News From CHEST Physician®

On December 14, the American Board of Internal Medicine (ABIM) announced an alternative to the 10-year Internal Medicine recertification exam, effective 2018. Currently, ABIM board–certified physicians can participate in Maintenance of Certification (MOC) by earning 100 MOC points every 5 years and passing a maintenance of certification exam every 10 years.

Beginning in 2018, physicians who are certified by the ABIM in Internal Medicine will have the option to take a lower-stakes exam every 2 years, rather than taking the current high-stakes exam every 10 years. The low-stakes exam option provides greater flexibility to the diplomate by allowing one to complete the examination at a convenient time set by the physician at home or in the office. While this new option will initially be available only to Internal Medicine diplomates, the ABIM intends to extend this alternative recertification model to subspecialties in the future.

CHEST is exploring how our education will evolve to address these key changes. For additional information, please visit ABIM’s website.

On December 14, the American Board of Internal Medicine (ABIM) announced an alternative to the 10-year Internal Medicine recertification exam, effective 2018. Currently, ABIM board–certified physicians can participate in Maintenance of Certification (MOC) by earning 100 MOC points every 5 years and passing a maintenance of certification exam every 10 years.

Beginning in 2018, physicians who are certified by the ABIM in Internal Medicine will have the option to take a lower-stakes exam every 2 years, rather than taking the current high-stakes exam every 10 years. The low-stakes exam option provides greater flexibility to the diplomate by allowing one to complete the examination at a convenient time set by the physician at home or in the office. While this new option will initially be available only to Internal Medicine diplomates, the ABIM intends to extend this alternative recertification model to subspecialties in the future.

CHEST is exploring how our education will evolve to address these key changes. For additional information, please visit ABIM’s website.

On December 14, the American Board of Internal Medicine (ABIM) announced an alternative to the 10-year Internal Medicine recertification exam, effective 2018. Currently, ABIM board–certified physicians can participate in Maintenance of Certification (MOC) by earning 100 MOC points every 5 years and passing a maintenance of certification exam every 10 years.

Beginning in 2018, physicians who are certified by the ABIM in Internal Medicine will have the option to take a lower-stakes exam every 2 years, rather than taking the current high-stakes exam every 10 years. The low-stakes exam option provides greater flexibility to the diplomate by allowing one to complete the examination at a convenient time set by the physician at home or in the office. While this new option will initially be available only to Internal Medicine diplomates, the ABIM intends to extend this alternative recertification model to subspecialties in the future.

CHEST is exploring how our education will evolve to address these key changes. For additional information, please visit ABIM’s website.

Oct 28 – Nov 1

Toronto, Ontario, Canada

Join us in wonderful Toronto for CHEST 2017, where we’ll connect a global community in clinical chest medicine. Our program will deliver current pulmonary, critical care, and sleep medicine topics presented by world-renowned faculty in a variety of innovative instruction formats. Take advantage of these opportunities to get involved now:

Submit Abstracts and Case Reports

Submission deadline: March 31

• Fellow Case Reports.
• Medical Student/Resident Case Reports.
• Global Case Reports.
• Clinical Case Puzzlers.

Learn more and submit at chest2017.abstractcentral.com.

Apply for 2017 CHEST Foundation Grants

Application deadline: March 31

The CHEST Foundation has started accepting applications for its clinical research, distinguished scholar, and community service grants. Every year, the CHEST Foundation awards more than a half-million dollars to the next generation of lung health champions.

The grants available are:

• GlaxoSmithKline Distinguished Scholar Research Grant in Respiratory Health: $150,000 over 3 years
• CHEST Foundation Research Grant in Lung Cancer: $50,000-$100,000* over 2 years
• CHEST Foundation Research Grant in Pulmonary Arterial Hypertension: $25,000 1-year grant
• CHEST Foundation and Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency: $25,000 1-year grant
• CHEST Foundation Research Grant in Nontuberculous Mycobacteria: $10,000-$30,000* 1-year grant
• CHEST Foundation Research Grant in Venous Thromboembolism: $30,000 1-year grant
• CHEST Foundation Research Grant in Pulmonary Fibrosis: $30,000 1-year grant
• CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease: $50,000 1-year grant
• CHEST Foundation Research Grant in Women’s Lung Health: $10,000 1-year grant
• CHEST Foundation Research Grant in Asthma: $15,000 - $30,000* 1-year grant
• CHEST Foundation Research Grant in Cystic Fibrosis: $30,000 1-year grant
• Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP: multiple awards up to $15,000 per 1-year grant

*Amount contingent on funding.Apply for grants at chestfoundation.org/grants.

Oct 28 – Nov 1

Toronto, Ontario, Canada

Join us in wonderful Toronto for CHEST 2017, where we’ll connect a global community in clinical chest medicine. Our program will deliver current pulmonary, critical care, and sleep medicine topics presented by world-renowned faculty in a variety of innovative instruction formats. Take advantage of these opportunities to get involved now:

Submit Abstracts and Case Reports

Submission deadline: March 31

• Fellow Case Reports.
• Medical Student/Resident Case Reports.
• Global Case Reports.
• Clinical Case Puzzlers.

Learn more and submit at chest2017.abstractcentral.com.

Apply for 2017 CHEST Foundation Grants

Application deadline: March 31

The CHEST Foundation has started accepting applications for its clinical research, distinguished scholar, and community service grants. Every year, the CHEST Foundation awards more than a half-million dollars to the next generation of lung health champions.

The grants available are:

• GlaxoSmithKline Distinguished Scholar Research Grant in Respiratory Health: $150,000 over 3 years
• CHEST Foundation Research Grant in Lung Cancer: $50,000-$100,000* over 2 years
• CHEST Foundation Research Grant in Pulmonary Arterial Hypertension: $25,000 1-year grant
• CHEST Foundation and Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency: $25,000 1-year grant
• CHEST Foundation Research Grant in Nontuberculous Mycobacteria: $10,000-$30,000* 1-year grant
• CHEST Foundation Research Grant in Venous Thromboembolism: $30,000 1-year grant
• CHEST Foundation Research Grant in Pulmonary Fibrosis: $30,000 1-year grant
• CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease: $50,000 1-year grant
• CHEST Foundation Research Grant in Women’s Lung Health: $10,000 1-year grant
• CHEST Foundation Research Grant in Asthma: $15,000 - $30,000* 1-year grant
• CHEST Foundation Research Grant in Cystic Fibrosis: $30,000 1-year grant
• Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP: multiple awards up to $15,000 per 1-year grant

*Amount contingent on funding.Apply for grants at chestfoundation.org/grants.

Oct 28 – Nov 1

Toronto, Ontario, Canada

Join us in wonderful Toronto for CHEST 2017, where we’ll connect a global community in clinical chest medicine. Our program will deliver current pulmonary, critical care, and sleep medicine topics presented by world-renowned faculty in a variety of innovative instruction formats. Take advantage of these opportunities to get involved now:

Submit Abstracts and Case Reports

Submission deadline: March 31

• Fellow Case Reports.
• Medical Student/Resident Case Reports.
• Global Case Reports.
• Clinical Case Puzzlers.

Learn more and submit at chest2017.abstractcentral.com.

Apply for 2017 CHEST Foundation Grants

Application deadline: March 31

The CHEST Foundation has started accepting applications for its clinical research, distinguished scholar, and community service grants. Every year, the CHEST Foundation awards more than a half-million dollars to the next generation of lung health champions.

The grants available are:

• GlaxoSmithKline Distinguished Scholar Research Grant in Respiratory Health: $150,000 over 3 years
• CHEST Foundation Research Grant in Lung Cancer: $50,000-$100,000* over 2 years
• CHEST Foundation Research Grant in Pulmonary Arterial Hypertension: $25,000 1-year grant
• CHEST Foundation and Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency: $25,000 1-year grant
• CHEST Foundation Research Grant in Nontuberculous Mycobacteria: $10,000-$30,000* 1-year grant
• CHEST Foundation Research Grant in Venous Thromboembolism: $30,000 1-year grant
• CHEST Foundation Research Grant in Pulmonary Fibrosis: $30,000 1-year grant
• CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease: $50,000 1-year grant
• CHEST Foundation Research Grant in Women’s Lung Health: $10,000 1-year grant
• CHEST Foundation Research Grant in Asthma: $15,000 - $30,000* 1-year grant
• CHEST Foundation Research Grant in Cystic Fibrosis: $30,000 1-year grant
• Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP: multiple awards up to $15,000 per 1-year grant

*Amount contingent on funding.Apply for grants at chestfoundation.org/grants.

In 2016, Catherine Oberg, MD, was awarded the CHEST Foundation Research Grant in Women’s Lung Health for her project on household air pollution in Ghana. In this recent interview with Dr. Oberg, she describes how she is championing lung health.

How I got involved

In medical school, I was very interested in international medicine and took a trip to Tanzania to do primary care work when I was in my fourth year. I saw firsthand how the people, women especially, sleep, cook, eat, and take care of their children and animals all in one house. I saw how direct smoke exposure from cooking caused symptoms of cough, phlegm, and shortness of breath. I knew this was an area where I could make an impact.

Tackling a leading cause of lung disease

In rural areas around the world, people cook with ineffective fuels, such as animal dung, that cause damaging household air pollution. This is a leading cause of asthma, COPD, and lung cancer worldwide, and it preferentially affects women and children because of their roles in the household. My project focuses on household air pollution with a goal to measure the effectiveness of utilizing a clean burning stove as an intervention.

We have a cohort of women in Ghana and have had randomized clusters using either a liquefied petroleum gas (LPG) clean burning stove or a traditional cook stove for 18 months now. We’re going to look at their lung function, inflammatory markers, and respiratory symptoms and compare the groups to see if the intervention has made a difference.

The impact

Being able to breathe is a function many of us take for granted. The ability to impact something this vital to everyday life is a really exciting and important challenge. It’s an area where I think we can make a big impact.

The future

This project could bring about further research and hopefully provide evidence supporting these types of interventions. The impact could affect millions of people around the world. The CHEST Foundation grant is providing materials that are the foundation of our project. This grant allows us to design better studies in the future, to educate patients in a more effective manner, and to prevent these life-threatening diseases.

The next CHEST Foundation grants cycle is open from February 1 to March 31, 2017. How will you champion lung health? Learn more about foundation grants and how you can apply at https://chest.realmagnet.land/chest-foundation-grants.

In 2016, Catherine Oberg, MD, was awarded the CHEST Foundation Research Grant in Women’s Lung Health for her project on household air pollution in Ghana. In this recent interview with Dr. Oberg, she describes how she is championing lung health.

How I got involved

In medical school, I was very interested in international medicine and took a trip to Tanzania to do primary care work when I was in my fourth year. I saw firsthand how the people, women especially, sleep, cook, eat, and take care of their children and animals all in one house. I saw how direct smoke exposure from cooking caused symptoms of cough, phlegm, and shortness of breath. I knew this was an area where I could make an impact.

Tackling a leading cause of lung disease

In rural areas around the world, people cook with ineffective fuels, such as animal dung, that cause damaging household air pollution. This is a leading cause of asthma, COPD, and lung cancer worldwide, and it preferentially affects women and children because of their roles in the household. My project focuses on household air pollution with a goal to measure the effectiveness of utilizing a clean burning stove as an intervention.

We have a cohort of women in Ghana and have had randomized clusters using either a liquefied petroleum gas (LPG) clean burning stove or a traditional cook stove for 18 months now. We’re going to look at their lung function, inflammatory markers, and respiratory symptoms and compare the groups to see if the intervention has made a difference.

The impact

Being able to breathe is a function many of us take for granted. The ability to impact something this vital to everyday life is a really exciting and important challenge. It’s an area where I think we can make a big impact.

The future

This project could bring about further research and hopefully provide evidence supporting these types of interventions. The impact could affect millions of people around the world. The CHEST Foundation grant is providing materials that are the foundation of our project. This grant allows us to design better studies in the future, to educate patients in a more effective manner, and to prevent these life-threatening diseases.

The next CHEST Foundation grants cycle is open from February 1 to March 31, 2017. How will you champion lung health? Learn more about foundation grants and how you can apply at https://chest.realmagnet.land/chest-foundation-grants.

In 2016, Catherine Oberg, MD, was awarded the CHEST Foundation Research Grant in Women’s Lung Health for her project on household air pollution in Ghana. In this recent interview with Dr. Oberg, she describes how she is championing lung health.

How I got involved

In medical school, I was very interested in international medicine and took a trip to Tanzania to do primary care work when I was in my fourth year. I saw firsthand how the people, women especially, sleep, cook, eat, and take care of their children and animals all in one house. I saw how direct smoke exposure from cooking caused symptoms of cough, phlegm, and shortness of breath. I knew this was an area where I could make an impact.

Tackling a leading cause of lung disease

In rural areas around the world, people cook with ineffective fuels, such as animal dung, that cause damaging household air pollution. This is a leading cause of asthma, COPD, and lung cancer worldwide, and it preferentially affects women and children because of their roles in the household. My project focuses on household air pollution with a goal to measure the effectiveness of utilizing a clean burning stove as an intervention.

We have a cohort of women in Ghana and have had randomized clusters using either a liquefied petroleum gas (LPG) clean burning stove or a traditional cook stove for 18 months now. We’re going to look at their lung function, inflammatory markers, and respiratory symptoms and compare the groups to see if the intervention has made a difference.

The impact

Being able to breathe is a function many of us take for granted. The ability to impact something this vital to everyday life is a really exciting and important challenge. It’s an area where I think we can make a big impact.

The future

This project could bring about further research and hopefully provide evidence supporting these types of interventions. The impact could affect millions of people around the world. The CHEST Foundation grant is providing materials that are the foundation of our project. This grant allows us to design better studies in the future, to educate patients in a more effective manner, and to prevent these life-threatening diseases.

The next CHEST Foundation grants cycle is open from February 1 to March 31, 2017. How will you champion lung health? Learn more about foundation grants and how you can apply at https://chest.realmagnet.land/chest-foundation-grants.

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

President 2008-2009

It was a great honor to be inaugurated as President of the American College of Chest Physicians at the 2008 Annual Meeting in Philadelphia. My chosen vocation was community-based private practice, and from my early years in practice, I found the opportunity to interact with the clinically oriented scholars of CHEST invaluable. My wife Susan and I fondly remember activities with staff, others in leadership, and their families. My immediate goals for my presidential year were to ensure the financial security of the College, in light of the evolving restrictions on industry funding, and to raise the profile of telemedicine for the care of patients with chronic conditions and the critically ill. However, that year is probably most remembered for the unanticipated need to formulate a step-down agreement with then-CEO Alvin Lever, who had served the College for the preceding 17 years.

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

President 2008-2009

It was a great honor to be inaugurated as President of the American College of Chest Physicians at the 2008 Annual Meeting in Philadelphia. My chosen vocation was community-based private practice, and from my early years in practice, I found the opportunity to interact with the clinically oriented scholars of CHEST invaluable. My wife Susan and I fondly remember activities with staff, others in leadership, and their families. My immediate goals for my presidential year were to ensure the financial security of the College, in light of the evolving restrictions on industry funding, and to raise the profile of telemedicine for the care of patients with chronic conditions and the critically ill. However, that year is probably most remembered for the unanticipated need to formulate a step-down agreement with then-CEO Alvin Lever, who had served the College for the preceding 17 years.

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

President 2008-2009

It was a great honor to be inaugurated as President of the American College of Chest Physicians at the 2008 Annual Meeting in Philadelphia. My chosen vocation was community-based private practice, and from my early years in practice, I found the opportunity to interact with the clinically oriented scholars of CHEST invaluable. My wife Susan and I fondly remember activities with staff, others in leadership, and their families. My immediate goals for my presidential year were to ensure the financial security of the College, in light of the evolving restrictions on industry funding, and to raise the profile of telemedicine for the care of patients with chronic conditions and the critically ill. However, that year is probably most remembered for the unanticipated need to formulate a step-down agreement with then-CEO Alvin Lever, who had served the College for the preceding 17 years.

Giants in Chest Medicine

Paul M. O’Byrne, MBBCh, FCCP. By S.E. Wenzel, MD.

Original Research

Prevalence and Localization of Pulmonary Embolism in Unexplained Acute Exacerbations of COPD: A Systematic Review and Meta-Analysis. By F.E. Aleva, MD, et al.

Commentary

The American College of Radiology Lung Imaging Reporting and Data System: Potential Drawbacks and Need for Revision. By H. J. Mehta, MD, et al.

Special Feature

Improving the Management of COPD in Women. By C.R. Jenkins, MD, et al.

Giants in Chest Medicine

Paul M. O’Byrne, MBBCh, FCCP. By S.E. Wenzel, MD.

Original Research

Prevalence and Localization of Pulmonary Embolism in Unexplained Acute Exacerbations of COPD: A Systematic Review and Meta-Analysis. By F.E. Aleva, MD, et al.

Commentary

The American College of Radiology Lung Imaging Reporting and Data System: Potential Drawbacks and Need for Revision. By H. J. Mehta, MD, et al.

Special Feature

Improving the Management of COPD in Women. By C.R. Jenkins, MD, et al.

Giants in Chest Medicine

Paul M. O’Byrne, MBBCh, FCCP. By S.E. Wenzel, MD.

Original Research

Prevalence and Localization of Pulmonary Embolism in Unexplained Acute Exacerbations of COPD: A Systematic Review and Meta-Analysis. By F.E. Aleva, MD, et al.

Commentary

The American College of Radiology Lung Imaging Reporting and Data System: Potential Drawbacks and Need for Revision. By H. J. Mehta, MD, et al.

Special Feature

Improving the Management of COPD in Women. By C.R. Jenkins, MD, et al.

Dear Colleagues,

It doesn’t seem possible, but I have just completed the first quarter of my term as your 79th President and recently returned from chairing my first board meeting – a scary experience to be sure. All in all, it went well. We officially offered Steve Welch the position of Executive Vice President, thereby ushering in one of our own to lead the organization. Steve has successfully served as CHEST’s interim EVP/CEO since May 2016, after 22 years of service with this organization, most recently as Senior Vice President of Publications and Digital Content. I am utterly and completely confident in our choice and want you to know he has the full backing of the board, the Past Presidents, and nearly every doctor he has come in contact with.

Gerard A. Silvestri, MD, MS, FCCP

President

Dear Colleagues,

It doesn’t seem possible, but I have just completed the first quarter of my term as your 79th President and recently returned from chairing my first board meeting – a scary experience to be sure. All in all, it went well. We officially offered Steve Welch the position of Executive Vice President, thereby ushering in one of our own to lead the organization. Steve has successfully served as CHEST’s interim EVP/CEO since May 2016, after 22 years of service with this organization, most recently as Senior Vice President of Publications and Digital Content. I am utterly and completely confident in our choice and want you to know he has the full backing of the board, the Past Presidents, and nearly every doctor he has come in contact with.

Gerard A. Silvestri, MD, MS, FCCP

President

Dear Colleagues,

It doesn’t seem possible, but I have just completed the first quarter of my term as your 79th President and recently returned from chairing my first board meeting – a scary experience to be sure. All in all, it went well. We officially offered Steve Welch the position of Executive Vice President, thereby ushering in one of our own to lead the organization. Steve has successfully served as CHEST’s interim EVP/CEO since May 2016, after 22 years of service with this organization, most recently as Senior Vice President of Publications and Digital Content. I am utterly and completely confident in our choice and want you to know he has the full backing of the board, the Past Presidents, and nearly every doctor he has come in contact with.

Gerard A. Silvestri, MD, MS, FCCP

President

“Nature’s condition, rightly interpreted, reveals a society’s culture and traditions as directly as does a novel or a newspaper or a code of laws.”

– Roderick F. Nash
 

Adverse effects of air pollution on human health have been known ever since the “Great London Smog” in 1952. Mankind is paying for rapid industrialization by adversely affecting the air that we breathe. The developed world has been able to improve the environmental standards by following stringent norms and practices regarding engines, fuels, and industrial safety. However, the same cannot be said about developing countries. Delhi, the capital of India, has seen high levels of air pollution for the last several decades.

The number of registered vehicles in Delhi has doubled over the last 10 years. This, along with rapidly increasing numbers of small scale industries and inconsistently regulated construction work, has led to ever-increasing levels of air pollution in Delhi. The city has witnessed smog for the last few years.

Common sources and pollutants with reference to Delhi

As in most cities around the world, rapid industrialization and increases in vehicles using fossil fuels are important contributors to ambient air pollution in Delhi. Additional sources of air pollution unique to Delhi include dust generation during building construction, ash generation from thermal power plants, crop residue burning in neighboring states, and burning of fossil fuels for domestic, as well as small scale, industrial use. Major pollutants include particulate matter (both PM2.5 and PM10), nitrogen oxides (NOx), carbon monoxide (CO), sulfur dioxide (SO2), and ozone (O3).

Delhi is distinct in its geographic location adjoining the Great Indian Desert (Thar) in the west and cool hilly regions in the north and east. This accounts for great seasonal variations in temperature, humidity, and wind speed. Also, being a landlocked territory, there are no moderating effects of sea breeze available to other metropolitan cities (like Mumbai and Chennai).

Dust storms during the summer from the neighboring state of Rajasthan cause an increase in suspended particulate matter (SPM). All these contribute to seasonal and climatic variations in air quality. In addition, the use of fire crackers during the festival of Diwali leads to dangerous levels of air pollution also.
 

Adverse health effects as witnessed in clinics and community

Many adults, without any prior history of respiratory illness, attended our outpatient department (OPD) with breathlessness, chest congestion, and wheezing requiring inhaled bronchodilators. A significant proportion of patients with previously diagnosed respiratory diseases (including COPD, bronchial asthma, or interstitial lung disease) reported to OPDs or emergency services with worsening cough, wheezing, and breathlessness. A few patients coming from outside Delhi for routine follow-up had exacerbation of COPD after coming to Delhi (personal observations).

We have previously reported increases in asthma, COPD, and acute coronary events (by 21.30%, 24.90%, and 24.30%, respectively) due to higher than acceptable levels of air pollutants in Delhi (Pande JN, et al. Indian J Chest Dis Allied Sci. 2002;44[1]:13). Another concerning development has been the increase in the number of persons being diagnosed with bronchial asthma in middle age, probably related to worsening air quality. Persons at extremes of age (young children and elderly) are particularly affected.
 

Studies in Delhi assessing ambient air pollution–related morbidity and mortality

Studies have used risk of mortality/morbidity due to air pollution model (Ri–MAP) to assess health impact of various air pollutants in Delhi. According to their estimates, there were 18,229 excess deaths in Delhi in the year 2010, more than 50% of which were due to cardiovascular or respiratory causes. Also, 26,525 excess hospital admissions due to COPD exacerbation could be attributed to ambient air pollution (Nagpure A, et al. Atmospheric Pollution Res. 2014;5[3]:1309).

Interventions: Work in progress

The Central Pollution Control Board convened an Expert Committee (Dr. Khilnani as a member) for formulation and implementation of Air Quality Index (AQI) in major Indian cities (http://cpcb.nic.in/FINAL-REPORT_AQI_.pdf).

Currently reported AQI is calculated by using the following parameters: sulfur dioxide (SO₂), nitrogen dioxide (NO₂), particulate matter (PM10,PM2.5) averaged over 24 hours, along with ozone (O3) and carbon monoxide (CO), averaged over 1-8 hours. AQI is classified as good (0-50), satisfactory (51-100), moderate (101-200), poor (201-300), very poor (301-400), and severe (greater than 401).

AQI is reported daily in leading newspapers along with public and private news channels. Thanks to the mainstream and social media, smog has become a commonly understood word. Air pollution is a hot topic of discussion among people of all socioeconomic and demographic strata.

Children of almost all schools in Delhi pledged not to use firecrackers this Diwali. People are increasingly sharing taxis or carpooling. Utilization of public transport is gradually increasing.

The Delhi government ordered temporarily shutting off the only working thermal power plant in the megacity (source of 10%-15% of ambient air pollution). The government is also working on an action plan based on air quality, which includes both preventive and prohibitive measures.

Delhi Transport Corporation operates one of the world’s largest fleets of compressed natural gas–operated buses. Delhi Metro Corporation has been lauded by the United Nations for its efforts in reducing the carbon footprint and air pollution.

Yet, a lot needs to be done to improve the air quality in Delhi. Last mile connectivity remains a big hurdle; improving this will go a long way in promoting use of public transport. Implementation of methods to reduce particulate matter generation at construction sites, promoting use of vehicles using electricity or compressed natural gas, increasing parking charges for vehicles, banning the use of diesel-driven heavy vehicles in the city, road cleaning with vacuum cleaners to reduce PM 10 generation, increasing green areas, and promoting carpooling or taxi sharing are some other initiatives that need to be implemented on priority. Delhi and surrounding states need to strengthen awareness drives and norms to discourage crop residue burning on a priority basis.
 

Conclusion

Delhi’s poor air quality during this winter has indeed affected the respiratory health of the population. Healthy people, as well as those with preexisting respiratory diseases, are adversely affected. A series of actions at the personal and institutional level is required to control this menace.
 

Dr. Khilnani is Professor, and Dr. Tiwari is Research Officer, Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India.

“Nature’s condition, rightly interpreted, reveals a society’s culture and traditions as directly as does a novel or a newspaper or a code of laws.”

– Roderick F. Nash
 

Adverse effects of air pollution on human health have been known ever since the “Great London Smog” in 1952. Mankind is paying for rapid industrialization by adversely affecting the air that we breathe. The developed world has been able to improve the environmental standards by following stringent norms and practices regarding engines, fuels, and industrial safety. However, the same cannot be said about developing countries. Delhi, the capital of India, has seen high levels of air pollution for the last several decades.

The number of registered vehicles in Delhi has doubled over the last 10 years. This, along with rapidly increasing numbers of small scale industries and inconsistently regulated construction work, has led to ever-increasing levels of air pollution in Delhi. The city has witnessed smog for the last few years.

Common sources and pollutants with reference to Delhi

As in most cities around the world, rapid industrialization and increases in vehicles using fossil fuels are important contributors to ambient air pollution in Delhi. Additional sources of air pollution unique to Delhi include dust generation during building construction, ash generation from thermal power plants, crop residue burning in neighboring states, and burning of fossil fuels for domestic, as well as small scale, industrial use. Major pollutants include particulate matter (both PM2.5 and PM10), nitrogen oxides (NOx), carbon monoxide (CO), sulfur dioxide (SO2), and ozone (O3).

Delhi is distinct in its geographic location adjoining the Great Indian Desert (Thar) in the west and cool hilly regions in the north and east. This accounts for great seasonal variations in temperature, humidity, and wind speed. Also, being a landlocked territory, there are no moderating effects of sea breeze available to other metropolitan cities (like Mumbai and Chennai).

Dust storms during the summer from the neighboring state of Rajasthan cause an increase in suspended particulate matter (SPM). All these contribute to seasonal and climatic variations in air quality. In addition, the use of fire crackers during the festival of Diwali leads to dangerous levels of air pollution also.
 

Adverse health effects as witnessed in clinics and community

Many adults, without any prior history of respiratory illness, attended our outpatient department (OPD) with breathlessness, chest congestion, and wheezing requiring inhaled bronchodilators. A significant proportion of patients with previously diagnosed respiratory diseases (including COPD, bronchial asthma, or interstitial lung disease) reported to OPDs or emergency services with worsening cough, wheezing, and breathlessness. A few patients coming from outside Delhi for routine follow-up had exacerbation of COPD after coming to Delhi (personal observations).

We have previously reported increases in asthma, COPD, and acute coronary events (by 21.30%, 24.90%, and 24.30%, respectively) due to higher than acceptable levels of air pollutants in Delhi (Pande JN, et al. Indian J Chest Dis Allied Sci. 2002;44[1]:13). Another concerning development has been the increase in the number of persons being diagnosed with bronchial asthma in middle age, probably related to worsening air quality. Persons at extremes of age (young children and elderly) are particularly affected.
 

Studies in Delhi assessing ambient air pollution–related morbidity and mortality

Studies have used risk of mortality/morbidity due to air pollution model (Ri–MAP) to assess health impact of various air pollutants in Delhi. According to their estimates, there were 18,229 excess deaths in Delhi in the year 2010, more than 50% of which were due to cardiovascular or respiratory causes. Also, 26,525 excess hospital admissions due to COPD exacerbation could be attributed to ambient air pollution (Nagpure A, et al. Atmospheric Pollution Res. 2014;5[3]:1309).

Interventions: Work in progress

The Central Pollution Control Board convened an Expert Committee (Dr. Khilnani as a member) for formulation and implementation of Air Quality Index (AQI) in major Indian cities (http://cpcb.nic.in/FINAL-REPORT_AQI_.pdf).

Currently reported AQI is calculated by using the following parameters: sulfur dioxide (SO₂), nitrogen dioxide (NO₂), particulate matter (PM10,PM2.5) averaged over 24 hours, along with ozone (O3) and carbon monoxide (CO), averaged over 1-8 hours. AQI is classified as good (0-50), satisfactory (51-100), moderate (101-200), poor (201-300), very poor (301-400), and severe (greater than 401).

AQI is reported daily in leading newspapers along with public and private news channels. Thanks to the mainstream and social media, smog has become a commonly understood word. Air pollution is a hot topic of discussion among people of all socioeconomic and demographic strata.

Children of almost all schools in Delhi pledged not to use firecrackers this Diwali. People are increasingly sharing taxis or carpooling. Utilization of public transport is gradually increasing.

The Delhi government ordered temporarily shutting off the only working thermal power plant in the megacity (source of 10%-15% of ambient air pollution). The government is also working on an action plan based on air quality, which includes both preventive and prohibitive measures.

Delhi Transport Corporation operates one of the world’s largest fleets of compressed natural gas–operated buses. Delhi Metro Corporation has been lauded by the United Nations for its efforts in reducing the carbon footprint and air pollution.

Yet, a lot needs to be done to improve the air quality in Delhi. Last mile connectivity remains a big hurdle; improving this will go a long way in promoting use of public transport. Implementation of methods to reduce particulate matter generation at construction sites, promoting use of vehicles using electricity or compressed natural gas, increasing parking charges for vehicles, banning the use of diesel-driven heavy vehicles in the city, road cleaning with vacuum cleaners to reduce PM 10 generation, increasing green areas, and promoting carpooling or taxi sharing are some other initiatives that need to be implemented on priority. Delhi and surrounding states need to strengthen awareness drives and norms to discourage crop residue burning on a priority basis.
 

Conclusion

Delhi’s poor air quality during this winter has indeed affected the respiratory health of the population. Healthy people, as well as those with preexisting respiratory diseases, are adversely affected. A series of actions at the personal and institutional level is required to control this menace.
 

Dr. Khilnani is Professor, and Dr. Tiwari is Research Officer, Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India.

“Nature’s condition, rightly interpreted, reveals a society’s culture and traditions as directly as does a novel or a newspaper or a code of laws.”

– Roderick F. Nash
 

Adverse effects of air pollution on human health have been known ever since the “Great London Smog” in 1952. Mankind is paying for rapid industrialization by adversely affecting the air that we breathe. The developed world has been able to improve the environmental standards by following stringent norms and practices regarding engines, fuels, and industrial safety. However, the same cannot be said about developing countries. Delhi, the capital of India, has seen high levels of air pollution for the last several decades.

The number of registered vehicles in Delhi has doubled over the last 10 years. This, along with rapidly increasing numbers of small scale industries and inconsistently regulated construction work, has led to ever-increasing levels of air pollution in Delhi. The city has witnessed smog for the last few years.

Common sources and pollutants with reference to Delhi

As in most cities around the world, rapid industrialization and increases in vehicles using fossil fuels are important contributors to ambient air pollution in Delhi. Additional sources of air pollution unique to Delhi include dust generation during building construction, ash generation from thermal power plants, crop residue burning in neighboring states, and burning of fossil fuels for domestic, as well as small scale, industrial use. Major pollutants include particulate matter (both PM2.5 and PM10), nitrogen oxides (NOx), carbon monoxide (CO), sulfur dioxide (SO2), and ozone (O3).

Delhi is distinct in its geographic location adjoining the Great Indian Desert (Thar) in the west and cool hilly regions in the north and east. This accounts for great seasonal variations in temperature, humidity, and wind speed. Also, being a landlocked territory, there are no moderating effects of sea breeze available to other metropolitan cities (like Mumbai and Chennai).

Dust storms during the summer from the neighboring state of Rajasthan cause an increase in suspended particulate matter (SPM). All these contribute to seasonal and climatic variations in air quality. In addition, the use of fire crackers during the festival of Diwali leads to dangerous levels of air pollution also.
 

Adverse health effects as witnessed in clinics and community

Many adults, without any prior history of respiratory illness, attended our outpatient department (OPD) with breathlessness, chest congestion, and wheezing requiring inhaled bronchodilators. A significant proportion of patients with previously diagnosed respiratory diseases (including COPD, bronchial asthma, or interstitial lung disease) reported to OPDs or emergency services with worsening cough, wheezing, and breathlessness. A few patients coming from outside Delhi for routine follow-up had exacerbation of COPD after coming to Delhi (personal observations).

We have previously reported increases in asthma, COPD, and acute coronary events (by 21.30%, 24.90%, and 24.30%, respectively) due to higher than acceptable levels of air pollutants in Delhi (Pande JN, et al. Indian J Chest Dis Allied Sci. 2002;44[1]:13). Another concerning development has been the increase in the number of persons being diagnosed with bronchial asthma in middle age, probably related to worsening air quality. Persons at extremes of age (young children and elderly) are particularly affected.
 

Studies in Delhi assessing ambient air pollution–related morbidity and mortality

Studies have used risk of mortality/morbidity due to air pollution model (Ri–MAP) to assess health impact of various air pollutants in Delhi. According to their estimates, there were 18,229 excess deaths in Delhi in the year 2010, more than 50% of which were due to cardiovascular or respiratory causes. Also, 26,525 excess hospital admissions due to COPD exacerbation could be attributed to ambient air pollution (Nagpure A, et al. Atmospheric Pollution Res. 2014;5[3]:1309).

Interventions: Work in progress

The Central Pollution Control Board convened an Expert Committee (Dr. Khilnani as a member) for formulation and implementation of Air Quality Index (AQI) in major Indian cities (http://cpcb.nic.in/FINAL-REPORT_AQI_.pdf).

Currently reported AQI is calculated by using the following parameters: sulfur dioxide (SO₂), nitrogen dioxide (NO₂), particulate matter (PM10,PM2.5) averaged over 24 hours, along with ozone (O3) and carbon monoxide (CO), averaged over 1-8 hours. AQI is classified as good (0-50), satisfactory (51-100), moderate (101-200), poor (201-300), very poor (301-400), and severe (greater than 401).

AQI is reported daily in leading newspapers along with public and private news channels. Thanks to the mainstream and social media, smog has become a commonly understood word. Air pollution is a hot topic of discussion among people of all socioeconomic and demographic strata.

Children of almost all schools in Delhi pledged not to use firecrackers this Diwali. People are increasingly sharing taxis or carpooling. Utilization of public transport is gradually increasing.

The Delhi government ordered temporarily shutting off the only working thermal power plant in the megacity (source of 10%-15% of ambient air pollution). The government is also working on an action plan based on air quality, which includes both preventive and prohibitive measures.

Delhi Transport Corporation operates one of the world’s largest fleets of compressed natural gas–operated buses. Delhi Metro Corporation has been lauded by the United Nations for its efforts in reducing the carbon footprint and air pollution.

Yet, a lot needs to be done to improve the air quality in Delhi. Last mile connectivity remains a big hurdle; improving this will go a long way in promoting use of public transport. Implementation of methods to reduce particulate matter generation at construction sites, promoting use of vehicles using electricity or compressed natural gas, increasing parking charges for vehicles, banning the use of diesel-driven heavy vehicles in the city, road cleaning with vacuum cleaners to reduce PM 10 generation, increasing green areas, and promoting carpooling or taxi sharing are some other initiatives that need to be implemented on priority. Delhi and surrounding states need to strengthen awareness drives and norms to discourage crop residue burning on a priority basis.
 

Conclusion

Delhi’s poor air quality during this winter has indeed affected the respiratory health of the population. Healthy people, as well as those with preexisting respiratory diseases, are adversely affected. A series of actions at the personal and institutional level is required to control this menace.
 

Dr. Khilnani is Professor, and Dr. Tiwari is Research Officer, Department of Pulmonary Medicine & Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India.

Clinical Research

The unrecognized battlefield in our hospitals: Lessons from the US Navy SEALs

Burnout syndrome (BOS) is a psychological state resulting from prolonged exposure to job stressors. It is characterized by a vicious cycle of emotional exhaustion, detachment from others, and a feeling of decreased accomplishment. Severe BOS is seen in up to 45% of physicians and 33% of nurses who work in ICUs.¹

BOS has far-reaching consequences, being associated with an alarmingly high prevalence of posttraumatic stress disorder (PTSD) and substance abuse, almost equivalent to that experienced by veterans returning from war.² BOS also is associated with self-reported suboptimal patient care practices.³This crisis has long been underrecognized, but now that we have identified the problem, where does that leave us? There are currently no quality studies evaluating how to best treat and prevent BOS/PTSD in health-care professionals. Previous studies have focused on addressing organizational factors to alleviate job stressors, but the psychosocial characteristics of the individual have been largely ignored.

Our medical education has historically focused on an individual’s intelligence quotient (IQ), but developing an individual’s emotional quotient (EQ) is just as valuable. It has long been known that Navy SEALs have the lowest prevalence of PTSD among combat veterans due partially to their specific training in emotional resilience and adaptive psychosocial coping mechanisms.

For this reason, the research team at the University of Texas Health Science Center at San Antonio is collaborating with the US Navy SEAL team to design and validate a tool that teaches critical care staff resilience training similar to what their combat trainees undergo. The goal is to curb these alarming trends in BOS and create a paradigm shift in medical education within medical and nursing schools.

Bravein Amalakuhan, MD

Fellow-in-Training Member

References

1. Embriaco N, Azoulay E, Barrau K, et al. Am J Respir Crit Care Med. 2007;175(7):686.

2. Mealer ML, Shelton A, Berg B, et al. Am J Respir Crit Care Med. 2007;175(7):693.

3. Shanafelt TD, Bradley KA, Wipf JE, et al. Ann Intern Med. 2002;136(5):358.

Critical Care

End of the era for age of blood concerns?

Blood transfusions are common in critically ill patients, with two in five adults admitted to an ICU receiving a transfusion.^1,2 Recently, randomized trials have found that more restrictive thresholds for transfusions are associated with improved outcomes.^3,4 One theorized explanation for this somewhat counterintuitive association is that the prolonged storage time (i.e., the age of the blood being transfused) might affect outcomes.

There have been three recent publications that help to shed some more light on this. First, Lacroix et al.⁵ performed a multicenter randomized blinded trial in over 2,400 critically ill patients in 64 centers comparing new blood (mean storage (±SD) of 6.1±4.9 days) vs old blood with storage of 22.0±8.4 days (P less than .001). There was no statistically significant difference in 90-day mortality.⁵

The second study is a meta-analysis by Alexander et al.⁶ The investigators looked at 12 trials and 5,229 patients and compared “fresh blood” or blood stored for 3-10 days to “older blood” stored for longer durations. They found that there was no difference in mortality and no difference in adverse events, such as acute transfusion reactions, when comparing the two groups.

Lastly, Heddle et al.⁷ conducted a randomized trial that compared outcomes in 20,858 hospitalized patients transfused with fresh blood (mean storage time 13.0±7.6 days) to older blood (mean storage time 23.6±8.9 days). They found no differences in mortality when comparing those transfused with fresh vs. old blood (8.7% vs. 9.1%). In addition, there was no difference when examining the predetermined subgroups, including those undergoing cardiovascular surgery, those with cancer, and those admitted to the ICU.

So, is this the end of an era for health-care provider concern about how long blood can be stored to be safe for ICU patients? Possibly.

There may still be high-risk populations (such as patients receiving massive transfusions) for which age of the blood does matter. In addition, it is still unclear based on the present data as to whether blood stored between 35 and 42 days has any significant inherent risk.

However, these publications among others suggest that the age of transfused blood may not matter, even in critically ill patients. Therefore, the present storage practices of many blood banks around the United States and beyond are validated by the present publications regarding the scarce resource of blood.

Christopher L. Carroll, MD, MS, FCCP

Steering Committee Member

Steven Greenberg, MD, FCCP

Steering Committee Member

References

1. Corwin HL, Gettinger A, Pearl RG, et al. Crit Care Med. 2004;32(1):39.

2. Vincent JL, Baron JF, Reinhart K, et al.; ABC (Anemia and Blood Transfusion in Critical Care) Investigators. JAMA. 2002;288(12):1499.

3. Holst LB, Haase N, Wetterslev J, et al.; TRISS Trial Group; Scandinavian Critical Care Trials Group. N Engl J Med. 2014;371(15):1381.

4. Lacroix J, Hebert PC, Hutchison JS, et al.; TRIPICU Investigators; Canadian Critical Care Trials Group; Pediatric Acute Lung Injury and Sepsis Investigators Network. N Engl J Med. 2007;356(16):1609.

5. Lacroix J, Hebert P, Fergusson DA, et al. N Engl J Med. 2015;372:1410.

6. Alexander PE, Barty R, Fei Y, et al. Blood. 2016;127(4):400.

7. Heddle NM, Cook RJ, Arnold DM, et al. N Engl J Med. 2016;375(2):1937.

Airways Disorders

Inhaled corticosteroids in COPD: When to hold and when to fold

The 2017 GOLD guidelines reiterated that inhaled corticosteroids (ICS) be reserved for COPD patients with continued symptoms and exacerbations, despite use of long-acting beta-agonists (LABAs) and long-acting muscarinic agents (LAMAs). ICS are appropriate in approximately 40% of patients; however, prescribing rates can exceed 80% (Yawn et al. 2016; Primary Care Respir J. 26:16068).

Recent literature has begun to define the appropriate use of ICS in COPD. ICS/LABA combinations improve outcomes in patients with moderate to very severe COPD with frequent exacerbations. However, ICS/LABA may not further diminish exacerbation risk compared with those treated with a LABA/LAMA combination (Wedzicha et al., N Engl J Med. 2016;374:2222).

While the addition of LAMA to an ICS/LABA combination (triple therapy) improved lung function and decreased exacerbation risk, the addition of ICS to LABA/LAMA combination did not decrease exacerbations (GOLD Guidelines 2017). It has been suggested that those with asthma-COPD overlap identified by sputum eosinophilia represent ideal candidates for ICS therapy (GINA Guideline 2016).

ICS use in COPD increases pneumonia risk. The risk was highest in the very group for which guidelines recommend its use – those with a FEV₁ less than 50% of predicted or with prior COPD exacerbation (Ernst et al. Eur Respir J. 2015;45:525).

ICS may be safely withdrawn in low-risk patients (FEV₁ less than 50% predicted and no exacerbations in the previous year [Yawn et al.]).

In a trial comparing patients with severe COPD (FEV₁ less than 50%) on continued LAMA/LABA/ICS triple therapy vs LAMA/LABA with ICS withdrawal, the risk of moderate or severe exacerbations at 52 weeks was not increased (Magnussen et al. N Engl J Med. 2014;371:1285).
 

Conclusions

Based on the 2017 GOLD guidelines:

• Monotherapy with ICS is not recommended in COPD.

• In patients with continued respiratory-related symptoms without exacerbations (GOLD group B), LAMA or LABA or LAMA/LABA combination is recommended. There is no recommendation for ICS in this group.

• In patients with frequent exacerbations (GOLD groups C and D), LAMA/LABA combinations are preferred to LABA/ICS because of superior effectiveness (especially in Group D) and the increased pneumonia risk with ICS. Escalation to triple therapy can be considered if there are continued exacerbations.

Allen Blaivas, DO, FCCP

Steering Committee Member

Navitha Ramesh, MD, MBBS

Fellow-in-Training Member

Home-Based Mechanical Ventilation and Neuromuscular Disease

Advances in neuromuscular disease

Spinal muscular atrophy (SMA) type 1 is the most deadly inherited disease among infants, with most infants dying by 1 to 2 years of age without supportive therapies, such as assisted ventilation. It is caused by homozygous deletions or mutations in the survival motor neuron 1 (SMN1) gene. Disease severity varies in part depending on the number of backup SMN2 gene copies that can produce some functional SMN protein (Arnold et al. Muscle Nerve. 2015;51[2]:157).

Recent developments of disease-modifying agents are giving hope to individuals with SMA and their families. Nusinersen (an antisense oligonucleotide) is an intrathecal medication that increases the production of functional SMN protein by increasing SMN2 exon 7 transcription (Chiriboga et al. Neurology. 2016;86[10]:890).

A recent open-label clinical trial by Finkel et al. (Lancet. 2017;388[10063]:3017) showed a “promising clinical response” that altered the natural history of disease progression. Most infants treated with multiple intrathecal doses of nusinersen had incremental improvement in their motor milestones and motor function (P = .008), as well as improved survival and/or avoidance of ventilation (P = .0014).

Moreover, the study found significant uptake of nusinersen by the motor neuron throughout the spinal cord and other neurons throughout the CNS. It appeared to be well tolerated. Disease-modifying medications may soon become “game changers” in many neuromuscular conditions.

However, a significant concern is the expected prohibitive cost both of a rare-disease-modifying therapy and of administrating intrathecal medications to fragile infants. As such, those obstacles will need to be overcome as neuromuscular clinics, hospitals, and payers start planning for the coming advances that our patients will be expecting.

Ahlam Mazi, MBBS

Fellow-in-Training Member

Interstitial and Diffuse Lung Disease

New advancements in predictive risk factors of IPF

In the last few years, many predictive risk factors were studied in clinical trials monitoring idiopathic pulmonary fibrosis (IPF), such as forced vital capacity and diffuse lung capacity for carbon monoxide (King TE Jr, et al. ASCEND Study Group. N Engl J Med. 2014;18;371­[12]:1172; Richeldi L, et al. INPULSIS Trial Investigators. N Engl J Med. 2015;20;373­[8]:782; Ley B, et al. Am J Respir Crit Care Med. 2016;15;194­[6]:711).

Recent data that have not yet been published by Carbone et al evaluate the prognostic value of the New York Heart Association index (NYHA) compared with high resolution CT scan, somatostatin receptor scintigraphy (octreoscan), and echocardiography in a study population of 128 patients suffering from IPF (61% male subjects), nonspecific interstitial pneumonia, and granulomatous lung diseases (alveolitis, sarcoidosis, granulomatosis with polyangiitis). All patients were confirmed histologically.

The NYHA came out as a reliable prognostic factor in each setting. In fact, the log-rank test showed significant differences among NYHA categories, as cases included with disease showed the worst survival rate while no death cases were observed when NYHA was negative.

Moreover, the prognostic value of NYHA was confirmed by multivariate analysis, where the survival rate results were significantly different among patients with level 7 after adjustment for other variables included in the model.

Furthermore, the prognostic value of the NYHA index was once again confirmed when the analysis was limited to cases with the histological pattern of IPF (usual interstitial pneumonia).

The authors, therefore, strongly recommend utilization of the NYHA index as a prognostic factor of IPF as well as granulomatous lung diseases.

Roberto Carbone, MD, FCCP

Steering Committee Member

Clinical Research

The unrecognized battlefield in our hospitals: Lessons from the US Navy SEALs

Burnout syndrome (BOS) is a psychological state resulting from prolonged exposure to job stressors. It is characterized by a vicious cycle of emotional exhaustion, detachment from others, and a feeling of decreased accomplishment. Severe BOS is seen in up to 45% of physicians and 33% of nurses who work in ICUs.¹

BOS has far-reaching consequences, being associated with an alarmingly high prevalence of posttraumatic stress disorder (PTSD) and substance abuse, almost equivalent to that experienced by veterans returning from war.² BOS also is associated with self-reported suboptimal patient care practices.³This crisis has long been underrecognized, but now that we have identified the problem, where does that leave us? There are currently no quality studies evaluating how to best treat and prevent BOS/PTSD in health-care professionals. Previous studies have focused on addressing organizational factors to alleviate job stressors, but the psychosocial characteristics of the individual have been largely ignored.

Our medical education has historically focused on an individual’s intelligence quotient (IQ), but developing an individual’s emotional quotient (EQ) is just as valuable. It has long been known that Navy SEALs have the lowest prevalence of PTSD among combat veterans due partially to their specific training in emotional resilience and adaptive psychosocial coping mechanisms.

For this reason, the research team at the University of Texas Health Science Center at San Antonio is collaborating with the US Navy SEAL team to design and validate a tool that teaches critical care staff resilience training similar to what their combat trainees undergo. The goal is to curb these alarming trends in BOS and create a paradigm shift in medical education within medical and nursing schools.

Bravein Amalakuhan, MD

Fellow-in-Training Member

References

1. Embriaco N, Azoulay E, Barrau K, et al. Am J Respir Crit Care Med. 2007;175(7):686.

2. Mealer ML, Shelton A, Berg B, et al. Am J Respir Crit Care Med. 2007;175(7):693.

3. Shanafelt TD, Bradley KA, Wipf JE, et al. Ann Intern Med. 2002;136(5):358.

Critical Care

End of the era for age of blood concerns?

Blood transfusions are common in critically ill patients, with two in five adults admitted to an ICU receiving a transfusion.^1,2 Recently, randomized trials have found that more restrictive thresholds for transfusions are associated with improved outcomes.^3,4 One theorized explanation for this somewhat counterintuitive association is that the prolonged storage time (i.e., the age of the blood being transfused) might affect outcomes.

There have been three recent publications that help to shed some more light on this. First, Lacroix et al.⁵ performed a multicenter randomized blinded trial in over 2,400 critically ill patients in 64 centers comparing new blood (mean storage (±SD) of 6.1±4.9 days) vs old blood with storage of 22.0±8.4 days (P less than .001). There was no statistically significant difference in 90-day mortality.⁵

The second study is a meta-analysis by Alexander et al.⁶ The investigators looked at 12 trials and 5,229 patients and compared “fresh blood” or blood stored for 3-10 days to “older blood” stored for longer durations. They found that there was no difference in mortality and no difference in adverse events, such as acute transfusion reactions, when comparing the two groups.

Lastly, Heddle et al.⁷ conducted a randomized trial that compared outcomes in 20,858 hospitalized patients transfused with fresh blood (mean storage time 13.0±7.6 days) to older blood (mean storage time 23.6±8.9 days). They found no differences in mortality when comparing those transfused with fresh vs. old blood (8.7% vs. 9.1%). In addition, there was no difference when examining the predetermined subgroups, including those undergoing cardiovascular surgery, those with cancer, and those admitted to the ICU.

So, is this the end of an era for health-care provider concern about how long blood can be stored to be safe for ICU patients? Possibly.

There may still be high-risk populations (such as patients receiving massive transfusions) for which age of the blood does matter. In addition, it is still unclear based on the present data as to whether blood stored between 35 and 42 days has any significant inherent risk.

However, these publications among others suggest that the age of transfused blood may not matter, even in critically ill patients. Therefore, the present storage practices of many blood banks around the United States and beyond are validated by the present publications regarding the scarce resource of blood.

Christopher L. Carroll, MD, MS, FCCP

Steering Committee Member

Steven Greenberg, MD, FCCP

Steering Committee Member

References

1. Corwin HL, Gettinger A, Pearl RG, et al. Crit Care Med. 2004;32(1):39.

2. Vincent JL, Baron JF, Reinhart K, et al.; ABC (Anemia and Blood Transfusion in Critical Care) Investigators. JAMA. 2002;288(12):1499.

3. Holst LB, Haase N, Wetterslev J, et al.; TRISS Trial Group; Scandinavian Critical Care Trials Group. N Engl J Med. 2014;371(15):1381.

4. Lacroix J, Hebert PC, Hutchison JS, et al.; TRIPICU Investigators; Canadian Critical Care Trials Group; Pediatric Acute Lung Injury and Sepsis Investigators Network. N Engl J Med. 2007;356(16):1609.

5. Lacroix J, Hebert P, Fergusson DA, et al. N Engl J Med. 2015;372:1410.

6. Alexander PE, Barty R, Fei Y, et al. Blood. 2016;127(4):400.

7. Heddle NM, Cook RJ, Arnold DM, et al. N Engl J Med. 2016;375(2):1937.

Airways Disorders

Inhaled corticosteroids in COPD: When to hold and when to fold

The 2017 GOLD guidelines reiterated that inhaled corticosteroids (ICS) be reserved for COPD patients with continued symptoms and exacerbations, despite use of long-acting beta-agonists (LABAs) and long-acting muscarinic agents (LAMAs). ICS are appropriate in approximately 40% of patients; however, prescribing rates can exceed 80% (Yawn et al. 2016; Primary Care Respir J. 26:16068).

Recent literature has begun to define the appropriate use of ICS in COPD. ICS/LABA combinations improve outcomes in patients with moderate to very severe COPD with frequent exacerbations. However, ICS/LABA may not further diminish exacerbation risk compared with those treated with a LABA/LAMA combination (Wedzicha et al., N Engl J Med. 2016;374:2222).

While the addition of LAMA to an ICS/LABA combination (triple therapy) improved lung function and decreased exacerbation risk, the addition of ICS to LABA/LAMA combination did not decrease exacerbations (GOLD Guidelines 2017). It has been suggested that those with asthma-COPD overlap identified by sputum eosinophilia represent ideal candidates for ICS therapy (GINA Guideline 2016).

ICS use in COPD increases pneumonia risk. The risk was highest in the very group for which guidelines recommend its use – those with a FEV₁ less than 50% of predicted or with prior COPD exacerbation (Ernst et al. Eur Respir J. 2015;45:525).

ICS may be safely withdrawn in low-risk patients (FEV₁ less than 50% predicted and no exacerbations in the previous year [Yawn et al.]).

In a trial comparing patients with severe COPD (FEV₁ less than 50%) on continued LAMA/LABA/ICS triple therapy vs LAMA/LABA with ICS withdrawal, the risk of moderate or severe exacerbations at 52 weeks was not increased (Magnussen et al. N Engl J Med. 2014;371:1285).
 

Conclusions

Based on the 2017 GOLD guidelines:

• Monotherapy with ICS is not recommended in COPD.

• In patients with continued respiratory-related symptoms without exacerbations (GOLD group B), LAMA or LABA or LAMA/LABA combination is recommended. There is no recommendation for ICS in this group.

• In patients with frequent exacerbations (GOLD groups C and D), LAMA/LABA combinations are preferred to LABA/ICS because of superior effectiveness (especially in Group D) and the increased pneumonia risk with ICS. Escalation to triple therapy can be considered if there are continued exacerbations.

Allen Blaivas, DO, FCCP

Steering Committee Member

Navitha Ramesh, MD, MBBS

Fellow-in-Training Member

Home-Based Mechanical Ventilation and Neuromuscular Disease

Advances in neuromuscular disease

Spinal muscular atrophy (SMA) type 1 is the most deadly inherited disease among infants, with most infants dying by 1 to 2 years of age without supportive therapies, such as assisted ventilation. It is caused by homozygous deletions or mutations in the survival motor neuron 1 (SMN1) gene. Disease severity varies in part depending on the number of backup SMN2 gene copies that can produce some functional SMN protein (Arnold et al. Muscle Nerve. 2015;51[2]:157).

Recent developments of disease-modifying agents are giving hope to individuals with SMA and their families. Nusinersen (an antisense oligonucleotide) is an intrathecal medication that increases the production of functional SMN protein by increasing SMN2 exon 7 transcription (Chiriboga et al. Neurology. 2016;86[10]:890).

A recent open-label clinical trial by Finkel et al. (Lancet. 2017;388[10063]:3017) showed a “promising clinical response” that altered the natural history of disease progression. Most infants treated with multiple intrathecal doses of nusinersen had incremental improvement in their motor milestones and motor function (P = .008), as well as improved survival and/or avoidance of ventilation (P = .0014).

Moreover, the study found significant uptake of nusinersen by the motor neuron throughout the spinal cord and other neurons throughout the CNS. It appeared to be well tolerated. Disease-modifying medications may soon become “game changers” in many neuromuscular conditions.

However, a significant concern is the expected prohibitive cost both of a rare-disease-modifying therapy and of administrating intrathecal medications to fragile infants. As such, those obstacles will need to be overcome as neuromuscular clinics, hospitals, and payers start planning for the coming advances that our patients will be expecting.

Ahlam Mazi, MBBS

Fellow-in-Training Member

Interstitial and Diffuse Lung Disease

New advancements in predictive risk factors of IPF

In the last few years, many predictive risk factors were studied in clinical trials monitoring idiopathic pulmonary fibrosis (IPF), such as forced vital capacity and diffuse lung capacity for carbon monoxide (King TE Jr, et al. ASCEND Study Group. N Engl J Med. 2014;18;371­[12]:1172; Richeldi L, et al. INPULSIS Trial Investigators. N Engl J Med. 2015;20;373­[8]:782; Ley B, et al. Am J Respir Crit Care Med. 2016;15;194­[6]:711).

Recent data that have not yet been published by Carbone et al evaluate the prognostic value of the New York Heart Association index (NYHA) compared with high resolution CT scan, somatostatin receptor scintigraphy (octreoscan), and echocardiography in a study population of 128 patients suffering from IPF (61% male subjects), nonspecific interstitial pneumonia, and granulomatous lung diseases (alveolitis, sarcoidosis, granulomatosis with polyangiitis). All patients were confirmed histologically.

The NYHA came out as a reliable prognostic factor in each setting. In fact, the log-rank test showed significant differences among NYHA categories, as cases included with disease showed the worst survival rate while no death cases were observed when NYHA was negative.

Moreover, the prognostic value of NYHA was confirmed by multivariate analysis, where the survival rate results were significantly different among patients with level 7 after adjustment for other variables included in the model.

Furthermore, the prognostic value of the NYHA index was once again confirmed when the analysis was limited to cases with the histological pattern of IPF (usual interstitial pneumonia).

The authors, therefore, strongly recommend utilization of the NYHA index as a prognostic factor of IPF as well as granulomatous lung diseases.

Roberto Carbone, MD, FCCP

Steering Committee Member

Clinical Research

The unrecognized battlefield in our hospitals: Lessons from the US Navy SEALs

Burnout syndrome (BOS) is a psychological state resulting from prolonged exposure to job stressors. It is characterized by a vicious cycle of emotional exhaustion, detachment from others, and a feeling of decreased accomplishment. Severe BOS is seen in up to 45% of physicians and 33% of nurses who work in ICUs.¹

BOS has far-reaching consequences, being associated with an alarmingly high prevalence of posttraumatic stress disorder (PTSD) and substance abuse, almost equivalent to that experienced by veterans returning from war.² BOS also is associated with self-reported suboptimal patient care practices.³This crisis has long been underrecognized, but now that we have identified the problem, where does that leave us? There are currently no quality studies evaluating how to best treat and prevent BOS/PTSD in health-care professionals. Previous studies have focused on addressing organizational factors to alleviate job stressors, but the psychosocial characteristics of the individual have been largely ignored.

Our medical education has historically focused on an individual’s intelligence quotient (IQ), but developing an individual’s emotional quotient (EQ) is just as valuable. It has long been known that Navy SEALs have the lowest prevalence of PTSD among combat veterans due partially to their specific training in emotional resilience and adaptive psychosocial coping mechanisms.

For this reason, the research team at the University of Texas Health Science Center at San Antonio is collaborating with the US Navy SEAL team to design and validate a tool that teaches critical care staff resilience training similar to what their combat trainees undergo. The goal is to curb these alarming trends in BOS and create a paradigm shift in medical education within medical and nursing schools.

Bravein Amalakuhan, MD

Fellow-in-Training Member

References

1. Embriaco N, Azoulay E, Barrau K, et al. Am J Respir Crit Care Med. 2007;175(7):686.

2. Mealer ML, Shelton A, Berg B, et al. Am J Respir Crit Care Med. 2007;175(7):693.

3. Shanafelt TD, Bradley KA, Wipf JE, et al. Ann Intern Med. 2002;136(5):358.

Critical Care

End of the era for age of blood concerns?

Blood transfusions are common in critically ill patients, with two in five adults admitted to an ICU receiving a transfusion.^1,2 Recently, randomized trials have found that more restrictive thresholds for transfusions are associated with improved outcomes.^3,4 One theorized explanation for this somewhat counterintuitive association is that the prolonged storage time (i.e., the age of the blood being transfused) might affect outcomes.

There have been three recent publications that help to shed some more light on this. First, Lacroix et al.⁵ performed a multicenter randomized blinded trial in over 2,400 critically ill patients in 64 centers comparing new blood (mean storage (±SD) of 6.1±4.9 days) vs old blood with storage of 22.0±8.4 days (P less than .001). There was no statistically significant difference in 90-day mortality.⁵

The second study is a meta-analysis by Alexander et al.⁶ The investigators looked at 12 trials and 5,229 patients and compared “fresh blood” or blood stored for 3-10 days to “older blood” stored for longer durations. They found that there was no difference in mortality and no difference in adverse events, such as acute transfusion reactions, when comparing the two groups.

Lastly, Heddle et al.⁷ conducted a randomized trial that compared outcomes in 20,858 hospitalized patients transfused with fresh blood (mean storage time 13.0±7.6 days) to older blood (mean storage time 23.6±8.9 days). They found no differences in mortality when comparing those transfused with fresh vs. old blood (8.7% vs. 9.1%). In addition, there was no difference when examining the predetermined subgroups, including those undergoing cardiovascular surgery, those with cancer, and those admitted to the ICU.

So, is this the end of an era for health-care provider concern about how long blood can be stored to be safe for ICU patients? Possibly.

There may still be high-risk populations (such as patients receiving massive transfusions) for which age of the blood does matter. In addition, it is still unclear based on the present data as to whether blood stored between 35 and 42 days has any significant inherent risk.

However, these publications among others suggest that the age of transfused blood may not matter, even in critically ill patients. Therefore, the present storage practices of many blood banks around the United States and beyond are validated by the present publications regarding the scarce resource of blood.

Christopher L. Carroll, MD, MS, FCCP

Steering Committee Member

Steven Greenberg, MD, FCCP

Steering Committee Member

References

1. Corwin HL, Gettinger A, Pearl RG, et al. Crit Care Med. 2004;32(1):39.

2. Vincent JL, Baron JF, Reinhart K, et al.; ABC (Anemia and Blood Transfusion in Critical Care) Investigators. JAMA. 2002;288(12):1499.

3. Holst LB, Haase N, Wetterslev J, et al.; TRISS Trial Group; Scandinavian Critical Care Trials Group. N Engl J Med. 2014;371(15):1381.

4. Lacroix J, Hebert PC, Hutchison JS, et al.; TRIPICU Investigators; Canadian Critical Care Trials Group; Pediatric Acute Lung Injury and Sepsis Investigators Network. N Engl J Med. 2007;356(16):1609.

5. Lacroix J, Hebert P, Fergusson DA, et al. N Engl J Med. 2015;372:1410.

6. Alexander PE, Barty R, Fei Y, et al. Blood. 2016;127(4):400.

7. Heddle NM, Cook RJ, Arnold DM, et al. N Engl J Med. 2016;375(2):1937.

Airways Disorders

Inhaled corticosteroids in COPD: When to hold and when to fold

The 2017 GOLD guidelines reiterated that inhaled corticosteroids (ICS) be reserved for COPD patients with continued symptoms and exacerbations, despite use of long-acting beta-agonists (LABAs) and long-acting muscarinic agents (LAMAs). ICS are appropriate in approximately 40% of patients; however, prescribing rates can exceed 80% (Yawn et al. 2016; Primary Care Respir J. 26:16068).

Recent literature has begun to define the appropriate use of ICS in COPD. ICS/LABA combinations improve outcomes in patients with moderate to very severe COPD with frequent exacerbations. However, ICS/LABA may not further diminish exacerbation risk compared with those treated with a LABA/LAMA combination (Wedzicha et al., N Engl J Med. 2016;374:2222).

While the addition of LAMA to an ICS/LABA combination (triple therapy) improved lung function and decreased exacerbation risk, the addition of ICS to LABA/LAMA combination did not decrease exacerbations (GOLD Guidelines 2017). It has been suggested that those with asthma-COPD overlap identified by sputum eosinophilia represent ideal candidates for ICS therapy (GINA Guideline 2016).

ICS use in COPD increases pneumonia risk. The risk was highest in the very group for which guidelines recommend its use – those with a FEV₁ less than 50% of predicted or with prior COPD exacerbation (Ernst et al. Eur Respir J. 2015;45:525).

ICS may be safely withdrawn in low-risk patients (FEV₁ less than 50% predicted and no exacerbations in the previous year [Yawn et al.]).

In a trial comparing patients with severe COPD (FEV₁ less than 50%) on continued LAMA/LABA/ICS triple therapy vs LAMA/LABA with ICS withdrawal, the risk of moderate or severe exacerbations at 52 weeks was not increased (Magnussen et al. N Engl J Med. 2014;371:1285).
 

Conclusions

Based on the 2017 GOLD guidelines:

• Monotherapy with ICS is not recommended in COPD.

• In patients with continued respiratory-related symptoms without exacerbations (GOLD group B), LAMA or LABA or LAMA/LABA combination is recommended. There is no recommendation for ICS in this group.

• In patients with frequent exacerbations (GOLD groups C and D), LAMA/LABA combinations are preferred to LABA/ICS because of superior effectiveness (especially in Group D) and the increased pneumonia risk with ICS. Escalation to triple therapy can be considered if there are continued exacerbations.

Allen Blaivas, DO, FCCP

Steering Committee Member

Navitha Ramesh, MD, MBBS

Fellow-in-Training Member

Home-Based Mechanical Ventilation and Neuromuscular Disease

Advances in neuromuscular disease

Spinal muscular atrophy (SMA) type 1 is the most deadly inherited disease among infants, with most infants dying by 1 to 2 years of age without supportive therapies, such as assisted ventilation. It is caused by homozygous deletions or mutations in the survival motor neuron 1 (SMN1) gene. Disease severity varies in part depending on the number of backup SMN2 gene copies that can produce some functional SMN protein (Arnold et al. Muscle Nerve. 2015;51[2]:157).

Recent developments of disease-modifying agents are giving hope to individuals with SMA and their families. Nusinersen (an antisense oligonucleotide) is an intrathecal medication that increases the production of functional SMN protein by increasing SMN2 exon 7 transcription (Chiriboga et al. Neurology. 2016;86[10]:890).

A recent open-label clinical trial by Finkel et al. (Lancet. 2017;388[10063]:3017) showed a “promising clinical response” that altered the natural history of disease progression. Most infants treated with multiple intrathecal doses of nusinersen had incremental improvement in their motor milestones and motor function (P = .008), as well as improved survival and/or avoidance of ventilation (P = .0014).

Moreover, the study found significant uptake of nusinersen by the motor neuron throughout the spinal cord and other neurons throughout the CNS. It appeared to be well tolerated. Disease-modifying medications may soon become “game changers” in many neuromuscular conditions.

However, a significant concern is the expected prohibitive cost both of a rare-disease-modifying therapy and of administrating intrathecal medications to fragile infants. As such, those obstacles will need to be overcome as neuromuscular clinics, hospitals, and payers start planning for the coming advances that our patients will be expecting.

Ahlam Mazi, MBBS

Fellow-in-Training Member

Interstitial and Diffuse Lung Disease

New advancements in predictive risk factors of IPF

In the last few years, many predictive risk factors were studied in clinical trials monitoring idiopathic pulmonary fibrosis (IPF), such as forced vital capacity and diffuse lung capacity for carbon monoxide (King TE Jr, et al. ASCEND Study Group. N Engl J Med. 2014;18;371­[12]:1172; Richeldi L, et al. INPULSIS Trial Investigators. N Engl J Med. 2015;20;373­[8]:782; Ley B, et al. Am J Respir Crit Care Med. 2016;15;194­[6]:711).

Recent data that have not yet been published by Carbone et al evaluate the prognostic value of the New York Heart Association index (NYHA) compared with high resolution CT scan, somatostatin receptor scintigraphy (octreoscan), and echocardiography in a study population of 128 patients suffering from IPF (61% male subjects), nonspecific interstitial pneumonia, and granulomatous lung diseases (alveolitis, sarcoidosis, granulomatosis with polyangiitis). All patients were confirmed histologically.

The NYHA came out as a reliable prognostic factor in each setting. In fact, the log-rank test showed significant differences among NYHA categories, as cases included with disease showed the worst survival rate while no death cases were observed when NYHA was negative.

Moreover, the prognostic value of NYHA was confirmed by multivariate analysis, where the survival rate results were significantly different among patients with level 7 after adjustment for other variables included in the model.

Furthermore, the prognostic value of the NYHA index was once again confirmed when the analysis was limited to cases with the histological pattern of IPF (usual interstitial pneumonia).

The authors, therefore, strongly recommend utilization of the NYHA index as a prognostic factor of IPF as well as granulomatous lung diseases.

Roberto Carbone, MD, FCCP

Steering Committee Member

The global burden of COPD is increasing and is one of the leading causes of disability worldwide. Attend COPD: Current Excellence and Future Development and join clinicians, experts, and specialists as they convene in Amsterdam to discuss best practices and future directions in diagnosis, treatment, and therapeutic innovations. Plan to discuss the latest cutting-edge findings in COPD with like-minded clinicians.

The conference, taking place at the NH Grand Hotel Krasnapolsky, in the center of Amsterdam, will include these session themes:

• History and burden of COPD.
• Polymorbidity in COPD.
• Infections and exacerbations in COPD.
• Current treatment of COPD.
• The future of COPD.

Don’t Miss These Speakers

• Dirkje Postma (Keynote speaker) – Professor of Pulmonary Medicine at the University of Groningen and the University Medical Center of Groningen. Professor Postma will give a keynote session “From Past to Present, Circle With COPD.”
• David M. Mannino (Conference chair) – Professor and Chair in the Department of Preventive Medicine and Environmental Health at the University of Kentucky (Lexington) College of Public Health. Dr. Mannino’s session topic is “The Natural History of COPD.”
• John Hurst, (Co-chair and speaker) – Senior Lecturer at University College, London, UK, Dr. Hurst’s session topic is “The Importance of Acute Exacerbations.”
• Alberto Papi (Co-chair and speaker) – Professor of Respiratory Medicine and Vice President of the School of Medicine at the University of Ferrara, Italy, and Director of the Respiratory Unit of the Department of Emergency Medicine, S. Anna University Hospital, Ferrara. Professor Papi’s talk will explore “The Role of Infections.”
• Peter J. Barnes (Conference speaker) – Margaret-Turner Warwick Professor of Medicine at the National Heart and Lung Institute, Head of Respiratory Medicine at Imperial College and Honorary Consultant Physician at Royal Brompton Hospital, London. Professor Barnes’ presentation will focus on “Future Novel Therapies.”
• Sally Singh (Conference speaker) - Professor of Pulmonary and Cardiac Rehabilitation at the University Hospitals of Leicester (one of the largest rehabilitation programs in the UK). Professor Singh’s session is on “Pulmonary Rehabilitation.”
• Nicholas Hopkinson (Conference speaker) – Dr. Hopkinson is a Reader in Respiratory Medicine & Honorary Consultant Physician at the National Heart and Lung Institute of Imperial College and the Royal Brompton Hospital. His session focuses on “Cigarette Smoking.”
• Joan Soriano (Conference speaker) - Since 2007, Dr. Soriano has been an Associate Editor of the European Respiratory Journal and since 2013 of the Lancet Respiratory Medicine. His session focuses on “Asthma-COPD Overlap.”

Learn more about what the conference has to offer and how to register at chestcopdconference.com.

The global burden of COPD is increasing and is one of the leading causes of disability worldwide. Attend COPD: Current Excellence and Future Development and join clinicians, experts, and specialists as they convene in Amsterdam to discuss best practices and future directions in diagnosis, treatment, and therapeutic innovations. Plan to discuss the latest cutting-edge findings in COPD with like-minded clinicians.

The conference, taking place at the NH Grand Hotel Krasnapolsky, in the center of Amsterdam, will include these session themes:

• History and burden of COPD.
• Polymorbidity in COPD.
• Infections and exacerbations in COPD.
• Current treatment of COPD.
• The future of COPD.

Don’t Miss These Speakers

• Dirkje Postma (Keynote speaker) – Professor of Pulmonary Medicine at the University of Groningen and the University Medical Center of Groningen. Professor Postma will give a keynote session “From Past to Present, Circle With COPD.”
• David M. Mannino (Conference chair) – Professor and Chair in the Department of Preventive Medicine and Environmental Health at the University of Kentucky (Lexington) College of Public Health. Dr. Mannino’s session topic is “The Natural History of COPD.”
• John Hurst, (Co-chair and speaker) – Senior Lecturer at University College, London, UK, Dr. Hurst’s session topic is “The Importance of Acute Exacerbations.”
• Alberto Papi (Co-chair and speaker) – Professor of Respiratory Medicine and Vice President of the School of Medicine at the University of Ferrara, Italy, and Director of the Respiratory Unit of the Department of Emergency Medicine, S. Anna University Hospital, Ferrara. Professor Papi’s talk will explore “The Role of Infections.”
• Peter J. Barnes (Conference speaker) – Margaret-Turner Warwick Professor of Medicine at the National Heart and Lung Institute, Head of Respiratory Medicine at Imperial College and Honorary Consultant Physician at Royal Brompton Hospital, London. Professor Barnes’ presentation will focus on “Future Novel Therapies.”
• Sally Singh (Conference speaker) - Professor of Pulmonary and Cardiac Rehabilitation at the University Hospitals of Leicester (one of the largest rehabilitation programs in the UK). Professor Singh’s session is on “Pulmonary Rehabilitation.”
• Nicholas Hopkinson (Conference speaker) – Dr. Hopkinson is a Reader in Respiratory Medicine & Honorary Consultant Physician at the National Heart and Lung Institute of Imperial College and the Royal Brompton Hospital. His session focuses on “Cigarette Smoking.”
• Joan Soriano (Conference speaker) - Since 2007, Dr. Soriano has been an Associate Editor of the European Respiratory Journal and since 2013 of the Lancet Respiratory Medicine. His session focuses on “Asthma-COPD Overlap.”

Learn more about what the conference has to offer and how to register at chestcopdconference.com.

The global burden of COPD is increasing and is one of the leading causes of disability worldwide. Attend COPD: Current Excellence and Future Development and join clinicians, experts, and specialists as they convene in Amsterdam to discuss best practices and future directions in diagnosis, treatment, and therapeutic innovations. Plan to discuss the latest cutting-edge findings in COPD with like-minded clinicians.

The conference, taking place at the NH Grand Hotel Krasnapolsky, in the center of Amsterdam, will include these session themes:

• History and burden of COPD.
• Polymorbidity in COPD.
• Infections and exacerbations in COPD.
• Current treatment of COPD.
• The future of COPD.

Don’t Miss These Speakers

• Dirkje Postma (Keynote speaker) – Professor of Pulmonary Medicine at the University of Groningen and the University Medical Center of Groningen. Professor Postma will give a keynote session “From Past to Present, Circle With COPD.”
• David M. Mannino (Conference chair) – Professor and Chair in the Department of Preventive Medicine and Environmental Health at the University of Kentucky (Lexington) College of Public Health. Dr. Mannino’s session topic is “The Natural History of COPD.”
• John Hurst, (Co-chair and speaker) – Senior Lecturer at University College, London, UK, Dr. Hurst’s session topic is “The Importance of Acute Exacerbations.”
• Alberto Papi (Co-chair and speaker) – Professor of Respiratory Medicine and Vice President of the School of Medicine at the University of Ferrara, Italy, and Director of the Respiratory Unit of the Department of Emergency Medicine, S. Anna University Hospital, Ferrara. Professor Papi’s talk will explore “The Role of Infections.”
• Peter J. Barnes (Conference speaker) – Margaret-Turner Warwick Professor of Medicine at the National Heart and Lung Institute, Head of Respiratory Medicine at Imperial College and Honorary Consultant Physician at Royal Brompton Hospital, London. Professor Barnes’ presentation will focus on “Future Novel Therapies.”
• Sally Singh (Conference speaker) - Professor of Pulmonary and Cardiac Rehabilitation at the University Hospitals of Leicester (one of the largest rehabilitation programs in the UK). Professor Singh’s session is on “Pulmonary Rehabilitation.”
• Nicholas Hopkinson (Conference speaker) – Dr. Hopkinson is a Reader in Respiratory Medicine & Honorary Consultant Physician at the National Heart and Lung Institute of Imperial College and the Royal Brompton Hospital. His session focuses on “Cigarette Smoking.”
• Joan Soriano (Conference speaker) - Since 2007, Dr. Soriano has been an Associate Editor of the European Respiratory Journal and since 2013 of the Lancet Respiratory Medicine. His session focuses on “Asthma-COPD Overlap.”

Learn more about what the conference has to offer and how to register at chestcopdconference.com.

On Dec. 23, 2016, the Chinese National Health and Family Planning Commission officially endorsed Pulmonary and Critical Care Medicine (PCCM) as a pilot subspecialty within China. PCCM is one of three subspecialties (together with neurosurgery and cardiology) to pioneer fellowship training education in China. With the official endorsement of PCCM, local efforts will progress within China to administer programs and extend the standards of training throughout medical education in China. PCCM certification will now become a requirement for appointment of pulmonary department chairs and for promotion within the subspecialty.

Since 2012, CHEST has worked closely with partners, such as the Chinese Thoracic Society, the Chinese Association of Chest Physicians, and the Chinese Medical Doctor Association, on the development of China’s first fellowship program offering standardized training in PCCM for Chinese physicians. As a result of these collective efforts, PCCM has now officially earned endorsement as a medical subspecialty – the first of its kind in a country where medical training typically ends after a physician completes residency training. Only a decade ago, physicians in China went directly into practice following medical school. The development of a PCCM subspecialty in China – made possible through the engagement of CHEST’s expert faculty and administration – parallels what has occurred over the past 3 decades in the United States, during which the fields of pulmonary and critical care medicine evolved into the combined subspecialty of PCCM.

The China-CHEST PCCM Fellowship Program was officially launched in 2013 with 12 participating Chinese institutions starting their PCCM training programs. By the end of 2017, 30 programs with 300 fellows and 60 faculty will be participating at institutions throughout China, with the potential to impact the care of thousands of patients. The China-PCCM Fellowship Program proudly graduated its first class of fellows in September 2016.

China-CHEST leaders, including Renli Qiao, MD, PhD, FCCP; Chen Wang, MD, PhD, FCCP; and Jack Buckley, MD, MPH, FCCP; with Steve Welch, CHEST Executive Vice President, recently participated in local site visits to provide ongoing education and support to Chinese PCCM fellowship programs. They also participated in the November 2016 Mingdao Forum in Beijing to highlight the history and achievements of the China-CHEST PCCM program.

The vast reach and clinical exposure of this program highlights how an international professional medical association like CHEST, through innovative education and strategic collaborative partnerships, is able to impact medical training both within and beyond its specialty on a global scale.

Darcy Marciniuk, MD, FCCP
Chair, China–CHEST PCCM Steering Committee
Professor of Medicine, University of Saskatchewan,
Saskatoon, SK, Canada

Renli Qiao, MD, PhD, FCCP
Medical Director, China–CHEST PCCM Program
Professor of Clinical Medicine,
Keck School of Medicine of USC,
Los Angeles, California

Robb Rabito, CHCP
Director, Education Operations CHEST
Glenview, Illinois

On Dec. 23, 2016, the Chinese National Health and Family Planning Commission officially endorsed Pulmonary and Critical Care Medicine (PCCM) as a pilot subspecialty within China. PCCM is one of three subspecialties (together with neurosurgery and cardiology) to pioneer fellowship training education in China. With the official endorsement of PCCM, local efforts will progress within China to administer programs and extend the standards of training throughout medical education in China. PCCM certification will now become a requirement for appointment of pulmonary department chairs and for promotion within the subspecialty.

Since 2012, CHEST has worked closely with partners, such as the Chinese Thoracic Society, the Chinese Association of Chest Physicians, and the Chinese Medical Doctor Association, on the development of China’s first fellowship program offering standardized training in PCCM for Chinese physicians. As a result of these collective efforts, PCCM has now officially earned endorsement as a medical subspecialty – the first of its kind in a country where medical training typically ends after a physician completes residency training. Only a decade ago, physicians in China went directly into practice following medical school. The development of a PCCM subspecialty in China – made possible through the engagement of CHEST’s expert faculty and administration – parallels what has occurred over the past 3 decades in the United States, during which the fields of pulmonary and critical care medicine evolved into the combined subspecialty of PCCM.

The China-CHEST PCCM Fellowship Program was officially launched in 2013 with 12 participating Chinese institutions starting their PCCM training programs. By the end of 2017, 30 programs with 300 fellows and 60 faculty will be participating at institutions throughout China, with the potential to impact the care of thousands of patients. The China-PCCM Fellowship Program proudly graduated its first class of fellows in September 2016.

China-CHEST leaders, including Renli Qiao, MD, PhD, FCCP; Chen Wang, MD, PhD, FCCP; and Jack Buckley, MD, MPH, FCCP; with Steve Welch, CHEST Executive Vice President, recently participated in local site visits to provide ongoing education and support to Chinese PCCM fellowship programs. They also participated in the November 2016 Mingdao Forum in Beijing to highlight the history and achievements of the China-CHEST PCCM program.

The vast reach and clinical exposure of this program highlights how an international professional medical association like CHEST, through innovative education and strategic collaborative partnerships, is able to impact medical training both within and beyond its specialty on a global scale.

Darcy Marciniuk, MD, FCCP
Chair, China–CHEST PCCM Steering Committee
Professor of Medicine, University of Saskatchewan,
Saskatoon, SK, Canada

Renli Qiao, MD, PhD, FCCP
Medical Director, China–CHEST PCCM Program
Professor of Clinical Medicine,
Keck School of Medicine of USC,
Los Angeles, California

Robb Rabito, CHCP
Director, Education Operations CHEST
Glenview, Illinois

On Dec. 23, 2016, the Chinese National Health and Family Planning Commission officially endorsed Pulmonary and Critical Care Medicine (PCCM) as a pilot subspecialty within China. PCCM is one of three subspecialties (together with neurosurgery and cardiology) to pioneer fellowship training education in China. With the official endorsement of PCCM, local efforts will progress within China to administer programs and extend the standards of training throughout medical education in China. PCCM certification will now become a requirement for appointment of pulmonary department chairs and for promotion within the subspecialty.

Since 2012, CHEST has worked closely with partners, such as the Chinese Thoracic Society, the Chinese Association of Chest Physicians, and the Chinese Medical Doctor Association, on the development of China’s first fellowship program offering standardized training in PCCM for Chinese physicians. As a result of these collective efforts, PCCM has now officially earned endorsement as a medical subspecialty – the first of its kind in a country where medical training typically ends after a physician completes residency training. Only a decade ago, physicians in China went directly into practice following medical school. The development of a PCCM subspecialty in China – made possible through the engagement of CHEST’s expert faculty and administration – parallels what has occurred over the past 3 decades in the United States, during which the fields of pulmonary and critical care medicine evolved into the combined subspecialty of PCCM.

The China-CHEST PCCM Fellowship Program was officially launched in 2013 with 12 participating Chinese institutions starting their PCCM training programs. By the end of 2017, 30 programs with 300 fellows and 60 faculty will be participating at institutions throughout China, with the potential to impact the care of thousands of patients. The China-PCCM Fellowship Program proudly graduated its first class of fellows in September 2016.

China-CHEST leaders, including Renli Qiao, MD, PhD, FCCP; Chen Wang, MD, PhD, FCCP; and Jack Buckley, MD, MPH, FCCP; with Steve Welch, CHEST Executive Vice President, recently participated in local site visits to provide ongoing education and support to Chinese PCCM fellowship programs. They also participated in the November 2016 Mingdao Forum in Beijing to highlight the history and achievements of the China-CHEST PCCM program.

The vast reach and clinical exposure of this program highlights how an international professional medical association like CHEST, through innovative education and strategic collaborative partnerships, is able to impact medical training both within and beyond its specialty on a global scale.

Darcy Marciniuk, MD, FCCP
Chair, China–CHEST PCCM Steering Committee
Professor of Medicine, University of Saskatchewan,
Saskatoon, SK, Canada

Renli Qiao, MD, PhD, FCCP
Medical Director, China–CHEST PCCM Program
Professor of Clinical Medicine,
Keck School of Medicine of USC,
Los Angeles, California

Robb Rabito, CHCP
Director, Education Operations CHEST
Glenview, Illinois