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CHEST Foundation thanks its generous donors
The CHEST Foundation was pleased to honor some of the top contributors to the Beyond Our Walls Capital Campaign during CHEST 2013. Donors who generously supported the new CHEST global headquarters and Innovation, Simulation, and Training Center enjoyed a lovely reception held on the 99th floor of Chicago’s Willis Tower. Special recognition was given to Boston Scientific and Olympus for contributing $1,000,000 each to the campaign. Also honored were $100,000 donors from Jackson Pulmonary Associates, PA, and Maggie Sharma.
(L-R) Paul A. Markowski, CAE and EVP/CEO of the ACCP; with representatives from Jackson Pulmonary Associates, PA: Dr. Timothy Cannon; Brian Hudson, and Dr. Benedict Ewaleifoh, FCCP; and Dr. John C. Alexander Jr., FCCP, Co-Chair Capital Campaign.
The new CHEST Global Headquarters in Glenview, Illinois.
Boston Scientific’s Beran Rose (center) with Paul A. Markowski, CAE and EVP/CEO of the American College of Chest Physicians (L), and Dr. John C. Alexander Jr., FCCP, Co-Chair Capital Campaign (R).
Maggie Sharma (center) representing the family of the late Dr. Om P. Sharma, Master FCCP, with Paul A. Markowski, CAE and EVP/CEO of the ACCP (L), and Dr. John C. Alexander Jr., FCCP, Co-Chair Capital Campaign (R).
Representatives from Olympus honored for the company’s generosity.
(L-R) Kelly M. Shriner of Boston Scientific with Dr. Stephanie M. Levine, FCCP, Chair of The CHEST Foundation, and Karen Passafaro of Boston Scientific.
The CHEST Foundation was pleased to honor some of the top contributors to the Beyond Our Walls Capital Campaign during CHEST 2013. Donors who generously supported the new CHEST global headquarters and Innovation, Simulation, and Training Center enjoyed a lovely reception held on the 99th floor of Chicago’s Willis Tower. Special recognition was given to Boston Scientific and Olympus for contributing $1,000,000 each to the campaign. Also honored were $100,000 donors from Jackson Pulmonary Associates, PA, and Maggie Sharma.
(L-R) Paul A. Markowski, CAE and EVP/CEO of the ACCP; with representatives from Jackson Pulmonary Associates, PA: Dr. Timothy Cannon; Brian Hudson, and Dr. Benedict Ewaleifoh, FCCP; and Dr. John C. Alexander Jr., FCCP, Co-Chair Capital Campaign.
The new CHEST Global Headquarters in Glenview, Illinois.
Boston Scientific’s Beran Rose (center) with Paul A. Markowski, CAE and EVP/CEO of the American College of Chest Physicians (L), and Dr. John C. Alexander Jr., FCCP, Co-Chair Capital Campaign (R).
Maggie Sharma (center) representing the family of the late Dr. Om P. Sharma, Master FCCP, with Paul A. Markowski, CAE and EVP/CEO of the ACCP (L), and Dr. John C. Alexander Jr., FCCP, Co-Chair Capital Campaign (R).
Representatives from Olympus honored for the company’s generosity.
(L-R) Kelly M. Shriner of Boston Scientific with Dr. Stephanie M. Levine, FCCP, Chair of The CHEST Foundation, and Karen Passafaro of Boston Scientific.
The CHEST Foundation was pleased to honor some of the top contributors to the Beyond Our Walls Capital Campaign during CHEST 2013. Donors who generously supported the new CHEST global headquarters and Innovation, Simulation, and Training Center enjoyed a lovely reception held on the 99th floor of Chicago’s Willis Tower. Special recognition was given to Boston Scientific and Olympus for contributing $1,000,000 each to the campaign. Also honored were $100,000 donors from Jackson Pulmonary Associates, PA, and Maggie Sharma.
(L-R) Paul A. Markowski, CAE and EVP/CEO of the ACCP; with representatives from Jackson Pulmonary Associates, PA: Dr. Timothy Cannon; Brian Hudson, and Dr. Benedict Ewaleifoh, FCCP; and Dr. John C. Alexander Jr., FCCP, Co-Chair Capital Campaign.
The new CHEST Global Headquarters in Glenview, Illinois.
Boston Scientific’s Beran Rose (center) with Paul A. Markowski, CAE and EVP/CEO of the American College of Chest Physicians (L), and Dr. John C. Alexander Jr., FCCP, Co-Chair Capital Campaign (R).
Maggie Sharma (center) representing the family of the late Dr. Om P. Sharma, Master FCCP, with Paul A. Markowski, CAE and EVP/CEO of the ACCP (L), and Dr. John C. Alexander Jr., FCCP, Co-Chair Capital Campaign (R).
Representatives from Olympus honored for the company’s generosity.
(L-R) Kelly M. Shriner of Boston Scientific with Dr. Stephanie M. Levine, FCCP, Chair of The CHEST Foundation, and Karen Passafaro of Boston Scientific.
New members join the CHEST Physician editorial board
Dr. Jennifer D. Cox, FCCP, is an Assistant Professor of Pulmonary and Critical Care Medicine and clerkship director for the fourth-year medical student Critical Care Selective, Morsani College of Medicine, University of South Florida, in Tampa, Florida. Her academic interests include medical student, resident, and fellow education and simulation training. Her clinical interests include mechanical ventilation, critical care, palliative care in the ICU and advanced bronchoscopic techniques in the diagnosis of pulmonary and mediastinal nodules and masses.
Dr. Eric J. Gartman, FCCP, is an Assistant Professor of Medicine,Warren Alpert Medical School,Brown University, in Providence, Rhode Island. He is the site director for the Brown Fellowship Training Program in Pulmonary and Critical Care Medicine. He is a staff physician at the Memorial Hospital of Rhode Island in the Division of Pulmonary, Critical Care, and Sleep Medicine. He serves several leadership roles locally, including President of the Rhode Island Thoracic Society and Assistant Director of the weekly statewide Brown chest conference. Dr. Gartman’s clinical and research interests are in airway diseases, pulmonary physiology, and critical care medicine.
Dr. Ramesh M. Gowda, MBBS, is Director, Peripheral Interventions, Cardiac Catheterization Laboratory, Beth Israel Medical Center, Heart Institute, New York, New York. He practices both general and interventional cardiology. He is proficient in radial access and a variety of newer techniques that treat peripheral arterial diseases. His procedures include but are not limited to coronary, carotid, and peripheral angiography; interventions; and pericardiocentesis. Dr. Gowda has served on the Cardiovascular Medicine and Surgery NetWork.
Dr. James A. L. Mathers Jr., FCCP, recently retired from Pulmonary Associates of Richmond, in Richmond, Virginia, with 30 years of private practice experience in pulmonary, critical care, and sleep medicine. Dr. Mathers has served the American College of Chest Physicians in numerous leadership roles including President in 2008-2009; Regent-at-Large on the Board of Regents; two terms on the Executive Committee of the Board; Trustee of The CHEST Foundation; Chair of the Government Relations Committee; and Chair of the Critical Care Work Group. Dr. Mathers has worked with national societies, legislators, and regulatory agencies to remove barriers to appropriate care for patients with diseases of the chest. He is currently a member of the National Association for Medical Direction of Respiratory Care and is the author of its monthly Washington Watchline.
Dr. Daniel R. Ouellette, FCCP, is an Associate Professor of Medicine, Wayne State University School of Medicine, in Detroit, Michigan, and a senior staff physician at Henry Ford Hospital in Detroit, where he chairs the Credentials Committee for the Pulmonary and Critical Care Fellowship Program. Dr. Ouellette has over 20 years of military service and was the consultant to the US Army Surgeon General for Pulmonary Medicine during the last several years of his military career. He is the Chair of the Guideline Oversight Committee for the American College of Chest Physicians (CHEST). Dr. Ouellette has been active in the leadership of CHEST with previous positions, including Chair of the Clinical Pulmonary NetWork, Chair of the Council of Governors, and a member of the Board of Regents. Dr. Ouellette’s clinical areas of interest include general pulmonary and critical care medicine and evidence-based practice.
Dr. Francis J. Podbielski, FCCP, is Visiting Clinical Associate Professor of Surgery at the University of Illinois at Chicago - College of Medicine and the Medical Director of the lung cancer program at Jordan Hospital in Plymouth, Massachusetts. He joined the American College of Chest Physicians in 1997 and has served as the Governor for Massachusetts and was the Vice-Chair and Chair of the US and Canadian Council of Governors, the Chair of the Membership Committee, a member of the Nominating Committee and the Chest Medicine Affairs Committee, a Vice-Chair of the Capital Campaign Committee, and a member of the Board of Regents of the College. Dr. Podbielski’s interests are thoracic oncology and surgical management of chest infections.
Dr. Eleanor M. Summerhill, FCCP, is an Associate Professor, Division of Pulmonary and Critical Care Medicine, Warren Alpert School of Medicine, Brown University, in Providence, Rhode Island. She is the Director of the Internal Medicine Residency Program at Memorial Hospital of Rhode Island. Dr. Summerhill has served on the American College of Chest Physicians (CHEST) Critical Care and Disaster Medicine NetWork steering committees and is a past Governor for Rhode Island. She has also been very active in developing the simulation-based difficult airway course for CHEST. Dr. Summerhill’s research interests include simulation in medical education, disaster preparedness, obstructive lung diseases, and respiratory muscle function.
Dr. Krishna Sundar, FCCP, is Medical Director of the Sleep-Wake Center and Associate Professor (Clinical) in the Division of Pulmonary and Critical Care Medicine, University of Utah, in Salt Lake City, Utah. He is board-certified in sleep medicine, pulmonary disease, critical care medicine, and internal medicine. Dr. Sundar’s research interests are centered on understanding the impact of OSA therapy in chronic lung disease and delineating mechanistic pathways of disease from untreated OSA. His work has included herpes reactivation in the ICU, use of ventilator strategies in influenza-ARDS, and understanding role of nonphagocytic NADPH oxidase in acute lung injury.
Dr. Jennifer D. Cox, FCCP, is an Assistant Professor of Pulmonary and Critical Care Medicine and clerkship director for the fourth-year medical student Critical Care Selective, Morsani College of Medicine, University of South Florida, in Tampa, Florida. Her academic interests include medical student, resident, and fellow education and simulation training. Her clinical interests include mechanical ventilation, critical care, palliative care in the ICU and advanced bronchoscopic techniques in the diagnosis of pulmonary and mediastinal nodules and masses.
Dr. Eric J. Gartman, FCCP, is an Assistant Professor of Medicine,Warren Alpert Medical School,Brown University, in Providence, Rhode Island. He is the site director for the Brown Fellowship Training Program in Pulmonary and Critical Care Medicine. He is a staff physician at the Memorial Hospital of Rhode Island in the Division of Pulmonary, Critical Care, and Sleep Medicine. He serves several leadership roles locally, including President of the Rhode Island Thoracic Society and Assistant Director of the weekly statewide Brown chest conference. Dr. Gartman’s clinical and research interests are in airway diseases, pulmonary physiology, and critical care medicine.
Dr. Ramesh M. Gowda, MBBS, is Director, Peripheral Interventions, Cardiac Catheterization Laboratory, Beth Israel Medical Center, Heart Institute, New York, New York. He practices both general and interventional cardiology. He is proficient in radial access and a variety of newer techniques that treat peripheral arterial diseases. His procedures include but are not limited to coronary, carotid, and peripheral angiography; interventions; and pericardiocentesis. Dr. Gowda has served on the Cardiovascular Medicine and Surgery NetWork.
Dr. James A. L. Mathers Jr., FCCP, recently retired from Pulmonary Associates of Richmond, in Richmond, Virginia, with 30 years of private practice experience in pulmonary, critical care, and sleep medicine. Dr. Mathers has served the American College of Chest Physicians in numerous leadership roles including President in 2008-2009; Regent-at-Large on the Board of Regents; two terms on the Executive Committee of the Board; Trustee of The CHEST Foundation; Chair of the Government Relations Committee; and Chair of the Critical Care Work Group. Dr. Mathers has worked with national societies, legislators, and regulatory agencies to remove barriers to appropriate care for patients with diseases of the chest. He is currently a member of the National Association for Medical Direction of Respiratory Care and is the author of its monthly Washington Watchline.
Dr. Daniel R. Ouellette, FCCP, is an Associate Professor of Medicine, Wayne State University School of Medicine, in Detroit, Michigan, and a senior staff physician at Henry Ford Hospital in Detroit, where he chairs the Credentials Committee for the Pulmonary and Critical Care Fellowship Program. Dr. Ouellette has over 20 years of military service and was the consultant to the US Army Surgeon General for Pulmonary Medicine during the last several years of his military career. He is the Chair of the Guideline Oversight Committee for the American College of Chest Physicians (CHEST). Dr. Ouellette has been active in the leadership of CHEST with previous positions, including Chair of the Clinical Pulmonary NetWork, Chair of the Council of Governors, and a member of the Board of Regents. Dr. Ouellette’s clinical areas of interest include general pulmonary and critical care medicine and evidence-based practice.
Dr. Francis J. Podbielski, FCCP, is Visiting Clinical Associate Professor of Surgery at the University of Illinois at Chicago - College of Medicine and the Medical Director of the lung cancer program at Jordan Hospital in Plymouth, Massachusetts. He joined the American College of Chest Physicians in 1997 and has served as the Governor for Massachusetts and was the Vice-Chair and Chair of the US and Canadian Council of Governors, the Chair of the Membership Committee, a member of the Nominating Committee and the Chest Medicine Affairs Committee, a Vice-Chair of the Capital Campaign Committee, and a member of the Board of Regents of the College. Dr. Podbielski’s interests are thoracic oncology and surgical management of chest infections.
Dr. Eleanor M. Summerhill, FCCP, is an Associate Professor, Division of Pulmonary and Critical Care Medicine, Warren Alpert School of Medicine, Brown University, in Providence, Rhode Island. She is the Director of the Internal Medicine Residency Program at Memorial Hospital of Rhode Island. Dr. Summerhill has served on the American College of Chest Physicians (CHEST) Critical Care and Disaster Medicine NetWork steering committees and is a past Governor for Rhode Island. She has also been very active in developing the simulation-based difficult airway course for CHEST. Dr. Summerhill’s research interests include simulation in medical education, disaster preparedness, obstructive lung diseases, and respiratory muscle function.
Dr. Krishna Sundar, FCCP, is Medical Director of the Sleep-Wake Center and Associate Professor (Clinical) in the Division of Pulmonary and Critical Care Medicine, University of Utah, in Salt Lake City, Utah. He is board-certified in sleep medicine, pulmonary disease, critical care medicine, and internal medicine. Dr. Sundar’s research interests are centered on understanding the impact of OSA therapy in chronic lung disease and delineating mechanistic pathways of disease from untreated OSA. His work has included herpes reactivation in the ICU, use of ventilator strategies in influenza-ARDS, and understanding role of nonphagocytic NADPH oxidase in acute lung injury.
Dr. Jennifer D. Cox, FCCP, is an Assistant Professor of Pulmonary and Critical Care Medicine and clerkship director for the fourth-year medical student Critical Care Selective, Morsani College of Medicine, University of South Florida, in Tampa, Florida. Her academic interests include medical student, resident, and fellow education and simulation training. Her clinical interests include mechanical ventilation, critical care, palliative care in the ICU and advanced bronchoscopic techniques in the diagnosis of pulmonary and mediastinal nodules and masses.
Dr. Eric J. Gartman, FCCP, is an Assistant Professor of Medicine,Warren Alpert Medical School,Brown University, in Providence, Rhode Island. He is the site director for the Brown Fellowship Training Program in Pulmonary and Critical Care Medicine. He is a staff physician at the Memorial Hospital of Rhode Island in the Division of Pulmonary, Critical Care, and Sleep Medicine. He serves several leadership roles locally, including President of the Rhode Island Thoracic Society and Assistant Director of the weekly statewide Brown chest conference. Dr. Gartman’s clinical and research interests are in airway diseases, pulmonary physiology, and critical care medicine.
Dr. Ramesh M. Gowda, MBBS, is Director, Peripheral Interventions, Cardiac Catheterization Laboratory, Beth Israel Medical Center, Heart Institute, New York, New York. He practices both general and interventional cardiology. He is proficient in radial access and a variety of newer techniques that treat peripheral arterial diseases. His procedures include but are not limited to coronary, carotid, and peripheral angiography; interventions; and pericardiocentesis. Dr. Gowda has served on the Cardiovascular Medicine and Surgery NetWork.
Dr. James A. L. Mathers Jr., FCCP, recently retired from Pulmonary Associates of Richmond, in Richmond, Virginia, with 30 years of private practice experience in pulmonary, critical care, and sleep medicine. Dr. Mathers has served the American College of Chest Physicians in numerous leadership roles including President in 2008-2009; Regent-at-Large on the Board of Regents; two terms on the Executive Committee of the Board; Trustee of The CHEST Foundation; Chair of the Government Relations Committee; and Chair of the Critical Care Work Group. Dr. Mathers has worked with national societies, legislators, and regulatory agencies to remove barriers to appropriate care for patients with diseases of the chest. He is currently a member of the National Association for Medical Direction of Respiratory Care and is the author of its monthly Washington Watchline.
Dr. Daniel R. Ouellette, FCCP, is an Associate Professor of Medicine, Wayne State University School of Medicine, in Detroit, Michigan, and a senior staff physician at Henry Ford Hospital in Detroit, where he chairs the Credentials Committee for the Pulmonary and Critical Care Fellowship Program. Dr. Ouellette has over 20 years of military service and was the consultant to the US Army Surgeon General for Pulmonary Medicine during the last several years of his military career. He is the Chair of the Guideline Oversight Committee for the American College of Chest Physicians (CHEST). Dr. Ouellette has been active in the leadership of CHEST with previous positions, including Chair of the Clinical Pulmonary NetWork, Chair of the Council of Governors, and a member of the Board of Regents. Dr. Ouellette’s clinical areas of interest include general pulmonary and critical care medicine and evidence-based practice.
Dr. Francis J. Podbielski, FCCP, is Visiting Clinical Associate Professor of Surgery at the University of Illinois at Chicago - College of Medicine and the Medical Director of the lung cancer program at Jordan Hospital in Plymouth, Massachusetts. He joined the American College of Chest Physicians in 1997 and has served as the Governor for Massachusetts and was the Vice-Chair and Chair of the US and Canadian Council of Governors, the Chair of the Membership Committee, a member of the Nominating Committee and the Chest Medicine Affairs Committee, a Vice-Chair of the Capital Campaign Committee, and a member of the Board of Regents of the College. Dr. Podbielski’s interests are thoracic oncology and surgical management of chest infections.
Dr. Eleanor M. Summerhill, FCCP, is an Associate Professor, Division of Pulmonary and Critical Care Medicine, Warren Alpert School of Medicine, Brown University, in Providence, Rhode Island. She is the Director of the Internal Medicine Residency Program at Memorial Hospital of Rhode Island. Dr. Summerhill has served on the American College of Chest Physicians (CHEST) Critical Care and Disaster Medicine NetWork steering committees and is a past Governor for Rhode Island. She has also been very active in developing the simulation-based difficult airway course for CHEST. Dr. Summerhill’s research interests include simulation in medical education, disaster preparedness, obstructive lung diseases, and respiratory muscle function.
Dr. Krishna Sundar, FCCP, is Medical Director of the Sleep-Wake Center and Associate Professor (Clinical) in the Division of Pulmonary and Critical Care Medicine, University of Utah, in Salt Lake City, Utah. He is board-certified in sleep medicine, pulmonary disease, critical care medicine, and internal medicine. Dr. Sundar’s research interests are centered on understanding the impact of OSA therapy in chronic lung disease and delineating mechanistic pathways of disease from untreated OSA. His work has included herpes reactivation in the ICU, use of ventilator strategies in influenza-ARDS, and understanding role of nonphagocytic NADPH oxidase in acute lung injury.
Winners-All at CHEST 2013
CHEST 2013 attendees were all around winners, experiencing the most well-attended CHEST meeting ever. Plus, we had special winners who were acknowledged during the meeting. Those recipients of the ACCP Awards, CHEST Foundation Awards, and Honor and Memorial Lecturers are listed on the CHEST 2013 website at chestmeeting.chestnet.org/Program.
Abstract and case report winner s and winners of CHEST Bingo are listed below. Congratulations to everyone!
Alfred Soffer Research Award Winners
This award is named in honor of Dr. Alfred Soffer, Master Fellow of the College, Editor in Chief of the CHEST journal from 1968 to 1993, and Executive Director for the ACCP from 1969 to 1992. The Alfred Soffer Research Award is granted to CHEST 2013 abstract presenters for their outstanding original research.
$1,250 award winners
Alexander Chen, MD
Damian Dupuy, MD
David Odell, MD, MMSc
$900 winners
Christopher L. Carroll, MD, FCCP
Francesca Gibellino, MD
Nichole T Tanner, MD, MS, FCCP
Young Investigator Award Winners
The Young Investigator Award is open to CHEST abstract presenters enrolled in a training or fellowship program or have completed a fellowship program within 5 years prior to CHEST 2013. Semifinalists were evaluated on the basis of their written abstract and their presentation at CHEST 2013.
$1,250 winners
Hiren J. Mehta, MD
James Ramsahai, MD and Kewan Aboulhosn, MD
Bilal Safadi, MD
$900 winners
Amit Banga, MD
Richard Hedelius, DO
David Rice, MD
Michael Silverberg, MD
Top Three Poster Award winners
Top Three Posters semifinalists were evaluated on their written abstract and quality of their poster presentation during CHEST 2013. The Top Three poster winners, based on the grade received during their presentation, will receive $750. All other semifinalists will receive $500. All categories were eligible.
$750 winners
Juan Fernandez Lahera, DMD
Vladimir Koblizek, MD
Andrea Loiselle, MD
$500 winners
Erin Murphy, MD
Capt. Andrew J. Skabelund, MC, USAF
Case Report Session Award winners
The following case report winners presented the "Best Case" in their respective CHEST 2013 session. Each winner will receive a $100 prize.
Airway Cases I: Douglas Closser
Airway Cases II: Rishi Mehta
Atypical Presentations in the ICU: Srikant Nannapaneni
Bronchology Cases I: Harry Nima-Zegarra
Bronchology Cases II: Christopher Erb
Cancer Cases I: David McNamara
Cancer Cases II: Rafid Fadul
Cardiovascular Cases I: Anup Singh
Cardiovascular Cases II: Kara Goss
Cardiovascular Critical Care: Satish Chandraprakasam
Critical Care Cases: Stacie Cook
ICU Cases: Stephen Baldassarri
ICU Complications:Frederick Clayton
Infectious Disease Cases I: Luke White (on behalf of Nalin Mallik)
Infectious Disease Cases II: Deirdre Kathman
Infectious Disease Cases III: Laura Hinkle
Infectious Disease Cases IV: Brooke Colbert
Interstitial Lung Disease Cases I: Ryan Kern
Interstitial Lung Disease Cases II: Natoushka Trenard
Miscellaneous Cases I: Maria Velez
Miscellaneous Cases II: Ian Lee
Miscellaneous Cases III: Aarti Mittal
Miscellaneous Cases IV: Justin Ardoin
Miscellaneous Cases V: Daniel Miller
Pleural Cases: Jason Bellardini
Pneumonia and Pneumonitis: Nadia Morgan
What’s New in the ICU: Deepa Kuchelan
CHEST 2013 - BINGO WINNERS
Monday, October 28
Jeri Humphries, PA-C
Pattan Mahaboob Khan, MD, FCCP
Carole Lovering, ACNP
Jeffrey W. Hawkins, MD, FCCP
Vijay S. Baid, MD, FCCP
Tuesday, October 29
Charles Peng, MD
Laura Miske, MSN
Sue Galanes, APN
COL Zygmunt Orzechowski
Vipul Shah, MD
Wednesday, October 30
J. Michael Petway, MD, FCCP
Lianne Lin, MD
Parimal T. Bharucha, MBBS
Lester W. Blair, MD, FCCP
Karen I. Mella, RRT
CHEST 2013 attendees were all around winners, experiencing the most well-attended CHEST meeting ever. Plus, we had special winners who were acknowledged during the meeting. Those recipients of the ACCP Awards, CHEST Foundation Awards, and Honor and Memorial Lecturers are listed on the CHEST 2013 website at chestmeeting.chestnet.org/Program.
Abstract and case report winner s and winners of CHEST Bingo are listed below. Congratulations to everyone!
Alfred Soffer Research Award Winners
This award is named in honor of Dr. Alfred Soffer, Master Fellow of the College, Editor in Chief of the CHEST journal from 1968 to 1993, and Executive Director for the ACCP from 1969 to 1992. The Alfred Soffer Research Award is granted to CHEST 2013 abstract presenters for their outstanding original research.
$1,250 award winners
Alexander Chen, MD
Damian Dupuy, MD
David Odell, MD, MMSc
$900 winners
Christopher L. Carroll, MD, FCCP
Francesca Gibellino, MD
Nichole T Tanner, MD, MS, FCCP
Young Investigator Award Winners
The Young Investigator Award is open to CHEST abstract presenters enrolled in a training or fellowship program or have completed a fellowship program within 5 years prior to CHEST 2013. Semifinalists were evaluated on the basis of their written abstract and their presentation at CHEST 2013.
$1,250 winners
Hiren J. Mehta, MD
James Ramsahai, MD and Kewan Aboulhosn, MD
Bilal Safadi, MD
$900 winners
Amit Banga, MD
Richard Hedelius, DO
David Rice, MD
Michael Silverberg, MD
Top Three Poster Award winners
Top Three Posters semifinalists were evaluated on their written abstract and quality of their poster presentation during CHEST 2013. The Top Three poster winners, based on the grade received during their presentation, will receive $750. All other semifinalists will receive $500. All categories were eligible.
$750 winners
Juan Fernandez Lahera, DMD
Vladimir Koblizek, MD
Andrea Loiselle, MD
$500 winners
Erin Murphy, MD
Capt. Andrew J. Skabelund, MC, USAF
Case Report Session Award winners
The following case report winners presented the "Best Case" in their respective CHEST 2013 session. Each winner will receive a $100 prize.
Airway Cases I: Douglas Closser
Airway Cases II: Rishi Mehta
Atypical Presentations in the ICU: Srikant Nannapaneni
Bronchology Cases I: Harry Nima-Zegarra
Bronchology Cases II: Christopher Erb
Cancer Cases I: David McNamara
Cancer Cases II: Rafid Fadul
Cardiovascular Cases I: Anup Singh
Cardiovascular Cases II: Kara Goss
Cardiovascular Critical Care: Satish Chandraprakasam
Critical Care Cases: Stacie Cook
ICU Cases: Stephen Baldassarri
ICU Complications:Frederick Clayton
Infectious Disease Cases I: Luke White (on behalf of Nalin Mallik)
Infectious Disease Cases II: Deirdre Kathman
Infectious Disease Cases III: Laura Hinkle
Infectious Disease Cases IV: Brooke Colbert
Interstitial Lung Disease Cases I: Ryan Kern
Interstitial Lung Disease Cases II: Natoushka Trenard
Miscellaneous Cases I: Maria Velez
Miscellaneous Cases II: Ian Lee
Miscellaneous Cases III: Aarti Mittal
Miscellaneous Cases IV: Justin Ardoin
Miscellaneous Cases V: Daniel Miller
Pleural Cases: Jason Bellardini
Pneumonia and Pneumonitis: Nadia Morgan
What’s New in the ICU: Deepa Kuchelan
CHEST 2013 - BINGO WINNERS
Monday, October 28
Jeri Humphries, PA-C
Pattan Mahaboob Khan, MD, FCCP
Carole Lovering, ACNP
Jeffrey W. Hawkins, MD, FCCP
Vijay S. Baid, MD, FCCP
Tuesday, October 29
Charles Peng, MD
Laura Miske, MSN
Sue Galanes, APN
COL Zygmunt Orzechowski
Vipul Shah, MD
Wednesday, October 30
J. Michael Petway, MD, FCCP
Lianne Lin, MD
Parimal T. Bharucha, MBBS
Lester W. Blair, MD, FCCP
Karen I. Mella, RRT
CHEST 2013 attendees were all around winners, experiencing the most well-attended CHEST meeting ever. Plus, we had special winners who were acknowledged during the meeting. Those recipients of the ACCP Awards, CHEST Foundation Awards, and Honor and Memorial Lecturers are listed on the CHEST 2013 website at chestmeeting.chestnet.org/Program.
Abstract and case report winner s and winners of CHEST Bingo are listed below. Congratulations to everyone!
Alfred Soffer Research Award Winners
This award is named in honor of Dr. Alfred Soffer, Master Fellow of the College, Editor in Chief of the CHEST journal from 1968 to 1993, and Executive Director for the ACCP from 1969 to 1992. The Alfred Soffer Research Award is granted to CHEST 2013 abstract presenters for their outstanding original research.
$1,250 award winners
Alexander Chen, MD
Damian Dupuy, MD
David Odell, MD, MMSc
$900 winners
Christopher L. Carroll, MD, FCCP
Francesca Gibellino, MD
Nichole T Tanner, MD, MS, FCCP
Young Investigator Award Winners
The Young Investigator Award is open to CHEST abstract presenters enrolled in a training or fellowship program or have completed a fellowship program within 5 years prior to CHEST 2013. Semifinalists were evaluated on the basis of their written abstract and their presentation at CHEST 2013.
$1,250 winners
Hiren J. Mehta, MD
James Ramsahai, MD and Kewan Aboulhosn, MD
Bilal Safadi, MD
$900 winners
Amit Banga, MD
Richard Hedelius, DO
David Rice, MD
Michael Silverberg, MD
Top Three Poster Award winners
Top Three Posters semifinalists were evaluated on their written abstract and quality of their poster presentation during CHEST 2013. The Top Three poster winners, based on the grade received during their presentation, will receive $750. All other semifinalists will receive $500. All categories were eligible.
$750 winners
Juan Fernandez Lahera, DMD
Vladimir Koblizek, MD
Andrea Loiselle, MD
$500 winners
Erin Murphy, MD
Capt. Andrew J. Skabelund, MC, USAF
Case Report Session Award winners
The following case report winners presented the "Best Case" in their respective CHEST 2013 session. Each winner will receive a $100 prize.
Airway Cases I: Douglas Closser
Airway Cases II: Rishi Mehta
Atypical Presentations in the ICU: Srikant Nannapaneni
Bronchology Cases I: Harry Nima-Zegarra
Bronchology Cases II: Christopher Erb
Cancer Cases I: David McNamara
Cancer Cases II: Rafid Fadul
Cardiovascular Cases I: Anup Singh
Cardiovascular Cases II: Kara Goss
Cardiovascular Critical Care: Satish Chandraprakasam
Critical Care Cases: Stacie Cook
ICU Cases: Stephen Baldassarri
ICU Complications:Frederick Clayton
Infectious Disease Cases I: Luke White (on behalf of Nalin Mallik)
Infectious Disease Cases II: Deirdre Kathman
Infectious Disease Cases III: Laura Hinkle
Infectious Disease Cases IV: Brooke Colbert
Interstitial Lung Disease Cases I: Ryan Kern
Interstitial Lung Disease Cases II: Natoushka Trenard
Miscellaneous Cases I: Maria Velez
Miscellaneous Cases II: Ian Lee
Miscellaneous Cases III: Aarti Mittal
Miscellaneous Cases IV: Justin Ardoin
Miscellaneous Cases V: Daniel Miller
Pleural Cases: Jason Bellardini
Pneumonia and Pneumonitis: Nadia Morgan
What’s New in the ICU: Deepa Kuchelan
CHEST 2013 - BINGO WINNERS
Monday, October 28
Jeri Humphries, PA-C
Pattan Mahaboob Khan, MD, FCCP
Carole Lovering, ACNP
Jeffrey W. Hawkins, MD, FCCP
Vijay S. Baid, MD, FCCP
Tuesday, October 29
Charles Peng, MD
Laura Miske, MSN
Sue Galanes, APN
COL Zygmunt Orzechowski
Vipul Shah, MD
Wednesday, October 30
J. Michael Petway, MD, FCCP
Lianne Lin, MD
Parimal T. Bharucha, MBBS
Lester W. Blair, MD, FCCP
Karen I. Mella, RRT
It’s all about the guidelines (part 2 of 3)
In the first article of this series, we touched on the importance of the guidelines for proper coding, whether it is in ICD-9-CM or ICD-10-CM (chestphysician.org [in News From CHEST]). This article will dive into the conventions (1.A) for ICD-10-CM. The first important notation is at the start of the section. Sometimes a coder may be confused when the guidelines at the front of the manual state one thing, and the chapter instructions seem to state something else.
At the beginning of Section 1 it states, "The conventions and instructions of the classification take precedence over guidelines." So, if the Tabular Index gives an instruction that is different than the guidelines in the front of the manual, follow the Tabular Index guidelines.
Section 1.A contains the conventions describing the general rules. Some of the highlights include:
1.A.2: Characters for categories, subcategories, and codes may be either a letter or a number. Categories are three characters, but if there is no further breakdown, it may also be a code. For example, I10 Essential (primary) hypertension is a three-character code with no further breakdown. I11 Hypertensive heart disease is a category that needs additional characters to denote a valid code (I11.0 or I11.9).
1.A.3: For reporting purposes, only codes are permissible, not categories or subcategories, and any applicable seventh character is required. In other words, you have to continue until there are no more characters in the subcategory. As in the previous example, it would be invalid to just stop at I11, as there is a fourth character breakdown.
1.A.4 and 1.A.5: These guidelines refer to the seventh character extenders and placeholders. ICD-10-CM utilizes a placeholder "X" for future expansion and to fill in the empty characters for codes that requires a seventh character extender, when they are not six characters in length. For example, S09.21- is traumatic rupture of right eardrum, but this is not a complete code as it requires a seventh character. The partial code is five characters in length. In order to append the seventh character in the seventh character position, a placeholder "X" must be used. If this were an initial encounter, the appropriate seventh character would be "A." In this circumstance, the complete code would be S09.21XA Traumatic rupture of right
eardrum, initial encounter.
1.A.6 to 1.A.9 are familiar guidelines explaining abbreviations used in the code book (for example, not elsewhere classified [NEC], not otherwise specified [NOS], etc).
1.A.12.a and 1.A.12.b: These guidelines explain the new exclusions for ICD-10-CM: "Excludes1" and "Excludes2." Excludes1 is a true exclusion and indicates that the code(s) listed under the Excludes1 should never be coded with the code above the Excludes1 note. For example, type 1 diabetes has an Excludes1 list that includes type 2 diabetes, gestational diabetes, and secondary diabetes. None of these diagnoses would be reported with type 1 diabetes on the same patient encounter.
Excludes2 indicates that the conditions excluded are not part of the condition listed above them. If the documentation states both conditions exist together, both should be reported. This will be seen with some acute on chronic conditions for which ICD-10-CM does not have a combination code. For example, category J01, acute sinusitis, has an Excludes2 note for chronic sinusitis. If a patient has documented acute on chronic maxillary sinusitis, J01.00 (acute maxillary sinusitis) would be reported along with J32.0 (chronic maxillary sinusitis).
The remaining conventions cover sequencing of codes, other verbiage (the use of "and," "with," "see," and so on), and default codes.
It is important to take the time to become familiar with the guidelines now in order to ensure proper, efficient code assignment when we go live.
Brenda Edwards entered the coding and billing profession 25 years ago and has been involved in many aspects of the field. Her current responsibilities include chart auditing, coding and compliance education, and contributing articles to AAPC and industry publications. Brenda is an AAPC ICD-10-CM trainer and has presented for AAPC workshops, regional conferences, and local chapter meetings. She has also served on the AAPCCA local chapter board of directors.
In the first article of this series, we touched on the importance of the guidelines for proper coding, whether it is in ICD-9-CM or ICD-10-CM (chestphysician.org [in News From CHEST]). This article will dive into the conventions (1.A) for ICD-10-CM. The first important notation is at the start of the section. Sometimes a coder may be confused when the guidelines at the front of the manual state one thing, and the chapter instructions seem to state something else.
At the beginning of Section 1 it states, "The conventions and instructions of the classification take precedence over guidelines." So, if the Tabular Index gives an instruction that is different than the guidelines in the front of the manual, follow the Tabular Index guidelines.
Section 1.A contains the conventions describing the general rules. Some of the highlights include:
1.A.2: Characters for categories, subcategories, and codes may be either a letter or a number. Categories are three characters, but if there is no further breakdown, it may also be a code. For example, I10 Essential (primary) hypertension is a three-character code with no further breakdown. I11 Hypertensive heart disease is a category that needs additional characters to denote a valid code (I11.0 or I11.9).
1.A.3: For reporting purposes, only codes are permissible, not categories or subcategories, and any applicable seventh character is required. In other words, you have to continue until there are no more characters in the subcategory. As in the previous example, it would be invalid to just stop at I11, as there is a fourth character breakdown.
1.A.4 and 1.A.5: These guidelines refer to the seventh character extenders and placeholders. ICD-10-CM utilizes a placeholder "X" for future expansion and to fill in the empty characters for codes that requires a seventh character extender, when they are not six characters in length. For example, S09.21- is traumatic rupture of right eardrum, but this is not a complete code as it requires a seventh character. The partial code is five characters in length. In order to append the seventh character in the seventh character position, a placeholder "X" must be used. If this were an initial encounter, the appropriate seventh character would be "A." In this circumstance, the complete code would be S09.21XA Traumatic rupture of right
eardrum, initial encounter.
1.A.6 to 1.A.9 are familiar guidelines explaining abbreviations used in the code book (for example, not elsewhere classified [NEC], not otherwise specified [NOS], etc).
1.A.12.a and 1.A.12.b: These guidelines explain the new exclusions for ICD-10-CM: "Excludes1" and "Excludes2." Excludes1 is a true exclusion and indicates that the code(s) listed under the Excludes1 should never be coded with the code above the Excludes1 note. For example, type 1 diabetes has an Excludes1 list that includes type 2 diabetes, gestational diabetes, and secondary diabetes. None of these diagnoses would be reported with type 1 diabetes on the same patient encounter.
Excludes2 indicates that the conditions excluded are not part of the condition listed above them. If the documentation states both conditions exist together, both should be reported. This will be seen with some acute on chronic conditions for which ICD-10-CM does not have a combination code. For example, category J01, acute sinusitis, has an Excludes2 note for chronic sinusitis. If a patient has documented acute on chronic maxillary sinusitis, J01.00 (acute maxillary sinusitis) would be reported along with J32.0 (chronic maxillary sinusitis).
The remaining conventions cover sequencing of codes, other verbiage (the use of "and," "with," "see," and so on), and default codes.
It is important to take the time to become familiar with the guidelines now in order to ensure proper, efficient code assignment when we go live.
Brenda Edwards entered the coding and billing profession 25 years ago and has been involved in many aspects of the field. Her current responsibilities include chart auditing, coding and compliance education, and contributing articles to AAPC and industry publications. Brenda is an AAPC ICD-10-CM trainer and has presented for AAPC workshops, regional conferences, and local chapter meetings. She has also served on the AAPCCA local chapter board of directors.
In the first article of this series, we touched on the importance of the guidelines for proper coding, whether it is in ICD-9-CM or ICD-10-CM (chestphysician.org [in News From CHEST]). This article will dive into the conventions (1.A) for ICD-10-CM. The first important notation is at the start of the section. Sometimes a coder may be confused when the guidelines at the front of the manual state one thing, and the chapter instructions seem to state something else.
At the beginning of Section 1 it states, "The conventions and instructions of the classification take precedence over guidelines." So, if the Tabular Index gives an instruction that is different than the guidelines in the front of the manual, follow the Tabular Index guidelines.
Section 1.A contains the conventions describing the general rules. Some of the highlights include:
1.A.2: Characters for categories, subcategories, and codes may be either a letter or a number. Categories are three characters, but if there is no further breakdown, it may also be a code. For example, I10 Essential (primary) hypertension is a three-character code with no further breakdown. I11 Hypertensive heart disease is a category that needs additional characters to denote a valid code (I11.0 or I11.9).
1.A.3: For reporting purposes, only codes are permissible, not categories or subcategories, and any applicable seventh character is required. In other words, you have to continue until there are no more characters in the subcategory. As in the previous example, it would be invalid to just stop at I11, as there is a fourth character breakdown.
1.A.4 and 1.A.5: These guidelines refer to the seventh character extenders and placeholders. ICD-10-CM utilizes a placeholder "X" for future expansion and to fill in the empty characters for codes that requires a seventh character extender, when they are not six characters in length. For example, S09.21- is traumatic rupture of right eardrum, but this is not a complete code as it requires a seventh character. The partial code is five characters in length. In order to append the seventh character in the seventh character position, a placeholder "X" must be used. If this were an initial encounter, the appropriate seventh character would be "A." In this circumstance, the complete code would be S09.21XA Traumatic rupture of right
eardrum, initial encounter.
1.A.6 to 1.A.9 are familiar guidelines explaining abbreviations used in the code book (for example, not elsewhere classified [NEC], not otherwise specified [NOS], etc).
1.A.12.a and 1.A.12.b: These guidelines explain the new exclusions for ICD-10-CM: "Excludes1" and "Excludes2." Excludes1 is a true exclusion and indicates that the code(s) listed under the Excludes1 should never be coded with the code above the Excludes1 note. For example, type 1 diabetes has an Excludes1 list that includes type 2 diabetes, gestational diabetes, and secondary diabetes. None of these diagnoses would be reported with type 1 diabetes on the same patient encounter.
Excludes2 indicates that the conditions excluded are not part of the condition listed above them. If the documentation states both conditions exist together, both should be reported. This will be seen with some acute on chronic conditions for which ICD-10-CM does not have a combination code. For example, category J01, acute sinusitis, has an Excludes2 note for chronic sinusitis. If a patient has documented acute on chronic maxillary sinusitis, J01.00 (acute maxillary sinusitis) would be reported along with J32.0 (chronic maxillary sinusitis).
The remaining conventions cover sequencing of codes, other verbiage (the use of "and," "with," "see," and so on), and default codes.
It is important to take the time to become familiar with the guidelines now in order to ensure proper, efficient code assignment when we go live.
Brenda Edwards entered the coding and billing profession 25 years ago and has been involved in many aspects of the field. Her current responsibilities include chart auditing, coding and compliance education, and contributing articles to AAPC and industry publications. Brenda is an AAPC ICD-10-CM trainer and has presented for AAPC workshops, regional conferences, and local chapter meetings. She has also served on the AAPCCA local chapter board of directors.
This month in CHEST: Editor’s Picks
Editorial
Spread the Word About the Journal in 2014: Measuring Impact, Improving Search Capability, Saying Goodbye and Hello to Section Editors, Honoring Giants, and Looking Forward to a New Visual Identity. By Dr. Richard S. Irwin; Nicki Augustyn; Cynthia T. French; Victoria Tedeschi; Jean Rice; Stephen J. Welch; on behalf of the Editorial Leadership Team.
Original Research
No Association of 25-Hydroxyvitamin D With Exacerbations in Primary Care Patients With COPD. By Dr. M. A. Puhan et al.
Albuterol Administration Is Commonly Associated With Increases in Serum Lactate in Patients With Asthma Treated for Acute Exacerbation of Asthma. By Dr. L. M. Lewis et al.
The Role of the Pulmonologist in Rapid On-site Cytologic Evaluation of Transbronchial Needle Aspiration: A Prospective Study. By Dr. M. Bonifazi et al.
Appropriate Sublobar Resection Choice for Ground Glass Opacity-Dominant Clinical Stage IA Lung Adenocarcinoma: Wedge Resection or Segmentectomy? By Dr. Y. Tsutani et al.
Commentary
Establishing Pulmonary and Critical Care Medicine as a Subspecialty in China: Joint Statement of the Chinese Thoracic Society and the American College of Chest Physicians. By Drs. Renli Qiao; Mark J. Rosen; Rongchang Chen; Sinan Wu; Darcy Marciniuk; Chen Wang; on behalf of the CTS-ACCP Pulmonary and Critical Care Medicine Workgroup.
Editorial
Spread the Word About the Journal in 2014: Measuring Impact, Improving Search Capability, Saying Goodbye and Hello to Section Editors, Honoring Giants, and Looking Forward to a New Visual Identity. By Dr. Richard S. Irwin; Nicki Augustyn; Cynthia T. French; Victoria Tedeschi; Jean Rice; Stephen J. Welch; on behalf of the Editorial Leadership Team.
Original Research
No Association of 25-Hydroxyvitamin D With Exacerbations in Primary Care Patients With COPD. By Dr. M. A. Puhan et al.
Albuterol Administration Is Commonly Associated With Increases in Serum Lactate in Patients With Asthma Treated for Acute Exacerbation of Asthma. By Dr. L. M. Lewis et al.
The Role of the Pulmonologist in Rapid On-site Cytologic Evaluation of Transbronchial Needle Aspiration: A Prospective Study. By Dr. M. Bonifazi et al.
Appropriate Sublobar Resection Choice for Ground Glass Opacity-Dominant Clinical Stage IA Lung Adenocarcinoma: Wedge Resection or Segmentectomy? By Dr. Y. Tsutani et al.
Commentary
Establishing Pulmonary and Critical Care Medicine as a Subspecialty in China: Joint Statement of the Chinese Thoracic Society and the American College of Chest Physicians. By Drs. Renli Qiao; Mark J. Rosen; Rongchang Chen; Sinan Wu; Darcy Marciniuk; Chen Wang; on behalf of the CTS-ACCP Pulmonary and Critical Care Medicine Workgroup.
Editorial
Spread the Word About the Journal in 2014: Measuring Impact, Improving Search Capability, Saying Goodbye and Hello to Section Editors, Honoring Giants, and Looking Forward to a New Visual Identity. By Dr. Richard S. Irwin; Nicki Augustyn; Cynthia T. French; Victoria Tedeschi; Jean Rice; Stephen J. Welch; on behalf of the Editorial Leadership Team.
Original Research
No Association of 25-Hydroxyvitamin D With Exacerbations in Primary Care Patients With COPD. By Dr. M. A. Puhan et al.
Albuterol Administration Is Commonly Associated With Increases in Serum Lactate in Patients With Asthma Treated for Acute Exacerbation of Asthma. By Dr. L. M. Lewis et al.
The Role of the Pulmonologist in Rapid On-site Cytologic Evaluation of Transbronchial Needle Aspiration: A Prospective Study. By Dr. M. Bonifazi et al.
Appropriate Sublobar Resection Choice for Ground Glass Opacity-Dominant Clinical Stage IA Lung Adenocarcinoma: Wedge Resection or Segmentectomy? By Dr. Y. Tsutani et al.
Commentary
Establishing Pulmonary and Critical Care Medicine as a Subspecialty in China: Joint Statement of the Chinese Thoracic Society and the American College of Chest Physicians. By Drs. Renli Qiao; Mark J. Rosen; Rongchang Chen; Sinan Wu; Darcy Marciniuk; Chen Wang; on behalf of the CTS-ACCP Pulmonary and Critical Care Medicine Workgroup.
CHEST Global Headquarters Wins Green Development Award
Our new CHEST Global Headquarters in Glenview, Illinois, won the prestigious "Green Development of the Year Award" from the NAIOP Chicago, on December 2, at their 2013 Awards for Excellence program. NAIOP is the premier organization for commercial real estate professionals in metropolitan Chicago.
Our new CHEST Global Headquarters in Glenview, Illinois, won the prestigious "Green Development of the Year Award" from the NAIOP Chicago, on December 2, at their 2013 Awards for Excellence program. NAIOP is the premier organization for commercial real estate professionals in metropolitan Chicago.
Our new CHEST Global Headquarters in Glenview, Illinois, won the prestigious "Green Development of the Year Award" from the NAIOP Chicago, on December 2, at their 2013 Awards for Excellence program. NAIOP is the premier organization for commercial real estate professionals in metropolitan Chicago.
New President-Designate to serve CHEST in 2015-2016
Dr. Barbara A. Phillips, FCCP, is a Professor of Pulmonary, Critical Care, and Sleep Medicine in the Department of Internal Medicine and Medical Director, Sleep Laboratory at the University of Kentucky College of Medicine. She is board-certified in internal medicine, pulmonary medicine, critical care medicine, and sleep medicine.
After joining the American College of Chest Physicians as an affiliate member in 1982, Dr. Phillips advanced to Fellow of the College in 1983. She became a member of the Sleep Medicine NetWork and ACCP Governor for Kentucky. She has chaired the Sleep Institute and is Deputy Editor, SEEK Editorial Board Sleep Medicine Second and Third Editions. Dr. Phillips chaired the National Sleep Foundation and has served on the boards of the American Lung Association, the American Academy of Sleep Medicine, and the American Board of Sleep Medicine.
Dr. Phillips received a Sleep Academic Award from the National Institutes of Health and was presented with the ACCP College Medalist Award at CHEST 2013. Dr. Phillips' research interests are effects of sleep apnea on performance and outcomes in commercial drivers, nonpharmacologic treatment of sleep apnea, and sleep in the aging. She will take the reins as President of the ACCP at CHEST 2015 in Montreal, Canada.
Dr. Barbara A. Phillips, FCCP, is a Professor of Pulmonary, Critical Care, and Sleep Medicine in the Department of Internal Medicine and Medical Director, Sleep Laboratory at the University of Kentucky College of Medicine. She is board-certified in internal medicine, pulmonary medicine, critical care medicine, and sleep medicine.
After joining the American College of Chest Physicians as an affiliate member in 1982, Dr. Phillips advanced to Fellow of the College in 1983. She became a member of the Sleep Medicine NetWork and ACCP Governor for Kentucky. She has chaired the Sleep Institute and is Deputy Editor, SEEK Editorial Board Sleep Medicine Second and Third Editions. Dr. Phillips chaired the National Sleep Foundation and has served on the boards of the American Lung Association, the American Academy of Sleep Medicine, and the American Board of Sleep Medicine.
Dr. Phillips received a Sleep Academic Award from the National Institutes of Health and was presented with the ACCP College Medalist Award at CHEST 2013. Dr. Phillips' research interests are effects of sleep apnea on performance and outcomes in commercial drivers, nonpharmacologic treatment of sleep apnea, and sleep in the aging. She will take the reins as President of the ACCP at CHEST 2015 in Montreal, Canada.
Dr. Barbara A. Phillips, FCCP, is a Professor of Pulmonary, Critical Care, and Sleep Medicine in the Department of Internal Medicine and Medical Director, Sleep Laboratory at the University of Kentucky College of Medicine. She is board-certified in internal medicine, pulmonary medicine, critical care medicine, and sleep medicine.
After joining the American College of Chest Physicians as an affiliate member in 1982, Dr. Phillips advanced to Fellow of the College in 1983. She became a member of the Sleep Medicine NetWork and ACCP Governor for Kentucky. She has chaired the Sleep Institute and is Deputy Editor, SEEK Editorial Board Sleep Medicine Second and Third Editions. Dr. Phillips chaired the National Sleep Foundation and has served on the boards of the American Lung Association, the American Academy of Sleep Medicine, and the American Board of Sleep Medicine.
Dr. Phillips received a Sleep Academic Award from the National Institutes of Health and was presented with the ACCP College Medalist Award at CHEST 2013. Dr. Phillips' research interests are effects of sleep apnea on performance and outcomes in commercial drivers, nonpharmacologic treatment of sleep apnea, and sleep in the aging. She will take the reins as President of the ACCP at CHEST 2015 in Montreal, Canada.
President’s Report: A new leader, a new year, but advancing in the same great direction!
First, thank you very much – I am honored to be the 76th President of the American College of Chest Physicians. Next, thank you to Dr. Darcy D. Marciniuk, FCCP, our 75th ACCP President, who worked very hard for the College this past year and did a stellar job. His accomplishments will no doubt stand the test of time. And, the ACCP team will continue to tap into Darcy’s skills in his role as our Immediate Past President.
Let me briefly introduce myself. My wife Barb, my two sons, Tyler and Jackson, and I live in Jackson, Mississippi. My daily Mississippi work life revolves around the University of Mississippi Medical Center, where I have been on faculty for nearly 20 years. We have over 9,000 employees and students on our campus daily. I have the privilege of working with a great group of colleagues who make my day-to-day life quite rewarding. Their considerable support is the reason I’m able to commit the time and energy to the ACCP Presidency this year.
Plan for the year
What does the ACCP team have planned for next year? Note, the word "team." This is not my plan, but a plan developed with you—our members’ input. The team consists of our ACCP staff, leadership, and, most importantly, members like you. Your guidance and requests have been heard. In fact, I do not have a presidential "theme" for the year, unless "focus as a team" can be called a theme. As a team, let’s finish all of the important core projects we have started! Not exactly a sexy banner-grabbing "theme," but pretty darn important!
I can’t say this any better than Darcy did last year, so I will simply quote him:
"Our core strength is providing what clinicians around the world want most: education which enables them to deliver the best possible clinical care. The ACCP does not purport to be everything to everyone. We’ve adopted a disciplined approach that allows us to excel at exactly what we do – provide the very best and essential learning opportunities for the practicing clinician. Our journal CHEST, the annual CHEST conference, board review courses, simulation offerings, leadership development, and other innovative programs are all planned with that focus and important goal in mind."
This upcoming year, we will continue to focus on our core strength that aligns with the interests we have heard from our members yet again—in three words—more clinical education.
New technology-driven headquarters
To do this, we will harness our new headquarters’ state-of-the-art Innovation, Simulation, and Training Center by offering more simulation and education opportunities that will be even more innovative. The ACCP recently achieved accreditation from the Society of Simulation in Healthcare. The ACCP is the only professional medical society to be accredited. But first, we need to finish building our new LEED-certified headquarters. We still have a bit more to do to finish up. And finish – we will. Our projected move in date is in February 2014.
Our new headquarters will be complemented by our ongoing investment in an all new information technology infrastructure, our new ACCP "central nervous system" - our brain. These technology systems will coordinate our many College projects, including our all-important member-focused activities. This "brain" will provide state-of-the-art connectivity for our members to seamlessly access our educational offerings and other College products. Members will be able to quickly acquire the essential new knowledge they need to care for their patients, for maintenance of certification requirements, and for personalized data to report their quality performance measures to meet future regulatory requirements.
All of these products and services will feature a new look and feel—our new visual brand identity, introduced during CHEST 2013 in Chicago and then launched online later that week
Guidelines, global, and more
More clinical practice guidelines are on the way. Already a trusted voice in guideline development, the ACCP team is developing new guidelines (and, updating prior guidelines) in a more nimble fashion (translate, faster) with a more user-friendly product (translate, more practical for the frontline provider). Work will be accelerating this year to bring you the latest guideline-based information that you need to provide the best and most up-to-date care for your patients.
More than 5,000 attendees experienced CHEST 2013 (a new record!), one of our yearly premier educational programs. The many innovative offerings reflected the hard work of the scientific program chair, Dr. Jack Buckley, and the entire ACCP team. Dr. Mark Metersky, from the University of Connecticut, is our program chair for CHEST 2014 to be held in Austin, Texas. Mark, the program committee, and the ACCP staff are already hard at work designing this meeting. Austin offers a unique venue that I’m sure you will enjoy.
ACCP’s commitment to providing exceptional global education for our international members remains very strong. And we plan to strategically expand this important commitment. Excitement continues to grow around CHEST World Congress 2014 to be held in Madrid, March 21-24. If you haven’t registered yet, do so soon. You won’t be disappointed. Drs. Richard Irwin and Joan Soriano, our co-chairs, and their program committee, have put together an exceptional program in collaboration with our sister society, SEPAR, the Spanish Society of Pneumology and Thoracic Surgery.
Health-care reform
What’s glaringly missing from this focus list? I purposely left to last the area creating the greatest anxiety for health-care providers today – health-care reform. Notice, I didn’t say "doctors," but instead "health-care providers." We cannot, and must not, forget that the entire medical team is impacted by these changes. Most importantly, our patients and their families are impacted. And, this is not an issue isolated to the United States. Globally, health-care systems, – including regulators, payers, and governments – want excellent, quality patient care for less cost, or, at least for no increased cost. But, through all of these health care reform efforts, we must keep in mind that we can’t lose the patient’s voice.
My dad is 92 and my mom is 89. Both are patients in this evolving, complex, health-care system. I have heard from my parents, and my patients, the same concerns: With these many health-care changes has come the loss of patient-focus. Compassion and caring seems, from the all-important patient’s perspective, to have been lost in the relentless drive to generate yet another RVU.
The health-care team must continue to provide the best patient-focused care possible in the face of this storm of health-care reform. This storm will not end anytime soon. But, the good news is, the ACCP team is here to help our nearly 19,000 members, and their teams, successfully navigate this storm. Let us be your trusted partner and provide the best focused educational opportunities, not only for pulmonary, critical care, and sleep medicine clinical content, but also education about these many health-care system changes. Our new CHEST Regulations and Reimbursement Committee will be focusing on crafting the best education possible to guide our members through these often confusing health-care waters. This all-encompassing education will enable all the members of the health-care team provide the best patient care possible.
I will be relying on all of you, our members, along with Paul A. Markowski, our Executive Vice President and CEO, Curt Sessler, FCCP, our President-Elect, Dr. Barbara A. Phillips, FCCP, our President-Designate, and all of our great ACCP staff to be sure we, as an ACCP TEAM, make the upcoming year the best it can be! I look forward to hearing from you about any questions you may have about these plans.
Thank you again for this opportunity to serve you, the ACCP, and our patients.
First, thank you very much – I am honored to be the 76th President of the American College of Chest Physicians. Next, thank you to Dr. Darcy D. Marciniuk, FCCP, our 75th ACCP President, who worked very hard for the College this past year and did a stellar job. His accomplishments will no doubt stand the test of time. And, the ACCP team will continue to tap into Darcy’s skills in his role as our Immediate Past President.
Let me briefly introduce myself. My wife Barb, my two sons, Tyler and Jackson, and I live in Jackson, Mississippi. My daily Mississippi work life revolves around the University of Mississippi Medical Center, where I have been on faculty for nearly 20 years. We have over 9,000 employees and students on our campus daily. I have the privilege of working with a great group of colleagues who make my day-to-day life quite rewarding. Their considerable support is the reason I’m able to commit the time and energy to the ACCP Presidency this year.
Plan for the year
What does the ACCP team have planned for next year? Note, the word "team." This is not my plan, but a plan developed with you—our members’ input. The team consists of our ACCP staff, leadership, and, most importantly, members like you. Your guidance and requests have been heard. In fact, I do not have a presidential "theme" for the year, unless "focus as a team" can be called a theme. As a team, let’s finish all of the important core projects we have started! Not exactly a sexy banner-grabbing "theme," but pretty darn important!
I can’t say this any better than Darcy did last year, so I will simply quote him:
"Our core strength is providing what clinicians around the world want most: education which enables them to deliver the best possible clinical care. The ACCP does not purport to be everything to everyone. We’ve adopted a disciplined approach that allows us to excel at exactly what we do – provide the very best and essential learning opportunities for the practicing clinician. Our journal CHEST, the annual CHEST conference, board review courses, simulation offerings, leadership development, and other innovative programs are all planned with that focus and important goal in mind."
This upcoming year, we will continue to focus on our core strength that aligns with the interests we have heard from our members yet again—in three words—more clinical education.
New technology-driven headquarters
To do this, we will harness our new headquarters’ state-of-the-art Innovation, Simulation, and Training Center by offering more simulation and education opportunities that will be even more innovative. The ACCP recently achieved accreditation from the Society of Simulation in Healthcare. The ACCP is the only professional medical society to be accredited. But first, we need to finish building our new LEED-certified headquarters. We still have a bit more to do to finish up. And finish – we will. Our projected move in date is in February 2014.
Our new headquarters will be complemented by our ongoing investment in an all new information technology infrastructure, our new ACCP "central nervous system" - our brain. These technology systems will coordinate our many College projects, including our all-important member-focused activities. This "brain" will provide state-of-the-art connectivity for our members to seamlessly access our educational offerings and other College products. Members will be able to quickly acquire the essential new knowledge they need to care for their patients, for maintenance of certification requirements, and for personalized data to report their quality performance measures to meet future regulatory requirements.
All of these products and services will feature a new look and feel—our new visual brand identity, introduced during CHEST 2013 in Chicago and then launched online later that week
Guidelines, global, and more
More clinical practice guidelines are on the way. Already a trusted voice in guideline development, the ACCP team is developing new guidelines (and, updating prior guidelines) in a more nimble fashion (translate, faster) with a more user-friendly product (translate, more practical for the frontline provider). Work will be accelerating this year to bring you the latest guideline-based information that you need to provide the best and most up-to-date care for your patients.
More than 5,000 attendees experienced CHEST 2013 (a new record!), one of our yearly premier educational programs. The many innovative offerings reflected the hard work of the scientific program chair, Dr. Jack Buckley, and the entire ACCP team. Dr. Mark Metersky, from the University of Connecticut, is our program chair for CHEST 2014 to be held in Austin, Texas. Mark, the program committee, and the ACCP staff are already hard at work designing this meeting. Austin offers a unique venue that I’m sure you will enjoy.
ACCP’s commitment to providing exceptional global education for our international members remains very strong. And we plan to strategically expand this important commitment. Excitement continues to grow around CHEST World Congress 2014 to be held in Madrid, March 21-24. If you haven’t registered yet, do so soon. You won’t be disappointed. Drs. Richard Irwin and Joan Soriano, our co-chairs, and their program committee, have put together an exceptional program in collaboration with our sister society, SEPAR, the Spanish Society of Pneumology and Thoracic Surgery.
Health-care reform
What’s glaringly missing from this focus list? I purposely left to last the area creating the greatest anxiety for health-care providers today – health-care reform. Notice, I didn’t say "doctors," but instead "health-care providers." We cannot, and must not, forget that the entire medical team is impacted by these changes. Most importantly, our patients and their families are impacted. And, this is not an issue isolated to the United States. Globally, health-care systems, – including regulators, payers, and governments – want excellent, quality patient care for less cost, or, at least for no increased cost. But, through all of these health care reform efforts, we must keep in mind that we can’t lose the patient’s voice.
My dad is 92 and my mom is 89. Both are patients in this evolving, complex, health-care system. I have heard from my parents, and my patients, the same concerns: With these many health-care changes has come the loss of patient-focus. Compassion and caring seems, from the all-important patient’s perspective, to have been lost in the relentless drive to generate yet another RVU.
The health-care team must continue to provide the best patient-focused care possible in the face of this storm of health-care reform. This storm will not end anytime soon. But, the good news is, the ACCP team is here to help our nearly 19,000 members, and their teams, successfully navigate this storm. Let us be your trusted partner and provide the best focused educational opportunities, not only for pulmonary, critical care, and sleep medicine clinical content, but also education about these many health-care system changes. Our new CHEST Regulations and Reimbursement Committee will be focusing on crafting the best education possible to guide our members through these often confusing health-care waters. This all-encompassing education will enable all the members of the health-care team provide the best patient care possible.
I will be relying on all of you, our members, along with Paul A. Markowski, our Executive Vice President and CEO, Curt Sessler, FCCP, our President-Elect, Dr. Barbara A. Phillips, FCCP, our President-Designate, and all of our great ACCP staff to be sure we, as an ACCP TEAM, make the upcoming year the best it can be! I look forward to hearing from you about any questions you may have about these plans.
Thank you again for this opportunity to serve you, the ACCP, and our patients.
First, thank you very much – I am honored to be the 76th President of the American College of Chest Physicians. Next, thank you to Dr. Darcy D. Marciniuk, FCCP, our 75th ACCP President, who worked very hard for the College this past year and did a stellar job. His accomplishments will no doubt stand the test of time. And, the ACCP team will continue to tap into Darcy’s skills in his role as our Immediate Past President.
Let me briefly introduce myself. My wife Barb, my two sons, Tyler and Jackson, and I live in Jackson, Mississippi. My daily Mississippi work life revolves around the University of Mississippi Medical Center, where I have been on faculty for nearly 20 years. We have over 9,000 employees and students on our campus daily. I have the privilege of working with a great group of colleagues who make my day-to-day life quite rewarding. Their considerable support is the reason I’m able to commit the time and energy to the ACCP Presidency this year.
Plan for the year
What does the ACCP team have planned for next year? Note, the word "team." This is not my plan, but a plan developed with you—our members’ input. The team consists of our ACCP staff, leadership, and, most importantly, members like you. Your guidance and requests have been heard. In fact, I do not have a presidential "theme" for the year, unless "focus as a team" can be called a theme. As a team, let’s finish all of the important core projects we have started! Not exactly a sexy banner-grabbing "theme," but pretty darn important!
I can’t say this any better than Darcy did last year, so I will simply quote him:
"Our core strength is providing what clinicians around the world want most: education which enables them to deliver the best possible clinical care. The ACCP does not purport to be everything to everyone. We’ve adopted a disciplined approach that allows us to excel at exactly what we do – provide the very best and essential learning opportunities for the practicing clinician. Our journal CHEST, the annual CHEST conference, board review courses, simulation offerings, leadership development, and other innovative programs are all planned with that focus and important goal in mind."
This upcoming year, we will continue to focus on our core strength that aligns with the interests we have heard from our members yet again—in three words—more clinical education.
New technology-driven headquarters
To do this, we will harness our new headquarters’ state-of-the-art Innovation, Simulation, and Training Center by offering more simulation and education opportunities that will be even more innovative. The ACCP recently achieved accreditation from the Society of Simulation in Healthcare. The ACCP is the only professional medical society to be accredited. But first, we need to finish building our new LEED-certified headquarters. We still have a bit more to do to finish up. And finish – we will. Our projected move in date is in February 2014.
Our new headquarters will be complemented by our ongoing investment in an all new information technology infrastructure, our new ACCP "central nervous system" - our brain. These technology systems will coordinate our many College projects, including our all-important member-focused activities. This "brain" will provide state-of-the-art connectivity for our members to seamlessly access our educational offerings and other College products. Members will be able to quickly acquire the essential new knowledge they need to care for their patients, for maintenance of certification requirements, and for personalized data to report their quality performance measures to meet future regulatory requirements.
All of these products and services will feature a new look and feel—our new visual brand identity, introduced during CHEST 2013 in Chicago and then launched online later that week
Guidelines, global, and more
More clinical practice guidelines are on the way. Already a trusted voice in guideline development, the ACCP team is developing new guidelines (and, updating prior guidelines) in a more nimble fashion (translate, faster) with a more user-friendly product (translate, more practical for the frontline provider). Work will be accelerating this year to bring you the latest guideline-based information that you need to provide the best and most up-to-date care for your patients.
More than 5,000 attendees experienced CHEST 2013 (a new record!), one of our yearly premier educational programs. The many innovative offerings reflected the hard work of the scientific program chair, Dr. Jack Buckley, and the entire ACCP team. Dr. Mark Metersky, from the University of Connecticut, is our program chair for CHEST 2014 to be held in Austin, Texas. Mark, the program committee, and the ACCP staff are already hard at work designing this meeting. Austin offers a unique venue that I’m sure you will enjoy.
ACCP’s commitment to providing exceptional global education for our international members remains very strong. And we plan to strategically expand this important commitment. Excitement continues to grow around CHEST World Congress 2014 to be held in Madrid, March 21-24. If you haven’t registered yet, do so soon. You won’t be disappointed. Drs. Richard Irwin and Joan Soriano, our co-chairs, and their program committee, have put together an exceptional program in collaboration with our sister society, SEPAR, the Spanish Society of Pneumology and Thoracic Surgery.
Health-care reform
What’s glaringly missing from this focus list? I purposely left to last the area creating the greatest anxiety for health-care providers today – health-care reform. Notice, I didn’t say "doctors," but instead "health-care providers." We cannot, and must not, forget that the entire medical team is impacted by these changes. Most importantly, our patients and their families are impacted. And, this is not an issue isolated to the United States. Globally, health-care systems, – including regulators, payers, and governments – want excellent, quality patient care for less cost, or, at least for no increased cost. But, through all of these health care reform efforts, we must keep in mind that we can’t lose the patient’s voice.
My dad is 92 and my mom is 89. Both are patients in this evolving, complex, health-care system. I have heard from my parents, and my patients, the same concerns: With these many health-care changes has come the loss of patient-focus. Compassion and caring seems, from the all-important patient’s perspective, to have been lost in the relentless drive to generate yet another RVU.
The health-care team must continue to provide the best patient-focused care possible in the face of this storm of health-care reform. This storm will not end anytime soon. But, the good news is, the ACCP team is here to help our nearly 19,000 members, and their teams, successfully navigate this storm. Let us be your trusted partner and provide the best focused educational opportunities, not only for pulmonary, critical care, and sleep medicine clinical content, but also education about these many health-care system changes. Our new CHEST Regulations and Reimbursement Committee will be focusing on crafting the best education possible to guide our members through these often confusing health-care waters. This all-encompassing education will enable all the members of the health-care team provide the best patient care possible.
I will be relying on all of you, our members, along with Paul A. Markowski, our Executive Vice President and CEO, Curt Sessler, FCCP, our President-Elect, Dr. Barbara A. Phillips, FCCP, our President-Designate, and all of our great ACCP staff to be sure we, as an ACCP TEAM, make the upcoming year the best it can be! I look forward to hearing from you about any questions you may have about these plans.
Thank you again for this opportunity to serve you, the ACCP, and our patients.
Networks: Infections, e-cigarettes, lipid guidelines, and MV
Chest Infections
Antibiotics that "mist the target"
The increase in multi-drug resistance (MDR) and the dearth of new antibiotics in the "pipeline" has prompted interest in aerosolized antibiotics (AA) for treating ventilator-associated pneumonia (VAP). Toxic antibiotics like colistin may be aerosolized, reaching high concentrations in distal airways with minimal systemic absorption.
Aerosolized antibiotics have mostly gained traction in the "adjunctive" role (added to systemic antibiotics). Advances in nebulizer technology, and adjustments in ventilator settings and the breathing circuit to optimize drug delivery, have paved the way for clinical application.
Rattanaumpawan and colleagues randomized 100 patients with VAP due to MDR gram-negative bacilli (GNB) to aerosolized colistin vs placebo in addition to IV antibiotics, without benefit in clinical outcomes (J Antimicrob Chemother. 2010;65[12]: 2645).
Three recent studies used advanced vibrating plate aerosolization: Lu and colleagues compared aerosolized colistin +/- IV aminoglycoside in 43 patients with VAP with MDR GNB vs IV antibiotics alone in 122 others with sensitive GNB (Anesthesiology. 2012;117[6]:1335); outcomes were similar.
In another study, 40 patients with drug-susceptible GNB received inhaled-only ceftazidime plus amikacin, vs systemic antibiotics. Treatment success was nonsignificantly higher in the aerosol-only group; antibiotic resistance developed only in the IV group (Am J Respir Crit Care Med. 2011;184[1]: 106). Niederman and colleagues, in a randomized VAP trial (n=69), found adjunctive inhaled amikacin reduced overall exposure to antibiotics with less clinical failure compared with control (Intensive Care Med. 2012;38[2]:263).
The advantage of AA may be in avoiding systemic antibiotic overexposure. Further studies will investigate adjunctive vs stand-alone AA, optimal dosing strategies, and agents for gram-positives.
Dr. Paul Richman, FCCP
Steering Committee Member
Dr. Michael Niederman, FCCP
Chair
BCG vaccination for TB: Time for a reexamination?
Bacillus Calmette-Guerin (BCG) is the single most widely used human vaccine in history, with over 3 billion individuals vaccinated in total and 100 million annually(Liu et al. Hum Vaccine. 2009;5[2]:70).
The vaccine was developed in the early 20th century from a strain of Mycobacterium bovis. The original virulent strain had become attenuated by numerous subcultures in vitro over 13 years by Calmette and Guerin(McShane et al. Tuberculosis [Edinb]. 2012;92[3]:283).
Over the past 100 years, BCG has been disseminated to many laboratories and countries for use and has required frequent subculturing. As a result, the strains have diverged and do not have the same virulence properties as the original, and BCG should not be viewed as a single organism(Liu et al. Hum Vaccine. 2009;5[2]:70). Strain divergence has been reduced due to lyophilization of cultures over the past 47 years. Naturally occurring mutants of BCG have deletions of major virulence factors that affect the ESX-1 protein secretion system, one of several secretion systems found in the TB genome. Absence of these proteins results in impaired growth of TB in macrophages, modulates phagolysosomal fusion, and reduces bacterial virulence. The ESX-1 secretion system plays a major role in virulence of TB, and loss of the system accounts for much of the loss of virulence of BCG (Liu et al. Hum Vaccine. 2009;5[2]:70). These mutations may contribute to differences in side effects and efficacy of the vaccine utilized in different locales.
Other virulence factors of TB and BCG relate to the lipid content/composition of the cell wall of mycobacteria. These lipids are also integrally involved in pathogenicity(Liu et al. Hum Vaccine. 2009;5[2]:70). Absence or mutations in these lipids result in attenuation of infection in both mouse and guinea pig models.
Human trials and decades of clinical experience with BCG have shown that it is useful for prevention of TB and particularly for interdiction of major complications of TB (dissemination, meningitis, and mortality) in children(Checkley et al. Trends Pharmacol Sciences. 2011;32[10]:601; Trunz et al. Lancet. 2006;367[9517]:1173).
The responses for pulmonary TB in younger and older adults are not as robust (Colditz et al. JAMA. 1994;271[9]:698). For decades, the World Health Organization (WHO) has recommended BCG in high-risk endemic areas and for children. BCG is not recommended in general in developed countries where the endemic rate of TB is low; the utility of the skin test for diagnosis of latent TB would be compromised and the false-positivity rate of the test would be high.
Recognizing that BCG is not an ideal vaccine despite its widespread utility and experience over decades, further research has used the results of BCG attenuation to pursue avenues to improve BCG or to advance other vaccine candidates(Liu et al. Hum Vaccine. 2009;5[2]:70; McShane et al. Tuberculosis [Edinb]. 2012;92[3]: 283; Checkley et al. Trends Pharmacol Sciences. 2011;32[10]:601; Jeyanathan et al. J Immunol. 2008;181[8]:5618; Hokey et al. Tuberculosis [Edinb]. 2011;91[1]:82; Morais et al. Tuberculosis [Edinb]. 2010;90[2]:135; McShane et al. Philos Trans R Soc Lond B Biol Sci. 2011;366[1579]:2782; Rowland et al. Expert Rev Vaccines.2011;10[5]:645).
The newer vaccines in development against TB will have to be at least as good as the current BCG vaccine. Global challenges to the successful control of TB include the development of newer treatment drugs due to the presence of multi-drug (MDR) and extensively drug resistant (XDR) strains, efforts to halt the progression of HIV, improvement of hygiene and environmental factors of developing countries, and continued research into refinements of BCG, as well as newer vaccines against TB. Only by these combined efforts will the burden of TB be reduced by 50% by 2015 and have ultimate eradication by 2050(World Health Organization. 2011; http:// www.stoptb.org/assets/documents/global/plan.TB).
Dr. Richard Winn, FCCP
Vice-Chair
Cardiovascular Medicine and Surgery
ACC/AHA lipid guidelines spark controversy
Years in the making, the new lipid guidelines1,2 released by the American Heart Association (AHA) and the American College of Cardiology (ACC) to coincide with the AHA annual meeting in November ignited a firestorm of controversy.
The guidelines resulted from a complex process that stretched out 9 years from the publication of the consensus lipid guidelines in 2004. Convened and funded by the National Institutes of Health, the guidelines were eventually put out under the aegis of the AHA and ACC. The National Lipid Association, originally included in the process, ultimately declined to endorse them.
What was most controversial about the new guidelines was the move away from treating lipids to a specific target, instead focusing on which patients have been shown in randomized clinical trials to benefit from lipid-lowering therapy. These patients fall into 4 general categories:
1. Secondary prevention in patients with previous coronary or cerebrovascular events
2. With LDL cholesterol >190 mg/dL
3. Type II diabetics aged 40-75
4. Patients aged 40-75 with a 10-year risk of cardiovascular disease exceeding 7.5% according to a new algorithm
It was this last group that caused the most controversy. The classification has the potential to greatly increase the number of patients considered for lipid-lowering therapy, by as many as 45 million Americans.3 Drs. Paul Ridker and Nancy Cook published data that challenged the accuracy of the proposed algorithm, showing that when calibrated against patients in large randomized trials, it may overestimate the risk by as much as 75%-150%.3
Defenders of the algorithm pointed out that patients in clinical trials may be at lower risk than those in the general population, and that the algorithm, despite its flaws, is most likely more accurate than the previous algorithms that were derived from the Framingham population more than 30 years ago.
Other experts felt that the new guidelines overstressed randomized clinical trials to the exclusion of epidemiologic and population-based observational data, data they felt demonstrate convincingly that treatment to lower targets produces better outcomes even if clinical trials were not designed to not show statistically significant differences between patients who meet targets and those who have even more substantial lipid-lowering.
What remains unclear is whether the controversy about the guidelines will introduce unwanted uncertainty into the field, leading clinicians and patients to question the value of lipid-lowering as a preventive therapy, or whether disagreement will spur healthy discussions that will ultimately lead to more clarity and improved outcomes. Time will tell.
Dr. Steven M. Hollenberg, FCCP
Steering Committee Member
References
1. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Nov 7. doi:pii: S0735-1097(13)06028-2. 10.1016/j.jacc.2013.11.002. [Epub ahead of print].
2. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Nov 12. [Epub ahead of print].
3. Ridker PM, Cook NR. Statins: new American guidelines for prevention of cardiovascular disease. Lancet. 2013; 382:1762-1765.
Clinical Pulmonary Medicine
e-Cigarettes: Promise or peril?
e-Cigarettes are battery-powered devices that convert nicotine and other ingredients into vapor, simulating the visual, sensory, and behavioral aspects of smoking without the combustion products accountable for smoking’s damaging effects. An ever-growing number of companies around the world manufacture a wide variety of e-cigarette brands, despite scant information on the safety of the ingredients for human inhalation. The electronic cigarette is an emerging phenomenon that is becoming increasingly popular with smokers worldwide. Users report buying them to help quit smoking, to reduce cigarette consumption, to relieve tobacco withdrawal symptoms due to workplace smoking restrictions, and to continue to have a "smoking" experience but with reduced health risks. Electronic cigarette sales increased from 50,000 in 2008 to 3.5 million in 2012.
As of 2011, in the United States, one in five adults who smoke has tried electronic cigarettes. Among grade 6 to 12 students in the United States, those who have ever used the product increased from 3.3% in 2011 to 6.8% in 2012.
Tobacco-industry scientists argue that e-cigarettes deliver lower amounts of nicotine than regular cigarettes, are less toxic, and don’t expose others to second-hand smoke. One recent study showed that e-cigarettes, with or without nicotine, were modestly effective at helping smokers to quit, with similar achievement of abstinence as with nicotine patches and few adverse events. A recent study from France’s National Consumers Institute, however, concluded that e-cigarettes are "potentially carcinogenic" because some brands contain levels of formaldehyde that approach those of conventional cigarettes.
Uncertainty exists about the place of e-cigarettes in tobacco control, and more research is urgently needed to clearly establish their overall benefits and harms at both individual and population levels. Until then, we should not assume they are safe simply because they appear to be less harmful than traditional cigarettes. FDA is refusing to let them into the country and may soon ban their sale, as major US medical associations have strongly urged against the e-tobacco products.
Dr. Sat Sharma, FCCP
Steering Committee Member
Allied Health
Implementing mechanical ventilation orders by "Doing the Math"
Many RCPs (myself included) prefer mechanical ventilation (MV) orders that specify a target arterial pH (pHa), in lieu of listing a respiratory rate (RR) and tidal volume (Vt). If a baseline arterial blood gas (ABG) report is in hand, it’s easy to identify the target arterial carbon dioxide tension (Paco2), which will elicit a homeostatic pHa: target Paco2 = (5/3) • [HCO3–].
For example, suppose that a patient exhibits the following ABGs following an overdose of barbiturates: pHa = 7.20; Paco2 = 68 mm Hg; and [HCO3 -] = 26 mEq/L. If 7.40 is the pHa that we wish to impose: target Paco2 = (5/3) • 26 = 43 mm Hg.
Suppose further that our hypothetical patient initially displayed an RR of 10 breaths/min. We can reach the target Paco2 by applying the following expression: RRfinal = RRinitial • (Paco2initial / Paco2final).
For our hypothetical patient, this expression reverts to: RRfinal = 10 breaths/min • (68 mm Hg/43 mm Hg) = 16 breaths/min! On the other hand, if the attending physician or house officer indicates that s/he wishes to elicit a pHa that’s near the lower limit of the homeostatic range, we can simply select a target Paco2 that’s a few mm Hg higher than that shown above. This strategy is usually employed when the patient is known to be a CO2-retainer.
Want to "drill down" on this material? A video, handout, script, and posttest are accessible at: ambulatorypractice.org/education-research/respiratorytherapy-education/ventilator-targets. Enjoy!
Bob Demers, RRT
Chair
Chest Infections
Antibiotics that "mist the target"
The increase in multi-drug resistance (MDR) and the dearth of new antibiotics in the "pipeline" has prompted interest in aerosolized antibiotics (AA) for treating ventilator-associated pneumonia (VAP). Toxic antibiotics like colistin may be aerosolized, reaching high concentrations in distal airways with minimal systemic absorption.
Aerosolized antibiotics have mostly gained traction in the "adjunctive" role (added to systemic antibiotics). Advances in nebulizer technology, and adjustments in ventilator settings and the breathing circuit to optimize drug delivery, have paved the way for clinical application.
Rattanaumpawan and colleagues randomized 100 patients with VAP due to MDR gram-negative bacilli (GNB) to aerosolized colistin vs placebo in addition to IV antibiotics, without benefit in clinical outcomes (J Antimicrob Chemother. 2010;65[12]: 2645).
Three recent studies used advanced vibrating plate aerosolization: Lu and colleagues compared aerosolized colistin +/- IV aminoglycoside in 43 patients with VAP with MDR GNB vs IV antibiotics alone in 122 others with sensitive GNB (Anesthesiology. 2012;117[6]:1335); outcomes were similar.
In another study, 40 patients with drug-susceptible GNB received inhaled-only ceftazidime plus amikacin, vs systemic antibiotics. Treatment success was nonsignificantly higher in the aerosol-only group; antibiotic resistance developed only in the IV group (Am J Respir Crit Care Med. 2011;184[1]: 106). Niederman and colleagues, in a randomized VAP trial (n=69), found adjunctive inhaled amikacin reduced overall exposure to antibiotics with less clinical failure compared with control (Intensive Care Med. 2012;38[2]:263).
The advantage of AA may be in avoiding systemic antibiotic overexposure. Further studies will investigate adjunctive vs stand-alone AA, optimal dosing strategies, and agents for gram-positives.
Dr. Paul Richman, FCCP
Steering Committee Member
Dr. Michael Niederman, FCCP
Chair
BCG vaccination for TB: Time for a reexamination?
Bacillus Calmette-Guerin (BCG) is the single most widely used human vaccine in history, with over 3 billion individuals vaccinated in total and 100 million annually(Liu et al. Hum Vaccine. 2009;5[2]:70).
The vaccine was developed in the early 20th century from a strain of Mycobacterium bovis. The original virulent strain had become attenuated by numerous subcultures in vitro over 13 years by Calmette and Guerin(McShane et al. Tuberculosis [Edinb]. 2012;92[3]:283).
Over the past 100 years, BCG has been disseminated to many laboratories and countries for use and has required frequent subculturing. As a result, the strains have diverged and do not have the same virulence properties as the original, and BCG should not be viewed as a single organism(Liu et al. Hum Vaccine. 2009;5[2]:70). Strain divergence has been reduced due to lyophilization of cultures over the past 47 years. Naturally occurring mutants of BCG have deletions of major virulence factors that affect the ESX-1 protein secretion system, one of several secretion systems found in the TB genome. Absence of these proteins results in impaired growth of TB in macrophages, modulates phagolysosomal fusion, and reduces bacterial virulence. The ESX-1 secretion system plays a major role in virulence of TB, and loss of the system accounts for much of the loss of virulence of BCG (Liu et al. Hum Vaccine. 2009;5[2]:70). These mutations may contribute to differences in side effects and efficacy of the vaccine utilized in different locales.
Other virulence factors of TB and BCG relate to the lipid content/composition of the cell wall of mycobacteria. These lipids are also integrally involved in pathogenicity(Liu et al. Hum Vaccine. 2009;5[2]:70). Absence or mutations in these lipids result in attenuation of infection in both mouse and guinea pig models.
Human trials and decades of clinical experience with BCG have shown that it is useful for prevention of TB and particularly for interdiction of major complications of TB (dissemination, meningitis, and mortality) in children(Checkley et al. Trends Pharmacol Sciences. 2011;32[10]:601; Trunz et al. Lancet. 2006;367[9517]:1173).
The responses for pulmonary TB in younger and older adults are not as robust (Colditz et al. JAMA. 1994;271[9]:698). For decades, the World Health Organization (WHO) has recommended BCG in high-risk endemic areas and for children. BCG is not recommended in general in developed countries where the endemic rate of TB is low; the utility of the skin test for diagnosis of latent TB would be compromised and the false-positivity rate of the test would be high.
Recognizing that BCG is not an ideal vaccine despite its widespread utility and experience over decades, further research has used the results of BCG attenuation to pursue avenues to improve BCG or to advance other vaccine candidates(Liu et al. Hum Vaccine. 2009;5[2]:70; McShane et al. Tuberculosis [Edinb]. 2012;92[3]: 283; Checkley et al. Trends Pharmacol Sciences. 2011;32[10]:601; Jeyanathan et al. J Immunol. 2008;181[8]:5618; Hokey et al. Tuberculosis [Edinb]. 2011;91[1]:82; Morais et al. Tuberculosis [Edinb]. 2010;90[2]:135; McShane et al. Philos Trans R Soc Lond B Biol Sci. 2011;366[1579]:2782; Rowland et al. Expert Rev Vaccines.2011;10[5]:645).
The newer vaccines in development against TB will have to be at least as good as the current BCG vaccine. Global challenges to the successful control of TB include the development of newer treatment drugs due to the presence of multi-drug (MDR) and extensively drug resistant (XDR) strains, efforts to halt the progression of HIV, improvement of hygiene and environmental factors of developing countries, and continued research into refinements of BCG, as well as newer vaccines against TB. Only by these combined efforts will the burden of TB be reduced by 50% by 2015 and have ultimate eradication by 2050(World Health Organization. 2011; http:// www.stoptb.org/assets/documents/global/plan.TB).
Dr. Richard Winn, FCCP
Vice-Chair
Cardiovascular Medicine and Surgery
ACC/AHA lipid guidelines spark controversy
Years in the making, the new lipid guidelines1,2 released by the American Heart Association (AHA) and the American College of Cardiology (ACC) to coincide with the AHA annual meeting in November ignited a firestorm of controversy.
The guidelines resulted from a complex process that stretched out 9 years from the publication of the consensus lipid guidelines in 2004. Convened and funded by the National Institutes of Health, the guidelines were eventually put out under the aegis of the AHA and ACC. The National Lipid Association, originally included in the process, ultimately declined to endorse them.
What was most controversial about the new guidelines was the move away from treating lipids to a specific target, instead focusing on which patients have been shown in randomized clinical trials to benefit from lipid-lowering therapy. These patients fall into 4 general categories:
1. Secondary prevention in patients with previous coronary or cerebrovascular events
2. With LDL cholesterol >190 mg/dL
3. Type II diabetics aged 40-75
4. Patients aged 40-75 with a 10-year risk of cardiovascular disease exceeding 7.5% according to a new algorithm
It was this last group that caused the most controversy. The classification has the potential to greatly increase the number of patients considered for lipid-lowering therapy, by as many as 45 million Americans.3 Drs. Paul Ridker and Nancy Cook published data that challenged the accuracy of the proposed algorithm, showing that when calibrated against patients in large randomized trials, it may overestimate the risk by as much as 75%-150%.3
Defenders of the algorithm pointed out that patients in clinical trials may be at lower risk than those in the general population, and that the algorithm, despite its flaws, is most likely more accurate than the previous algorithms that were derived from the Framingham population more than 30 years ago.
Other experts felt that the new guidelines overstressed randomized clinical trials to the exclusion of epidemiologic and population-based observational data, data they felt demonstrate convincingly that treatment to lower targets produces better outcomes even if clinical trials were not designed to not show statistically significant differences between patients who meet targets and those who have even more substantial lipid-lowering.
What remains unclear is whether the controversy about the guidelines will introduce unwanted uncertainty into the field, leading clinicians and patients to question the value of lipid-lowering as a preventive therapy, or whether disagreement will spur healthy discussions that will ultimately lead to more clarity and improved outcomes. Time will tell.
Dr. Steven M. Hollenberg, FCCP
Steering Committee Member
References
1. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Nov 7. doi:pii: S0735-1097(13)06028-2. 10.1016/j.jacc.2013.11.002. [Epub ahead of print].
2. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Nov 12. [Epub ahead of print].
3. Ridker PM, Cook NR. Statins: new American guidelines for prevention of cardiovascular disease. Lancet. 2013; 382:1762-1765.
Clinical Pulmonary Medicine
e-Cigarettes: Promise or peril?
e-Cigarettes are battery-powered devices that convert nicotine and other ingredients into vapor, simulating the visual, sensory, and behavioral aspects of smoking without the combustion products accountable for smoking’s damaging effects. An ever-growing number of companies around the world manufacture a wide variety of e-cigarette brands, despite scant information on the safety of the ingredients for human inhalation. The electronic cigarette is an emerging phenomenon that is becoming increasingly popular with smokers worldwide. Users report buying them to help quit smoking, to reduce cigarette consumption, to relieve tobacco withdrawal symptoms due to workplace smoking restrictions, and to continue to have a "smoking" experience but with reduced health risks. Electronic cigarette sales increased from 50,000 in 2008 to 3.5 million in 2012.
As of 2011, in the United States, one in five adults who smoke has tried electronic cigarettes. Among grade 6 to 12 students in the United States, those who have ever used the product increased from 3.3% in 2011 to 6.8% in 2012.
Tobacco-industry scientists argue that e-cigarettes deliver lower amounts of nicotine than regular cigarettes, are less toxic, and don’t expose others to second-hand smoke. One recent study showed that e-cigarettes, with or without nicotine, were modestly effective at helping smokers to quit, with similar achievement of abstinence as with nicotine patches and few adverse events. A recent study from France’s National Consumers Institute, however, concluded that e-cigarettes are "potentially carcinogenic" because some brands contain levels of formaldehyde that approach those of conventional cigarettes.
Uncertainty exists about the place of e-cigarettes in tobacco control, and more research is urgently needed to clearly establish their overall benefits and harms at both individual and population levels. Until then, we should not assume they are safe simply because they appear to be less harmful than traditional cigarettes. FDA is refusing to let them into the country and may soon ban their sale, as major US medical associations have strongly urged against the e-tobacco products.
Dr. Sat Sharma, FCCP
Steering Committee Member
Allied Health
Implementing mechanical ventilation orders by "Doing the Math"
Many RCPs (myself included) prefer mechanical ventilation (MV) orders that specify a target arterial pH (pHa), in lieu of listing a respiratory rate (RR) and tidal volume (Vt). If a baseline arterial blood gas (ABG) report is in hand, it’s easy to identify the target arterial carbon dioxide tension (Paco2), which will elicit a homeostatic pHa: target Paco2 = (5/3) • [HCO3–].
For example, suppose that a patient exhibits the following ABGs following an overdose of barbiturates: pHa = 7.20; Paco2 = 68 mm Hg; and [HCO3 -] = 26 mEq/L. If 7.40 is the pHa that we wish to impose: target Paco2 = (5/3) • 26 = 43 mm Hg.
Suppose further that our hypothetical patient initially displayed an RR of 10 breaths/min. We can reach the target Paco2 by applying the following expression: RRfinal = RRinitial • (Paco2initial / Paco2final).
For our hypothetical patient, this expression reverts to: RRfinal = 10 breaths/min • (68 mm Hg/43 mm Hg) = 16 breaths/min! On the other hand, if the attending physician or house officer indicates that s/he wishes to elicit a pHa that’s near the lower limit of the homeostatic range, we can simply select a target Paco2 that’s a few mm Hg higher than that shown above. This strategy is usually employed when the patient is known to be a CO2-retainer.
Want to "drill down" on this material? A video, handout, script, and posttest are accessible at: ambulatorypractice.org/education-research/respiratorytherapy-education/ventilator-targets. Enjoy!
Bob Demers, RRT
Chair
Chest Infections
Antibiotics that "mist the target"
The increase in multi-drug resistance (MDR) and the dearth of new antibiotics in the "pipeline" has prompted interest in aerosolized antibiotics (AA) for treating ventilator-associated pneumonia (VAP). Toxic antibiotics like colistin may be aerosolized, reaching high concentrations in distal airways with minimal systemic absorption.
Aerosolized antibiotics have mostly gained traction in the "adjunctive" role (added to systemic antibiotics). Advances in nebulizer technology, and adjustments in ventilator settings and the breathing circuit to optimize drug delivery, have paved the way for clinical application.
Rattanaumpawan and colleagues randomized 100 patients with VAP due to MDR gram-negative bacilli (GNB) to aerosolized colistin vs placebo in addition to IV antibiotics, without benefit in clinical outcomes (J Antimicrob Chemother. 2010;65[12]: 2645).
Three recent studies used advanced vibrating plate aerosolization: Lu and colleagues compared aerosolized colistin +/- IV aminoglycoside in 43 patients with VAP with MDR GNB vs IV antibiotics alone in 122 others with sensitive GNB (Anesthesiology. 2012;117[6]:1335); outcomes were similar.
In another study, 40 patients with drug-susceptible GNB received inhaled-only ceftazidime plus amikacin, vs systemic antibiotics. Treatment success was nonsignificantly higher in the aerosol-only group; antibiotic resistance developed only in the IV group (Am J Respir Crit Care Med. 2011;184[1]: 106). Niederman and colleagues, in a randomized VAP trial (n=69), found adjunctive inhaled amikacin reduced overall exposure to antibiotics with less clinical failure compared with control (Intensive Care Med. 2012;38[2]:263).
The advantage of AA may be in avoiding systemic antibiotic overexposure. Further studies will investigate adjunctive vs stand-alone AA, optimal dosing strategies, and agents for gram-positives.
Dr. Paul Richman, FCCP
Steering Committee Member
Dr. Michael Niederman, FCCP
Chair
BCG vaccination for TB: Time for a reexamination?
Bacillus Calmette-Guerin (BCG) is the single most widely used human vaccine in history, with over 3 billion individuals vaccinated in total and 100 million annually(Liu et al. Hum Vaccine. 2009;5[2]:70).
The vaccine was developed in the early 20th century from a strain of Mycobacterium bovis. The original virulent strain had become attenuated by numerous subcultures in vitro over 13 years by Calmette and Guerin(McShane et al. Tuberculosis [Edinb]. 2012;92[3]:283).
Over the past 100 years, BCG has been disseminated to many laboratories and countries for use and has required frequent subculturing. As a result, the strains have diverged and do not have the same virulence properties as the original, and BCG should not be viewed as a single organism(Liu et al. Hum Vaccine. 2009;5[2]:70). Strain divergence has been reduced due to lyophilization of cultures over the past 47 years. Naturally occurring mutants of BCG have deletions of major virulence factors that affect the ESX-1 protein secretion system, one of several secretion systems found in the TB genome. Absence of these proteins results in impaired growth of TB in macrophages, modulates phagolysosomal fusion, and reduces bacterial virulence. The ESX-1 secretion system plays a major role in virulence of TB, and loss of the system accounts for much of the loss of virulence of BCG (Liu et al. Hum Vaccine. 2009;5[2]:70). These mutations may contribute to differences in side effects and efficacy of the vaccine utilized in different locales.
Other virulence factors of TB and BCG relate to the lipid content/composition of the cell wall of mycobacteria. These lipids are also integrally involved in pathogenicity(Liu et al. Hum Vaccine. 2009;5[2]:70). Absence or mutations in these lipids result in attenuation of infection in both mouse and guinea pig models.
Human trials and decades of clinical experience with BCG have shown that it is useful for prevention of TB and particularly for interdiction of major complications of TB (dissemination, meningitis, and mortality) in children(Checkley et al. Trends Pharmacol Sciences. 2011;32[10]:601; Trunz et al. Lancet. 2006;367[9517]:1173).
The responses for pulmonary TB in younger and older adults are not as robust (Colditz et al. JAMA. 1994;271[9]:698). For decades, the World Health Organization (WHO) has recommended BCG in high-risk endemic areas and for children. BCG is not recommended in general in developed countries where the endemic rate of TB is low; the utility of the skin test for diagnosis of latent TB would be compromised and the false-positivity rate of the test would be high.
Recognizing that BCG is not an ideal vaccine despite its widespread utility and experience over decades, further research has used the results of BCG attenuation to pursue avenues to improve BCG or to advance other vaccine candidates(Liu et al. Hum Vaccine. 2009;5[2]:70; McShane et al. Tuberculosis [Edinb]. 2012;92[3]: 283; Checkley et al. Trends Pharmacol Sciences. 2011;32[10]:601; Jeyanathan et al. J Immunol. 2008;181[8]:5618; Hokey et al. Tuberculosis [Edinb]. 2011;91[1]:82; Morais et al. Tuberculosis [Edinb]. 2010;90[2]:135; McShane et al. Philos Trans R Soc Lond B Biol Sci. 2011;366[1579]:2782; Rowland et al. Expert Rev Vaccines.2011;10[5]:645).
The newer vaccines in development against TB will have to be at least as good as the current BCG vaccine. Global challenges to the successful control of TB include the development of newer treatment drugs due to the presence of multi-drug (MDR) and extensively drug resistant (XDR) strains, efforts to halt the progression of HIV, improvement of hygiene and environmental factors of developing countries, and continued research into refinements of BCG, as well as newer vaccines against TB. Only by these combined efforts will the burden of TB be reduced by 50% by 2015 and have ultimate eradication by 2050(World Health Organization. 2011; http:// www.stoptb.org/assets/documents/global/plan.TB).
Dr. Richard Winn, FCCP
Vice-Chair
Cardiovascular Medicine and Surgery
ACC/AHA lipid guidelines spark controversy
Years in the making, the new lipid guidelines1,2 released by the American Heart Association (AHA) and the American College of Cardiology (ACC) to coincide with the AHA annual meeting in November ignited a firestorm of controversy.
The guidelines resulted from a complex process that stretched out 9 years from the publication of the consensus lipid guidelines in 2004. Convened and funded by the National Institutes of Health, the guidelines were eventually put out under the aegis of the AHA and ACC. The National Lipid Association, originally included in the process, ultimately declined to endorse them.
What was most controversial about the new guidelines was the move away from treating lipids to a specific target, instead focusing on which patients have been shown in randomized clinical trials to benefit from lipid-lowering therapy. These patients fall into 4 general categories:
1. Secondary prevention in patients with previous coronary or cerebrovascular events
2. With LDL cholesterol >190 mg/dL
3. Type II diabetics aged 40-75
4. Patients aged 40-75 with a 10-year risk of cardiovascular disease exceeding 7.5% according to a new algorithm
It was this last group that caused the most controversy. The classification has the potential to greatly increase the number of patients considered for lipid-lowering therapy, by as many as 45 million Americans.3 Drs. Paul Ridker and Nancy Cook published data that challenged the accuracy of the proposed algorithm, showing that when calibrated against patients in large randomized trials, it may overestimate the risk by as much as 75%-150%.3
Defenders of the algorithm pointed out that patients in clinical trials may be at lower risk than those in the general population, and that the algorithm, despite its flaws, is most likely more accurate than the previous algorithms that were derived from the Framingham population more than 30 years ago.
Other experts felt that the new guidelines overstressed randomized clinical trials to the exclusion of epidemiologic and population-based observational data, data they felt demonstrate convincingly that treatment to lower targets produces better outcomes even if clinical trials were not designed to not show statistically significant differences between patients who meet targets and those who have even more substantial lipid-lowering.
What remains unclear is whether the controversy about the guidelines will introduce unwanted uncertainty into the field, leading clinicians and patients to question the value of lipid-lowering as a preventive therapy, or whether disagreement will spur healthy discussions that will ultimately lead to more clarity and improved outcomes. Time will tell.
Dr. Steven M. Hollenberg, FCCP
Steering Committee Member
References
1. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Nov 7. doi:pii: S0735-1097(13)06028-2. 10.1016/j.jacc.2013.11.002. [Epub ahead of print].
2. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013 Nov 12. [Epub ahead of print].
3. Ridker PM, Cook NR. Statins: new American guidelines for prevention of cardiovascular disease. Lancet. 2013; 382:1762-1765.
Clinical Pulmonary Medicine
e-Cigarettes: Promise or peril?
e-Cigarettes are battery-powered devices that convert nicotine and other ingredients into vapor, simulating the visual, sensory, and behavioral aspects of smoking without the combustion products accountable for smoking’s damaging effects. An ever-growing number of companies around the world manufacture a wide variety of e-cigarette brands, despite scant information on the safety of the ingredients for human inhalation. The electronic cigarette is an emerging phenomenon that is becoming increasingly popular with smokers worldwide. Users report buying them to help quit smoking, to reduce cigarette consumption, to relieve tobacco withdrawal symptoms due to workplace smoking restrictions, and to continue to have a "smoking" experience but with reduced health risks. Electronic cigarette sales increased from 50,000 in 2008 to 3.5 million in 2012.
As of 2011, in the United States, one in five adults who smoke has tried electronic cigarettes. Among grade 6 to 12 students in the United States, those who have ever used the product increased from 3.3% in 2011 to 6.8% in 2012.
Tobacco-industry scientists argue that e-cigarettes deliver lower amounts of nicotine than regular cigarettes, are less toxic, and don’t expose others to second-hand smoke. One recent study showed that e-cigarettes, with or without nicotine, were modestly effective at helping smokers to quit, with similar achievement of abstinence as with nicotine patches and few adverse events. A recent study from France’s National Consumers Institute, however, concluded that e-cigarettes are "potentially carcinogenic" because some brands contain levels of formaldehyde that approach those of conventional cigarettes.
Uncertainty exists about the place of e-cigarettes in tobacco control, and more research is urgently needed to clearly establish their overall benefits and harms at both individual and population levels. Until then, we should not assume they are safe simply because they appear to be less harmful than traditional cigarettes. FDA is refusing to let them into the country and may soon ban their sale, as major US medical associations have strongly urged against the e-tobacco products.
Dr. Sat Sharma, FCCP
Steering Committee Member
Allied Health
Implementing mechanical ventilation orders by "Doing the Math"
Many RCPs (myself included) prefer mechanical ventilation (MV) orders that specify a target arterial pH (pHa), in lieu of listing a respiratory rate (RR) and tidal volume (Vt). If a baseline arterial blood gas (ABG) report is in hand, it’s easy to identify the target arterial carbon dioxide tension (Paco2), which will elicit a homeostatic pHa: target Paco2 = (5/3) • [HCO3–].
For example, suppose that a patient exhibits the following ABGs following an overdose of barbiturates: pHa = 7.20; Paco2 = 68 mm Hg; and [HCO3 -] = 26 mEq/L. If 7.40 is the pHa that we wish to impose: target Paco2 = (5/3) • 26 = 43 mm Hg.
Suppose further that our hypothetical patient initially displayed an RR of 10 breaths/min. We can reach the target Paco2 by applying the following expression: RRfinal = RRinitial • (Paco2initial / Paco2final).
For our hypothetical patient, this expression reverts to: RRfinal = 10 breaths/min • (68 mm Hg/43 mm Hg) = 16 breaths/min! On the other hand, if the attending physician or house officer indicates that s/he wishes to elicit a pHa that’s near the lower limit of the homeostatic range, we can simply select a target Paco2 that’s a few mm Hg higher than that shown above. This strategy is usually employed when the patient is known to be a CO2-retainer.
Want to "drill down" on this material? A video, handout, script, and posttest are accessible at: ambulatorypractice.org/education-research/respiratorytherapy-education/ventilator-targets. Enjoy!
Bob Demers, RRT
Chair
Sleep strategies – Obstructive sleep apnea syndrome and cognitive impairment
Obstructive sleep apnea syndrome (OSAS) is a very common, underrecognized disorder with significant implications for individual and global health. Over the past few decades, our understanding of OSAS has improved, leading to earlier diagnosis and treatment. In turn, increasing awareness of this disorder has yielded greater recognition of the sequelae associated with OSAS, including heart disease, stroke, and cognitive impairment.
OSAS can affect cognition across the lifespan from infants to geriatric patients. Habitual snoring during the first year of life has been associated with lower scores on the Bayley Scales of Infant and Toddler Development, comparable with those seen in infants with iron-deficiency anemia (Grigg-Damberger et al. Curr Opin Pulm Med. 2012;18[6]:580). Such scores can predict future intelligence quotient scores, educational achievements, and job performance (Dezoate et al. Child. 2003;29[5]:367). OSAS of any severity as well as habitual snoring has been shown to increase the risk of hyperactivity, inattention, and poor school performance in children (Bourke et al. Sleep Med. 2011; 12[3]:222), and some of these metrics have been shown to improve with therapy. Thus, even primary snoring in children should not be considered a wholly benign condition.
Mild cognitive impairment (MCI) is defined as a subtle but measurable cognitive dysfunction, greater than that which would be expected with normal aging; memory loss is typically the presenting symptom. The conversion rate of MCI to frank dementia is roughly 15% per year (Petersen et al. Arch Neurol. 1999;56[3]:303). OSAS has been shown to be associated with MCI in adults (Cosentino et al. Sleep Med. 2008;9[8]:831); studies have also shown OSAS to be associated with impaired vigilance (Findley et al. Chest. 1995;108[3]:619) and executive function (Naismith et al. J Clin Exp Neuropsychol. 2004;26[1]:43). Thus, the cognitive dysfunction associated with OSAS is a real and measurable problem. If these relationships are causal, as one might suspect, aggressive screening for OSAS in patients with MCI might be warranted in the hope of reversing the disorder.
There are likely to be multiple mechanisms underlying the association between cognitive impairment and OSAS. Excessive daytime sleepiness can induce an impairment of vigilance and memory, both of which are components of cognitive function. A vicious cycle may ensue, with patients forgetting to use their CPAP, leading to worsening cognition. Intermittent hypoxemia is associated with a pro-inflammatory state and endothelial dysfunction that may be the intermediate mechanism by which cognitive impairment occurs. Genetic factors may modulate the association between cognitive impairment and OSAS. The apolipoprotein E4 allele located on chromosome 19 is a strong risk factor for early-onset Alzheimer’s disease and has been shown to increase the risk of developing both OSAS (Kadotani et al. JAMA. 2001;285[22]:2888) and neurocognitive decline among patients with OSAS (Gozal et al. Neurology. 2007;69[3]:243). A higher intelligence quotient, younger age, and higher education level may protect the brain from the detrimental effects of the intermittent hypoxia associated with OSAS (Grigg-Damberger et al. Curr Opin Pulm Med. 2012;18[6]:580). The situation becomes even more complex when considering other comorbidities often exist in the OSA population and can affect cognition, including tobacco and alcohol use, stroke, hypothyroidism, congestive heart failure, obesity, psychoactive medication use, and depression, among others.
Neuroimaging techniques have been used to identify brain abnormalities in patients with OSAS. Functional and structural changes, as well as altered levels of neurochemical mediators like N-acetyl aspartate and choline, have been reported. A common finding among MRI studies is decreased volume of the hippocampus; functional MRI has shown decreased brain activation in the cingulate cortex and other brain regions during sustained attention tasks, compared with control subjects (Ayalon et al. Sleep. 2009;32[3]:373). Both of these brain areas, which are involved with memory consolidation, are also affected by gray-matter loss in patients with OSAS (Macey et al. Am J Respir Crit Care Med. 2002;166[10]: 1382). These changes may explain symptoms of retrograde and anterograde amnesia in such patients.
If OSAS is associated with cognitive impairment, then treatment might reverse the brain changes causing this impairment. A small study evaluated cognitive performance and brain morphology before and after CPAP treatment in patients with OSAS (Canessa et al. Am J Respir Crit Care Med. 2011;183[100]:1419). Testing before CPAP treatment showed impairment in several cognitive domains and focal reductions of gray-matter volume in the left hippocampus and several other brain areas when compared with healthy age- and education-matched control subjects. After CPAP treatment for 3 months, significant improvements in memory, attention, executive function, and gray-matter volume in hippocampal and frontal structures were seen, suggesting that even a short duration of CPAP treatment can partially reverse the brain abnormalities of OSAS.
The duration of disease prior to therapy in these patients is unknown, but it is notable that patients with frank cognitive deterioration were excluded; whether more severe cognitive impairment would improve with therapy for sleep-disordered breathing remains unknown. It is possible that if left untreated, these changes could progress and become irreversible. Thus, emphasis should be placed on early diagnosis and treatment of OSAS.
Newer stimulant medications like armodafinil have been shown to improve not only sleepiness but also long-term memory (Roth et al. Sleep Breath. 2008;12[1]:53). Although these medications are FDA-approved for the treatment of residual sleepiness in patients with treated sleep apnea, their role in improving cognitive function needs to be evaluated further.
It is important for sleep medicine physicians to be cognizant of the effects of OSAS on cognitive function and to screen for it in their clinics. One simple screening instrument is the MCFSI (Mail-In Cognitive Function Screening Instrument), which is a self-administered test designed to identify cognitive impairment (Walsh et al. Alzheimer Dis Assoc Disord. 2006;20(4 Suppl 3):S170). The authors have found this tool to be a quick and effective screening tool in their patients with OSAS, although large studies validating it in this population are lacking.
It is our practice to refer patients with significantly abnormal scores on preliminary tests to a neuropsychologist for complete evaluation, which could involve the administration of tasks specifically designed to test for vigilance and working memory like the psychomotor vigilance task and digit span, providing more objective evidence of cognitive impairment. It also serves as a baseline for the individual patient for long-term follow-up.
The long-term implications of OSAS on cognitive function are just beginning to be realized. The importance of early diagnosis and treatment of OSAS is becoming more evident, as we may be able to stop or partially reverse some of the underlying neurologic abnormalities with treatment. Given the strong association between OSAS and cognitive impairment, we recommend that all patients with MCI or frank dementia be screened for OSAS as a potentially reversible cause of these conditions; polysomnography should subsequently be offered to those patients who are deemed to be high risk for having OSA. Discussions with cognitively impaired patients about the implications of nonadherence with CPAP should be reiterated at each visit, particularly given the significant barrier that such impairment may create to reliable use of therapy.
Drs. Walters and Lal are from the Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC.
Editor’s Note
Evidence continues to mount demonstrating the multiple systemic effects of sleep apnea; in this month’s Sleep Strategies, Drs. Walters and Lal review the cognitive repercussions of untreated sleep-disordered breathing. Given what we know about the growing prevalence of sleep apnea, should we consider more aggressive screening for OSA in patients demonstrating cognitive decline in much the same way we screen those with refractory hypertension or atrial fibrillation? While the sheer volume of referrals that could stem from such a practice may be daunting, the opportunity to potentially impact the natural history of dementia seems too promising to ignore.
Dr. David Schulman, FCCP, Section Editor
Evidence continues to mount demonstrating the multiple systemic effects of sleep apnea; in this month’s Sleep Strategies, Drs. Walters and Lal review the cognitive repercussions of untreated sleep-disordered breathing. Given what we know about the growing prevalence of sleep apnea, should we consider more aggressive screening for OSA in patients demonstrating cognitive decline in much the same way we screen those with refractory hypertension or atrial fibrillation? While the sheer volume of referrals that could stem from such a practice may be daunting, the opportunity to potentially impact the natural history of dementia seems too promising to ignore.
Dr. David Schulman, FCCP
Mild cognitive impairment (MCI), cognitive dysfunction,
Evidence continues to mount demonstrating the multiple systemic effects of sleep apnea; in this month’s Sleep Strategies, Drs. Walters and Lal review the cognitive repercussions of untreated sleep-disordered breathing. Given what we know about the growing prevalence of sleep apnea, should we consider more aggressive screening for OSA in patients demonstrating cognitive decline in much the same way we screen those with refractory hypertension or atrial fibrillation? While the sheer volume of referrals that could stem from such a practice may be daunting, the opportunity to potentially impact the natural history of dementia seems too promising to ignore.
Dr. David Schulman, FCCP
Evidence continues to mount demonstrating the multiple systemic effects of sleep apnea; in this month’s Sleep Strategies, Drs. Walters and Lal review the cognitive repercussions of untreated sleep-disordered breathing. Given what we know about the growing prevalence of sleep apnea, should we consider more aggressive screening for OSA in patients demonstrating cognitive decline in much the same way we screen those with refractory hypertension or atrial fibrillation? While the sheer volume of referrals that could stem from such a practice may be daunting, the opportunity to potentially impact the natural history of dementia seems too promising to ignore.
Dr. David Schulman, FCCP
Obstructive sleep apnea syndrome (OSAS) is a very common, underrecognized disorder with significant implications for individual and global health. Over the past few decades, our understanding of OSAS has improved, leading to earlier diagnosis and treatment. In turn, increasing awareness of this disorder has yielded greater recognition of the sequelae associated with OSAS, including heart disease, stroke, and cognitive impairment.
OSAS can affect cognition across the lifespan from infants to geriatric patients. Habitual snoring during the first year of life has been associated with lower scores on the Bayley Scales of Infant and Toddler Development, comparable with those seen in infants with iron-deficiency anemia (Grigg-Damberger et al. Curr Opin Pulm Med. 2012;18[6]:580). Such scores can predict future intelligence quotient scores, educational achievements, and job performance (Dezoate et al. Child. 2003;29[5]:367). OSAS of any severity as well as habitual snoring has been shown to increase the risk of hyperactivity, inattention, and poor school performance in children (Bourke et al. Sleep Med. 2011; 12[3]:222), and some of these metrics have been shown to improve with therapy. Thus, even primary snoring in children should not be considered a wholly benign condition.
Mild cognitive impairment (MCI) is defined as a subtle but measurable cognitive dysfunction, greater than that which would be expected with normal aging; memory loss is typically the presenting symptom. The conversion rate of MCI to frank dementia is roughly 15% per year (Petersen et al. Arch Neurol. 1999;56[3]:303). OSAS has been shown to be associated with MCI in adults (Cosentino et al. Sleep Med. 2008;9[8]:831); studies have also shown OSAS to be associated with impaired vigilance (Findley et al. Chest. 1995;108[3]:619) and executive function (Naismith et al. J Clin Exp Neuropsychol. 2004;26[1]:43). Thus, the cognitive dysfunction associated with OSAS is a real and measurable problem. If these relationships are causal, as one might suspect, aggressive screening for OSAS in patients with MCI might be warranted in the hope of reversing the disorder.
There are likely to be multiple mechanisms underlying the association between cognitive impairment and OSAS. Excessive daytime sleepiness can induce an impairment of vigilance and memory, both of which are components of cognitive function. A vicious cycle may ensue, with patients forgetting to use their CPAP, leading to worsening cognition. Intermittent hypoxemia is associated with a pro-inflammatory state and endothelial dysfunction that may be the intermediate mechanism by which cognitive impairment occurs. Genetic factors may modulate the association between cognitive impairment and OSAS. The apolipoprotein E4 allele located on chromosome 19 is a strong risk factor for early-onset Alzheimer’s disease and has been shown to increase the risk of developing both OSAS (Kadotani et al. JAMA. 2001;285[22]:2888) and neurocognitive decline among patients with OSAS (Gozal et al. Neurology. 2007;69[3]:243). A higher intelligence quotient, younger age, and higher education level may protect the brain from the detrimental effects of the intermittent hypoxia associated with OSAS (Grigg-Damberger et al. Curr Opin Pulm Med. 2012;18[6]:580). The situation becomes even more complex when considering other comorbidities often exist in the OSA population and can affect cognition, including tobacco and alcohol use, stroke, hypothyroidism, congestive heart failure, obesity, psychoactive medication use, and depression, among others.
Neuroimaging techniques have been used to identify brain abnormalities in patients with OSAS. Functional and structural changes, as well as altered levels of neurochemical mediators like N-acetyl aspartate and choline, have been reported. A common finding among MRI studies is decreased volume of the hippocampus; functional MRI has shown decreased brain activation in the cingulate cortex and other brain regions during sustained attention tasks, compared with control subjects (Ayalon et al. Sleep. 2009;32[3]:373). Both of these brain areas, which are involved with memory consolidation, are also affected by gray-matter loss in patients with OSAS (Macey et al. Am J Respir Crit Care Med. 2002;166[10]: 1382). These changes may explain symptoms of retrograde and anterograde amnesia in such patients.
If OSAS is associated with cognitive impairment, then treatment might reverse the brain changes causing this impairment. A small study evaluated cognitive performance and brain morphology before and after CPAP treatment in patients with OSAS (Canessa et al. Am J Respir Crit Care Med. 2011;183[100]:1419). Testing before CPAP treatment showed impairment in several cognitive domains and focal reductions of gray-matter volume in the left hippocampus and several other brain areas when compared with healthy age- and education-matched control subjects. After CPAP treatment for 3 months, significant improvements in memory, attention, executive function, and gray-matter volume in hippocampal and frontal structures were seen, suggesting that even a short duration of CPAP treatment can partially reverse the brain abnormalities of OSAS.
The duration of disease prior to therapy in these patients is unknown, but it is notable that patients with frank cognitive deterioration were excluded; whether more severe cognitive impairment would improve with therapy for sleep-disordered breathing remains unknown. It is possible that if left untreated, these changes could progress and become irreversible. Thus, emphasis should be placed on early diagnosis and treatment of OSAS.
Newer stimulant medications like armodafinil have been shown to improve not only sleepiness but also long-term memory (Roth et al. Sleep Breath. 2008;12[1]:53). Although these medications are FDA-approved for the treatment of residual sleepiness in patients with treated sleep apnea, their role in improving cognitive function needs to be evaluated further.
It is important for sleep medicine physicians to be cognizant of the effects of OSAS on cognitive function and to screen for it in their clinics. One simple screening instrument is the MCFSI (Mail-In Cognitive Function Screening Instrument), which is a self-administered test designed to identify cognitive impairment (Walsh et al. Alzheimer Dis Assoc Disord. 2006;20(4 Suppl 3):S170). The authors have found this tool to be a quick and effective screening tool in their patients with OSAS, although large studies validating it in this population are lacking.
It is our practice to refer patients with significantly abnormal scores on preliminary tests to a neuropsychologist for complete evaluation, which could involve the administration of tasks specifically designed to test for vigilance and working memory like the psychomotor vigilance task and digit span, providing more objective evidence of cognitive impairment. It also serves as a baseline for the individual patient for long-term follow-up.
The long-term implications of OSAS on cognitive function are just beginning to be realized. The importance of early diagnosis and treatment of OSAS is becoming more evident, as we may be able to stop or partially reverse some of the underlying neurologic abnormalities with treatment. Given the strong association between OSAS and cognitive impairment, we recommend that all patients with MCI or frank dementia be screened for OSAS as a potentially reversible cause of these conditions; polysomnography should subsequently be offered to those patients who are deemed to be high risk for having OSA. Discussions with cognitively impaired patients about the implications of nonadherence with CPAP should be reiterated at each visit, particularly given the significant barrier that such impairment may create to reliable use of therapy.
Drs. Walters and Lal are from the Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC.
Editor’s Note
Evidence continues to mount demonstrating the multiple systemic effects of sleep apnea; in this month’s Sleep Strategies, Drs. Walters and Lal review the cognitive repercussions of untreated sleep-disordered breathing. Given what we know about the growing prevalence of sleep apnea, should we consider more aggressive screening for OSA in patients demonstrating cognitive decline in much the same way we screen those with refractory hypertension or atrial fibrillation? While the sheer volume of referrals that could stem from such a practice may be daunting, the opportunity to potentially impact the natural history of dementia seems too promising to ignore.
Dr. David Schulman, FCCP, Section Editor
Obstructive sleep apnea syndrome (OSAS) is a very common, underrecognized disorder with significant implications for individual and global health. Over the past few decades, our understanding of OSAS has improved, leading to earlier diagnosis and treatment. In turn, increasing awareness of this disorder has yielded greater recognition of the sequelae associated with OSAS, including heart disease, stroke, and cognitive impairment.
OSAS can affect cognition across the lifespan from infants to geriatric patients. Habitual snoring during the first year of life has been associated with lower scores on the Bayley Scales of Infant and Toddler Development, comparable with those seen in infants with iron-deficiency anemia (Grigg-Damberger et al. Curr Opin Pulm Med. 2012;18[6]:580). Such scores can predict future intelligence quotient scores, educational achievements, and job performance (Dezoate et al. Child. 2003;29[5]:367). OSAS of any severity as well as habitual snoring has been shown to increase the risk of hyperactivity, inattention, and poor school performance in children (Bourke et al. Sleep Med. 2011; 12[3]:222), and some of these metrics have been shown to improve with therapy. Thus, even primary snoring in children should not be considered a wholly benign condition.
Mild cognitive impairment (MCI) is defined as a subtle but measurable cognitive dysfunction, greater than that which would be expected with normal aging; memory loss is typically the presenting symptom. The conversion rate of MCI to frank dementia is roughly 15% per year (Petersen et al. Arch Neurol. 1999;56[3]:303). OSAS has been shown to be associated with MCI in adults (Cosentino et al. Sleep Med. 2008;9[8]:831); studies have also shown OSAS to be associated with impaired vigilance (Findley et al. Chest. 1995;108[3]:619) and executive function (Naismith et al. J Clin Exp Neuropsychol. 2004;26[1]:43). Thus, the cognitive dysfunction associated with OSAS is a real and measurable problem. If these relationships are causal, as one might suspect, aggressive screening for OSAS in patients with MCI might be warranted in the hope of reversing the disorder.
There are likely to be multiple mechanisms underlying the association between cognitive impairment and OSAS. Excessive daytime sleepiness can induce an impairment of vigilance and memory, both of which are components of cognitive function. A vicious cycle may ensue, with patients forgetting to use their CPAP, leading to worsening cognition. Intermittent hypoxemia is associated with a pro-inflammatory state and endothelial dysfunction that may be the intermediate mechanism by which cognitive impairment occurs. Genetic factors may modulate the association between cognitive impairment and OSAS. The apolipoprotein E4 allele located on chromosome 19 is a strong risk factor for early-onset Alzheimer’s disease and has been shown to increase the risk of developing both OSAS (Kadotani et al. JAMA. 2001;285[22]:2888) and neurocognitive decline among patients with OSAS (Gozal et al. Neurology. 2007;69[3]:243). A higher intelligence quotient, younger age, and higher education level may protect the brain from the detrimental effects of the intermittent hypoxia associated with OSAS (Grigg-Damberger et al. Curr Opin Pulm Med. 2012;18[6]:580). The situation becomes even more complex when considering other comorbidities often exist in the OSA population and can affect cognition, including tobacco and alcohol use, stroke, hypothyroidism, congestive heart failure, obesity, psychoactive medication use, and depression, among others.
Neuroimaging techniques have been used to identify brain abnormalities in patients with OSAS. Functional and structural changes, as well as altered levels of neurochemical mediators like N-acetyl aspartate and choline, have been reported. A common finding among MRI studies is decreased volume of the hippocampus; functional MRI has shown decreased brain activation in the cingulate cortex and other brain regions during sustained attention tasks, compared with control subjects (Ayalon et al. Sleep. 2009;32[3]:373). Both of these brain areas, which are involved with memory consolidation, are also affected by gray-matter loss in patients with OSAS (Macey et al. Am J Respir Crit Care Med. 2002;166[10]: 1382). These changes may explain symptoms of retrograde and anterograde amnesia in such patients.
If OSAS is associated with cognitive impairment, then treatment might reverse the brain changes causing this impairment. A small study evaluated cognitive performance and brain morphology before and after CPAP treatment in patients with OSAS (Canessa et al. Am J Respir Crit Care Med. 2011;183[100]:1419). Testing before CPAP treatment showed impairment in several cognitive domains and focal reductions of gray-matter volume in the left hippocampus and several other brain areas when compared with healthy age- and education-matched control subjects. After CPAP treatment for 3 months, significant improvements in memory, attention, executive function, and gray-matter volume in hippocampal and frontal structures were seen, suggesting that even a short duration of CPAP treatment can partially reverse the brain abnormalities of OSAS.
The duration of disease prior to therapy in these patients is unknown, but it is notable that patients with frank cognitive deterioration were excluded; whether more severe cognitive impairment would improve with therapy for sleep-disordered breathing remains unknown. It is possible that if left untreated, these changes could progress and become irreversible. Thus, emphasis should be placed on early diagnosis and treatment of OSAS.
Newer stimulant medications like armodafinil have been shown to improve not only sleepiness but also long-term memory (Roth et al. Sleep Breath. 2008;12[1]:53). Although these medications are FDA-approved for the treatment of residual sleepiness in patients with treated sleep apnea, their role in improving cognitive function needs to be evaluated further.
It is important for sleep medicine physicians to be cognizant of the effects of OSAS on cognitive function and to screen for it in their clinics. One simple screening instrument is the MCFSI (Mail-In Cognitive Function Screening Instrument), which is a self-administered test designed to identify cognitive impairment (Walsh et al. Alzheimer Dis Assoc Disord. 2006;20(4 Suppl 3):S170). The authors have found this tool to be a quick and effective screening tool in their patients with OSAS, although large studies validating it in this population are lacking.
It is our practice to refer patients with significantly abnormal scores on preliminary tests to a neuropsychologist for complete evaluation, which could involve the administration of tasks specifically designed to test for vigilance and working memory like the psychomotor vigilance task and digit span, providing more objective evidence of cognitive impairment. It also serves as a baseline for the individual patient for long-term follow-up.
The long-term implications of OSAS on cognitive function are just beginning to be realized. The importance of early diagnosis and treatment of OSAS is becoming more evident, as we may be able to stop or partially reverse some of the underlying neurologic abnormalities with treatment. Given the strong association between OSAS and cognitive impairment, we recommend that all patients with MCI or frank dementia be screened for OSAS as a potentially reversible cause of these conditions; polysomnography should subsequently be offered to those patients who are deemed to be high risk for having OSA. Discussions with cognitively impaired patients about the implications of nonadherence with CPAP should be reiterated at each visit, particularly given the significant barrier that such impairment may create to reliable use of therapy.
Drs. Walters and Lal are from the Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC.
Editor’s Note
Evidence continues to mount demonstrating the multiple systemic effects of sleep apnea; in this month’s Sleep Strategies, Drs. Walters and Lal review the cognitive repercussions of untreated sleep-disordered breathing. Given what we know about the growing prevalence of sleep apnea, should we consider more aggressive screening for OSA in patients demonstrating cognitive decline in much the same way we screen those with refractory hypertension or atrial fibrillation? While the sheer volume of referrals that could stem from such a practice may be daunting, the opportunity to potentially impact the natural history of dementia seems too promising to ignore.
Dr. David Schulman, FCCP, Section Editor
Mild cognitive impairment (MCI), cognitive dysfunction,
Mild cognitive impairment (MCI), cognitive dysfunction,
