Society News

Eileen Metzger Bulger, MD, FACS, chief of trauma and trauma medical director for adults and pediatrics, Harborview Medical Center, Seattle, WA, begins serving as the new Chair of the American College of Surgeons (ACS) Committee on Trauma (COT) this month. Dr. Bulger was appointed as the next COT Chair in October 2017 by the ACS Board of Regents. She is the 20th Chair of the COT, succeeding Ronald M. Stewart, MD, FACS, of San Antonio, TX.

“We look forward to Dr. Bulger’s exceptional vision and leadership as she directs the COT into its 96th year of working to improve the care of the injured patient. She is the perfect person to lead the COT into its next century of transforming care and reducing injuries across the globe,” Dr. Stewart said.

A diplomate of the American Board of Surgery, Dr. Bulger also is board certified in surgical critical care. She earned a medical doctorate at Cornell University Medical College, New York, NY (1992). She completed a residency in general surgery at the University of Washington (UW), Seattle (1992–1999), where she concurrently completed a two-year National Institutes of Health Trauma Research Fellowship during her years of residency training (1995–1997), and then went on to complete a surgical critical care fellowship at UW in 2000.
 

Recognized leadership

Throughout her career, Dr. Bulger has mentored many surgical residents in paper and scholarship competitions. For nearly two decades, she has served as the co-principal or principal investigator of a variety of innovative, grant-funded research projects related to trauma care, some of which focus on improving outcomes for crash injury victims, pediatric patients, and older adults.

Since her initial involvement with the COT in 2002, Dr. Bulger has contributed to many COT activities, often serving in a leadership role. She is a Course Instructor for the internationally recognized Advanced Trauma Life Support® (ATLS®) program, and she served as the COT Washington State Chair (2003–2006); Region X Chief (2006–2012); Chair of the Emergency Medical Services Committee (2011–2015); Chair of the Membership Committee (2014–2017); and Executive Committee member (2014–2017).

The COT is dedicated to all phases of injury care, from prevention to rehabilitation. The committee is supported by a network of 65 state and provincial committees, 11 international committees, and five military committees, and the majority of members are ACS Fellows.

Eileen Metzger Bulger, MD, FACS, chief of trauma and trauma medical director for adults and pediatrics, Harborview Medical Center, Seattle, WA, begins serving as the new Chair of the American College of Surgeons (ACS) Committee on Trauma (COT) this month. Dr. Bulger was appointed as the next COT Chair in October 2017 by the ACS Board of Regents. She is the 20th Chair of the COT, succeeding Ronald M. Stewart, MD, FACS, of San Antonio, TX.

“We look forward to Dr. Bulger’s exceptional vision and leadership as she directs the COT into its 96th year of working to improve the care of the injured patient. She is the perfect person to lead the COT into its next century of transforming care and reducing injuries across the globe,” Dr. Stewart said.

A diplomate of the American Board of Surgery, Dr. Bulger also is board certified in surgical critical care. She earned a medical doctorate at Cornell University Medical College, New York, NY (1992). She completed a residency in general surgery at the University of Washington (UW), Seattle (1992–1999), where she concurrently completed a two-year National Institutes of Health Trauma Research Fellowship during her years of residency training (1995–1997), and then went on to complete a surgical critical care fellowship at UW in 2000.
 

Recognized leadership

Throughout her career, Dr. Bulger has mentored many surgical residents in paper and scholarship competitions. For nearly two decades, she has served as the co-principal or principal investigator of a variety of innovative, grant-funded research projects related to trauma care, some of which focus on improving outcomes for crash injury victims, pediatric patients, and older adults.

Since her initial involvement with the COT in 2002, Dr. Bulger has contributed to many COT activities, often serving in a leadership role. She is a Course Instructor for the internationally recognized Advanced Trauma Life Support® (ATLS®) program, and she served as the COT Washington State Chair (2003–2006); Region X Chief (2006–2012); Chair of the Emergency Medical Services Committee (2011–2015); Chair of the Membership Committee (2014–2017); and Executive Committee member (2014–2017).

The COT is dedicated to all phases of injury care, from prevention to rehabilitation. The committee is supported by a network of 65 state and provincial committees, 11 international committees, and five military committees, and the majority of members are ACS Fellows.

Eileen Metzger Bulger, MD, FACS, chief of trauma and trauma medical director for adults and pediatrics, Harborview Medical Center, Seattle, WA, begins serving as the new Chair of the American College of Surgeons (ACS) Committee on Trauma (COT) this month. Dr. Bulger was appointed as the next COT Chair in October 2017 by the ACS Board of Regents. She is the 20th Chair of the COT, succeeding Ronald M. Stewart, MD, FACS, of San Antonio, TX.

“We look forward to Dr. Bulger’s exceptional vision and leadership as she directs the COT into its 96th year of working to improve the care of the injured patient. She is the perfect person to lead the COT into its next century of transforming care and reducing injuries across the globe,” Dr. Stewart said.

A diplomate of the American Board of Surgery, Dr. Bulger also is board certified in surgical critical care. She earned a medical doctorate at Cornell University Medical College, New York, NY (1992). She completed a residency in general surgery at the University of Washington (UW), Seattle (1992–1999), where she concurrently completed a two-year National Institutes of Health Trauma Research Fellowship during her years of residency training (1995–1997), and then went on to complete a surgical critical care fellowship at UW in 2000.
 

Recognized leadership

Throughout her career, Dr. Bulger has mentored many surgical residents in paper and scholarship competitions. For nearly two decades, she has served as the co-principal or principal investigator of a variety of innovative, grant-funded research projects related to trauma care, some of which focus on improving outcomes for crash injury victims, pediatric patients, and older adults.

Since her initial involvement with the COT in 2002, Dr. Bulger has contributed to many COT activities, often serving in a leadership role. She is a Course Instructor for the internationally recognized Advanced Trauma Life Support® (ATLS®) program, and she served as the COT Washington State Chair (2003–2006); Region X Chief (2006–2012); Chair of the Emergency Medical Services Committee (2011–2015); Chair of the Membership Committee (2014–2017); and Executive Committee member (2014–2017).

The COT is dedicated to all phases of injury care, from prevention to rehabilitation. The committee is supported by a network of 65 state and provincial committees, 11 international committees, and five military committees, and the majority of members are ACS Fellows.

On February 9, Congress passed and President Trump signed into law the Bipartisan Budget Act of 2018. The law addresses many key physician and patient issues, including important technical corrections to the Merit-based Incentive Payment System (MIPS) that the American College of Surgeons (ACS) strongly favors.

The law addresses several other ACS priorities, including:

The addition of a long-term funding extension (10 years) for the Children’s Health Insurance Program (CHIP), ensuring that children continue to have access to surgical care

The inclusion of language that eases electronic health record system meaningful use requirements, alleviating some of the burdens imposed on physicians and their practices

Additional funding to address the opioid epidemic and to support the work of the National Institutes of Health Repeal of the Independent Payment Advisory Board

For more information, contact Mark Lukaszewski, ACS Congressional Lobbyist, at [email protected].






 

On February 9, Congress passed and President Trump signed into law the Bipartisan Budget Act of 2018. The law addresses many key physician and patient issues, including important technical corrections to the Merit-based Incentive Payment System (MIPS) that the American College of Surgeons (ACS) strongly favors.

The law addresses several other ACS priorities, including:

The addition of a long-term funding extension (10 years) for the Children’s Health Insurance Program (CHIP), ensuring that children continue to have access to surgical care

The inclusion of language that eases electronic health record system meaningful use requirements, alleviating some of the burdens imposed on physicians and their practices

Additional funding to address the opioid epidemic and to support the work of the National Institutes of Health Repeal of the Independent Payment Advisory Board

For more information, contact Mark Lukaszewski, ACS Congressional Lobbyist, at [email protected].






 

On February 9, Congress passed and President Trump signed into law the Bipartisan Budget Act of 2018. The law addresses many key physician and patient issues, including important technical corrections to the Merit-based Incentive Payment System (MIPS) that the American College of Surgeons (ACS) strongly favors.

The law addresses several other ACS priorities, including:

The addition of a long-term funding extension (10 years) for the Children’s Health Insurance Program (CHIP), ensuring that children continue to have access to surgical care

The inclusion of language that eases electronic health record system meaningful use requirements, alleviating some of the burdens imposed on physicians and their practices

Additional funding to address the opioid epidemic and to support the work of the National Institutes of Health Repeal of the Independent Payment Advisory Board

For more information, contact Mark Lukaszewski, ACS Congressional Lobbyist, at [email protected].






 

The American Medical Association (AMA) Interim Meeting of the House of Delegates (HOD) took place November 11–14, 2017, in Honolulu, HI. A total of 532 delegates were in attendance to debate the policy implications of 36 reports and 99 resolutions.

The American College of Surgeons (ACS) sent a six-member delegation to the meeting. The ACS also participates in AMA activities in other capacities, including in the AMA Young Physician Section Assembly, the AMA Resident and Fellow Section Assembly, and the AMA Council on Medical Education. These three groups met in conjunction with the HOD meeting. See the sidebar on page 74 for the list of ACS delegates and their other AMA roles.
 

ACS cosponsored issues

The AMA HOD brings together a variety of perspectives in medicine, and the job of the ACS delegation is to shape AMA policy consistent with College priorities. One way the ACS achieves this objective is by cosponsoring resolutions that have been submitted by other delegations and that are relevant to the College Fellowship. The ACS delegation cosponsored the following three resolutions at the November meeting—two on scope-of-practice issues and one on physician payment—all of which were adopted.

Resolution 214, Advanced Practice Registered Nurse (APRN) Compact, was initiated by the American Society of Anesthesiologists and strengthened with amendments. AMA policy opposes enactment of the Advanced APRN Multistate Compact because of its potential to supersede state laws that require APRNs to practice under physician supervision, as well as legislation that authorizes the independent practice of medicine by any individual who has not completed the state’s requirement for licensure to practice medicine. The AMA will convene an in-person meeting of relevant physician stakeholders to create a consistent national strategy to prevent fulfillment of the APRN Compact.

Resolution 230, Oppose Physician Assistant Independent Practice, with support from a spectrum of state medical and national specialty societies, continued the theme of opposition to legislation or regulation that allows physician extenders—in this case physician assistants—to practice independently. Another resolution addressed the emerging advanced physician assistant degree known as doctor of medical science. The AMA opposes holders of this degree from being recognized as a new category of health care practitioners licensed for the independent practice of medicine.

Resolution 808, Opposition to Reduced Payment for the 25-Modifier, was offered by the American Academy of Dermatology. The resolution was a response to private insurers discounting evaluation and management (E/M) codes by 50 percent when linked through the 25-modifier to a procedure on the same day. This resolution passed as simplified by amendment to have AMA aggressively and immediately advocate, through any legal means possible (such as direct payor negotiations, regulations, legislation, or litigation), for non-reduced allowable payment of appropriately reported 25-modifier E/M codes when linked with procedures.
 

Other HOD-adopted resolutions of interest

BOT (Board of Trustees) Report 5, Effective Peer Review, amended the AMA Physician and Medical Staff Member Bill of Rights to add “protection from any retaliatory actions” to the list of immunity rights when physicians participate in good faith peer-review activities. In testimony at the reference committee, the delegation highlighted the value of the new ACS “red book,” Optimal Resources for Surgical Quality and Safety, for establishing peer-review standards in surgical care.

Council on Science and Public Health Report 2, Targeted Education to Increase Organ Donation, amended the AMA policy, Methods to Increase the U.S. Organ Donor Pool. As a result, the AMA supports studies that evaluate the effectiveness of mandated choice and presumed consent models for increasing organ donation and urges development of effective methods to inform populations with historically low participation rates about donating.

Resolution 953, Fees for Taking Maintenance of Certification (MOC) Examination, amended AMA MOC policy to assert that the MOC process should reflect the cost of development and administration of the MOC components, ensure a fair fee structure, and not hinder patient care. The AMA will advocate that value in MOC includes cost-effectiveness with full financial transparency, respect for physicians’ time and patient care commitments, alignment of MOC requirements with other regulator and payor requirements, and adherence to an evidence basis for both MOC content and processes.

Not every item was viewed favorably at the AMA meeting. Council on Ethical and Judicial Affairs (CEJA) Report 1, Competence, Self-Assessment and Self-Awareness, sought to provide guidance for physicians in determining their own competence when practicing medicine. The council observed, “As an ethical responsibility, competence encompasses more than medical knowledge and skill. It requires physicians to understand that as a practical matter in the care of actual patients, competence is fluid and dependent on context.” Considerable testimony emphasized a lack of reliable tools and available resources to assist physicians in self-assessment. Thus, the report was referred back to CEJA for more work.
 

Surgical caucus

In addition to facilitating an agenda review and business meeting for surgeons, anesthesiologists, and emergency physicians, the caucus sponsored a popular education session, Hazards of the Deep: Trauma in Paradise. Michael Hayashi, MD, FACS, Chair of the Hawaii Committee on Trauma, discussed system challenges in caring for injured patients from geographically remote and less populated areas. Lieutenant Matthew Brown, MC, USN, an undersea/diving medical officer stationed at Pearl Harbor, HI, shared insights about injuries and medical conditions experienced by scuba divers, swimmers, surfers, and other beach enthusiasts.
 

Leadership transition

After extended service on the delegation, including eight years as Chair, Dr. Armstrong bid “aloha” to the HOD as a retiring delegate. Dr. Turner has accepted the role as Chair, maintaining continued College leadership in the HOD.
 

Next meeting

The next meeting of the AMA HOD is scheduled for June 9–13 in Chicago, IL. In addition to debate on numerous issues, elections for AMA officers, trustees, and councils will be held at the meeting. Surgeons with suggestions for potential resolutions or questions about ACS activities at the AMA HOD should e-mail [email protected]
 

ACS Delegation at the AMA HOD

John H. Armstrong, MD, FACS (Delegation Chair), acute care surgery, Tampa, FL

Brian J. Gavitt, MD, MPH (also Young Physicians Section delegate), general surgery, Cincinnati, OH

Jacob Moalem, MD, FACS, general surgery, Rochester, NY

Leigh A. Neumayer, MD, FACS, general surgery, Tucson, AZ; Chair, ACS Board of Regents

Naveen F. Sangji, MD (also Resident and Fellow Section delegate), general surgery resident, Boston, MA

Patricia L. Turner, MD, FACS, general surgery, Chicago, IL; Director, ACS Division of Member Services; member and immediate past-chair, AMA Council on Medical EducationDr. Armstrong is affiliate associate professor of surgery, University of South Florida Morsani College of Medicine, Tampa, and former Florida Surgeon General and Secretary of Health (2012–2016). He is a member, ACS Health Policy and Advocacy Group, and Past-Chair, ACS Professional Association political action committee (ACSPA-SurgeonsPAC).



Mr. Sutton is Manager, State Affairs, ACS Division of Advocacy and Health Policy.

The American Medical Association (AMA) Interim Meeting of the House of Delegates (HOD) took place November 11–14, 2017, in Honolulu, HI. A total of 532 delegates were in attendance to debate the policy implications of 36 reports and 99 resolutions.

The American College of Surgeons (ACS) sent a six-member delegation to the meeting. The ACS also participates in AMA activities in other capacities, including in the AMA Young Physician Section Assembly, the AMA Resident and Fellow Section Assembly, and the AMA Council on Medical Education. These three groups met in conjunction with the HOD meeting. See the sidebar on page 74 for the list of ACS delegates and their other AMA roles.
 

ACS cosponsored issues

The AMA HOD brings together a variety of perspectives in medicine, and the job of the ACS delegation is to shape AMA policy consistent with College priorities. One way the ACS achieves this objective is by cosponsoring resolutions that have been submitted by other delegations and that are relevant to the College Fellowship. The ACS delegation cosponsored the following three resolutions at the November meeting—two on scope-of-practice issues and one on physician payment—all of which were adopted.

Resolution 214, Advanced Practice Registered Nurse (APRN) Compact, was initiated by the American Society of Anesthesiologists and strengthened with amendments. AMA policy opposes enactment of the Advanced APRN Multistate Compact because of its potential to supersede state laws that require APRNs to practice under physician supervision, as well as legislation that authorizes the independent practice of medicine by any individual who has not completed the state’s requirement for licensure to practice medicine. The AMA will convene an in-person meeting of relevant physician stakeholders to create a consistent national strategy to prevent fulfillment of the APRN Compact.

Resolution 230, Oppose Physician Assistant Independent Practice, with support from a spectrum of state medical and national specialty societies, continued the theme of opposition to legislation or regulation that allows physician extenders—in this case physician assistants—to practice independently. Another resolution addressed the emerging advanced physician assistant degree known as doctor of medical science. The AMA opposes holders of this degree from being recognized as a new category of health care practitioners licensed for the independent practice of medicine.

Resolution 808, Opposition to Reduced Payment for the 25-Modifier, was offered by the American Academy of Dermatology. The resolution was a response to private insurers discounting evaluation and management (E/M) codes by 50 percent when linked through the 25-modifier to a procedure on the same day. This resolution passed as simplified by amendment to have AMA aggressively and immediately advocate, through any legal means possible (such as direct payor negotiations, regulations, legislation, or litigation), for non-reduced allowable payment of appropriately reported 25-modifier E/M codes when linked with procedures.
 

Other HOD-adopted resolutions of interest

BOT (Board of Trustees) Report 5, Effective Peer Review, amended the AMA Physician and Medical Staff Member Bill of Rights to add “protection from any retaliatory actions” to the list of immunity rights when physicians participate in good faith peer-review activities. In testimony at the reference committee, the delegation highlighted the value of the new ACS “red book,” Optimal Resources for Surgical Quality and Safety, for establishing peer-review standards in surgical care.

Council on Science and Public Health Report 2, Targeted Education to Increase Organ Donation, amended the AMA policy, Methods to Increase the U.S. Organ Donor Pool. As a result, the AMA supports studies that evaluate the effectiveness of mandated choice and presumed consent models for increasing organ donation and urges development of effective methods to inform populations with historically low participation rates about donating.

Resolution 953, Fees for Taking Maintenance of Certification (MOC) Examination, amended AMA MOC policy to assert that the MOC process should reflect the cost of development and administration of the MOC components, ensure a fair fee structure, and not hinder patient care. The AMA will advocate that value in MOC includes cost-effectiveness with full financial transparency, respect for physicians’ time and patient care commitments, alignment of MOC requirements with other regulator and payor requirements, and adherence to an evidence basis for both MOC content and processes.

Not every item was viewed favorably at the AMA meeting. Council on Ethical and Judicial Affairs (CEJA) Report 1, Competence, Self-Assessment and Self-Awareness, sought to provide guidance for physicians in determining their own competence when practicing medicine. The council observed, “As an ethical responsibility, competence encompasses more than medical knowledge and skill. It requires physicians to understand that as a practical matter in the care of actual patients, competence is fluid and dependent on context.” Considerable testimony emphasized a lack of reliable tools and available resources to assist physicians in self-assessment. Thus, the report was referred back to CEJA for more work.
 

Surgical caucus

In addition to facilitating an agenda review and business meeting for surgeons, anesthesiologists, and emergency physicians, the caucus sponsored a popular education session, Hazards of the Deep: Trauma in Paradise. Michael Hayashi, MD, FACS, Chair of the Hawaii Committee on Trauma, discussed system challenges in caring for injured patients from geographically remote and less populated areas. Lieutenant Matthew Brown, MC, USN, an undersea/diving medical officer stationed at Pearl Harbor, HI, shared insights about injuries and medical conditions experienced by scuba divers, swimmers, surfers, and other beach enthusiasts.
 

Leadership transition

After extended service on the delegation, including eight years as Chair, Dr. Armstrong bid “aloha” to the HOD as a retiring delegate. Dr. Turner has accepted the role as Chair, maintaining continued College leadership in the HOD.
 

Next meeting

The next meeting of the AMA HOD is scheduled for June 9–13 in Chicago, IL. In addition to debate on numerous issues, elections for AMA officers, trustees, and councils will be held at the meeting. Surgeons with suggestions for potential resolutions or questions about ACS activities at the AMA HOD should e-mail [email protected]
 

ACS Delegation at the AMA HOD

John H. Armstrong, MD, FACS (Delegation Chair), acute care surgery, Tampa, FL

Brian J. Gavitt, MD, MPH (also Young Physicians Section delegate), general surgery, Cincinnati, OH

Jacob Moalem, MD, FACS, general surgery, Rochester, NY

Leigh A. Neumayer, MD, FACS, general surgery, Tucson, AZ; Chair, ACS Board of Regents

Naveen F. Sangji, MD (also Resident and Fellow Section delegate), general surgery resident, Boston, MA

Patricia L. Turner, MD, FACS, general surgery, Chicago, IL; Director, ACS Division of Member Services; member and immediate past-chair, AMA Council on Medical EducationDr. Armstrong is affiliate associate professor of surgery, University of South Florida Morsani College of Medicine, Tampa, and former Florida Surgeon General and Secretary of Health (2012–2016). He is a member, ACS Health Policy and Advocacy Group, and Past-Chair, ACS Professional Association political action committee (ACSPA-SurgeonsPAC).



Mr. Sutton is Manager, State Affairs, ACS Division of Advocacy and Health Policy.

The American Medical Association (AMA) Interim Meeting of the House of Delegates (HOD) took place November 11–14, 2017, in Honolulu, HI. A total of 532 delegates were in attendance to debate the policy implications of 36 reports and 99 resolutions.

The American College of Surgeons (ACS) sent a six-member delegation to the meeting. The ACS also participates in AMA activities in other capacities, including in the AMA Young Physician Section Assembly, the AMA Resident and Fellow Section Assembly, and the AMA Council on Medical Education. These three groups met in conjunction with the HOD meeting. See the sidebar on page 74 for the list of ACS delegates and their other AMA roles.
 

ACS cosponsored issues

The AMA HOD brings together a variety of perspectives in medicine, and the job of the ACS delegation is to shape AMA policy consistent with College priorities. One way the ACS achieves this objective is by cosponsoring resolutions that have been submitted by other delegations and that are relevant to the College Fellowship. The ACS delegation cosponsored the following three resolutions at the November meeting—two on scope-of-practice issues and one on physician payment—all of which were adopted.

Resolution 214, Advanced Practice Registered Nurse (APRN) Compact, was initiated by the American Society of Anesthesiologists and strengthened with amendments. AMA policy opposes enactment of the Advanced APRN Multistate Compact because of its potential to supersede state laws that require APRNs to practice under physician supervision, as well as legislation that authorizes the independent practice of medicine by any individual who has not completed the state’s requirement for licensure to practice medicine. The AMA will convene an in-person meeting of relevant physician stakeholders to create a consistent national strategy to prevent fulfillment of the APRN Compact.

Resolution 230, Oppose Physician Assistant Independent Practice, with support from a spectrum of state medical and national specialty societies, continued the theme of opposition to legislation or regulation that allows physician extenders—in this case physician assistants—to practice independently. Another resolution addressed the emerging advanced physician assistant degree known as doctor of medical science. The AMA opposes holders of this degree from being recognized as a new category of health care practitioners licensed for the independent practice of medicine.

Resolution 808, Opposition to Reduced Payment for the 25-Modifier, was offered by the American Academy of Dermatology. The resolution was a response to private insurers discounting evaluation and management (E/M) codes by 50 percent when linked through the 25-modifier to a procedure on the same day. This resolution passed as simplified by amendment to have AMA aggressively and immediately advocate, through any legal means possible (such as direct payor negotiations, regulations, legislation, or litigation), for non-reduced allowable payment of appropriately reported 25-modifier E/M codes when linked with procedures.
 

Other HOD-adopted resolutions of interest

BOT (Board of Trustees) Report 5, Effective Peer Review, amended the AMA Physician and Medical Staff Member Bill of Rights to add “protection from any retaliatory actions” to the list of immunity rights when physicians participate in good faith peer-review activities. In testimony at the reference committee, the delegation highlighted the value of the new ACS “red book,” Optimal Resources for Surgical Quality and Safety, for establishing peer-review standards in surgical care.

Council on Science and Public Health Report 2, Targeted Education to Increase Organ Donation, amended the AMA policy, Methods to Increase the U.S. Organ Donor Pool. As a result, the AMA supports studies that evaluate the effectiveness of mandated choice and presumed consent models for increasing organ donation and urges development of effective methods to inform populations with historically low participation rates about donating.

Resolution 953, Fees for Taking Maintenance of Certification (MOC) Examination, amended AMA MOC policy to assert that the MOC process should reflect the cost of development and administration of the MOC components, ensure a fair fee structure, and not hinder patient care. The AMA will advocate that value in MOC includes cost-effectiveness with full financial transparency, respect for physicians’ time and patient care commitments, alignment of MOC requirements with other regulator and payor requirements, and adherence to an evidence basis for both MOC content and processes.

Not every item was viewed favorably at the AMA meeting. Council on Ethical and Judicial Affairs (CEJA) Report 1, Competence, Self-Assessment and Self-Awareness, sought to provide guidance for physicians in determining their own competence when practicing medicine. The council observed, “As an ethical responsibility, competence encompasses more than medical knowledge and skill. It requires physicians to understand that as a practical matter in the care of actual patients, competence is fluid and dependent on context.” Considerable testimony emphasized a lack of reliable tools and available resources to assist physicians in self-assessment. Thus, the report was referred back to CEJA for more work.
 

Surgical caucus

In addition to facilitating an agenda review and business meeting for surgeons, anesthesiologists, and emergency physicians, the caucus sponsored a popular education session, Hazards of the Deep: Trauma in Paradise. Michael Hayashi, MD, FACS, Chair of the Hawaii Committee on Trauma, discussed system challenges in caring for injured patients from geographically remote and less populated areas. Lieutenant Matthew Brown, MC, USN, an undersea/diving medical officer stationed at Pearl Harbor, HI, shared insights about injuries and medical conditions experienced by scuba divers, swimmers, surfers, and other beach enthusiasts.
 

Leadership transition

After extended service on the delegation, including eight years as Chair, Dr. Armstrong bid “aloha” to the HOD as a retiring delegate. Dr. Turner has accepted the role as Chair, maintaining continued College leadership in the HOD.
 

Next meeting

The next meeting of the AMA HOD is scheduled for June 9–13 in Chicago, IL. In addition to debate on numerous issues, elections for AMA officers, trustees, and councils will be held at the meeting. Surgeons with suggestions for potential resolutions or questions about ACS activities at the AMA HOD should e-mail [email protected]
 

ACS Delegation at the AMA HOD

John H. Armstrong, MD, FACS (Delegation Chair), acute care surgery, Tampa, FL

Brian J. Gavitt, MD, MPH (also Young Physicians Section delegate), general surgery, Cincinnati, OH

Jacob Moalem, MD, FACS, general surgery, Rochester, NY

Leigh A. Neumayer, MD, FACS, general surgery, Tucson, AZ; Chair, ACS Board of Regents

Naveen F. Sangji, MD (also Resident and Fellow Section delegate), general surgery resident, Boston, MA

Patricia L. Turner, MD, FACS, general surgery, Chicago, IL; Director, ACS Division of Member Services; member and immediate past-chair, AMA Council on Medical EducationDr. Armstrong is affiliate associate professor of surgery, University of South Florida Morsani College of Medicine, Tampa, and former Florida Surgeon General and Secretary of Health (2012–2016). He is a member, ACS Health Policy and Advocacy Group, and Past-Chair, ACS Professional Association political action committee (ACSPA-SurgeonsPAC).



Mr. Sutton is Manager, State Affairs, ACS Division of Advocacy and Health Policy.

Registration is open to attend an American College of Surgeons (ACS) 2018 General Surgery Coding Workshop. With Medicare and third-party payor policy and coding changes taking effect this year, it is imperative that surgeons have accurate and up-to-date information to protect their reimbursements and optimize efficiency.

During the coding workshop, you will learn how to report surgical procedures and medical services and will have access to the tools necessary to succeed, including a coding workbook to keep for future reference with checklists, resource guides, templates, and examples. Physicians receive up to 6.5 AMA PRA Category 1 Credits™ for each day of participation. In addition, each day of the workshop meets AAPC guidelines for 6.5 continuing education units.

The ACS will offer the following five remaining coding workshops in 2018:

Chicago, IL, April 12–13

New York, NY, May 17–19

Nashville, TN, August 9–10

Chicago, IL, November 1–3

The ACS also will offer a three-day course, including a day devoted to trauma and critical care coding at the New York City and (November) Chicago workshops.

Register for a course at www.karenzupko.com/workshops2/gensurg-workshops/. For more information about the 2018 ACS coding workshops, visit the ACS website www.facs.org/advocacy/practmanagement/workshops or e-mail [email protected].

Registration is open to attend an American College of Surgeons (ACS) 2018 General Surgery Coding Workshop. With Medicare and third-party payor policy and coding changes taking effect this year, it is imperative that surgeons have accurate and up-to-date information to protect their reimbursements and optimize efficiency.

During the coding workshop, you will learn how to report surgical procedures and medical services and will have access to the tools necessary to succeed, including a coding workbook to keep for future reference with checklists, resource guides, templates, and examples. Physicians receive up to 6.5 AMA PRA Category 1 Credits™ for each day of participation. In addition, each day of the workshop meets AAPC guidelines for 6.5 continuing education units.

The ACS will offer the following five remaining coding workshops in 2018:

Chicago, IL, April 12–13

New York, NY, May 17–19

Nashville, TN, August 9–10

Chicago, IL, November 1–3

The ACS also will offer a three-day course, including a day devoted to trauma and critical care coding at the New York City and (November) Chicago workshops.

Register for a course at www.karenzupko.com/workshops2/gensurg-workshops/. For more information about the 2018 ACS coding workshops, visit the ACS website www.facs.org/advocacy/practmanagement/workshops or e-mail [email protected].

Registration is open to attend an American College of Surgeons (ACS) 2018 General Surgery Coding Workshop. With Medicare and third-party payor policy and coding changes taking effect this year, it is imperative that surgeons have accurate and up-to-date information to protect their reimbursements and optimize efficiency.

During the coding workshop, you will learn how to report surgical procedures and medical services and will have access to the tools necessary to succeed, including a coding workbook to keep for future reference with checklists, resource guides, templates, and examples. Physicians receive up to 6.5 AMA PRA Category 1 Credits™ for each day of participation. In addition, each day of the workshop meets AAPC guidelines for 6.5 continuing education units.

The ACS will offer the following five remaining coding workshops in 2018:

Chicago, IL, April 12–13

New York, NY, May 17–19

Nashville, TN, August 9–10

Chicago, IL, November 1–3

The ACS also will offer a three-day course, including a day devoted to trauma and critical care coding at the New York City and (November) Chicago workshops.

Register for a course at www.karenzupko.com/workshops2/gensurg-workshops/. For more information about the 2018 ACS coding workshops, visit the ACS website www.facs.org/advocacy/practmanagement/workshops or e-mail [email protected].

To help address the severe shortage of surgeons in Sub-Saharan Africa, the American College of Surgeons (ACS) and the College of Surgeons of East, Central, and Southern Africa (COSECSA) have developed a scholarship program to support women in surgical residency, help them complete their training, and encourage other women in medicine to consider surgery as a profession. 

The program is open to senior female surgical residents enrolled in the COSECSA region. Each $2,500 scholarship will go toward educational expenses, including accreditation, the fellowship examination, and five-years of membership dues to COSECSA and the ACS.  Applicants should include a personal statement indicating future goals, a current curriculum vitae, and a letter of support from the surgical training program director.  Completed applications should be sent via e-mail to [email protected] and will be reviewed in conjunction with the Operation Giving Back committee. 

Applications are due no later than April 1.  Contact [email protected] with any questions. 

To help address the severe shortage of surgeons in Sub-Saharan Africa, the American College of Surgeons (ACS) and the College of Surgeons of East, Central, and Southern Africa (COSECSA) have developed a scholarship program to support women in surgical residency, help them complete their training, and encourage other women in medicine to consider surgery as a profession. 

The program is open to senior female surgical residents enrolled in the COSECSA region. Each $2,500 scholarship will go toward educational expenses, including accreditation, the fellowship examination, and five-years of membership dues to COSECSA and the ACS.  Applicants should include a personal statement indicating future goals, a current curriculum vitae, and a letter of support from the surgical training program director.  Completed applications should be sent via e-mail to [email protected] and will be reviewed in conjunction with the Operation Giving Back committee. 

Applications are due no later than April 1.  Contact [email protected] with any questions. 

To help address the severe shortage of surgeons in Sub-Saharan Africa, the American College of Surgeons (ACS) and the College of Surgeons of East, Central, and Southern Africa (COSECSA) have developed a scholarship program to support women in surgical residency, help them complete their training, and encourage other women in medicine to consider surgery as a profession. 

The program is open to senior female surgical residents enrolled in the COSECSA region. Each $2,500 scholarship will go toward educational expenses, including accreditation, the fellowship examination, and five-years of membership dues to COSECSA and the ACS.  Applicants should include a personal statement indicating future goals, a current curriculum vitae, and a letter of support from the surgical training program director.  Completed applications should be sent via e-mail to [email protected] and will be reviewed in conjunction with the Operation Giving Back committee. 

Applications are due no later than April 1.  Contact [email protected] with any questions. 

SVS has partnered with Guidelines Central to create a Pocket Guide version of the new AAA guidelines. Also available are pocket guides on Management of Diabetic Foot, Peripheral Arterial Disease and Venous Leg Ulcers.

SVS members can access the digital versions for free; printed guidelines vary in price. The guidelines also are available as a bundled set.  Slide sets of the guidelines, useful as educational tools, also are available online.

SVS has partnered with Guidelines Central to create a Pocket Guide version of the new AAA guidelines. Also available are pocket guides on Management of Diabetic Foot, Peripheral Arterial Disease and Venous Leg Ulcers.

SVS members can access the digital versions for free; printed guidelines vary in price. The guidelines also are available as a bundled set.  Slide sets of the guidelines, useful as educational tools, also are available online.

SVS has partnered with Guidelines Central to create a Pocket Guide version of the new AAA guidelines. Also available are pocket guides on Management of Diabetic Foot, Peripheral Arterial Disease and Venous Leg Ulcers.

SVS members can access the digital versions for free; printed guidelines vary in price. The guidelines also are available as a bundled set.  Slide sets of the guidelines, useful as educational tools, also are available online.

Registration and housing for the 2018 Vascular Annual Meeting are now open. Register today for VAM, June 20 to 23 in Boston, including looking over housing options. Following a full day of postgraduate courses, VESS abstracts, workshops and international programming on Wednesday, June 20, abstract-based scientific sessions will open June 21 and continue to June 23. The Exhibit Hall will be open June 21 to 22.

Catch the highlights of this year's annual meeting here.

Registration and housing for the 2018 Vascular Annual Meeting are now open. Register today for VAM, June 20 to 23 in Boston, including looking over housing options. Following a full day of postgraduate courses, VESS abstracts, workshops and international programming on Wednesday, June 20, abstract-based scientific sessions will open June 21 and continue to June 23. The Exhibit Hall will be open June 21 to 22.

Catch the highlights of this year's annual meeting here.

Registration and housing for the 2018 Vascular Annual Meeting are now open. Register today for VAM, June 20 to 23 in Boston, including looking over housing options. Following a full day of postgraduate courses, VESS abstracts, workshops and international programming on Wednesday, June 20, abstract-based scientific sessions will open June 21 and continue to June 23. The Exhibit Hall will be open June 21 to 22.

Catch the highlights of this year's annual meeting here.

Obstructive sleep apnea (OSA) contributes a major health burden to society due to its high prevalence and substantial neurocognitive and cardiovascular consequences. Estimates suggest that at least 10% of adults in North America are afflicted with OSA, making it probably the most common respiratory disease in the developed world (Peppard et al. Am J Epidemiol. 2013;177[9]:1006). Nasal CPAP is a highly efficacious therapy that has been shown to improve neurocognitive and cardiovascular outcomes. However, CPAP is not always well tolerated. Alternative therapies, such as oral appliances and upper airway surgery, have highly variable efficacy, and evidence of important clinical benefits are uncertain. Therefore, efforts are ongoing to determine optimal alternative strategies for therapy.

In order to treat any condition optimally, one needs to be able to predict who is at highest risk of developing the condition, then to assess the consequences if left untreated, and finally to be able to predict response to various treatment options. Currently, the OSA field is still in its early stages of our understanding. Clinically, we are often faced with patients who have varying presentations and manifestations, but, for reasons that are unclear. For instance, two individuals with the same body mass index may have very different clinical manifestations, one with severe OSA and one without any OSA. Similarly, two individuals with an apnea hypopnea index of 40 events per hour (ie, severe OSA) may have very different symptoms attributable to OSA, eg, one could be asymptomatic and the other could be debilitated from sleepiness. We and others have been making efforts to determine why these phenomenon occur. At present, the techniques to define mechanisms underlying OSA are labor-intensive, requiring one or two overnight experiments to gather meaningful data. Although we are gathering new insights based on these techniques, efforts are ongoing to simplify these approaches and to make assessment of pathophysiologic characteristics more accessible to the clinician (Orr et al. Am J Respir Crit Care Med. 2017 Nov 30. doi: 10.1164/rccm.201707-1357LE. [Epub ahead of print]).

We ultimately believe that a thorough analysis of a sleep recording combined with demographic data and other readily available clinical data (perhaps plasma biomarkers) may yield sufficient information for us to know why OSA is occurring and what interventions might be helpful for an individual patient. Currently, our use of the polysomnogram to derive only an apnea hypopnea index does not take full advantage of the available data. An apnea hypopnea index can be readily obtained from home sleep testing and does not truly provide much insight into why a given individual has OSA, what symptoms are attributable to OSA, and what interventions might be considered for the afflicted individual. By analogy, if the only useful data derived from an ECG were a heart rate, the test would rapidly become obsolete. Along these lines, if the only role for the sleep clinician was to prescribe CPAP to everyone with an AHI greater than 5/h, there would be little need or interest in specialized training. In contrast, we suggest that rich insights regarding pathophysiology and mechanisms should be gathered and may influence clinical management of patients afflicted with OSA. Thus, we encourage more thorough analyses of available data to maximize information gleaned and, ultimately, to optimize clinical outcomes.

Recent studies suggest that sleep apnea occurs for varying reasons, a concept that is now thought to be clinically important (Jordan et al. Lancet. 2014;383[9918]:736). We draw a crucial distinction between endotypes (mechanisms underlying disease) and phenotypes (clinical expression of disease). Important endotypes include compromised upper airway anatomy, dysfunction in pharyngeal dilator muscles, unstable ventilatory control (high loop gain), and low arousal threshold (wake up easily), among others. Important phenotypes of sleep apnea are emerging and still evolving to include minimally symptomatic OSA, OSA with daytime sleepiness, and OSA with major cardiometabolic risk, among others. Several important concepts have emerged regarding different OSA endotypes and phenotypes:

1 The mechanism underlying OSA may predict potential response to therapeutic interventions. For instance, the endotype of OSA with unstable ventilatory control (high loop gain) may respond to agents such as oxygen and acetazolamide, which serve to stabilize control of breathing. In patients with anatomical compromise at the level of the velopharynx, uvulopalatopharyngoplasty may be an effective intervention. For patients with multiple pathophysiologic abnormalities, combination therapy may be required to alleviate OSA (Edwards et al. Sleep. 2016;9[11]:1973).

2 Given that OSA has many underlying etiologies, efforts are underway to determine whether individuals with different risk factors for OSA develop their disease based on varying mechanisms. As an example, people with posttraumatic stress disorder (PTSD) may be at increased risk of OSA perhaps on the basis of a low threshold for arousal (Orr et al. JCSM. 2017, 13[1]: 57-63). Another example would be patients with neuromuscular disease who may be at risk of OSA primarily based on impaired pharyngeal dilator muscle function.

3 A new concept is emerging whereby endotypes of OSA may actually predict differing OSA phenotypes. In theory, loop gain-driven OSA may have different consequences from OSA driven by compromise of pharyngeal anatomy. To this point, data suggest that OSA in the elderly may not have as many consequences as OSA in younger people matched on severity of illness. OSA in the elderly has lower loop gain than OSA in younger people and is associated with less negative intrathoracic pressure at the time of arousal as compared with younger individuals with OSA (Kobayashi et al. Chest. 2010; 137[6]:1310). As such, the endotype of OSA in the elderly may explain why the clinical consequences are fewer than in the younger OSA counterparts.

4 The mechanism underlying OSA may be important in determining response to clinical interventions, such as nasal CPAP. Patients with a low arousal threshold may be prone to insomnia when placed on CPAP and could theoretically be poorly tolerant of therapy based on disrupted sleep architecture. Such patients may benefit from non-myorelaxant hypnotic therapy to consolidate sleep and improve CPAP adherence. In addition, patients with high loop gain (unstable ventilatory control) may be prone to develop central apneas when placed on CPAP therapy (Stanchina et al. Ann Am Thorac Soc. 2015;12[9]:1351). These patients may benefit from newer technologies, eg, auto or adaptive servo ventilation - ASV. High loop gain has also been shown to predict failure of upper airway surgery as a treatment for OSA by several groups (Li et al. JCSM. 2017;13[9]:1029). Such patients should, perhaps, undergo nonsurgical therapies for OSA.

We emphasize that some of the points being made are somewhat speculative and, thus, encourage further basic and clinical research to test our assumptions. Robust, multicenter clinical trials assessing hard outcomes will ultimately be required to change the current standard of care. Nonetheless, we believe that a more thorough understanding of OSA pathogenesis can help guide clinical care today and will be critical to the optimal treatment of afflicted individuals tomorrow.

Dr. Owens is Assistant Clinical Professor of Medicine; Dr. Deacon is a Post-Doctoral Research Scholar; and Dr. Malhotra is Kenneth M. Moser Professor of Medicine and Chief, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego.

Obstructive sleep apnea (OSA) contributes a major health burden to society due to its high prevalence and substantial neurocognitive and cardiovascular consequences. Estimates suggest that at least 10% of adults in North America are afflicted with OSA, making it probably the most common respiratory disease in the developed world (Peppard et al. Am J Epidemiol. 2013;177[9]:1006). Nasal CPAP is a highly efficacious therapy that has been shown to improve neurocognitive and cardiovascular outcomes. However, CPAP is not always well tolerated. Alternative therapies, such as oral appliances and upper airway surgery, have highly variable efficacy, and evidence of important clinical benefits are uncertain. Therefore, efforts are ongoing to determine optimal alternative strategies for therapy.

In order to treat any condition optimally, one needs to be able to predict who is at highest risk of developing the condition, then to assess the consequences if left untreated, and finally to be able to predict response to various treatment options. Currently, the OSA field is still in its early stages of our understanding. Clinically, we are often faced with patients who have varying presentations and manifestations, but, for reasons that are unclear. For instance, two individuals with the same body mass index may have very different clinical manifestations, one with severe OSA and one without any OSA. Similarly, two individuals with an apnea hypopnea index of 40 events per hour (ie, severe OSA) may have very different symptoms attributable to OSA, eg, one could be asymptomatic and the other could be debilitated from sleepiness. We and others have been making efforts to determine why these phenomenon occur. At present, the techniques to define mechanisms underlying OSA are labor-intensive, requiring one or two overnight experiments to gather meaningful data. Although we are gathering new insights based on these techniques, efforts are ongoing to simplify these approaches and to make assessment of pathophysiologic characteristics more accessible to the clinician (Orr et al. Am J Respir Crit Care Med. 2017 Nov 30. doi: 10.1164/rccm.201707-1357LE. [Epub ahead of print]).

We ultimately believe that a thorough analysis of a sleep recording combined with demographic data and other readily available clinical data (perhaps plasma biomarkers) may yield sufficient information for us to know why OSA is occurring and what interventions might be helpful for an individual patient. Currently, our use of the polysomnogram to derive only an apnea hypopnea index does not take full advantage of the available data. An apnea hypopnea index can be readily obtained from home sleep testing and does not truly provide much insight into why a given individual has OSA, what symptoms are attributable to OSA, and what interventions might be considered for the afflicted individual. By analogy, if the only useful data derived from an ECG were a heart rate, the test would rapidly become obsolete. Along these lines, if the only role for the sleep clinician was to prescribe CPAP to everyone with an AHI greater than 5/h, there would be little need or interest in specialized training. In contrast, we suggest that rich insights regarding pathophysiology and mechanisms should be gathered and may influence clinical management of patients afflicted with OSA. Thus, we encourage more thorough analyses of available data to maximize information gleaned and, ultimately, to optimize clinical outcomes.

Recent studies suggest that sleep apnea occurs for varying reasons, a concept that is now thought to be clinically important (Jordan et al. Lancet. 2014;383[9918]:736). We draw a crucial distinction between endotypes (mechanisms underlying disease) and phenotypes (clinical expression of disease). Important endotypes include compromised upper airway anatomy, dysfunction in pharyngeal dilator muscles, unstable ventilatory control (high loop gain), and low arousal threshold (wake up easily), among others. Important phenotypes of sleep apnea are emerging and still evolving to include minimally symptomatic OSA, OSA with daytime sleepiness, and OSA with major cardiometabolic risk, among others. Several important concepts have emerged regarding different OSA endotypes and phenotypes:

1 The mechanism underlying OSA may predict potential response to therapeutic interventions. For instance, the endotype of OSA with unstable ventilatory control (high loop gain) may respond to agents such as oxygen and acetazolamide, which serve to stabilize control of breathing. In patients with anatomical compromise at the level of the velopharynx, uvulopalatopharyngoplasty may be an effective intervention. For patients with multiple pathophysiologic abnormalities, combination therapy may be required to alleviate OSA (Edwards et al. Sleep. 2016;9[11]:1973).

2 Given that OSA has many underlying etiologies, efforts are underway to determine whether individuals with different risk factors for OSA develop their disease based on varying mechanisms. As an example, people with posttraumatic stress disorder (PTSD) may be at increased risk of OSA perhaps on the basis of a low threshold for arousal (Orr et al. JCSM. 2017, 13[1]: 57-63). Another example would be patients with neuromuscular disease who may be at risk of OSA primarily based on impaired pharyngeal dilator muscle function.

3 A new concept is emerging whereby endotypes of OSA may actually predict differing OSA phenotypes. In theory, loop gain-driven OSA may have different consequences from OSA driven by compromise of pharyngeal anatomy. To this point, data suggest that OSA in the elderly may not have as many consequences as OSA in younger people matched on severity of illness. OSA in the elderly has lower loop gain than OSA in younger people and is associated with less negative intrathoracic pressure at the time of arousal as compared with younger individuals with OSA (Kobayashi et al. Chest. 2010; 137[6]:1310). As such, the endotype of OSA in the elderly may explain why the clinical consequences are fewer than in the younger OSA counterparts.

4 The mechanism underlying OSA may be important in determining response to clinical interventions, such as nasal CPAP. Patients with a low arousal threshold may be prone to insomnia when placed on CPAP and could theoretically be poorly tolerant of therapy based on disrupted sleep architecture. Such patients may benefit from non-myorelaxant hypnotic therapy to consolidate sleep and improve CPAP adherence. In addition, patients with high loop gain (unstable ventilatory control) may be prone to develop central apneas when placed on CPAP therapy (Stanchina et al. Ann Am Thorac Soc. 2015;12[9]:1351). These patients may benefit from newer technologies, eg, auto or adaptive servo ventilation - ASV. High loop gain has also been shown to predict failure of upper airway surgery as a treatment for OSA by several groups (Li et al. JCSM. 2017;13[9]:1029). Such patients should, perhaps, undergo nonsurgical therapies for OSA.

We emphasize that some of the points being made are somewhat speculative and, thus, encourage further basic and clinical research to test our assumptions. Robust, multicenter clinical trials assessing hard outcomes will ultimately be required to change the current standard of care. Nonetheless, we believe that a more thorough understanding of OSA pathogenesis can help guide clinical care today and will be critical to the optimal treatment of afflicted individuals tomorrow.

Dr. Owens is Assistant Clinical Professor of Medicine; Dr. Deacon is a Post-Doctoral Research Scholar; and Dr. Malhotra is Kenneth M. Moser Professor of Medicine and Chief, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego.

Obstructive sleep apnea (OSA) contributes a major health burden to society due to its high prevalence and substantial neurocognitive and cardiovascular consequences. Estimates suggest that at least 10% of adults in North America are afflicted with OSA, making it probably the most common respiratory disease in the developed world (Peppard et al. Am J Epidemiol. 2013;177[9]:1006). Nasal CPAP is a highly efficacious therapy that has been shown to improve neurocognitive and cardiovascular outcomes. However, CPAP is not always well tolerated. Alternative therapies, such as oral appliances and upper airway surgery, have highly variable efficacy, and evidence of important clinical benefits are uncertain. Therefore, efforts are ongoing to determine optimal alternative strategies for therapy.

In order to treat any condition optimally, one needs to be able to predict who is at highest risk of developing the condition, then to assess the consequences if left untreated, and finally to be able to predict response to various treatment options. Currently, the OSA field is still in its early stages of our understanding. Clinically, we are often faced with patients who have varying presentations and manifestations, but, for reasons that are unclear. For instance, two individuals with the same body mass index may have very different clinical manifestations, one with severe OSA and one without any OSA. Similarly, two individuals with an apnea hypopnea index of 40 events per hour (ie, severe OSA) may have very different symptoms attributable to OSA, eg, one could be asymptomatic and the other could be debilitated from sleepiness. We and others have been making efforts to determine why these phenomenon occur. At present, the techniques to define mechanisms underlying OSA are labor-intensive, requiring one or two overnight experiments to gather meaningful data. Although we are gathering new insights based on these techniques, efforts are ongoing to simplify these approaches and to make assessment of pathophysiologic characteristics more accessible to the clinician (Orr et al. Am J Respir Crit Care Med. 2017 Nov 30. doi: 10.1164/rccm.201707-1357LE. [Epub ahead of print]).

We ultimately believe that a thorough analysis of a sleep recording combined with demographic data and other readily available clinical data (perhaps plasma biomarkers) may yield sufficient information for us to know why OSA is occurring and what interventions might be helpful for an individual patient. Currently, our use of the polysomnogram to derive only an apnea hypopnea index does not take full advantage of the available data. An apnea hypopnea index can be readily obtained from home sleep testing and does not truly provide much insight into why a given individual has OSA, what symptoms are attributable to OSA, and what interventions might be considered for the afflicted individual. By analogy, if the only useful data derived from an ECG were a heart rate, the test would rapidly become obsolete. Along these lines, if the only role for the sleep clinician was to prescribe CPAP to everyone with an AHI greater than 5/h, there would be little need or interest in specialized training. In contrast, we suggest that rich insights regarding pathophysiology and mechanisms should be gathered and may influence clinical management of patients afflicted with OSA. Thus, we encourage more thorough analyses of available data to maximize information gleaned and, ultimately, to optimize clinical outcomes.

Recent studies suggest that sleep apnea occurs for varying reasons, a concept that is now thought to be clinically important (Jordan et al. Lancet. 2014;383[9918]:736). We draw a crucial distinction between endotypes (mechanisms underlying disease) and phenotypes (clinical expression of disease). Important endotypes include compromised upper airway anatomy, dysfunction in pharyngeal dilator muscles, unstable ventilatory control (high loop gain), and low arousal threshold (wake up easily), among others. Important phenotypes of sleep apnea are emerging and still evolving to include minimally symptomatic OSA, OSA with daytime sleepiness, and OSA with major cardiometabolic risk, among others. Several important concepts have emerged regarding different OSA endotypes and phenotypes:

1 The mechanism underlying OSA may predict potential response to therapeutic interventions. For instance, the endotype of OSA with unstable ventilatory control (high loop gain) may respond to agents such as oxygen and acetazolamide, which serve to stabilize control of breathing. In patients with anatomical compromise at the level of the velopharynx, uvulopalatopharyngoplasty may be an effective intervention. For patients with multiple pathophysiologic abnormalities, combination therapy may be required to alleviate OSA (Edwards et al. Sleep. 2016;9[11]:1973).

2 Given that OSA has many underlying etiologies, efforts are underway to determine whether individuals with different risk factors for OSA develop their disease based on varying mechanisms. As an example, people with posttraumatic stress disorder (PTSD) may be at increased risk of OSA perhaps on the basis of a low threshold for arousal (Orr et al. JCSM. 2017, 13[1]: 57-63). Another example would be patients with neuromuscular disease who may be at risk of OSA primarily based on impaired pharyngeal dilator muscle function.

3 A new concept is emerging whereby endotypes of OSA may actually predict differing OSA phenotypes. In theory, loop gain-driven OSA may have different consequences from OSA driven by compromise of pharyngeal anatomy. To this point, data suggest that OSA in the elderly may not have as many consequences as OSA in younger people matched on severity of illness. OSA in the elderly has lower loop gain than OSA in younger people and is associated with less negative intrathoracic pressure at the time of arousal as compared with younger individuals with OSA (Kobayashi et al. Chest. 2010; 137[6]:1310). As such, the endotype of OSA in the elderly may explain why the clinical consequences are fewer than in the younger OSA counterparts.

4 The mechanism underlying OSA may be important in determining response to clinical interventions, such as nasal CPAP. Patients with a low arousal threshold may be prone to insomnia when placed on CPAP and could theoretically be poorly tolerant of therapy based on disrupted sleep architecture. Such patients may benefit from non-myorelaxant hypnotic therapy to consolidate sleep and improve CPAP adherence. In addition, patients with high loop gain (unstable ventilatory control) may be prone to develop central apneas when placed on CPAP therapy (Stanchina et al. Ann Am Thorac Soc. 2015;12[9]:1351). These patients may benefit from newer technologies, eg, auto or adaptive servo ventilation - ASV. High loop gain has also been shown to predict failure of upper airway surgery as a treatment for OSA by several groups (Li et al. JCSM. 2017;13[9]:1029). Such patients should, perhaps, undergo nonsurgical therapies for OSA.

We emphasize that some of the points being made are somewhat speculative and, thus, encourage further basic and clinical research to test our assumptions. Robust, multicenter clinical trials assessing hard outcomes will ultimately be required to change the current standard of care. Nonetheless, we believe that a more thorough understanding of OSA pathogenesis can help guide clinical care today and will be critical to the optimal treatment of afflicted individuals tomorrow.

Dr. Owens is Assistant Clinical Professor of Medicine; Dr. Deacon is a Post-Doctoral Research Scholar; and Dr. Malhotra is Kenneth M. Moser Professor of Medicine and Chief, Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego.

Through the Leadership Development and Diversity Committee, the SVS continues its strong commitment to leadership development in women. The Women's Leadership Training Grant seeks to identify female surgeons who want to sharpen their leadership skills. A $5,000 award will defray costs for travel, hotel accommodations and registration expenses to attend relevant courses and/or other leadership training opportunities and activities. Application deadline is March 14.

Through the Leadership Development and Diversity Committee, the SVS continues its strong commitment to leadership development in women. The Women's Leadership Training Grant seeks to identify female surgeons who want to sharpen their leadership skills. A $5,000 award will defray costs for travel, hotel accommodations and registration expenses to attend relevant courses and/or other leadership training opportunities and activities. Application deadline is March 14.

Through the Leadership Development and Diversity Committee, the SVS continues its strong commitment to leadership development in women. The Women's Leadership Training Grant seeks to identify female surgeons who want to sharpen their leadership skills. A $5,000 award will defray costs for travel, hotel accommodations and registration expenses to attend relevant courses and/or other leadership training opportunities and activities. Application deadline is March 14.

The SVS Foundation will accept applications through March 16 for funds from its Disaster Relief Fund. The fund can be used for recovery efforts in areas that have experienced catastrophes.

Monies support programs, initiated by SVS members, that provide short-term emergency assistance and longer-term aid for vascular surgery practices and vascular patients in disaster-devastated communities.

The SVS Foundation will accept applications through March 16 for funds from its Disaster Relief Fund. The fund can be used for recovery efforts in areas that have experienced catastrophes.

Monies support programs, initiated by SVS members, that provide short-term emergency assistance and longer-term aid for vascular surgery practices and vascular patients in disaster-devastated communities.

The SVS Foundation will accept applications through March 16 for funds from its Disaster Relief Fund. The fund can be used for recovery efforts in areas that have experienced catastrophes.

Monies support programs, initiated by SVS members, that provide short-term emergency assistance and longer-term aid for vascular surgery practices and vascular patients in disaster-devastated communities.