51% developed RV failure, defined as a clinical syndrome (reduced cardiac output) in the presence of RV dysfunction on transthoracic echocardiogram (TTE) (Marra A et al. Chest. 2022;161[2]:535). Total numbers for RV dysfunction and RV dilation on TTE were 78% and 91% respectively, so many of those with RV changes on TTE did not progress to clinical failure. In essence then, TTE signs of RV dysfunction are sensitive but not specific for clinical RV failure.

Rates for survival to decannulation were far lower when RV failure was present (27%) vs. absent (84%). Given these numbers, we felt a reduction in RV failure would be an important target for improving outcomes for patients with COVID-19 ARDS receiving ECMO. Existing studies on RV failure in patients with ARDS receiving ECMO are plagued by scant data, small sample sizes, differences in diagnostic criteria, and heterogenous treatment approaches. Despite these limitations, we felt the need to make changes in our approach to RV management.

Because outcomes once clinical RV-failure occurs are so poor, we focused on prevention. While we’re short on data and evidence-based medicine (EBM) here, we know a lot about the physiology of COVID19, the pulmonary vasculature, and the right side of the heart. There are multiple physiologic and disease-related pathways that converge to produce RV-failure in patients with COVID-19 ARDS on ECMO (Sato R et al. Crit Care. 2021;25:172). Ongoing relative hypoxemia, hypercapnia, acidemia, and microvascular thromboses/immunothromboses can all lead to increased pulmonary vascular resistance (PVR) and an increased workload for the RV (Zochios V et al. ASAIO Journal. 2022; 68[4]:456). ARDS management typically involves high positive end-expiratory pressure (PEEP), which can produce RV-PA uncoupling (Wanner P et al. J Clin Med. 2020;9:432).

We do know that ECMO relieves the stress on the right side of the heart by improving hypoxemia, hypercapnia, and acidemia while allowing for reduction in PEEP (Zochios V et al. ASAIO Journal. 2022; 68[4]:456). In addition to ECMO, proning and pulmonary vasodilators offload RV by further reducing pulmonary pressures (Sato R et al. Crit Care. 2021;25:172). Lastly, a right ventricular assist device (RVAD) can dissipate the work required by the RV and prevent decompensation. Collectively, these therapies can be considered preventive.

Knowing the RV parameters on RV are sensitive but not specific for outcomes though, when should some of these treatments be instituted? It’s clear that once RV failure has developed it’s probably too late, but it’s hard to find data to guide us on when to act. One institution used right ventricular assist devices (RVADs) at the time of ECMO initiation with protocolized care and achieved a survival to discharge rate of 73% (Mustafa AK et al. JAMA Surgery. 2020;155[10]:990). The publication generated enthusiasm for RVAD support with ECMO, but it’s possible the protocolized care drove the high survival rate, at least in part.

At our institution, we developed our own protocol for evaluation of the RV with proactive treatment based on specific targets. We performed daily, bedside TTE and assessed the RV fractional area of change (FAC) and outflow tract velocity time integral (VTI). These parameters provide a quantitative assessment of global RV function, and FAC is directly related to ability to wean from ECMO support (Maharaj V et al. ASAIO Journal. 2022;68[6]:772). We avoided using the tricuspid annular plain systolic excursion (TAPSE) due to its poor sensitivity (Marra AM et al. Chest. 2022;161[2]:535). Patients receiving ECMO with subjective, global mild to moderate RV dysfunction on TTE with worsening clinical data, an FAC of 20%-35%, and a VTI of 10-14 cm were treated with aggressive diuresis, pulmonary vasodilators, and inotropy for 48 hours. If there was no improvement or deterioration, an RVAD was placed. For patients with signs of severe RV dysfunction (FAC < 20% or VTI < 10 cm), we proceeded directly to RVAD. We’re currently collecting data and tracking outcomes.

While data exist on various interventions in RV failure due to COVID-19 ARDS with ECMO, our understanding of this disease is still in its infancy. The optimal timing of interventions to manage and prevent RV failure is not known. We would argue that those who wait for RV failure to occur before instituting protective or supportive therapies are missing the opportunity to impact outcomes. We currently do not have the evidence to support the specific protocol we’ve outlined here and instituted at our hospital. However, we do believe there’s enough literature and experience to support the concept that close monitoring of RV function is critical for patients with COVID19 ARDS receiving ECMO. Failure to anticipate worsening function on the way to failure means reacting to it rather than staving it off. By then, it’s too late.
 

Dr. Thomas is Maj, USAF, assistant professor, pulmonary/critical care; Dr. O’Neil is Maj, USAF, pediatric and ECMO intensivist, PICU medical director; and Dr. Villalobos is Capt, USAF, assistant professor, pulmonary/critical care, medical ICU director, Brooke Army Medical Center, San Antonio, Tex. The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, or the Department of Defense or the U.S. government.

The SARS-CoV-2 pandemic changed the way intensivists approach extracorporeal membrane oxygenation (ECMO). Patients with COVID-19 acute respiratory distress syndrome (ARDS) placed on ECMO have a high prevalence of right ventricular (RV) failure, which is associated with reduced survival (Maharaj V et al. ASAIO Journal. 2022;68[6]:772). In 2021, our institution supported 51 patients with COVID-19 ARDS with ECMO: 51% developed RV failure, defined as a clinical syndrome (reduced cardiac output) in the presence of RV dysfunction on transthoracic echocardiogram (TTE) (Marra A et al. Chest. 2022;161[2]:535). Total numbers for RV dysfunction and RV dilation on TTE were 78% and 91% respectively, so many of those with RV changes on TTE did not progress to clinical failure. In essence then, TTE signs of RV dysfunction are sensitive but not specific for clinical RV failure.

Rates for survival to decannulation were far lower when RV failure was present (27%) vs. absent (84%). Given these numbers, we felt a reduction in RV failure would be an important target for improving outcomes for patients with COVID-19 ARDS receiving ECMO. Existing studies on RV failure in patients with ARDS receiving ECMO are plagued by scant data, small sample sizes, differences in diagnostic criteria, and heterogenous treatment approaches. Despite these limitations, we felt the need to make changes in our approach to RV management.

Because outcomes once clinical RV-failure occurs are so poor, we focused on prevention. While we’re short on data and evidence-based medicine (EBM) here, we know a lot about the physiology of COVID19, the pulmonary vasculature, and the right side of the heart. There are multiple physiologic and disease-related pathways that converge to produce RV-failure in patients with COVID-19 ARDS on ECMO (Sato R et al. Crit Care. 2021;25:172). Ongoing relative hypoxemia, hypercapnia, acidemia, and microvascular thromboses/immunothromboses can all lead to increased pulmonary vascular resistance (PVR) and an increased workload for the RV (Zochios V et al. ASAIO Journal. 2022; 68[4]:456). ARDS management typically involves high positive end-expiratory pressure (PEEP), which can produce RV-PA uncoupling (Wanner P et al. J Clin Med. 2020;9:432).

We do know that ECMO relieves the stress on the right side of the heart by improving hypoxemia, hypercapnia, and acidemia while allowing for reduction in PEEP (Zochios V et al. ASAIO Journal. 2022; 68[4]:456). In addition to ECMO, proning and pulmonary vasodilators offload RV by further reducing pulmonary pressures (Sato R et al. Crit Care. 2021;25:172). Lastly, a right ventricular assist device (RVAD) can dissipate the work required by the RV and prevent decompensation. Collectively, these therapies can be considered preventive.

Knowing the RV parameters on RV are sensitive but not specific for outcomes though, when should some of these treatments be instituted? It’s clear that once RV failure has developed it’s probably too late, but it’s hard to find data to guide us on when to act. One institution used right ventricular assist devices (RVADs) at the time of ECMO initiation with protocolized care and achieved a survival to discharge rate of 73% (Mustafa AK et al. JAMA Surgery. 2020;155[10]:990). The publication generated enthusiasm for RVAD support with ECMO, but it’s possible the protocolized care drove the high survival rate, at least in part.

At our institution, we developed our own protocol for evaluation of the RV with proactive treatment based on specific targets. We performed daily, bedside TTE and assessed the RV fractional area of change (FAC) and outflow tract velocity time integral (VTI). These parameters provide a quantitative assessment of global RV function, and FAC is directly related to ability to wean from ECMO support (Maharaj V et al. ASAIO Journal. 2022;68[6]:772). We avoided using the tricuspid annular plain systolic excursion (TAPSE) due to its poor sensitivity (Marra AM et al. Chest. 2022;161[2]:535). Patients receiving ECMO with subjective, global mild to moderate RV dysfunction on TTE with worsening clinical data, an FAC of 20%-35%, and a VTI of 10-14 cm were treated with aggressive diuresis, pulmonary vasodilators, and inotropy for 48 hours. If there was no improvement or deterioration, an RVAD was placed. For patients with signs of severe RV dysfunction (FAC < 20% or VTI < 10 cm), we proceeded directly to RVAD. We’re currently collecting data and tracking outcomes.

While data exist on various interventions in RV failure due to COVID-19 ARDS with ECMO, our understanding of this disease is still in its infancy. The optimal timing of interventions to manage and prevent RV failure is not known. We would argue that those who wait for RV failure to occur before instituting protective or supportive therapies are missing the opportunity to impact outcomes. We currently do not have the evidence to support the specific protocol we’ve outlined here and instituted at our hospital. However, we do believe there’s enough literature and experience to support the concept that close monitoring of RV function is critical for patients with COVID19 ARDS receiving ECMO. Failure to anticipate worsening function on the way to failure means reacting to it rather than staving it off. By then, it’s too late.
 

Dr. Thomas is Maj, USAF, assistant professor, pulmonary/critical care; Dr. O’Neil is Maj, USAF, pediatric and ECMO intensivist, PICU medical director; and Dr. Villalobos is Capt, USAF, assistant professor, pulmonary/critical care, medical ICU director, Brooke Army Medical Center, San Antonio, Tex. The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, or the Department of Defense or the U.S. government.

The SARS-CoV-2 pandemic changed the way intensivists approach extracorporeal membrane oxygenation (ECMO). Patients with COVID-19 acute respiratory distress syndrome (ARDS) placed on ECMO have a high prevalence of right ventricular (RV) failure, which is associated with reduced survival (Maharaj V et al. ASAIO Journal. 2022;68[6]:772). In 2021, our institution supported 51 patients with COVID-19 ARDS with ECMO: 51% developed RV failure, defined as a clinical syndrome (reduced cardiac output) in the presence of RV dysfunction on transthoracic echocardiogram (TTE) (Marra A et al. Chest. 2022;161[2]:535). Total numbers for RV dysfunction and RV dilation on TTE were 78% and 91% respectively, so many of those with RV changes on TTE did not progress to clinical failure. In essence then, TTE signs of RV dysfunction are sensitive but not specific for clinical RV failure.

Rates for survival to decannulation were far lower when RV failure was present (27%) vs. absent (84%). Given these numbers, we felt a reduction in RV failure would be an important target for improving outcomes for patients with COVID-19 ARDS receiving ECMO. Existing studies on RV failure in patients with ARDS receiving ECMO are plagued by scant data, small sample sizes, differences in diagnostic criteria, and heterogenous treatment approaches. Despite these limitations, we felt the need to make changes in our approach to RV management.

Because outcomes once clinical RV-failure occurs are so poor, we focused on prevention. While we’re short on data and evidence-based medicine (EBM) here, we know a lot about the physiology of COVID19, the pulmonary vasculature, and the right side of the heart. There are multiple physiologic and disease-related pathways that converge to produce RV-failure in patients with COVID-19 ARDS on ECMO (Sato R et al. Crit Care. 2021;25:172). Ongoing relative hypoxemia, hypercapnia, acidemia, and microvascular thromboses/immunothromboses can all lead to increased pulmonary vascular resistance (PVR) and an increased workload for the RV (Zochios V et al. ASAIO Journal. 2022; 68[4]:456). ARDS management typically involves high positive end-expiratory pressure (PEEP), which can produce RV-PA uncoupling (Wanner P et al. J Clin Med. 2020;9:432).

We do know that ECMO relieves the stress on the right side of the heart by improving hypoxemia, hypercapnia, and acidemia while allowing for reduction in PEEP (Zochios V et al. ASAIO Journal. 2022; 68[4]:456). In addition to ECMO, proning and pulmonary vasodilators offload RV by further reducing pulmonary pressures (Sato R et al. Crit Care. 2021;25:172). Lastly, a right ventricular assist device (RVAD) can dissipate the work required by the RV and prevent decompensation. Collectively, these therapies can be considered preventive.

Knowing the RV parameters on RV are sensitive but not specific for outcomes though, when should some of these treatments be instituted? It’s clear that once RV failure has developed it’s probably too late, but it’s hard to find data to guide us on when to act. One institution used right ventricular assist devices (RVADs) at the time of ECMO initiation with protocolized care and achieved a survival to discharge rate of 73% (Mustafa AK et al. JAMA Surgery. 2020;155[10]:990). The publication generated enthusiasm for RVAD support with ECMO, but it’s possible the protocolized care drove the high survival rate, at least in part.

At our institution, we developed our own protocol for evaluation of the RV with proactive treatment based on specific targets. We performed daily, bedside TTE and assessed the RV fractional area of change (FAC) and outflow tract velocity time integral (VTI). These parameters provide a quantitative assessment of global RV function, and FAC is directly related to ability to wean from ECMO support (Maharaj V et al. ASAIO Journal. 2022;68[6]:772). We avoided using the tricuspid annular plain systolic excursion (TAPSE) due to its poor sensitivity (Marra AM et al. Chest. 2022;161[2]:535). Patients receiving ECMO with subjective, global mild to moderate RV dysfunction on TTE with worsening clinical data, an FAC of 20%-35%, and a VTI of 10-14 cm were treated with aggressive diuresis, pulmonary vasodilators, and inotropy for 48 hours. If there was no improvement or deterioration, an RVAD was placed. For patients with signs of severe RV dysfunction (FAC < 20% or VTI < 10 cm), we proceeded directly to RVAD. We’re currently collecting data and tracking outcomes.

While data exist on various interventions in RV failure due to COVID-19 ARDS with ECMO, our understanding of this disease is still in its infancy. The optimal timing of interventions to manage and prevent RV failure is not known. We would argue that those who wait for RV failure to occur before instituting protective or supportive therapies are missing the opportunity to impact outcomes. We currently do not have the evidence to support the specific protocol we’ve outlined here and instituted at our hospital. However, we do believe there’s enough literature and experience to support the concept that close monitoring of RV function is critical for patients with COVID19 ARDS receiving ECMO. Failure to anticipate worsening function on the way to failure means reacting to it rather than staving it off. By then, it’s too late.
 

Dr. Thomas is Maj, USAF, assistant professor, pulmonary/critical care; Dr. O’Neil is Maj, USAF, pediatric and ECMO intensivist, PICU medical director; and Dr. Villalobos is Capt, USAF, assistant professor, pulmonary/critical care, medical ICU director, Brooke Army Medical Center, San Antonio, Tex. The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, or the Department of Defense or the U.S. government.

Since the first SARS-CoV-2 (COVID-19) outbreak in Wuhan, China, in December 2019, more than 6.6 million deaths have occurred. Management strategies for patients with COVID-19 pneumonia/ARDS have continued to evolve during the pandemic. One of the strategies for those cases refractory to traditional ARDS treatments has been the use of extracorporeal membrane oxygenation (ECMO).

Before the COVID-19 pandemic, a substantial amount of data regarding the use of ECMO in ARDS was gathered during the H1N1 influenza outbreak in 2009. Mortality ranged from 8% to 65% (Zangrillo, et al. Crit Care. 2013;17[1]:R30). From these data, we learned the importance of patient selection. Young patients with few co-morbidities and less than 7 days supported by mechanical ventilation did remarkably better than elderly patients or those who had prolonged positive-pressure ventilation prior to ECMO.  

To date, the mortality rate for COVID-19 patients with ARDS requiring ECMO is 48% based on data from ELSO. Interestingly though, using May 1, 2020, as a cutoff date, mortality rates for patients with COVID-19 receiving ECMO significantly increased from 37% to 52% (Barbaro, et al. Lancet. 2021;398[10307]:1230). This escalation in mortality engendered concern that ECMO may not be useful in treating patients with COVID-19 and ARDS.

Several factors can be cited for this increase in mortality. First, many new ECMO programs launched after May 1. These new programs had a higher mortality rate (59%) compared with established programs, suggesting that program and provider experience play a significant role in patient outcomes (Barbaro, et al. Lancet. 2021;398[10307]:1230). Second, patients in the latter part of 2020 experienced much longer intervals between the onset of symptoms and time of intubation. Clinicians had a tendency to delay intubation as long as possible. Subsequently, the number of days receiving high flow nasal oxygen or noninvasive ventilation (NIV) was significantly longer (Schmidt, et al. Crit Care. 2021;25[1]:355). These data suggest that prolonged NIV on high Fio2 may be a negative prognostic indicator and should be considered when assessing a patient’s candidacy for ECMO.

Early in the pandemic, clinicians realized that average ECMO run times for patients with COVID-19 and ARDS were significantly longer, 15 vs 9 days, respectively (Jacobs, et al. Ann Thorac Surg. 2022;113[5]:1452). With such long run times, beds were slow to turn over, and a shortage of ECMO beds resulted during the height of the pandemic. In a retrospective study, Gannon looked at 90 patients, all of whom were deemed medically appropriate for ECMO. Two groups were created: (1) no capacity for ECMO vs (2) ECMO provided. Mortality rates were staggering at 89% and 43%, respectively (P =.001) (Gannon, et al. Am J Respir Crit Care Med. 2022;205[11]:1354). This study demonstrated a profound point: during a pandemic, when demand overcomes supply, there is a unique opportunity to see the effect of lifesaving therapies, such as ECMO, on outcomes. This study was particularly poignant, as the average age of the patients was 40 years old.  

It is now widely accepted that prone positioning has survival benefit in ARDS. Prone positioning while receiving ECMO has generally been avoided due to concern for potential complications associated with the cannula(s). However, it has been shown that prone positioning while receiving veno-venous (VV) -ECMO reduces mortality rates, 37% proned vs 50% supine positioning (P =.02) (Giani, et al. Ann Am Thorac Soc. 2021;18[3]:495). In this study, no major complications occurred, and minor complications occurred in 6% of the proning events. Prone positioning improves ventilation-perfusion mismatch and reduces hypoxic vasoconstriction, which is thought to be right-sided heart-protective.  

Right-sided heart dysfunction (RHD) is common in ARDS, whether COVID-19-related or not. The pathogenesis includes hypoxic vasoconstriction, pulmonary fibrosis, and ventilator-induced lung injury. Pulmonary microthrombi and patient-specific characteristics, such as obesity, are additional factors leading to RHD in patients with COVID-19. During the pandemic, several articles described using right-sided heart protective cannulation strategies for patients with COVID-19 requiring ECMO with favorable results (Mustafa, et al. JAMA Surg. 2020;155[10]:990; Cain, et al. J Surg Res. 2021;264:81-89). This right-sided heart protective strategy involves inserting a single access dual lumen cannula into the right internal jugular vein, which is advanced into the pulmonary artery, effectively bypassing the right ventricle. This setup is more typical of right ventricle assist device (RVAD), rather than typical VV-ECMO, which returns blood to the right atrium. Unfortunately, these studies did not include echocardiographic information to evaluate the effects of this intervention on RVD, and this is an area for future research. However, this vein to pulmonary artery strategy was found to facilitate decreased sedation, earlier liberation from mechanical ventilation, reduced need for tracheostomy, improved mobilization out of bed, and ease in prone positioning (Mustafa, et al. JAMA Surg. 2020;155[10]:990).

In conclusion, there is evidence to support the use of ECMO in patients with COVID-19 patients and ARDS failing conventional mechanical ventilation. The success of ECMO therapy is highly dependent on patient selection. Prolonged use of NIV on high Fio2 may be a negative predictor of ECMO survival and should be considered when assessing a patient for ECMO candidacy. Prone positioning with ECMO has been shown to have survival benefit and should be considered in all patients receiving ECMO.
 

Dr. Gaillard, Dr. Staples, and Dr. Kapoor are with the Department of Anesthesiology, Section on Critical Care, at Wake Forest School of Medicine in Winston-Salem, N.C. Dr. Gaillard is also with the Department of Emergency Medicine and Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology at Wake Forest School of Medicine.

Since the first SARS-CoV-2 (COVID-19) outbreak in Wuhan, China, in December 2019, more than 6.6 million deaths have occurred. Management strategies for patients with COVID-19 pneumonia/ARDS have continued to evolve during the pandemic. One of the strategies for those cases refractory to traditional ARDS treatments has been the use of extracorporeal membrane oxygenation (ECMO).

Before the COVID-19 pandemic, a substantial amount of data regarding the use of ECMO in ARDS was gathered during the H1N1 influenza outbreak in 2009. Mortality ranged from 8% to 65% (Zangrillo, et al. Crit Care. 2013;17[1]:R30). From these data, we learned the importance of patient selection. Young patients with few co-morbidities and less than 7 days supported by mechanical ventilation did remarkably better than elderly patients or those who had prolonged positive-pressure ventilation prior to ECMO.  

To date, the mortality rate for COVID-19 patients with ARDS requiring ECMO is 48% based on data from ELSO. Interestingly though, using May 1, 2020, as a cutoff date, mortality rates for patients with COVID-19 receiving ECMO significantly increased from 37% to 52% (Barbaro, et al. Lancet. 2021;398[10307]:1230). This escalation in mortality engendered concern that ECMO may not be useful in treating patients with COVID-19 and ARDS.

Several factors can be cited for this increase in mortality. First, many new ECMO programs launched after May 1. These new programs had a higher mortality rate (59%) compared with established programs, suggesting that program and provider experience play a significant role in patient outcomes (Barbaro, et al. Lancet. 2021;398[10307]:1230). Second, patients in the latter part of 2020 experienced much longer intervals between the onset of symptoms and time of intubation. Clinicians had a tendency to delay intubation as long as possible. Subsequently, the number of days receiving high flow nasal oxygen or noninvasive ventilation (NIV) was significantly longer (Schmidt, et al. Crit Care. 2021;25[1]:355). These data suggest that prolonged NIV on high Fio2 may be a negative prognostic indicator and should be considered when assessing a patient’s candidacy for ECMO.

Early in the pandemic, clinicians realized that average ECMO run times for patients with COVID-19 and ARDS were significantly longer, 15 vs 9 days, respectively (Jacobs, et al. Ann Thorac Surg. 2022;113[5]:1452). With such long run times, beds were slow to turn over, and a shortage of ECMO beds resulted during the height of the pandemic. In a retrospective study, Gannon looked at 90 patients, all of whom were deemed medically appropriate for ECMO. Two groups were created: (1) no capacity for ECMO vs (2) ECMO provided. Mortality rates were staggering at 89% and 43%, respectively (P =.001) (Gannon, et al. Am J Respir Crit Care Med. 2022;205[11]:1354). This study demonstrated a profound point: during a pandemic, when demand overcomes supply, there is a unique opportunity to see the effect of lifesaving therapies, such as ECMO, on outcomes. This study was particularly poignant, as the average age of the patients was 40 years old.  

It is now widely accepted that prone positioning has survival benefit in ARDS. Prone positioning while receiving ECMO has generally been avoided due to concern for potential complications associated with the cannula(s). However, it has been shown that prone positioning while receiving veno-venous (VV) -ECMO reduces mortality rates, 37% proned vs 50% supine positioning (P =.02) (Giani, et al. Ann Am Thorac Soc. 2021;18[3]:495). In this study, no major complications occurred, and minor complications occurred in 6% of the proning events. Prone positioning improves ventilation-perfusion mismatch and reduces hypoxic vasoconstriction, which is thought to be right-sided heart-protective.  

Right-sided heart dysfunction (RHD) is common in ARDS, whether COVID-19-related or not. The pathogenesis includes hypoxic vasoconstriction, pulmonary fibrosis, and ventilator-induced lung injury. Pulmonary microthrombi and patient-specific characteristics, such as obesity, are additional factors leading to RHD in patients with COVID-19. During the pandemic, several articles described using right-sided heart protective cannulation strategies for patients with COVID-19 requiring ECMO with favorable results (Mustafa, et al. JAMA Surg. 2020;155[10]:990; Cain, et al. J Surg Res. 2021;264:81-89). This right-sided heart protective strategy involves inserting a single access dual lumen cannula into the right internal jugular vein, which is advanced into the pulmonary artery, effectively bypassing the right ventricle. This setup is more typical of right ventricle assist device (RVAD), rather than typical VV-ECMO, which returns blood to the right atrium. Unfortunately, these studies did not include echocardiographic information to evaluate the effects of this intervention on RVD, and this is an area for future research. However, this vein to pulmonary artery strategy was found to facilitate decreased sedation, earlier liberation from mechanical ventilation, reduced need for tracheostomy, improved mobilization out of bed, and ease in prone positioning (Mustafa, et al. JAMA Surg. 2020;155[10]:990).

In conclusion, there is evidence to support the use of ECMO in patients with COVID-19 patients and ARDS failing conventional mechanical ventilation. The success of ECMO therapy is highly dependent on patient selection. Prolonged use of NIV on high Fio2 may be a negative predictor of ECMO survival and should be considered when assessing a patient for ECMO candidacy. Prone positioning with ECMO has been shown to have survival benefit and should be considered in all patients receiving ECMO.
 

Dr. Gaillard, Dr. Staples, and Dr. Kapoor are with the Department of Anesthesiology, Section on Critical Care, at Wake Forest School of Medicine in Winston-Salem, N.C. Dr. Gaillard is also with the Department of Emergency Medicine and Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology at Wake Forest School of Medicine.

Since the first SARS-CoV-2 (COVID-19) outbreak in Wuhan, China, in December 2019, more than 6.6 million deaths have occurred. Management strategies for patients with COVID-19 pneumonia/ARDS have continued to evolve during the pandemic. One of the strategies for those cases refractory to traditional ARDS treatments has been the use of extracorporeal membrane oxygenation (ECMO).

Before the COVID-19 pandemic, a substantial amount of data regarding the use of ECMO in ARDS was gathered during the H1N1 influenza outbreak in 2009. Mortality ranged from 8% to 65% (Zangrillo, et al. Crit Care. 2013;17[1]:R30). From these data, we learned the importance of patient selection. Young patients with few co-morbidities and less than 7 days supported by mechanical ventilation did remarkably better than elderly patients or those who had prolonged positive-pressure ventilation prior to ECMO.  

To date, the mortality rate for COVID-19 patients with ARDS requiring ECMO is 48% based on data from ELSO. Interestingly though, using May 1, 2020, as a cutoff date, mortality rates for patients with COVID-19 receiving ECMO significantly increased from 37% to 52% (Barbaro, et al. Lancet. 2021;398[10307]:1230). This escalation in mortality engendered concern that ECMO may not be useful in treating patients with COVID-19 and ARDS.

Several factors can be cited for this increase in mortality. First, many new ECMO programs launched after May 1. These new programs had a higher mortality rate (59%) compared with established programs, suggesting that program and provider experience play a significant role in patient outcomes (Barbaro, et al. Lancet. 2021;398[10307]:1230). Second, patients in the latter part of 2020 experienced much longer intervals between the onset of symptoms and time of intubation. Clinicians had a tendency to delay intubation as long as possible. Subsequently, the number of days receiving high flow nasal oxygen or noninvasive ventilation (NIV) was significantly longer (Schmidt, et al. Crit Care. 2021;25[1]:355). These data suggest that prolonged NIV on high Fio2 may be a negative prognostic indicator and should be considered when assessing a patient’s candidacy for ECMO.

Early in the pandemic, clinicians realized that average ECMO run times for patients with COVID-19 and ARDS were significantly longer, 15 vs 9 days, respectively (Jacobs, et al. Ann Thorac Surg. 2022;113[5]:1452). With such long run times, beds were slow to turn over, and a shortage of ECMO beds resulted during the height of the pandemic. In a retrospective study, Gannon looked at 90 patients, all of whom were deemed medically appropriate for ECMO. Two groups were created: (1) no capacity for ECMO vs (2) ECMO provided. Mortality rates were staggering at 89% and 43%, respectively (P =.001) (Gannon, et al. Am J Respir Crit Care Med. 2022;205[11]:1354). This study demonstrated a profound point: during a pandemic, when demand overcomes supply, there is a unique opportunity to see the effect of lifesaving therapies, such as ECMO, on outcomes. This study was particularly poignant, as the average age of the patients was 40 years old.  

It is now widely accepted that prone positioning has survival benefit in ARDS. Prone positioning while receiving ECMO has generally been avoided due to concern for potential complications associated with the cannula(s). However, it has been shown that prone positioning while receiving veno-venous (VV) -ECMO reduces mortality rates, 37% proned vs 50% supine positioning (P =.02) (Giani, et al. Ann Am Thorac Soc. 2021;18[3]:495). In this study, no major complications occurred, and minor complications occurred in 6% of the proning events. Prone positioning improves ventilation-perfusion mismatch and reduces hypoxic vasoconstriction, which is thought to be right-sided heart-protective.  

Right-sided heart dysfunction (RHD) is common in ARDS, whether COVID-19-related or not. The pathogenesis includes hypoxic vasoconstriction, pulmonary fibrosis, and ventilator-induced lung injury. Pulmonary microthrombi and patient-specific characteristics, such as obesity, are additional factors leading to RHD in patients with COVID-19. During the pandemic, several articles described using right-sided heart protective cannulation strategies for patients with COVID-19 requiring ECMO with favorable results (Mustafa, et al. JAMA Surg. 2020;155[10]:990; Cain, et al. J Surg Res. 2021;264:81-89). This right-sided heart protective strategy involves inserting a single access dual lumen cannula into the right internal jugular vein, which is advanced into the pulmonary artery, effectively bypassing the right ventricle. This setup is more typical of right ventricle assist device (RVAD), rather than typical VV-ECMO, which returns blood to the right atrium. Unfortunately, these studies did not include echocardiographic information to evaluate the effects of this intervention on RVD, and this is an area for future research. However, this vein to pulmonary artery strategy was found to facilitate decreased sedation, earlier liberation from mechanical ventilation, reduced need for tracheostomy, improved mobilization out of bed, and ease in prone positioning (Mustafa, et al. JAMA Surg. 2020;155[10]:990).

In conclusion, there is evidence to support the use of ECMO in patients with COVID-19 patients and ARDS failing conventional mechanical ventilation. The success of ECMO therapy is highly dependent on patient selection. Prolonged use of NIV on high Fio2 may be a negative predictor of ECMO survival and should be considered when assessing a patient for ECMO candidacy. Prone positioning with ECMO has been shown to have survival benefit and should be considered in all patients receiving ECMO.
 

Dr. Gaillard, Dr. Staples, and Dr. Kapoor are with the Department of Anesthesiology, Section on Critical Care, at Wake Forest School of Medicine in Winston-Salem, N.C. Dr. Gaillard is also with the Department of Emergency Medicine and Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology at Wake Forest School of Medicine.

Diffuse Lung Disease & Transplant Network

Interstitial Lung Disease Section

Delay in diagnosis of IPF: How bad is the problem?

Idiopathic pulmonary fibrosis (IPF) is a devastating disease with a poor prognosis. Antifibrotic therapies for IPF are only capable of slowing disease progression without reversing established fibrosis. As such, the therapeutic efficacy of antifibrotic therapy may be reduced in patients whose diagnosis is delayed.

Unfortunately, diagnostic delay is common in IPF. Studies demonstrate that IPF diagnosis is delayed by more than a year after symptom onset in 43% of subjects, and more than 3 years in 19% of subjects (Cosgrove GP et al. BMC Pulm Med. 2018;18[9]). Approximately one-third of patients with IPF have undergone chest CT imaging more than 3 years prior to diagnosis, and around the same proportion has seen a pulmonologist within the same time span (Mooney J, et al. Ann Am Thorac Soc. 2019;16[3]:393). A median delay to IPF diagnosis of 2.2 years was noted in patients presenting to a tertiary academic medical center and was associated with an increased risk of death independent of age, sex, and forced vital capacity (adjusted hazard ratio per doubling of delay was 1.3) (Lamas DJ et al. Am J Respir Crit Care Med. 2011;184:842).

Robust improvements are clearly required for identifying patients with IPF earlier in their disease course. The Bridging Specialties Initiative from CHEST and the Three Lakes Foundation is one resource designed to improve the timely diagnosis of ILD (ILD Clinician Toolkit available at https://www.chestnet.org/Guidelines-and-Topic-Collections/Bridging-Specialties/Timely-Diagnosis-for-ILD-Patients/Clinician-Toolkit). This, and other initiatives will hopefully reduce delays in diagnosing IPF, allowing for optimal patient care.

Adrian Shifren, MBBCh, FCCP, Member-at-Large

Saniya Khan, MD, MBBS, Member-at-Large

Robert Case Jr., MD, Pulmonary & Critical Care Fellow
 

Critical Care Network

Mechanical Ventilation and Airways Section

Noninvasive ventilation

Noninvasive ventilation (NIV) is a ventilation modality that supports breathing by using mechanically assisted breaths without the need for intubation or a surgical airway. NIV is divided into two main types, negative-pressure ventilation (NPV) and noninvasive positive-pressure ventilation (NIPPV).

NPV

NPV periodically generates a negative (subatmospheric) pressure on the thorax wall, reflecting the natural breathing mechanism. As this negative pressure is transmitted into the thorax, normal atmospheric pressure air outside the thorax is pulled in for inhalation. Initiated by the negative pressure generator switching off, exhalation is passive due to elastic recoil of the lung and chest wall. The iron lung was a neck-to-toe horizontal cylinder used for NPV during the polio epidemic. New NPV devices are designed to fit the thorax only, using a cuirass (a torso-covering body armor molded shell).

For years, NPV use declined as NIPPV use increased. However, during the shortage of NIPPV devices during COVID and a recent recall of certain CPAP devices, NPV use has increased. NPV is an excellent alternative for those who cannot tolerate a facial mask due to facial deformity, claustrophobia, or excessive airway secretion (Corrado A et al. European Resp J. 2002;20[1]:187).
 

NIPPV

NIPPV is divided into several subtypes, including continuous positive airway pressure (CPAP), bilevel positive airway pressure (BPAP or BiPAP), and average volume-assured pressure support (AVAPS or VAPS). CPAP is defined as a single pressure delivered in inhalation (Pi) and exhalation (Pe). The increased mean airway pressure provides improved oxygenation (O₂) but not ventilation (CO₂). BPAP uses dual pressures with Pi higher than Pe. The increased mean airway pressure provides improved O₂ while the difference between Pi minus Pe increases ventilation and decreases CO₂.

AVAPS is a form of BPAP where Pi varies in an automated range to achieve the ordered tidal volume. In AVAPS, the generator adjusts Pi based on the average delivered tidal volume. If the average delivered tidal volume is less than the set tidal volume, Pi gradually increases while not exceeding Pi Max. Patients notice improved comfort of AVAPS with a variable Pi vs. BPAP with a fixed Pi (Frank A et al. Chest. 2018;154[4]:1060A).

Samantha Tauscher, DO, Resident-in-Training

Herbert Patrick, MD, MSEE, FCCP , Member-at-Large
 

Pulmonary Vascular & Cardiovascular Disease Network

Pulmonary Vascular Disease Section

A RACE to the finish: Revisiting the role of BPA in the management of CTEPH

Pulmonary thromboendarterectomy (PTE) is the treatment of choice for patients with CTEPH (Kim NH et al. Eur Respir J. 2019;53:1801915). However, this leaves about 40% of CTEPH patients who are not operative candidates due to inaccessible distal clot burden or significant comorbidities (Pepke-Zaba J et al. Circulation 2011;124:1973). For these inoperable situations, riociguat is the only FDA-approved medical therapy (Delcroix M et al. Eur Respir J. 2021;57:2002828). Balloon pulmonary angioplasty (BPA) became a treatment option for these patients in the last 2 decades. As technique refined, BPA demonstrated improved safety data along with improved hemodynamics and increased exercise capacity (Kataoka M et al. Circ Cardiovasc Interv. 2012;5:756).

A recently published crossover study, the RACE trial, compared riociguat with BPA in treating inoperable CTEPH (Jaïs X et al. Lancet Respir Med. 2022;10[10]:961). Patients were randomly assigned to either riociguat or BPA for 26 weeks. At 26 weeks, patients with pulmonary vascular resistance (PVR) more than 4 Woods Units (WU) were crossed over to receive either BPA or riociguat therapy. At 26 weeks, the BPA arm showed a greater reduction in PVR but more complications, including lung injury and hemoptysis. After a 26-week crossover period, the reduction in PVR was similar in both arms. The complication rate in the BPA arm was lower when preceded by riociguat.

In patients with inoperable CTEPH, BPA has emerged as an attractive management option in addition to the medical therapy with riociguat. However, BPA should be performed at expert centers with experience. Further studies are needed to strengthen the role and optimal timing of BPA in management of post PTE patients with residual PH.

Samantha Pettigrew, MD, Fellow-in-Training

Janine Vintich, MD, FCCP, Member-at-Large

Diffuse Lung Disease & Transplant Network

Interstitial Lung Disease Section

Delay in diagnosis of IPF: How bad is the problem?

Idiopathic pulmonary fibrosis (IPF) is a devastating disease with a poor prognosis. Antifibrotic therapies for IPF are only capable of slowing disease progression without reversing established fibrosis. As such, the therapeutic efficacy of antifibrotic therapy may be reduced in patients whose diagnosis is delayed.

Unfortunately, diagnostic delay is common in IPF. Studies demonstrate that IPF diagnosis is delayed by more than a year after symptom onset in 43% of subjects, and more than 3 years in 19% of subjects (Cosgrove GP et al. BMC Pulm Med. 2018;18[9]). Approximately one-third of patients with IPF have undergone chest CT imaging more than 3 years prior to diagnosis, and around the same proportion has seen a pulmonologist within the same time span (Mooney J, et al. Ann Am Thorac Soc. 2019;16[3]:393). A median delay to IPF diagnosis of 2.2 years was noted in patients presenting to a tertiary academic medical center and was associated with an increased risk of death independent of age, sex, and forced vital capacity (adjusted hazard ratio per doubling of delay was 1.3) (Lamas DJ et al. Am J Respir Crit Care Med. 2011;184:842).

Robust improvements are clearly required for identifying patients with IPF earlier in their disease course. The Bridging Specialties Initiative from CHEST and the Three Lakes Foundation is one resource designed to improve the timely diagnosis of ILD (ILD Clinician Toolkit available at https://www.chestnet.org/Guidelines-and-Topic-Collections/Bridging-Specialties/Timely-Diagnosis-for-ILD-Patients/Clinician-Toolkit). This, and other initiatives will hopefully reduce delays in diagnosing IPF, allowing for optimal patient care.

Adrian Shifren, MBBCh, FCCP, Member-at-Large

Saniya Khan, MD, MBBS, Member-at-Large

Robert Case Jr., MD, Pulmonary & Critical Care Fellow
 

Critical Care Network

Mechanical Ventilation and Airways Section

Noninvasive ventilation

Noninvasive ventilation (NIV) is a ventilation modality that supports breathing by using mechanically assisted breaths without the need for intubation or a surgical airway. NIV is divided into two main types, negative-pressure ventilation (NPV) and noninvasive positive-pressure ventilation (NIPPV).

NPV

NPV periodically generates a negative (subatmospheric) pressure on the thorax wall, reflecting the natural breathing mechanism. As this negative pressure is transmitted into the thorax, normal atmospheric pressure air outside the thorax is pulled in for inhalation. Initiated by the negative pressure generator switching off, exhalation is passive due to elastic recoil of the lung and chest wall. The iron lung was a neck-to-toe horizontal cylinder used for NPV during the polio epidemic. New NPV devices are designed to fit the thorax only, using a cuirass (a torso-covering body armor molded shell).

For years, NPV use declined as NIPPV use increased. However, during the shortage of NIPPV devices during COVID and a recent recall of certain CPAP devices, NPV use has increased. NPV is an excellent alternative for those who cannot tolerate a facial mask due to facial deformity, claustrophobia, or excessive airway secretion (Corrado A et al. European Resp J. 2002;20[1]:187).
 

NIPPV

NIPPV is divided into several subtypes, including continuous positive airway pressure (CPAP), bilevel positive airway pressure (BPAP or BiPAP), and average volume-assured pressure support (AVAPS or VAPS). CPAP is defined as a single pressure delivered in inhalation (Pi) and exhalation (Pe). The increased mean airway pressure provides improved oxygenation (O₂) but not ventilation (CO₂). BPAP uses dual pressures with Pi higher than Pe. The increased mean airway pressure provides improved O₂ while the difference between Pi minus Pe increases ventilation and decreases CO₂.

AVAPS is a form of BPAP where Pi varies in an automated range to achieve the ordered tidal volume. In AVAPS, the generator adjusts Pi based on the average delivered tidal volume. If the average delivered tidal volume is less than the set tidal volume, Pi gradually increases while not exceeding Pi Max. Patients notice improved comfort of AVAPS with a variable Pi vs. BPAP with a fixed Pi (Frank A et al. Chest. 2018;154[4]:1060A).

Samantha Tauscher, DO, Resident-in-Training

Herbert Patrick, MD, MSEE, FCCP , Member-at-Large
 

Pulmonary Vascular & Cardiovascular Disease Network

Pulmonary Vascular Disease Section

A RACE to the finish: Revisiting the role of BPA in the management of CTEPH

Pulmonary thromboendarterectomy (PTE) is the treatment of choice for patients with CTEPH (Kim NH et al. Eur Respir J. 2019;53:1801915). However, this leaves about 40% of CTEPH patients who are not operative candidates due to inaccessible distal clot burden or significant comorbidities (Pepke-Zaba J et al. Circulation 2011;124:1973). For these inoperable situations, riociguat is the only FDA-approved medical therapy (Delcroix M et al. Eur Respir J. 2021;57:2002828). Balloon pulmonary angioplasty (BPA) became a treatment option for these patients in the last 2 decades. As technique refined, BPA demonstrated improved safety data along with improved hemodynamics and increased exercise capacity (Kataoka M et al. Circ Cardiovasc Interv. 2012;5:756).

A recently published crossover study, the RACE trial, compared riociguat with BPA in treating inoperable CTEPH (Jaïs X et al. Lancet Respir Med. 2022;10[10]:961). Patients were randomly assigned to either riociguat or BPA for 26 weeks. At 26 weeks, patients with pulmonary vascular resistance (PVR) more than 4 Woods Units (WU) were crossed over to receive either BPA or riociguat therapy. At 26 weeks, the BPA arm showed a greater reduction in PVR but more complications, including lung injury and hemoptysis. After a 26-week crossover period, the reduction in PVR was similar in both arms. The complication rate in the BPA arm was lower when preceded by riociguat.

In patients with inoperable CTEPH, BPA has emerged as an attractive management option in addition to the medical therapy with riociguat. However, BPA should be performed at expert centers with experience. Further studies are needed to strengthen the role and optimal timing of BPA in management of post PTE patients with residual PH.

Samantha Pettigrew, MD, Fellow-in-Training

Janine Vintich, MD, FCCP, Member-at-Large

Diffuse Lung Disease & Transplant Network

Interstitial Lung Disease Section

Delay in diagnosis of IPF: How bad is the problem?

Idiopathic pulmonary fibrosis (IPF) is a devastating disease with a poor prognosis. Antifibrotic therapies for IPF are only capable of slowing disease progression without reversing established fibrosis. As such, the therapeutic efficacy of antifibrotic therapy may be reduced in patients whose diagnosis is delayed.

Unfortunately, diagnostic delay is common in IPF. Studies demonstrate that IPF diagnosis is delayed by more than a year after symptom onset in 43% of subjects, and more than 3 years in 19% of subjects (Cosgrove GP et al. BMC Pulm Med. 2018;18[9]). Approximately one-third of patients with IPF have undergone chest CT imaging more than 3 years prior to diagnosis, and around the same proportion has seen a pulmonologist within the same time span (Mooney J, et al. Ann Am Thorac Soc. 2019;16[3]:393). A median delay to IPF diagnosis of 2.2 years was noted in patients presenting to a tertiary academic medical center and was associated with an increased risk of death independent of age, sex, and forced vital capacity (adjusted hazard ratio per doubling of delay was 1.3) (Lamas DJ et al. Am J Respir Crit Care Med. 2011;184:842).

Robust improvements are clearly required for identifying patients with IPF earlier in their disease course. The Bridging Specialties Initiative from CHEST and the Three Lakes Foundation is one resource designed to improve the timely diagnosis of ILD (ILD Clinician Toolkit available at https://www.chestnet.org/Guidelines-and-Topic-Collections/Bridging-Specialties/Timely-Diagnosis-for-ILD-Patients/Clinician-Toolkit). This, and other initiatives will hopefully reduce delays in diagnosing IPF, allowing for optimal patient care.

Adrian Shifren, MBBCh, FCCP, Member-at-Large

Saniya Khan, MD, MBBS, Member-at-Large

Robert Case Jr., MD, Pulmonary & Critical Care Fellow
 

Critical Care Network

Mechanical Ventilation and Airways Section

Noninvasive ventilation

Noninvasive ventilation (NIV) is a ventilation modality that supports breathing by using mechanically assisted breaths without the need for intubation or a surgical airway. NIV is divided into two main types, negative-pressure ventilation (NPV) and noninvasive positive-pressure ventilation (NIPPV).

NPV

NPV periodically generates a negative (subatmospheric) pressure on the thorax wall, reflecting the natural breathing mechanism. As this negative pressure is transmitted into the thorax, normal atmospheric pressure air outside the thorax is pulled in for inhalation. Initiated by the negative pressure generator switching off, exhalation is passive due to elastic recoil of the lung and chest wall. The iron lung was a neck-to-toe horizontal cylinder used for NPV during the polio epidemic. New NPV devices are designed to fit the thorax only, using a cuirass (a torso-covering body armor molded shell).

For years, NPV use declined as NIPPV use increased. However, during the shortage of NIPPV devices during COVID and a recent recall of certain CPAP devices, NPV use has increased. NPV is an excellent alternative for those who cannot tolerate a facial mask due to facial deformity, claustrophobia, or excessive airway secretion (Corrado A et al. European Resp J. 2002;20[1]:187).
 

NIPPV

NIPPV is divided into several subtypes, including continuous positive airway pressure (CPAP), bilevel positive airway pressure (BPAP or BiPAP), and average volume-assured pressure support (AVAPS or VAPS). CPAP is defined as a single pressure delivered in inhalation (Pi) and exhalation (Pe). The increased mean airway pressure provides improved oxygenation (O₂) but not ventilation (CO₂). BPAP uses dual pressures with Pi higher than Pe. The increased mean airway pressure provides improved O₂ while the difference between Pi minus Pe increases ventilation and decreases CO₂.

AVAPS is a form of BPAP where Pi varies in an automated range to achieve the ordered tidal volume. In AVAPS, the generator adjusts Pi based on the average delivered tidal volume. If the average delivered tidal volume is less than the set tidal volume, Pi gradually increases while not exceeding Pi Max. Patients notice improved comfort of AVAPS with a variable Pi vs. BPAP with a fixed Pi (Frank A et al. Chest. 2018;154[4]:1060A).

Samantha Tauscher, DO, Resident-in-Training

Herbert Patrick, MD, MSEE, FCCP , Member-at-Large
 

Pulmonary Vascular & Cardiovascular Disease Network

Pulmonary Vascular Disease Section

A RACE to the finish: Revisiting the role of BPA in the management of CTEPH

Pulmonary thromboendarterectomy (PTE) is the treatment of choice for patients with CTEPH (Kim NH et al. Eur Respir J. 2019;53:1801915). However, this leaves about 40% of CTEPH patients who are not operative candidates due to inaccessible distal clot burden or significant comorbidities (Pepke-Zaba J et al. Circulation 2011;124:1973). For these inoperable situations, riociguat is the only FDA-approved medical therapy (Delcroix M et al. Eur Respir J. 2021;57:2002828). Balloon pulmonary angioplasty (BPA) became a treatment option for these patients in the last 2 decades. As technique refined, BPA demonstrated improved safety data along with improved hemodynamics and increased exercise capacity (Kataoka M et al. Circ Cardiovasc Interv. 2012;5:756).

A recently published crossover study, the RACE trial, compared riociguat with BPA in treating inoperable CTEPH (Jaïs X et al. Lancet Respir Med. 2022;10[10]:961). Patients were randomly assigned to either riociguat or BPA for 26 weeks. At 26 weeks, patients with pulmonary vascular resistance (PVR) more than 4 Woods Units (WU) were crossed over to receive either BPA or riociguat therapy. At 26 weeks, the BPA arm showed a greater reduction in PVR but more complications, including lung injury and hemoptysis. After a 26-week crossover period, the reduction in PVR was similar in both arms. The complication rate in the BPA arm was lower when preceded by riociguat.

In patients with inoperable CTEPH, BPA has emerged as an attractive management option in addition to the medical therapy with riociguat. However, BPA should be performed at expert centers with experience. Further studies are needed to strengthen the role and optimal timing of BPA in management of post PTE patients with residual PH.

Samantha Pettigrew, MD, Fellow-in-Training

Janine Vintich, MD, FCCP, Member-at-Large

CHEST FOUNDATION GRANT AWARDS

CHEST Foundation Research Grant in Women’s Lung Health Disparities

Laura Sanapo, MD, The Miriam Hospital, Providence, R.I.

This grant is jointly supported by the CHEST Foundation and the Respiratory Health Association.



CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease

Benjamin Wu, MD, New York University

This grant is supported by AstraZeneca.



CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease

Richard Zou, MD, University of Pittsburgh Medical Center

This grant is supported by the CHEST Foundation.



CHEST Foundation and AASM Foundation Research Grant in Sleep Medicine

Gonzalo Labarca, MD, Universidad San Sebastian, Concepción, Chile

This grant is jointly supported by the CHEST Foundation and AASM Foundation.



CHEST Foundation and American Academy of Dental Sleep Medicine Research Grant in Sleep Apnea

Sherri Katz, MD, FCCP, Children’s Hospital of Eastern Ontario, Ottawa

This grant is supported by the CHEST Foundation and American Academy of Dental Sleep Medicine.



CHEST Foundation Research Grant in Sleep Medicine

Nancy Stewart, DO, University of Kansas Medical Center, Kansas City

This grant is supported by Jazz Pharmaceuticals.



CHEST Foundation Research Grant in Severe Asthma

Gareth Walters, MD, University Hospitals Birmingham (England)

This grant is supported by AstraZeneca.

CHEST Foundation Research Grant in Severe Asthma

Andréanne Côté, MD, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec

This grant is supported by AstraZeneca.



CHEST Foundation and APCCMPD Research Grant in Medical Education

Christopher Leba, MD, MPH, University of California, San Francisco

This grant is jointly supported by the CHEST Foundation and APCCMPD.



CHEST Foundation Research Grant in COVID-19

Clea Barnett, MD, New York University

This grant is supported by the CHEST Foundation.



CHEST Foundation Research Grant in Critical Care

Katherine Walker, MD, Brigham and Women’s Hospital, Harvard Medical School, Boston

This grant is supported by the CHEST Foundation.

CHEST Foundation Research Grant in Venous Thromboembolism

Daniel Lachant, DO, University of Rochester (N.Y.) Medical Center/Strong Memorial Hospital

This grant is supported by the CHEST Foundation.



CHEST Foundation Research Grant in Pulmonary Hypertension

Christina Thornton, MD, PhD, University of Calgary (Alta.)

This grant is supported by the CHEST Foundation.



CHEST Foundation Research Grant in Pulmonary Fibrosis

Christina Eckhardt, MD, Columbia University, New York

This grant is supported by an independent grant from Boehringer Ingelheim Pharmaceuticals and Genentech.



CHEST Foundation Research Grant in Pulmonary Fibrosis

John Kim, MD, University of Virginia, Charlottesville

This grant is supported by an independent grant from Boehringer Ingelheim Pharmaceuticals and Genentech.



John R. Addrizzo, MD, FCCP Research Grant in Sarcoidosis

Kerry Hena, MD, New York University

This grant is in honor of John R. Addrizzo, MD, FCCP and is jointly supported by the Addrizzo family and the CHEST Foundation.



CHEST Foundation Research Grant in Pediatric Lung Health

Adam Shapiro, MD, McGill University Health Centre, Montreal

This grant is supported by the CHEST Foundation.



CHEST Foundation Young Investigator Grant

Sameer Avasarala, MD, Case Western Reserve University, Cleveland

This grant is supported by the CHEST Foundation.



CHEST/ALA/ATS Respiratory Health Equity Research Award

Matthew Triplette, MD, Fred Hutchinson Cancer Research Center, Seattle

The Respiratory Health Equity Research Award is jointly supported by the American Lung Association, the American Thoracic Society, and the CHEST Foundation.



CHEST/ALA/ATS Respiratory Health Equity Research Award

Ayobami Akenroye, MD, MPH, Brigham and Women’s Hospital, Boston

The Respiratory Health Equity Research Award is jointly supported by the American Lung Association, the American Thoracic Society, and the CHEST Foundation.



CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Lorriane Odhiambo, PhD, Augusta (Ga.) University

This grant is supported by the CHEST Foundation.



CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Katie Stevens, Team Telomere, New York

This grant is supported by the CHEST Foundation.



CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Matthew Sharpe, MD, The University of Kansas Medical Center, Kansas City

This grant is supported by the CHEST Foundation.
 

SCIENTIFIC ABSTRACT AWARDS

Alfred Soffer Research Awards

Presented abstracts will be judged by session moderators, and award recipients will be selected for their outstanding original scientific research. Finalists will be evaluated on the basis of their written abstract and the quality of their oral presentation. This award is named in honor of Alfred Soffer, MD, Master FCCP, who was Editor in Chief of the journal CHEST® from 1968 to 1993, and Executive Director of CHEST from 1969 to 1992.



Young Investigator Awards

Investigators who are enrolled in a training or fellowship program or who have completed a fellowship program within 5 years prior to CHEST 2022 are eligible for Young Investigator Awards.

Presenters will be evaluated on the basis of their written abstract and presentation. Recipients will be selected by judges from the Scientific Presentations and Awards Committee for their outstanding original scientific research.

Top Rapid Fire Abstract Award

Awards are granted to two presenters from all the rapid fire sessions at the CHEST Annual Meeting for outstanding original scientific research and presentation



Top Case Report Award

Awards are granted to one presenter in each oral case report session at the CHEST Annual Meeting for outstanding original scientific research and presentation



Top Rapid Fire Case Report Award

Awards are granted to one presenter in each rapid fire oral case report session at the CHEST Annual Meeting for outstanding original scientific research and presentation

 

ALFRED SOFFER RESEARCH AWARD WINNERS

Palak Rath, MD

A Sense Of Urgency: Boarding Of Critical Care Medicine Patients In The ED

Syed Nazeer Mahmood, MD

Quantifying The Risk For Overtreatment And Undertreatment Of Severe Community Onset Pneumonia
 

YOUNG INVESTIGATOR AWARD WINNERS

Anusha Devarajan, MD, MBBS

Pneumomediastinum And Pneumothorax In COVID-19 Pneumonia: A Matched Case-Control Study

Marjan Islam, MD

Thoracic Ultrasound In COVID-19: Use Of Lung And Diaphragm Ultrasound In Evaluating Dyspnea In Survivors Of Critical Illness From COVID-19 Pneumonia In A Post-ICU Clinic

Aaron St Laurent, MD

Duchenne Muscular Dystrophy Respiratory Profiles From Real-World Registry Data: A Retrospective Longitudinal Study
 

ABSTRACT RAPID FIRE WINNERS

Andrew J.O. Davis, MD

Early Gas Exchange Parameters Not Associated With Survival In COVID-19-Associated ARDS Patients Requiring Prolonged Venovenous Extracorporeal Membrane Oxygenation

Benjamin Emmanuel

Clinical Outcomes In Patients With Severe Asthma Who Had Or Had Not Initiated Biologic Therapy: Results From The CLEAR Study
 

CASE REPORT SESSION WINNERS

Sathya Alekhya Bukkuri

Smarca4-Deficient Undifferentiated Tumor: A Rare Thoracic Malignancy

Zachary A. Banbury, MD

Fungal Aortitis In A Patient For Whom Blood Transfusion Is Not An Option: A Rare But Potentially Fatal Complication Of Aortic Valve Replacement

Harinivaas Shanmugavel Geetha, MD

Respiratory Distress After Potentially Fatal Aspirin Overdose: When To Intubate?

Lisa Hayes

Systemic Epstein-Barr Virus-Related T-Cell Lymphoproliferative Disorder: A Rare Cause Of Dyspnea And Pulmonary Infiltrates In An Immunocompetent Adult

Mohammed Alsaggaf, MBBS

Calcium Oxalate Deposition In Pulmonary Aspergillosis

Cheyenne Snavely

Traffic Jam In The Vasculature: A Case Of Pulmonary Leukostasis

Clarissa Smith, MD

Talcoma In Lung Cancer Screening: A Rare Benign Cause Of PET Scan Avidity

Nitin Gupta, MD

The Clue Is In The Blood Gas: A Rare Manifestation Of Lactic Acidosis

Moses Hayrabedian, MD

A Century-Old Infection Mimicking Malignancy: A Case Of Diffuse Histoplasmosis

Gabriel R. Schroeder, MD

A Case Of Wind-Instrument Associated Hypersensitivity Pneumonitis

Fizza Sajid, DO

Leaping From Lush Tropical Environments To The L-Train: A Case Of Severe Leptospirosis In New York City

Krista R. Dollar, MD

Looking Past The Ground Glass: It Was Only Skin Deep

Konstantin Golubykh, MD

Point-Of-Care Ultrasound In The Timely Diagnosis Of Colonic Necrosis

Arsal Tharwani

Abdominal Compression In End-Stage Fibrotic Interstitial Lung Disease (ILD) Improves Respiratory Compliance

Ryan Kozloski

When Asthma Isn’t: Multispecialty Approach To Fibrosing Mediastinitis

Zach S. Jarrett, DO

Vanishing Cancer: A Case Of Smoking-Related Organizing Pneumonia

Stephen Simeone

Intravascular Papillary Endothelial Hyperplasia Presenting As Thrombus In Transit With Acute Pulmonary Embolism

David Gruen, MD

Tackling Posterior Reversible Encephalopathy Syndrome (PRES): A Rare Case Of Subtherapeutic Tacrolimus Causing PRES In Steroid-Resistant Nephropathy

Nicholas Kunce, MD

An Unusual Case Of Subacute Bacterial Endocarditis Presenting With Catastrophic Subarachnoid Hemorrhage

Phillip J. Gary, MD

Sarcoid-Like Reaction After Treatment With Pembrolizumab

Shreya Podder, MD

Endobronchial Valves For Treatment Of Persistent Air Leak After Secondary Spontaneous Pneumothorax In Patients With Cystic Fibrosis

Alina Aw Wasim, MD, MBBS

Chest-Wall Castleman Disease Mimicking Thymoma Drop Metastasis

Ndausung Udongwo

The ‘Rat Bite Sign” On Cardiac MRI: Left Dominant Arrhythmogenic Cardiomyopathy As An Atypical Etiology Of Sudden Cardiac Arrest

Grant Senyei, MD

Management Of Ventriculopleural Shunt-Associated Pleural Effusion

Garima Singh, MD

COVID-19-Associated Thrombotic Thrombocytopenia Purpura (TTP)
 

CASE REPORT RAPID FIRE WINNERS

Sandeep Patri

Hyperammonemia Postlung Transplantation: An Uncommon But Life-Threatening Complication

Trung Nguyen

Dyspnea During Pregnancy Revealing Multiple Pulmonary Arteriovenous Malformations And A New Diagnosis Of Hereditary Hemorrhagic Telangiectasia

Pedro J. Baez, MD

Adenoid Cystic Adenocarcinoma: A Rare Esophageal Malignancy Misdiagnosed As COPD

Brette Guckian, DO

Management Of Pulmonary Cement Emboli After Kyphoplasty

Brinn Demars, DO

Tumor Emboli In The Pulmonary Artery Secondary To Chondrosarcoma: A Rare Presentation Mimicking Pulmonary Thromboembolism

Aakriti Arora

A Case Of Pulmonary Hypertension As A Possible Extracranial Manifestation Of Moyamoya Disease

Racine Elaine Reinoso

Clot In Transit: The Role Of Point-Of-Care Ultrasound In Early Diagnosis And Improved Outcomes

Qiraat Azeem, MD

A Case Of Autosomal-Dominant Hyper-IgE Syndrome Masquerading As Cystic Fibrosis

Jason R. Ballengee, DO

Third-Trimester Pregnancy Complicated By Non-Small Cell Lung Cancer Initially Presenting With Central Airway Obstruction And Stenosis

Sam Shafer

Caught In The Fray: Neurosarcoidosis Presenting As Chronic Respiratory Failure

Takkin Lo, MD, MPH

China White In Asthmatic Recreational Drug Users: Does It Contribute To Pneumatocele Development?

Sanjeev Shrestha, MD

Successful Treatment Of Microscopic Polyangiitis Using Novel Steroid-Sparing Agent Avacopan

Kristina Menchaca, MD

Cardiac Tamponade Without The Beck Triad: A Complication Of Severe Hypothyroidism

Olivia Millay, BS

Spontaneous Coronary Artery Dissection Of Left Anterior Descending Artery Complicated By Ventricular Septal Rupture

Akruti P. Prabhakar, DO

Delayed Lead Perforation Of The Right Atrium In The Presence Of Persistent Left Superior Vena Cava: A Rare Coincidence

Kevin Hsu, MD

A Modified Valsalva Maneuver For Ventilated And Sedated Patients With Unstable Supraventricular Tachycardia

Nang San Hti Lar Seng

Cardiovascular Manifestations Of Paraaortic Paragangliomas

Rocio Castillo-Larios

Membranous Dehiscence After Tracheal Resection And Reconstruction Healed Spontaneously With Conservative Treatment

Fizza Sajid, DO

A Young Broken Heart, Reversed

Janeen Grant-Sittol, MD

Inhaled Tranexamic Acid Use For Massive Hemoptysis In Vasculitis-Induced Bronchoalveolar Hemorrhage

Raman G. Kutty, Md, PhD

Progressive Lung Infiltrates In Patient With Acquired Immunodeficiency: A Rare Case Of GLILD

Tanwe Shende

Mycobacterium Shimoidei: A Rare Nontuberculous Infection In A U.S. Patient

Sarah M. Upson, MD

Not Your Typical Lactic Acidosis

Prachi Saluja, MD

Late-Onset Immune Thrombotic Thrombocytopenic Purpura (TTP) After Asymptomatic COVID-19 Infection

Steven S. Wu, MD

Type 1 Multiple Endocrine Neoplasia-Associated Tracheobronchial Tumors Managed By Rigid Bronchoscopy-Directed Multimodal Tumor Destruction

Konstantin Golubykh, MD

The Reversal That Helped: Role Of Bedside Echocardiography In Takotsubo Cardiomyopathy

Eric Salomon, MD

Obstructive Tracheobronchial Pulmonary Aspergillosis Managed With Local Bronchoscopic Intervention Alone

Daniel Hoesterey, MD

A Rare Case Of Critical Illness Due To Eczema Herpeticum With Disseminated Herpes Simplex Virus Infection

Awab U. Khan, DO

Severe Colchicine Toxicity In A Suicide Attempt Causing Multiorgan Failure: A Survival Story

Jacob Cebulko

Disseminated Strongyloidiasis In A Patient With Acute Lymphocytic Leukemia

Hasan Baher, MD

Hiding In Plain Sight: Disseminated Pulmonary TB

Navneet Ramesh

Multimodal Management Of Gastric Variceal Bleeding In Hemorrhagic Shock

Jason L. Peng, MD

Improving Compliance With Continuous Anterior Chest Compression In ARDS Caused By COVID-19: A Case Series

Sushan Gupta, MD

Complete Resolution Of Vasoreactive Pulmonary Artery Hypertension In Chronic Hypersensitive Pneumonitis

Mamta S. Chhabria, MD

A Fistulous Issue: Gastropleural Fistula As A Complication Of Gastrectomy

Anita Singh, DO, MBA

Identifying A Novel Surfactant Protein Mutation In A Family With Pulmonary Fibrosis

Rana Prathap Padappayil, MBBS

Delayed Cerebral Venous Sinus Thrombosis (CSVT) After An Invasive Meningioma Resection: An Uncommon Presentation Of A Common Complication

Rubabin Tooba, MD

The Morphing Cavity: An Image Series Of A Patient’s Pulmonary Infarction Over Time

Sally Ziatabar, DO

A Rare Case Of Disseminated Blastomycosis

Sumukh Arun Kumar

Incidental Pulmonary Cavitary Lesions As An Uncommon Presentation Of Lemierre Syndrome

Sophia Emetu

Pet Peeve: Dyspnea From Undiagnosed Pasteurella Multocida Empyema

Chidambaram Ramasamy, MD

A Case Of Diffuse Alveolar-Septal Pulmonary Amyloidosis And Cardiomyopathy

Rachel Swier

Acid-Fast Bacteria In Bronchiectasis: If The Glass Slipper Does Not Fit, Non-TB Mycobacteria, Consider Tsukamurella

Catherine Durant, MD

Idiopathic Multicentric Castleman Disease With Tafro Syndrome And Sjögren Syndrome

Ali Al-Hilli, MD, MSc

Sarcoidosis-Like Reaction During Treatment For Metastatic Breast Cancer With CDK 4/6 Inhibitors: Just An Epiphenomenon Or A Causal Relationship?

Scott Slusarenko, DO

Rapidly Progressive Perimyocarditis In SARS-CoV-2 Infection

Agatha M. Formoso, MD

Two Infants Presenting With Polymicrobial Pneumonia And Hypoxemic Respiratory Failure Associated With Heterozygous Variants In Carmil2 And Itk

Juan Adams-Chahin

The Silence Of “Lam”: A Case Of Tuberous Sclerosis Complex Associated With Lymphangioleiomyomatosis (Lam)

Kathleen Capaccione, MD

Lung Cancer Is Not Always The Answer: Exploring The Differential Diagnosis Of Thoracic Masses

Joann Wongvravit, DO

West Nile-Induced Myasthenia Gravis Crisis: An Unexpected Case Of Respiratory Failure

Ethan Karle, Do

A Rare Cause Of Community-Acquired Bacterial Pneumonia In A Patient With Poorly Controlled Diabetes

Taylor C. Becker, MD

Calcified Cavitary Conundrum: Delayed Diagnosis Of Histoplasmosis

Anneka Hutton, MD

Disseminated Listeriosis: A Deadly Triplicate

Omar Kandah, DO

COVID-19 Cardiac Tamponade With Cardiogenic Shock In A Previously Vaccinated Young Adult: A Case Report

Cihan Caglayan, MD

Partial Anomalous Pulmonary Venous Connection Diagnosed After Central Venous Catheter Placement

Michelle Jones, DO

Delayed Hemophagocytic Lymphohistiocytosis (HLH) Diagnosis In A Patient With Pulmonary Sarcoidosis And Newly Diagnosed T-Cell Lymphoma: A Case Report

Mariah Evarts, MD

A Normotensive Woman With Profound Lactic Acidosis And Stress-Induced Cardiomyopathy

Rachel V. Tan, MD

A Four-Boding Future: Polyviral Infection With SARS-CoV-2, Parainfluenza Virus Type 3, Influenza A, And Adenovirus

Thanh Hoang

Recurrent Syncope From Intermittent Torsades In Loperamide Abuse

Alissa Ali, MD

Ground Glass Opacities In A Patient Receiving Treatment With All-Trans Retinoic Acid And Arsenic Trioxide

Sean M. Masi, DO, MBA

Ferritin-Guided Therapeutic Plasma Exchange (TPE) Administration In COVID-19-Induced Cytokine Storm Syndrome: A Case Series

Anjali Sachdeva

Successful Biopsy Of Aortopulmonary Window Lymph Node With Robotic-Assisted Bronchoscopy

Rehan Saeed, MD

Multiple Sclerosis After COVID-19: A Sign Of Things To Come?

Harshitha Mergey Devender

Invasive Pulmonary Aspergillosis Associated With Nonspecific Interstitial Pneumonia Causing Recurrent Respiratory Failure



Be sure to check out the other award winners on page 20 in the January issue of CHEST Physician: https://tinyurl.com/2bcdcbj3 .

CHEST FOUNDATION GRANT AWARDS

CHEST Foundation Research Grant in Women’s Lung Health Disparities

Laura Sanapo, MD, The Miriam Hospital, Providence, R.I.

This grant is jointly supported by the CHEST Foundation and the Respiratory Health Association.



CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease

Benjamin Wu, MD, New York University

This grant is supported by AstraZeneca.



CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease

Richard Zou, MD, University of Pittsburgh Medical Center

This grant is supported by the CHEST Foundation.



CHEST Foundation and AASM Foundation Research Grant in Sleep Medicine

Gonzalo Labarca, MD, Universidad San Sebastian, Concepción, Chile

This grant is jointly supported by the CHEST Foundation and AASM Foundation.



CHEST Foundation and American Academy of Dental Sleep Medicine Research Grant in Sleep Apnea

Sherri Katz, MD, FCCP, Children’s Hospital of Eastern Ontario, Ottawa

This grant is supported by the CHEST Foundation and American Academy of Dental Sleep Medicine.



CHEST Foundation Research Grant in Sleep Medicine

Nancy Stewart, DO, University of Kansas Medical Center, Kansas City

This grant is supported by Jazz Pharmaceuticals.



CHEST Foundation Research Grant in Severe Asthma

Gareth Walters, MD, University Hospitals Birmingham (England)

This grant is supported by AstraZeneca.

CHEST Foundation Research Grant in Severe Asthma

Andréanne Côté, MD, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec

This grant is supported by AstraZeneca.



CHEST Foundation and APCCMPD Research Grant in Medical Education

Christopher Leba, MD, MPH, University of California, San Francisco

This grant is jointly supported by the CHEST Foundation and APCCMPD.



CHEST Foundation Research Grant in COVID-19

Clea Barnett, MD, New York University

This grant is supported by the CHEST Foundation.



CHEST Foundation Research Grant in Critical Care

Katherine Walker, MD, Brigham and Women’s Hospital, Harvard Medical School, Boston

This grant is supported by the CHEST Foundation.

CHEST Foundation Research Grant in Venous Thromboembolism

Daniel Lachant, DO, University of Rochester (N.Y.) Medical Center/Strong Memorial Hospital

This grant is supported by the CHEST Foundation.



CHEST Foundation Research Grant in Pulmonary Hypertension

Christina Thornton, MD, PhD, University of Calgary (Alta.)

This grant is supported by the CHEST Foundation.



CHEST Foundation Research Grant in Pulmonary Fibrosis

Christina Eckhardt, MD, Columbia University, New York

This grant is supported by an independent grant from Boehringer Ingelheim Pharmaceuticals and Genentech.



CHEST Foundation Research Grant in Pulmonary Fibrosis

John Kim, MD, University of Virginia, Charlottesville

This grant is supported by an independent grant from Boehringer Ingelheim Pharmaceuticals and Genentech.



John R. Addrizzo, MD, FCCP Research Grant in Sarcoidosis

Kerry Hena, MD, New York University

This grant is in honor of John R. Addrizzo, MD, FCCP and is jointly supported by the Addrizzo family and the CHEST Foundation.



CHEST Foundation Research Grant in Pediatric Lung Health

Adam Shapiro, MD, McGill University Health Centre, Montreal

This grant is supported by the CHEST Foundation.



CHEST Foundation Young Investigator Grant

Sameer Avasarala, MD, Case Western Reserve University, Cleveland

This grant is supported by the CHEST Foundation.



CHEST/ALA/ATS Respiratory Health Equity Research Award

Matthew Triplette, MD, Fred Hutchinson Cancer Research Center, Seattle

The Respiratory Health Equity Research Award is jointly supported by the American Lung Association, the American Thoracic Society, and the CHEST Foundation.



CHEST/ALA/ATS Respiratory Health Equity Research Award

Ayobami Akenroye, MD, MPH, Brigham and Women’s Hospital, Boston

The Respiratory Health Equity Research Award is jointly supported by the American Lung Association, the American Thoracic Society, and the CHEST Foundation.



CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Lorriane Odhiambo, PhD, Augusta (Ga.) University

This grant is supported by the CHEST Foundation.



CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Katie Stevens, Team Telomere, New York

This grant is supported by the CHEST Foundation.



CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Matthew Sharpe, MD, The University of Kansas Medical Center, Kansas City

This grant is supported by the CHEST Foundation.
 

SCIENTIFIC ABSTRACT AWARDS

Alfred Soffer Research Awards

Presented abstracts will be judged by session moderators, and award recipients will be selected for their outstanding original scientific research. Finalists will be evaluated on the basis of their written abstract and the quality of their oral presentation. This award is named in honor of Alfred Soffer, MD, Master FCCP, who was Editor in Chief of the journal CHEST® from 1968 to 1993, and Executive Director of CHEST from 1969 to 1992.



Young Investigator Awards

Investigators who are enrolled in a training or fellowship program or who have completed a fellowship program within 5 years prior to CHEST 2022 are eligible for Young Investigator Awards.

Presenters will be evaluated on the basis of their written abstract and presentation. Recipients will be selected by judges from the Scientific Presentations and Awards Committee for their outstanding original scientific research.

Top Rapid Fire Abstract Award

Awards are granted to two presenters from all the rapid fire sessions at the CHEST Annual Meeting for outstanding original scientific research and presentation



Top Case Report Award

Awards are granted to one presenter in each oral case report session at the CHEST Annual Meeting for outstanding original scientific research and presentation



Top Rapid Fire Case Report Award

Awards are granted to one presenter in each rapid fire oral case report session at the CHEST Annual Meeting for outstanding original scientific research and presentation

 

ALFRED SOFFER RESEARCH AWARD WINNERS

Palak Rath, MD

A Sense Of Urgency: Boarding Of Critical Care Medicine Patients In The ED

Syed Nazeer Mahmood, MD

Quantifying The Risk For Overtreatment And Undertreatment Of Severe Community Onset Pneumonia
 

YOUNG INVESTIGATOR AWARD WINNERS

Anusha Devarajan, MD, MBBS

Pneumomediastinum And Pneumothorax In COVID-19 Pneumonia: A Matched Case-Control Study

Marjan Islam, MD

Thoracic Ultrasound In COVID-19: Use Of Lung And Diaphragm Ultrasound In Evaluating Dyspnea In Survivors Of Critical Illness From COVID-19 Pneumonia In A Post-ICU Clinic

Aaron St Laurent, MD

Duchenne Muscular Dystrophy Respiratory Profiles From Real-World Registry Data: A Retrospective Longitudinal Study
 

ABSTRACT RAPID FIRE WINNERS

Andrew J.O. Davis, MD

Early Gas Exchange Parameters Not Associated With Survival In COVID-19-Associated ARDS Patients Requiring Prolonged Venovenous Extracorporeal Membrane Oxygenation

Benjamin Emmanuel

Clinical Outcomes In Patients With Severe Asthma Who Had Or Had Not Initiated Biologic Therapy: Results From The CLEAR Study
 

CASE REPORT SESSION WINNERS

Sathya Alekhya Bukkuri

Smarca4-Deficient Undifferentiated Tumor: A Rare Thoracic Malignancy

Zachary A. Banbury, MD

Fungal Aortitis In A Patient For Whom Blood Transfusion Is Not An Option: A Rare But Potentially Fatal Complication Of Aortic Valve Replacement

Harinivaas Shanmugavel Geetha, MD

Respiratory Distress After Potentially Fatal Aspirin Overdose: When To Intubate?

Lisa Hayes

Systemic Epstein-Barr Virus-Related T-Cell Lymphoproliferative Disorder: A Rare Cause Of Dyspnea And Pulmonary Infiltrates In An Immunocompetent Adult

Mohammed Alsaggaf, MBBS

Calcium Oxalate Deposition In Pulmonary Aspergillosis

Cheyenne Snavely

Traffic Jam In The Vasculature: A Case Of Pulmonary Leukostasis

Clarissa Smith, MD

Talcoma In Lung Cancer Screening: A Rare Benign Cause Of PET Scan Avidity

Nitin Gupta, MD

The Clue Is In The Blood Gas: A Rare Manifestation Of Lactic Acidosis

Moses Hayrabedian, MD

A Century-Old Infection Mimicking Malignancy: A Case Of Diffuse Histoplasmosis

Gabriel R. Schroeder, MD

A Case Of Wind-Instrument Associated Hypersensitivity Pneumonitis

Fizza Sajid, DO

Leaping From Lush Tropical Environments To The L-Train: A Case Of Severe Leptospirosis In New York City

Krista R. Dollar, MD

Looking Past The Ground Glass: It Was Only Skin Deep

Konstantin Golubykh, MD

Point-Of-Care Ultrasound In The Timely Diagnosis Of Colonic Necrosis

Arsal Tharwani

Abdominal Compression In End-Stage Fibrotic Interstitial Lung Disease (ILD) Improves Respiratory Compliance

Ryan Kozloski

When Asthma Isn’t: Multispecialty Approach To Fibrosing Mediastinitis

Zach S. Jarrett, DO

Vanishing Cancer: A Case Of Smoking-Related Organizing Pneumonia

Stephen Simeone

Intravascular Papillary Endothelial Hyperplasia Presenting As Thrombus In Transit With Acute Pulmonary Embolism

David Gruen, MD

Tackling Posterior Reversible Encephalopathy Syndrome (PRES): A Rare Case Of Subtherapeutic Tacrolimus Causing PRES In Steroid-Resistant Nephropathy

Nicholas Kunce, MD

An Unusual Case Of Subacute Bacterial Endocarditis Presenting With Catastrophic Subarachnoid Hemorrhage

Phillip J. Gary, MD

Sarcoid-Like Reaction After Treatment With Pembrolizumab

Shreya Podder, MD

Endobronchial Valves For Treatment Of Persistent Air Leak After Secondary Spontaneous Pneumothorax In Patients With Cystic Fibrosis

Alina Aw Wasim, MD, MBBS

Chest-Wall Castleman Disease Mimicking Thymoma Drop Metastasis

Ndausung Udongwo

The ‘Rat Bite Sign” On Cardiac MRI: Left Dominant Arrhythmogenic Cardiomyopathy As An Atypical Etiology Of Sudden Cardiac Arrest

Grant Senyei, MD

Management Of Ventriculopleural Shunt-Associated Pleural Effusion

Garima Singh, MD

COVID-19-Associated Thrombotic Thrombocytopenia Purpura (TTP)
 

CASE REPORT RAPID FIRE WINNERS

Sandeep Patri

Hyperammonemia Postlung Transplantation: An Uncommon But Life-Threatening Complication

Trung Nguyen

Dyspnea During Pregnancy Revealing Multiple Pulmonary Arteriovenous Malformations And A New Diagnosis Of Hereditary Hemorrhagic Telangiectasia

Pedro J. Baez, MD

Adenoid Cystic Adenocarcinoma: A Rare Esophageal Malignancy Misdiagnosed As COPD

Brette Guckian, DO

Management Of Pulmonary Cement Emboli After Kyphoplasty

Brinn Demars, DO

Tumor Emboli In The Pulmonary Artery Secondary To Chondrosarcoma: A Rare Presentation Mimicking Pulmonary Thromboembolism

Aakriti Arora

A Case Of Pulmonary Hypertension As A Possible Extracranial Manifestation Of Moyamoya Disease

Racine Elaine Reinoso

Clot In Transit: The Role Of Point-Of-Care Ultrasound In Early Diagnosis And Improved Outcomes

Qiraat Azeem, MD

A Case Of Autosomal-Dominant Hyper-IgE Syndrome Masquerading As Cystic Fibrosis

Jason R. Ballengee, DO

Third-Trimester Pregnancy Complicated By Non-Small Cell Lung Cancer Initially Presenting With Central Airway Obstruction And Stenosis

Sam Shafer

Caught In The Fray: Neurosarcoidosis Presenting As Chronic Respiratory Failure

Takkin Lo, MD, MPH

China White In Asthmatic Recreational Drug Users: Does It Contribute To Pneumatocele Development?

Sanjeev Shrestha, MD

Successful Treatment Of Microscopic Polyangiitis Using Novel Steroid-Sparing Agent Avacopan

Kristina Menchaca, MD

Cardiac Tamponade Without The Beck Triad: A Complication Of Severe Hypothyroidism

Olivia Millay, BS

Spontaneous Coronary Artery Dissection Of Left Anterior Descending Artery Complicated By Ventricular Septal Rupture

Akruti P. Prabhakar, DO

Delayed Lead Perforation Of The Right Atrium In The Presence Of Persistent Left Superior Vena Cava: A Rare Coincidence

Kevin Hsu, MD

A Modified Valsalva Maneuver For Ventilated And Sedated Patients With Unstable Supraventricular Tachycardia

Nang San Hti Lar Seng

Cardiovascular Manifestations Of Paraaortic Paragangliomas

Rocio Castillo-Larios

Membranous Dehiscence After Tracheal Resection And Reconstruction Healed Spontaneously With Conservative Treatment

Fizza Sajid, DO

A Young Broken Heart, Reversed

Janeen Grant-Sittol, MD

Inhaled Tranexamic Acid Use For Massive Hemoptysis In Vasculitis-Induced Bronchoalveolar Hemorrhage

Raman G. Kutty, Md, PhD

Progressive Lung Infiltrates In Patient With Acquired Immunodeficiency: A Rare Case Of GLILD

Tanwe Shende

Mycobacterium Shimoidei: A Rare Nontuberculous Infection In A U.S. Patient

Sarah M. Upson, MD

Not Your Typical Lactic Acidosis

Prachi Saluja, MD

Late-Onset Immune Thrombotic Thrombocytopenic Purpura (TTP) After Asymptomatic COVID-19 Infection

Steven S. Wu, MD

Type 1 Multiple Endocrine Neoplasia-Associated Tracheobronchial Tumors Managed By Rigid Bronchoscopy-Directed Multimodal Tumor Destruction

Konstantin Golubykh, MD

The Reversal That Helped: Role Of Bedside Echocardiography In Takotsubo Cardiomyopathy

Eric Salomon, MD

Obstructive Tracheobronchial Pulmonary Aspergillosis Managed With Local Bronchoscopic Intervention Alone

Daniel Hoesterey, MD

A Rare Case Of Critical Illness Due To Eczema Herpeticum With Disseminated Herpes Simplex Virus Infection

Awab U. Khan, DO

Severe Colchicine Toxicity In A Suicide Attempt Causing Multiorgan Failure: A Survival Story

Jacob Cebulko

Disseminated Strongyloidiasis In A Patient With Acute Lymphocytic Leukemia

Hasan Baher, MD

Hiding In Plain Sight: Disseminated Pulmonary TB

Navneet Ramesh

Multimodal Management Of Gastric Variceal Bleeding In Hemorrhagic Shock

Jason L. Peng, MD

Improving Compliance With Continuous Anterior Chest Compression In ARDS Caused By COVID-19: A Case Series

Sushan Gupta, MD

Complete Resolution Of Vasoreactive Pulmonary Artery Hypertension In Chronic Hypersensitive Pneumonitis

Mamta S. Chhabria, MD

A Fistulous Issue: Gastropleural Fistula As A Complication Of Gastrectomy

Anita Singh, DO, MBA

Identifying A Novel Surfactant Protein Mutation In A Family With Pulmonary Fibrosis

Rana Prathap Padappayil, MBBS

Delayed Cerebral Venous Sinus Thrombosis (CSVT) After An Invasive Meningioma Resection: An Uncommon Presentation Of A Common Complication

Rubabin Tooba, MD

The Morphing Cavity: An Image Series Of A Patient’s Pulmonary Infarction Over Time

Sally Ziatabar, DO

A Rare Case Of Disseminated Blastomycosis

Sumukh Arun Kumar

Incidental Pulmonary Cavitary Lesions As An Uncommon Presentation Of Lemierre Syndrome

Sophia Emetu

Pet Peeve: Dyspnea From Undiagnosed Pasteurella Multocida Empyema

Chidambaram Ramasamy, MD

A Case Of Diffuse Alveolar-Septal Pulmonary Amyloidosis And Cardiomyopathy

Rachel Swier

Acid-Fast Bacteria In Bronchiectasis: If The Glass Slipper Does Not Fit, Non-TB Mycobacteria, Consider Tsukamurella

Catherine Durant, MD

Idiopathic Multicentric Castleman Disease With Tafro Syndrome And Sjögren Syndrome

Ali Al-Hilli, MD, MSc

Sarcoidosis-Like Reaction During Treatment For Metastatic Breast Cancer With CDK 4/6 Inhibitors: Just An Epiphenomenon Or A Causal Relationship?

Scott Slusarenko, DO

Rapidly Progressive Perimyocarditis In SARS-CoV-2 Infection

Agatha M. Formoso, MD

Two Infants Presenting With Polymicrobial Pneumonia And Hypoxemic Respiratory Failure Associated With Heterozygous Variants In Carmil2 And Itk

Juan Adams-Chahin

The Silence Of “Lam”: A Case Of Tuberous Sclerosis Complex Associated With Lymphangioleiomyomatosis (Lam)

Kathleen Capaccione, MD

Lung Cancer Is Not Always The Answer: Exploring The Differential Diagnosis Of Thoracic Masses

Joann Wongvravit, DO

West Nile-Induced Myasthenia Gravis Crisis: An Unexpected Case Of Respiratory Failure

Ethan Karle, Do

A Rare Cause Of Community-Acquired Bacterial Pneumonia In A Patient With Poorly Controlled Diabetes

Taylor C. Becker, MD

Calcified Cavitary Conundrum: Delayed Diagnosis Of Histoplasmosis

Anneka Hutton, MD

Disseminated Listeriosis: A Deadly Triplicate

Omar Kandah, DO

COVID-19 Cardiac Tamponade With Cardiogenic Shock In A Previously Vaccinated Young Adult: A Case Report

Cihan Caglayan, MD

Partial Anomalous Pulmonary Venous Connection Diagnosed After Central Venous Catheter Placement

Michelle Jones, DO

Delayed Hemophagocytic Lymphohistiocytosis (HLH) Diagnosis In A Patient With Pulmonary Sarcoidosis And Newly Diagnosed T-Cell Lymphoma: A Case Report

Mariah Evarts, MD

A Normotensive Woman With Profound Lactic Acidosis And Stress-Induced Cardiomyopathy

Rachel V. Tan, MD

A Four-Boding Future: Polyviral Infection With SARS-CoV-2, Parainfluenza Virus Type 3, Influenza A, And Adenovirus

Thanh Hoang

Recurrent Syncope From Intermittent Torsades In Loperamide Abuse

Alissa Ali, MD

Ground Glass Opacities In A Patient Receiving Treatment With All-Trans Retinoic Acid And Arsenic Trioxide

Sean M. Masi, DO, MBA

Ferritin-Guided Therapeutic Plasma Exchange (TPE) Administration In COVID-19-Induced Cytokine Storm Syndrome: A Case Series

Anjali Sachdeva

Successful Biopsy Of Aortopulmonary Window Lymph Node With Robotic-Assisted Bronchoscopy

Rehan Saeed, MD

Multiple Sclerosis After COVID-19: A Sign Of Things To Come?

Harshitha Mergey Devender

Invasive Pulmonary Aspergillosis Associated With Nonspecific Interstitial Pneumonia Causing Recurrent Respiratory Failure



Be sure to check out the other award winners on page 20 in the January issue of CHEST Physician: https://tinyurl.com/2bcdcbj3 .

CHEST FOUNDATION GRANT AWARDS

CHEST Foundation Research Grant in Women’s Lung Health Disparities

Laura Sanapo, MD, The Miriam Hospital, Providence, R.I.

This grant is jointly supported by the CHEST Foundation and the Respiratory Health Association.



CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease

Benjamin Wu, MD, New York University

This grant is supported by AstraZeneca.



CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease

Richard Zou, MD, University of Pittsburgh Medical Center

This grant is supported by the CHEST Foundation.



CHEST Foundation and AASM Foundation Research Grant in Sleep Medicine

Gonzalo Labarca, MD, Universidad San Sebastian, Concepción, Chile

This grant is jointly supported by the CHEST Foundation and AASM Foundation.



CHEST Foundation and American Academy of Dental Sleep Medicine Research Grant in Sleep Apnea

Sherri Katz, MD, FCCP, Children’s Hospital of Eastern Ontario, Ottawa

This grant is supported by the CHEST Foundation and American Academy of Dental Sleep Medicine.



CHEST Foundation Research Grant in Sleep Medicine

Nancy Stewart, DO, University of Kansas Medical Center, Kansas City

This grant is supported by Jazz Pharmaceuticals.



CHEST Foundation Research Grant in Severe Asthma

Gareth Walters, MD, University Hospitals Birmingham (England)

This grant is supported by AstraZeneca.

CHEST Foundation Research Grant in Severe Asthma

Andréanne Côté, MD, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec

This grant is supported by AstraZeneca.



CHEST Foundation and APCCMPD Research Grant in Medical Education

Christopher Leba, MD, MPH, University of California, San Francisco

This grant is jointly supported by the CHEST Foundation and APCCMPD.



CHEST Foundation Research Grant in COVID-19

Clea Barnett, MD, New York University

This grant is supported by the CHEST Foundation.



CHEST Foundation Research Grant in Critical Care

Katherine Walker, MD, Brigham and Women’s Hospital, Harvard Medical School, Boston

This grant is supported by the CHEST Foundation.

CHEST Foundation Research Grant in Venous Thromboembolism

Daniel Lachant, DO, University of Rochester (N.Y.) Medical Center/Strong Memorial Hospital

This grant is supported by the CHEST Foundation.



CHEST Foundation Research Grant in Pulmonary Hypertension

Christina Thornton, MD, PhD, University of Calgary (Alta.)

This grant is supported by the CHEST Foundation.



CHEST Foundation Research Grant in Pulmonary Fibrosis

Christina Eckhardt, MD, Columbia University, New York

This grant is supported by an independent grant from Boehringer Ingelheim Pharmaceuticals and Genentech.



CHEST Foundation Research Grant in Pulmonary Fibrosis

John Kim, MD, University of Virginia, Charlottesville

This grant is supported by an independent grant from Boehringer Ingelheim Pharmaceuticals and Genentech.



John R. Addrizzo, MD, FCCP Research Grant in Sarcoidosis

Kerry Hena, MD, New York University

This grant is in honor of John R. Addrizzo, MD, FCCP and is jointly supported by the Addrizzo family and the CHEST Foundation.



CHEST Foundation Research Grant in Pediatric Lung Health

Adam Shapiro, MD, McGill University Health Centre, Montreal

This grant is supported by the CHEST Foundation.



CHEST Foundation Young Investigator Grant

Sameer Avasarala, MD, Case Western Reserve University, Cleveland

This grant is supported by the CHEST Foundation.



CHEST/ALA/ATS Respiratory Health Equity Research Award

Matthew Triplette, MD, Fred Hutchinson Cancer Research Center, Seattle

The Respiratory Health Equity Research Award is jointly supported by the American Lung Association, the American Thoracic Society, and the CHEST Foundation.



CHEST/ALA/ATS Respiratory Health Equity Research Award

Ayobami Akenroye, MD, MPH, Brigham and Women’s Hospital, Boston

The Respiratory Health Equity Research Award is jointly supported by the American Lung Association, the American Thoracic Society, and the CHEST Foundation.



CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Lorriane Odhiambo, PhD, Augusta (Ga.) University

This grant is supported by the CHEST Foundation.



CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Katie Stevens, Team Telomere, New York

This grant is supported by the CHEST Foundation.



CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Matthew Sharpe, MD, The University of Kansas Medical Center, Kansas City

This grant is supported by the CHEST Foundation.
 

SCIENTIFIC ABSTRACT AWARDS

Alfred Soffer Research Awards

Presented abstracts will be judged by session moderators, and award recipients will be selected for their outstanding original scientific research. Finalists will be evaluated on the basis of their written abstract and the quality of their oral presentation. This award is named in honor of Alfred Soffer, MD, Master FCCP, who was Editor in Chief of the journal CHEST® from 1968 to 1993, and Executive Director of CHEST from 1969 to 1992.



Young Investigator Awards

Investigators who are enrolled in a training or fellowship program or who have completed a fellowship program within 5 years prior to CHEST 2022 are eligible for Young Investigator Awards.

Presenters will be evaluated on the basis of their written abstract and presentation. Recipients will be selected by judges from the Scientific Presentations and Awards Committee for their outstanding original scientific research.

Top Rapid Fire Abstract Award

Awards are granted to two presenters from all the rapid fire sessions at the CHEST Annual Meeting for outstanding original scientific research and presentation



Top Case Report Award

Awards are granted to one presenter in each oral case report session at the CHEST Annual Meeting for outstanding original scientific research and presentation



Top Rapid Fire Case Report Award

Awards are granted to one presenter in each rapid fire oral case report session at the CHEST Annual Meeting for outstanding original scientific research and presentation

 

ALFRED SOFFER RESEARCH AWARD WINNERS

Palak Rath, MD

A Sense Of Urgency: Boarding Of Critical Care Medicine Patients In The ED

Syed Nazeer Mahmood, MD

Quantifying The Risk For Overtreatment And Undertreatment Of Severe Community Onset Pneumonia
 

YOUNG INVESTIGATOR AWARD WINNERS

Anusha Devarajan, MD, MBBS

Pneumomediastinum And Pneumothorax In COVID-19 Pneumonia: A Matched Case-Control Study

Marjan Islam, MD

Thoracic Ultrasound In COVID-19: Use Of Lung And Diaphragm Ultrasound In Evaluating Dyspnea In Survivors Of Critical Illness From COVID-19 Pneumonia In A Post-ICU Clinic

Aaron St Laurent, MD

Duchenne Muscular Dystrophy Respiratory Profiles From Real-World Registry Data: A Retrospective Longitudinal Study
 

ABSTRACT RAPID FIRE WINNERS

Andrew J.O. Davis, MD

Early Gas Exchange Parameters Not Associated With Survival In COVID-19-Associated ARDS Patients Requiring Prolonged Venovenous Extracorporeal Membrane Oxygenation

Benjamin Emmanuel

Clinical Outcomes In Patients With Severe Asthma Who Had Or Had Not Initiated Biologic Therapy: Results From The CLEAR Study
 

CASE REPORT SESSION WINNERS

Sathya Alekhya Bukkuri

Smarca4-Deficient Undifferentiated Tumor: A Rare Thoracic Malignancy

Zachary A. Banbury, MD

Fungal Aortitis In A Patient For Whom Blood Transfusion Is Not An Option: A Rare But Potentially Fatal Complication Of Aortic Valve Replacement

Harinivaas Shanmugavel Geetha, MD

Respiratory Distress After Potentially Fatal Aspirin Overdose: When To Intubate?

Lisa Hayes

Systemic Epstein-Barr Virus-Related T-Cell Lymphoproliferative Disorder: A Rare Cause Of Dyspnea And Pulmonary Infiltrates In An Immunocompetent Adult

Mohammed Alsaggaf, MBBS

Calcium Oxalate Deposition In Pulmonary Aspergillosis

Cheyenne Snavely

Traffic Jam In The Vasculature: A Case Of Pulmonary Leukostasis

Clarissa Smith, MD

Talcoma In Lung Cancer Screening: A Rare Benign Cause Of PET Scan Avidity

Nitin Gupta, MD

The Clue Is In The Blood Gas: A Rare Manifestation Of Lactic Acidosis

Moses Hayrabedian, MD

A Century-Old Infection Mimicking Malignancy: A Case Of Diffuse Histoplasmosis

Gabriel R. Schroeder, MD

A Case Of Wind-Instrument Associated Hypersensitivity Pneumonitis

Fizza Sajid, DO

Leaping From Lush Tropical Environments To The L-Train: A Case Of Severe Leptospirosis In New York City

Krista R. Dollar, MD

Looking Past The Ground Glass: It Was Only Skin Deep

Konstantin Golubykh, MD

Point-Of-Care Ultrasound In The Timely Diagnosis Of Colonic Necrosis

Arsal Tharwani

Abdominal Compression In End-Stage Fibrotic Interstitial Lung Disease (ILD) Improves Respiratory Compliance

Ryan Kozloski

When Asthma Isn’t: Multispecialty Approach To Fibrosing Mediastinitis

Zach S. Jarrett, DO

Vanishing Cancer: A Case Of Smoking-Related Organizing Pneumonia

Stephen Simeone

Intravascular Papillary Endothelial Hyperplasia Presenting As Thrombus In Transit With Acute Pulmonary Embolism

David Gruen, MD

Tackling Posterior Reversible Encephalopathy Syndrome (PRES): A Rare Case Of Subtherapeutic Tacrolimus Causing PRES In Steroid-Resistant Nephropathy

Nicholas Kunce, MD

An Unusual Case Of Subacute Bacterial Endocarditis Presenting With Catastrophic Subarachnoid Hemorrhage

Phillip J. Gary, MD

Sarcoid-Like Reaction After Treatment With Pembrolizumab

Shreya Podder, MD

Endobronchial Valves For Treatment Of Persistent Air Leak After Secondary Spontaneous Pneumothorax In Patients With Cystic Fibrosis

Alina Aw Wasim, MD, MBBS

Chest-Wall Castleman Disease Mimicking Thymoma Drop Metastasis

Ndausung Udongwo

The ‘Rat Bite Sign” On Cardiac MRI: Left Dominant Arrhythmogenic Cardiomyopathy As An Atypical Etiology Of Sudden Cardiac Arrest

Grant Senyei, MD

Management Of Ventriculopleural Shunt-Associated Pleural Effusion

Garima Singh, MD

COVID-19-Associated Thrombotic Thrombocytopenia Purpura (TTP)
 

CASE REPORT RAPID FIRE WINNERS

Sandeep Patri

Hyperammonemia Postlung Transplantation: An Uncommon But Life-Threatening Complication

Trung Nguyen

Dyspnea During Pregnancy Revealing Multiple Pulmonary Arteriovenous Malformations And A New Diagnosis Of Hereditary Hemorrhagic Telangiectasia

Pedro J. Baez, MD

Adenoid Cystic Adenocarcinoma: A Rare Esophageal Malignancy Misdiagnosed As COPD

Brette Guckian, DO

Management Of Pulmonary Cement Emboli After Kyphoplasty

Brinn Demars, DO

Tumor Emboli In The Pulmonary Artery Secondary To Chondrosarcoma: A Rare Presentation Mimicking Pulmonary Thromboembolism

Aakriti Arora

A Case Of Pulmonary Hypertension As A Possible Extracranial Manifestation Of Moyamoya Disease

Racine Elaine Reinoso

Clot In Transit: The Role Of Point-Of-Care Ultrasound In Early Diagnosis And Improved Outcomes

Qiraat Azeem, MD

A Case Of Autosomal-Dominant Hyper-IgE Syndrome Masquerading As Cystic Fibrosis

Jason R. Ballengee, DO

Third-Trimester Pregnancy Complicated By Non-Small Cell Lung Cancer Initially Presenting With Central Airway Obstruction And Stenosis

Sam Shafer

Caught In The Fray: Neurosarcoidosis Presenting As Chronic Respiratory Failure

Takkin Lo, MD, MPH

China White In Asthmatic Recreational Drug Users: Does It Contribute To Pneumatocele Development?

Sanjeev Shrestha, MD

Successful Treatment Of Microscopic Polyangiitis Using Novel Steroid-Sparing Agent Avacopan

Kristina Menchaca, MD

Cardiac Tamponade Without The Beck Triad: A Complication Of Severe Hypothyroidism

Olivia Millay, BS

Spontaneous Coronary Artery Dissection Of Left Anterior Descending Artery Complicated By Ventricular Septal Rupture

Akruti P. Prabhakar, DO

Delayed Lead Perforation Of The Right Atrium In The Presence Of Persistent Left Superior Vena Cava: A Rare Coincidence

Kevin Hsu, MD

A Modified Valsalva Maneuver For Ventilated And Sedated Patients With Unstable Supraventricular Tachycardia

Nang San Hti Lar Seng

Cardiovascular Manifestations Of Paraaortic Paragangliomas

Rocio Castillo-Larios

Membranous Dehiscence After Tracheal Resection And Reconstruction Healed Spontaneously With Conservative Treatment

Fizza Sajid, DO

A Young Broken Heart, Reversed

Janeen Grant-Sittol, MD

Inhaled Tranexamic Acid Use For Massive Hemoptysis In Vasculitis-Induced Bronchoalveolar Hemorrhage

Raman G. Kutty, Md, PhD

Progressive Lung Infiltrates In Patient With Acquired Immunodeficiency: A Rare Case Of GLILD

Tanwe Shende

Mycobacterium Shimoidei: A Rare Nontuberculous Infection In A U.S. Patient

Sarah M. Upson, MD

Not Your Typical Lactic Acidosis

Prachi Saluja, MD

Late-Onset Immune Thrombotic Thrombocytopenic Purpura (TTP) After Asymptomatic COVID-19 Infection

Steven S. Wu, MD

Type 1 Multiple Endocrine Neoplasia-Associated Tracheobronchial Tumors Managed By Rigid Bronchoscopy-Directed Multimodal Tumor Destruction

Konstantin Golubykh, MD

The Reversal That Helped: Role Of Bedside Echocardiography In Takotsubo Cardiomyopathy

Eric Salomon, MD

Obstructive Tracheobronchial Pulmonary Aspergillosis Managed With Local Bronchoscopic Intervention Alone

Daniel Hoesterey, MD

A Rare Case Of Critical Illness Due To Eczema Herpeticum With Disseminated Herpes Simplex Virus Infection

Awab U. Khan, DO

Severe Colchicine Toxicity In A Suicide Attempt Causing Multiorgan Failure: A Survival Story

Jacob Cebulko

Disseminated Strongyloidiasis In A Patient With Acute Lymphocytic Leukemia

Hasan Baher, MD

Hiding In Plain Sight: Disseminated Pulmonary TB

Navneet Ramesh

Multimodal Management Of Gastric Variceal Bleeding In Hemorrhagic Shock

Jason L. Peng, MD

Improving Compliance With Continuous Anterior Chest Compression In ARDS Caused By COVID-19: A Case Series

Sushan Gupta, MD

Complete Resolution Of Vasoreactive Pulmonary Artery Hypertension In Chronic Hypersensitive Pneumonitis

Mamta S. Chhabria, MD

A Fistulous Issue: Gastropleural Fistula As A Complication Of Gastrectomy

Anita Singh, DO, MBA

Identifying A Novel Surfactant Protein Mutation In A Family With Pulmonary Fibrosis

Rana Prathap Padappayil, MBBS

Delayed Cerebral Venous Sinus Thrombosis (CSVT) After An Invasive Meningioma Resection: An Uncommon Presentation Of A Common Complication

Rubabin Tooba, MD

The Morphing Cavity: An Image Series Of A Patient’s Pulmonary Infarction Over Time

Sally Ziatabar, DO

A Rare Case Of Disseminated Blastomycosis

Sumukh Arun Kumar

Incidental Pulmonary Cavitary Lesions As An Uncommon Presentation Of Lemierre Syndrome

Sophia Emetu

Pet Peeve: Dyspnea From Undiagnosed Pasteurella Multocida Empyema

Chidambaram Ramasamy, MD

A Case Of Diffuse Alveolar-Septal Pulmonary Amyloidosis And Cardiomyopathy

Rachel Swier

Acid-Fast Bacteria In Bronchiectasis: If The Glass Slipper Does Not Fit, Non-TB Mycobacteria, Consider Tsukamurella

Catherine Durant, MD

Idiopathic Multicentric Castleman Disease With Tafro Syndrome And Sjögren Syndrome

Ali Al-Hilli, MD, MSc

Sarcoidosis-Like Reaction During Treatment For Metastatic Breast Cancer With CDK 4/6 Inhibitors: Just An Epiphenomenon Or A Causal Relationship?

Scott Slusarenko, DO

Rapidly Progressive Perimyocarditis In SARS-CoV-2 Infection

Agatha M. Formoso, MD

Two Infants Presenting With Polymicrobial Pneumonia And Hypoxemic Respiratory Failure Associated With Heterozygous Variants In Carmil2 And Itk

Juan Adams-Chahin

The Silence Of “Lam”: A Case Of Tuberous Sclerosis Complex Associated With Lymphangioleiomyomatosis (Lam)

Kathleen Capaccione, MD

Lung Cancer Is Not Always The Answer: Exploring The Differential Diagnosis Of Thoracic Masses

Joann Wongvravit, DO

West Nile-Induced Myasthenia Gravis Crisis: An Unexpected Case Of Respiratory Failure

Ethan Karle, Do

A Rare Cause Of Community-Acquired Bacterial Pneumonia In A Patient With Poorly Controlled Diabetes

Taylor C. Becker, MD

Calcified Cavitary Conundrum: Delayed Diagnosis Of Histoplasmosis

Anneka Hutton, MD

Disseminated Listeriosis: A Deadly Triplicate

Omar Kandah, DO

COVID-19 Cardiac Tamponade With Cardiogenic Shock In A Previously Vaccinated Young Adult: A Case Report

Cihan Caglayan, MD

Partial Anomalous Pulmonary Venous Connection Diagnosed After Central Venous Catheter Placement

Michelle Jones, DO

Delayed Hemophagocytic Lymphohistiocytosis (HLH) Diagnosis In A Patient With Pulmonary Sarcoidosis And Newly Diagnosed T-Cell Lymphoma: A Case Report

Mariah Evarts, MD

A Normotensive Woman With Profound Lactic Acidosis And Stress-Induced Cardiomyopathy

Rachel V. Tan, MD

A Four-Boding Future: Polyviral Infection With SARS-CoV-2, Parainfluenza Virus Type 3, Influenza A, And Adenovirus

Thanh Hoang

Recurrent Syncope From Intermittent Torsades In Loperamide Abuse

Alissa Ali, MD

Ground Glass Opacities In A Patient Receiving Treatment With All-Trans Retinoic Acid And Arsenic Trioxide

Sean M. Masi, DO, MBA

Ferritin-Guided Therapeutic Plasma Exchange (TPE) Administration In COVID-19-Induced Cytokine Storm Syndrome: A Case Series

Anjali Sachdeva

Successful Biopsy Of Aortopulmonary Window Lymph Node With Robotic-Assisted Bronchoscopy

Rehan Saeed, MD

Multiple Sclerosis After COVID-19: A Sign Of Things To Come?

Harshitha Mergey Devender

Invasive Pulmonary Aspergillosis Associated With Nonspecific Interstitial Pneumonia Causing Recurrent Respiratory Failure



Be sure to check out the other award winners on page 20 in the January issue of CHEST Physician: https://tinyurl.com/2bcdcbj3 .

A new randomized, open-label French trial offers more evidence that the discontinuation of oxytocin treatment after the earliest stages of labor may be safe. Stopping oxytocin didn’t appear to affect neonatal outcomes, compared with continual use of the medication. However, the first stage of labor lasted slightly longer – not surprisingly – in those in the intervention group, and many of those who stopped oxytocin treatment resumed it later.

“Our trial did not show any impact of oxytocin discontinuation in the active [labor] stage on neonatal morbidity cesarean delivery, postpartum hemorrhage, birth experience, and postpartum depression,” said Aude Girault, MD, PhD, of Paris Cité University, in a presentation in San Francisco at the meeting sponsored by the Society for Maternal-Fetal Medicine.

The goal of the STOPOXY study is to build upon previous research that found oxytocin discontinuation didn’t boost the risk of cesarean delivery rates, uterine hyperstimulation, and abnormal fetal heart rate, Dr. Girault said. “These studies were underpowered to show any effects on neonatal morbidity,” so she and colleagues decided to dig deeper into the issue by launching the new trial.

From 2020 to 2022, researchers assigned 2,367 women who received oxytocin before 4 centimeters dilation to either continue with the drug (n = 1,192) or discontinue it before reaching 6 centimeters dilation (n = 1,175). Overall, the women were pregnant for the first time (around 55%) with a median age around 32 years and body mass index around 24.1 kg/m². All had live, singleton, full-term babies.

More than a third – 37% – of those who discontinued oxytocin resumed treatment with the medication, while 5% of those in the control group stopped taking it.

The neonatal morbidity rate – defined via a composite variable based on umbilical arterial pH, umbilical arterial lactates, Apgar score, and/or neonatal ICU admission – was 10.0% in the intervention group and 10.1% in the control group (P = .94), the researchers reported. Cesarean delivery rates were similar (18.8% vs. 16.5%, respectively; P = .22). Apart from the duration of the active first stage, which was significantly higher in the intervention group (100 min [ interquartile range, 50-208 min] vs. 90 min [IQR, 45-150 min]; P = .001), there were no significant differences between the groups.

Dr. Girault said this increase in labor duration was “moderate and clinically debatable.”

In an interview, oncologist-gynecologist George Saade, MD, of the University of Texas Medical Branch, Galveston, noted that “oxytocin is frequently used for either induction or augmentation of labor ... with the goal of improving maternal and neonatal outcomes.”

Oxytocin itself is not expensive, Dr. Saade said. “However, when it is given, the patient requires more monitoring, which may increase cost.”

There’s debate over the proper use of oxytocin, which is available in a synthetic version as Pitocin, and researchers have been trying to understand whether it can safely be discontinued early in labor.

Potential side effects of oxytocin include heart disorders such as arrhythmia, asphyxia, neonatal seizure, and jaundice, low Apgar score, and fetal death. A boxed warning says: “Because the available data are inadequate to evaluate the benefits-to-risks considerations, oxytocin is not indicated for elective induction of labor.”

However, “overall oxytocin is commonly used and very safe as long as careful protocols are followed,” David N. Hackney, MD, MS, of University Hospitals Cleveland, said in an interview. “The medication itself does not have many negative side effects. With very high doses there can be a concern for water intoxication, though this is clinically very uncommon. Some prior studies have raised concerns about the use of oxytocin and subsequent long-term neurodevelopmental outcomes, though these associations are likely confounders and the mainstream opinion is that these are not truly biologically causative associations.”

A 2021 study in The BMJ randomly assigned 1,200 women to continue or discontinue oxytocin. There was a slight increase in cesarean sections in the discontinuation group but significantly lower risks of uterine hyperstimulation and abnormal fetal heart rate.

Dr. Hackney, who didn’t take part in the new study, said the trial is “well conducted and well executed.” However, it needs peer review before any of its findings should change practice.

He added that differences in delivery protocols between the United States and France should be considered. As he noted, Dr. Girault mentioned in a Q&A after her presentation that delayed second-stage labor is more common in France than in the United States.

The study was funded by the French National Ministry of Health. Disclosures for the authors were not provided. Dr. Saade and Dr. Hackney have no disclosures.

A new randomized, open-label French trial offers more evidence that the discontinuation of oxytocin treatment after the earliest stages of labor may be safe. Stopping oxytocin didn’t appear to affect neonatal outcomes, compared with continual use of the medication. However, the first stage of labor lasted slightly longer – not surprisingly – in those in the intervention group, and many of those who stopped oxytocin treatment resumed it later.

“Our trial did not show any impact of oxytocin discontinuation in the active [labor] stage on neonatal morbidity cesarean delivery, postpartum hemorrhage, birth experience, and postpartum depression,” said Aude Girault, MD, PhD, of Paris Cité University, in a presentation in San Francisco at the meeting sponsored by the Society for Maternal-Fetal Medicine.

The goal of the STOPOXY study is to build upon previous research that found oxytocin discontinuation didn’t boost the risk of cesarean delivery rates, uterine hyperstimulation, and abnormal fetal heart rate, Dr. Girault said. “These studies were underpowered to show any effects on neonatal morbidity,” so she and colleagues decided to dig deeper into the issue by launching the new trial.

From 2020 to 2022, researchers assigned 2,367 women who received oxytocin before 4 centimeters dilation to either continue with the drug (n = 1,192) or discontinue it before reaching 6 centimeters dilation (n = 1,175). Overall, the women were pregnant for the first time (around 55%) with a median age around 32 years and body mass index around 24.1 kg/m². All had live, singleton, full-term babies.

More than a third – 37% – of those who discontinued oxytocin resumed treatment with the medication, while 5% of those in the control group stopped taking it.

The neonatal morbidity rate – defined via a composite variable based on umbilical arterial pH, umbilical arterial lactates, Apgar score, and/or neonatal ICU admission – was 10.0% in the intervention group and 10.1% in the control group (P = .94), the researchers reported. Cesarean delivery rates were similar (18.8% vs. 16.5%, respectively; P = .22). Apart from the duration of the active first stage, which was significantly higher in the intervention group (100 min [ interquartile range, 50-208 min] vs. 90 min [IQR, 45-150 min]; P = .001), there were no significant differences between the groups.

Dr. Girault said this increase in labor duration was “moderate and clinically debatable.”

In an interview, oncologist-gynecologist George Saade, MD, of the University of Texas Medical Branch, Galveston, noted that “oxytocin is frequently used for either induction or augmentation of labor ... with the goal of improving maternal and neonatal outcomes.”

Oxytocin itself is not expensive, Dr. Saade said. “However, when it is given, the patient requires more monitoring, which may increase cost.”

There’s debate over the proper use of oxytocin, which is available in a synthetic version as Pitocin, and researchers have been trying to understand whether it can safely be discontinued early in labor.

Potential side effects of oxytocin include heart disorders such as arrhythmia, asphyxia, neonatal seizure, and jaundice, low Apgar score, and fetal death. A boxed warning says: “Because the available data are inadequate to evaluate the benefits-to-risks considerations, oxytocin is not indicated for elective induction of labor.”

However, “overall oxytocin is commonly used and very safe as long as careful protocols are followed,” David N. Hackney, MD, MS, of University Hospitals Cleveland, said in an interview. “The medication itself does not have many negative side effects. With very high doses there can be a concern for water intoxication, though this is clinically very uncommon. Some prior studies have raised concerns about the use of oxytocin and subsequent long-term neurodevelopmental outcomes, though these associations are likely confounders and the mainstream opinion is that these are not truly biologically causative associations.”

A 2021 study in The BMJ randomly assigned 1,200 women to continue or discontinue oxytocin. There was a slight increase in cesarean sections in the discontinuation group but significantly lower risks of uterine hyperstimulation and abnormal fetal heart rate.

Dr. Hackney, who didn’t take part in the new study, said the trial is “well conducted and well executed.” However, it needs peer review before any of its findings should change practice.

He added that differences in delivery protocols between the United States and France should be considered. As he noted, Dr. Girault mentioned in a Q&A after her presentation that delayed second-stage labor is more common in France than in the United States.

The study was funded by the French National Ministry of Health. Disclosures for the authors were not provided. Dr. Saade and Dr. Hackney have no disclosures.

A new randomized, open-label French trial offers more evidence that the discontinuation of oxytocin treatment after the earliest stages of labor may be safe. Stopping oxytocin didn’t appear to affect neonatal outcomes, compared with continual use of the medication. However, the first stage of labor lasted slightly longer – not surprisingly – in those in the intervention group, and many of those who stopped oxytocin treatment resumed it later.

“Our trial did not show any impact of oxytocin discontinuation in the active [labor] stage on neonatal morbidity cesarean delivery, postpartum hemorrhage, birth experience, and postpartum depression,” said Aude Girault, MD, PhD, of Paris Cité University, in a presentation in San Francisco at the meeting sponsored by the Society for Maternal-Fetal Medicine.

The goal of the STOPOXY study is to build upon previous research that found oxytocin discontinuation didn’t boost the risk of cesarean delivery rates, uterine hyperstimulation, and abnormal fetal heart rate, Dr. Girault said. “These studies were underpowered to show any effects on neonatal morbidity,” so she and colleagues decided to dig deeper into the issue by launching the new trial.

From 2020 to 2022, researchers assigned 2,367 women who received oxytocin before 4 centimeters dilation to either continue with the drug (n = 1,192) or discontinue it before reaching 6 centimeters dilation (n = 1,175). Overall, the women were pregnant for the first time (around 55%) with a median age around 32 years and body mass index around 24.1 kg/m². All had live, singleton, full-term babies.

More than a third – 37% – of those who discontinued oxytocin resumed treatment with the medication, while 5% of those in the control group stopped taking it.

The neonatal morbidity rate – defined via a composite variable based on umbilical arterial pH, umbilical arterial lactates, Apgar score, and/or neonatal ICU admission – was 10.0% in the intervention group and 10.1% in the control group (P = .94), the researchers reported. Cesarean delivery rates were similar (18.8% vs. 16.5%, respectively; P = .22). Apart from the duration of the active first stage, which was significantly higher in the intervention group (100 min [ interquartile range, 50-208 min] vs. 90 min [IQR, 45-150 min]; P = .001), there were no significant differences between the groups.

Dr. Girault said this increase in labor duration was “moderate and clinically debatable.”

In an interview, oncologist-gynecologist George Saade, MD, of the University of Texas Medical Branch, Galveston, noted that “oxytocin is frequently used for either induction or augmentation of labor ... with the goal of improving maternal and neonatal outcomes.”

Oxytocin itself is not expensive, Dr. Saade said. “However, when it is given, the patient requires more monitoring, which may increase cost.”

There’s debate over the proper use of oxytocin, which is available in a synthetic version as Pitocin, and researchers have been trying to understand whether it can safely be discontinued early in labor.

Potential side effects of oxytocin include heart disorders such as arrhythmia, asphyxia, neonatal seizure, and jaundice, low Apgar score, and fetal death. A boxed warning says: “Because the available data are inadequate to evaluate the benefits-to-risks considerations, oxytocin is not indicated for elective induction of labor.”

However, “overall oxytocin is commonly used and very safe as long as careful protocols are followed,” David N. Hackney, MD, MS, of University Hospitals Cleveland, said in an interview. “The medication itself does not have many negative side effects. With very high doses there can be a concern for water intoxication, though this is clinically very uncommon. Some prior studies have raised concerns about the use of oxytocin and subsequent long-term neurodevelopmental outcomes, though these associations are likely confounders and the mainstream opinion is that these are not truly biologically causative associations.”

A 2021 study in The BMJ randomly assigned 1,200 women to continue or discontinue oxytocin. There was a slight increase in cesarean sections in the discontinuation group but significantly lower risks of uterine hyperstimulation and abnormal fetal heart rate.

Dr. Hackney, who didn’t take part in the new study, said the trial is “well conducted and well executed.” However, it needs peer review before any of its findings should change practice.

He added that differences in delivery protocols between the United States and France should be considered. As he noted, Dr. Girault mentioned in a Q&A after her presentation that delayed second-stage labor is more common in France than in the United States.

The study was funded by the French National Ministry of Health. Disclosures for the authors were not provided. Dr. Saade and Dr. Hackney have no disclosures.