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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.

It's nearly here! The 2018 Vascular Annual Meeting takes a big step forward this week with the opening of housing and registration. Prepare to sign up for VAM, June 20 to 23 in Boston.

Following a full day of postgraduate courses, VESS abstracts, workshops and international programming, 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.

It's nearly here! The 2018 Vascular Annual Meeting takes a big step forward this week with the opening of housing and registration. Prepare to sign up for VAM, June 20 to 23 in Boston.

Following a full day of postgraduate courses, VESS abstracts, workshops and international programming, 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.

It's nearly here! The 2018 Vascular Annual Meeting takes a big step forward this week with the opening of housing and registration. Prepare to sign up for VAM, June 20 to 23 in Boston.

Following a full day of postgraduate courses, VESS abstracts, workshops and international programming, 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.

A new review of the literature on chronic venous insufficiency in pregnant women reveals considerable guidance for their treatment. CVI occurs in up to 80% of pregnant women, while around 7 of every 1,000 pregnant mothers face venous thromboembolism and pulmonary embolism.

As reported in the March edition of the Journal of Vascular Surgery: Venous and Lymphatic Disorders, clinicians from Johns Hopkins Hospital and the Greater Baltimore Medical Center led by vascular surgeon Dr. Jennifer Heller, analyzed 80 studies related to pregnancy, VTE and CVI.

Pregnancy causes significant hemodynamic changes within the circulatory system.  While these are considered essential for the health of the developing fetus, the changes place considerable stress on the expectant mother’s heart and lower extremity veins. 

Chronic venous insufficiency (CVI), marked by varicose veins, pain, edema, itching, skin discoloration, night cramps and heaviness are all common, particularly during the third trimester.  Venous thromboembolism (VTE) and pulmonary embolism (PE) affects pregnant women nearly five times more than non-pregnant women.  In fact, VTE is the number one cause of maternal death in developing countries.

With regards to the hemodynamic and physiologic changes, the review reveals pregnancy:

• Decreases systemic vascular resistance
• Increases heart rate
• Increases cardiac output
• Decreases deep venous blood flow
• Increases deep vein diameters, and
• Induces a hypercoagulable state

Treatment strategies for primary CVI in pregnancy, which occurs in up to 80% of women, were reviewed and include indications for non-pharmacologic therapies (compression, reflexology, water emersion), and pharmacologic treatments (non-steroidal anti-inflammatory drugs, fondaparinux, and low-molecular-weight heparin).

With an incidence up to 7 per 1,000 pregnancies, acute VTE remains an important issue in pregnancy.  The authors provided a thorough review of VTE prevention during pregnancy, and VTE treatment during pregnancy (including indications for caval filters and management of iliofemoral thrombosis).

“It is important for physicians to comprehend the full extent of the hemodynamic factors that contribute to the increased risk of lower extremity venous disease as well as the most appropriate and effective evidence-based management options,” stated Dr. Heller.  “While prophylaxis and treatment of VTE has been extensively studied in pregnancy, further research is required to look at the potential effectiveness and long-term safety profiles of new oral anticoagulants in the mother and fetus.” 

She also hopes that future randomized trials will evaluate treatment strategies to relieve symptoms associated with chronic venous insufficiency during pregnancy.

Complete understanding of these issues helps physicians prepare their patients for these eventualities during pregnancy and treat venous complications effectively. 

To download the complete article, open access through April 30, click here.  

A new review of the literature on chronic venous insufficiency in pregnant women reveals considerable guidance for their treatment. CVI occurs in up to 80% of pregnant women, while around 7 of every 1,000 pregnant mothers face venous thromboembolism and pulmonary embolism.

As reported in the March edition of the Journal of Vascular Surgery: Venous and Lymphatic Disorders, clinicians from Johns Hopkins Hospital and the Greater Baltimore Medical Center led by vascular surgeon Dr. Jennifer Heller, analyzed 80 studies related to pregnancy, VTE and CVI.

Pregnancy causes significant hemodynamic changes within the circulatory system.  While these are considered essential for the health of the developing fetus, the changes place considerable stress on the expectant mother’s heart and lower extremity veins. 

Chronic venous insufficiency (CVI), marked by varicose veins, pain, edema, itching, skin discoloration, night cramps and heaviness are all common, particularly during the third trimester.  Venous thromboembolism (VTE) and pulmonary embolism (PE) affects pregnant women nearly five times more than non-pregnant women.  In fact, VTE is the number one cause of maternal death in developing countries.

With regards to the hemodynamic and physiologic changes, the review reveals pregnancy:

• Decreases systemic vascular resistance
• Increases heart rate
• Increases cardiac output
• Decreases deep venous blood flow
• Increases deep vein diameters, and
• Induces a hypercoagulable state

Treatment strategies for primary CVI in pregnancy, which occurs in up to 80% of women, were reviewed and include indications for non-pharmacologic therapies (compression, reflexology, water emersion), and pharmacologic treatments (non-steroidal anti-inflammatory drugs, fondaparinux, and low-molecular-weight heparin).

With an incidence up to 7 per 1,000 pregnancies, acute VTE remains an important issue in pregnancy.  The authors provided a thorough review of VTE prevention during pregnancy, and VTE treatment during pregnancy (including indications for caval filters and management of iliofemoral thrombosis).

“It is important for physicians to comprehend the full extent of the hemodynamic factors that contribute to the increased risk of lower extremity venous disease as well as the most appropriate and effective evidence-based management options,” stated Dr. Heller.  “While prophylaxis and treatment of VTE has been extensively studied in pregnancy, further research is required to look at the potential effectiveness and long-term safety profiles of new oral anticoagulants in the mother and fetus.” 

She also hopes that future randomized trials will evaluate treatment strategies to relieve symptoms associated with chronic venous insufficiency during pregnancy.

Complete understanding of these issues helps physicians prepare their patients for these eventualities during pregnancy and treat venous complications effectively. 

To download the complete article, open access through April 30, click here.  

A new review of the literature on chronic venous insufficiency in pregnant women reveals considerable guidance for their treatment. CVI occurs in up to 80% of pregnant women, while around 7 of every 1,000 pregnant mothers face venous thromboembolism and pulmonary embolism.

As reported in the March edition of the Journal of Vascular Surgery: Venous and Lymphatic Disorders, clinicians from Johns Hopkins Hospital and the Greater Baltimore Medical Center led by vascular surgeon Dr. Jennifer Heller, analyzed 80 studies related to pregnancy, VTE and CVI.

Pregnancy causes significant hemodynamic changes within the circulatory system.  While these are considered essential for the health of the developing fetus, the changes place considerable stress on the expectant mother’s heart and lower extremity veins. 

Chronic venous insufficiency (CVI), marked by varicose veins, pain, edema, itching, skin discoloration, night cramps and heaviness are all common, particularly during the third trimester.  Venous thromboembolism (VTE) and pulmonary embolism (PE) affects pregnant women nearly five times more than non-pregnant women.  In fact, VTE is the number one cause of maternal death in developing countries.

With regards to the hemodynamic and physiologic changes, the review reveals pregnancy:

• Decreases systemic vascular resistance
• Increases heart rate
• Increases cardiac output
• Decreases deep venous blood flow
• Increases deep vein diameters, and
• Induces a hypercoagulable state

Treatment strategies for primary CVI in pregnancy, which occurs in up to 80% of women, were reviewed and include indications for non-pharmacologic therapies (compression, reflexology, water emersion), and pharmacologic treatments (non-steroidal anti-inflammatory drugs, fondaparinux, and low-molecular-weight heparin).

With an incidence up to 7 per 1,000 pregnancies, acute VTE remains an important issue in pregnancy.  The authors provided a thorough review of VTE prevention during pregnancy, and VTE treatment during pregnancy (including indications for caval filters and management of iliofemoral thrombosis).

“It is important for physicians to comprehend the full extent of the hemodynamic factors that contribute to the increased risk of lower extremity venous disease as well as the most appropriate and effective evidence-based management options,” stated Dr. Heller.  “While prophylaxis and treatment of VTE has been extensively studied in pregnancy, further research is required to look at the potential effectiveness and long-term safety profiles of new oral anticoagulants in the mother and fetus.” 

She also hopes that future randomized trials will evaluate treatment strategies to relieve symptoms associated with chronic venous insufficiency during pregnancy.

Complete understanding of these issues helps physicians prepare their patients for these eventualities during pregnancy and treat venous complications effectively. 

To download the complete article, open access through April 30, click here.  

Physicians should consider prescribing high-dose angiotensin inhibitors for patients with chronic limb-threatening ischemia (CLTI), a recent study from Harvard University suggests.

The report was published in the March edition of the Journal of Vascular Surgery by researchers from the Division of Vascular and Endovascular Surgery from the Beth Israel Deaconess Medical Center led by vascular surgeon Dr. Marc Schermerhorn.

The team conducted a retrospective review of 1,161 patients between 2005 and 2014 and evaluated the effect of renin-angiotensin system (RAS) inhibition on mortality in patients undergoing revascularization (both endovascular and surgical bypass) for CLTI.

In this population, RAS inhibition resulted in: 
•    Reduced mortality (67% versus 54% survival at three years)
•    Lower 30-day myocardial infarction (1.6% versus 4.3%)
•    No difference in major adverse limb events, amputation, or reinterventions

“These benefits were restricted to those prescribed high-dose RAS inhibition, and not realized in those on lower doses,” noted first author Dr. Thomas Bodewes.  As such, the authors recommend that, “physicians should strive to maintain patients on high-dose RAS inhibition, provided that such doses are tolerated in terms of blood pressure.”
Patients with CLTI are heavily burdened with atherosclerosis, which affects nearly all important vascular beds, including the cerebral, coronary, peripheral, renal and mesenteric circulatory systems.
 
A growing body of evidence suggests that renin-angiotensin system (RAS) inhibition has multiple cardiovascular benefits including:
•    Blood pressure control
•    Decrease in preload and afterload
•    Stabilization of plaque
•    Inhibition of smooth muscle proliferation
•    Improved vascular endothelial function
•    Reduced ventricular hypertrophy
•    Enhanced fibrinolysis

Despite this evidence, questions remain. The authors note that this was a retrospective single institution review and despite adjustment for multiple variables, the association between RAS inhibitor use and long-term outcomes may be confounded by other factors including some that were unmeasured. 
There are relatively modest number of non-white patients, and actual use of the medications beyond hospital discharge among the study patients is unknown. There are potential side effects to the use of RAS inhibitors that providers must consider in the dosing of these medications. Larger confirmatory studies are needed to confirm these findings and strengthen the evidence.

ClIck here to read the full-article, which is free to non-subscribers until April 30.

Physicians should consider prescribing high-dose angiotensin inhibitors for patients with chronic limb-threatening ischemia (CLTI), a recent study from Harvard University suggests.

The report was published in the March edition of the Journal of Vascular Surgery by researchers from the Division of Vascular and Endovascular Surgery from the Beth Israel Deaconess Medical Center led by vascular surgeon Dr. Marc Schermerhorn.

The team conducted a retrospective review of 1,161 patients between 2005 and 2014 and evaluated the effect of renin-angiotensin system (RAS) inhibition on mortality in patients undergoing revascularization (both endovascular and surgical bypass) for CLTI.

In this population, RAS inhibition resulted in: 
•    Reduced mortality (67% versus 54% survival at three years)
•    Lower 30-day myocardial infarction (1.6% versus 4.3%)
•    No difference in major adverse limb events, amputation, or reinterventions

“These benefits were restricted to those prescribed high-dose RAS inhibition, and not realized in those on lower doses,” noted first author Dr. Thomas Bodewes.  As such, the authors recommend that, “physicians should strive to maintain patients on high-dose RAS inhibition, provided that such doses are tolerated in terms of blood pressure.”
Patients with CLTI are heavily burdened with atherosclerosis, which affects nearly all important vascular beds, including the cerebral, coronary, peripheral, renal and mesenteric circulatory systems.
 
A growing body of evidence suggests that renin-angiotensin system (RAS) inhibition has multiple cardiovascular benefits including:
•    Blood pressure control
•    Decrease in preload and afterload
•    Stabilization of plaque
•    Inhibition of smooth muscle proliferation
•    Improved vascular endothelial function
•    Reduced ventricular hypertrophy
•    Enhanced fibrinolysis

Despite this evidence, questions remain. The authors note that this was a retrospective single institution review and despite adjustment for multiple variables, the association between RAS inhibitor use and long-term outcomes may be confounded by other factors including some that were unmeasured. 
There are relatively modest number of non-white patients, and actual use of the medications beyond hospital discharge among the study patients is unknown. There are potential side effects to the use of RAS inhibitors that providers must consider in the dosing of these medications. Larger confirmatory studies are needed to confirm these findings and strengthen the evidence.

ClIck here to read the full-article, which is free to non-subscribers until April 30.

Physicians should consider prescribing high-dose angiotensin inhibitors for patients with chronic limb-threatening ischemia (CLTI), a recent study from Harvard University suggests.

The report was published in the March edition of the Journal of Vascular Surgery by researchers from the Division of Vascular and Endovascular Surgery from the Beth Israel Deaconess Medical Center led by vascular surgeon Dr. Marc Schermerhorn.

The team conducted a retrospective review of 1,161 patients between 2005 and 2014 and evaluated the effect of renin-angiotensin system (RAS) inhibition on mortality in patients undergoing revascularization (both endovascular and surgical bypass) for CLTI.

In this population, RAS inhibition resulted in: 
•    Reduced mortality (67% versus 54% survival at three years)
•    Lower 30-day myocardial infarction (1.6% versus 4.3%)
•    No difference in major adverse limb events, amputation, or reinterventions

“These benefits were restricted to those prescribed high-dose RAS inhibition, and not realized in those on lower doses,” noted first author Dr. Thomas Bodewes.  As such, the authors recommend that, “physicians should strive to maintain patients on high-dose RAS inhibition, provided that such doses are tolerated in terms of blood pressure.”
Patients with CLTI are heavily burdened with atherosclerosis, which affects nearly all important vascular beds, including the cerebral, coronary, peripheral, renal and mesenteric circulatory systems.
 
A growing body of evidence suggests that renin-angiotensin system (RAS) inhibition has multiple cardiovascular benefits including:
•    Blood pressure control
•    Decrease in preload and afterload
•    Stabilization of plaque
•    Inhibition of smooth muscle proliferation
•    Improved vascular endothelial function
•    Reduced ventricular hypertrophy
•    Enhanced fibrinolysis

Despite this evidence, questions remain. The authors note that this was a retrospective single institution review and despite adjustment for multiple variables, the association between RAS inhibitor use and long-term outcomes may be confounded by other factors including some that were unmeasured. 
There are relatively modest number of non-white patients, and actual use of the medications beyond hospital discharge among the study patients is unknown. There are potential side effects to the use of RAS inhibitors that providers must consider in the dosing of these medications. Larger confirmatory studies are needed to confirm these findings and strengthen the evidence.

ClIck here to read the full-article, which is free to non-subscribers until April 30.

AGA Legacy Society members share a desire to guarantee long-term support for digestive disease research. Through their foresight and generosity, they help ensure the continued momentum of discovery and patient education that has characterized GI medicine in recent decades. Legacy Society member donations directly support young GI investigators as they establish independent research careers.

Legacy Society members are the most generous individual donors to the AGA Research Foundation. Members of the AGA Legacy Society provide tax-deductible gifts to the AGA Research Foundation of $5,000 or more per year for 5 years ($25,000 total) or $50,000 or more in a planned gift, such as a bequest. All Legacy Society contributions go directly to support research awards.

AGA members support young researchers at a critical decision point in their lives – when many consider giving up their research careers due to a lack of funding. “I am honored to be a recipient of the Research Scholar Award. I would like to thank the foundation for their generous contribution that will fund a crucial transition in my career,” said Jose Saenz, MD, PhD, Washington University School of Medicine and 2017 AGA – Gastric Cancer Foundation Research Scholar Award recipient.

The makings of a grand celebration

Beginning with a memorable gathering at the United States Library of Congress in 2007, the AGA Benefactors’ Dinner has welcomed members of the AGA Legacy Society and other AGA dignitaries to special locations nationwide. The Folger Shakespeare Library will be the location of the 2018 AGA Research Foundation Benefactors Dinner during DDW in Washington, DC. Just steps from the Capitol, the Great Hall and Pastor Reading room are a spectacular setting for an enjoyable evening with friends. Members of the AGA Legacy Society will be among the distinguished honorees at the annual event.

[email protected]

AGA Legacy Society members share a desire to guarantee long-term support for digestive disease research. Through their foresight and generosity, they help ensure the continued momentum of discovery and patient education that has characterized GI medicine in recent decades. Legacy Society member donations directly support young GI investigators as they establish independent research careers.

Legacy Society members are the most generous individual donors to the AGA Research Foundation. Members of the AGA Legacy Society provide tax-deductible gifts to the AGA Research Foundation of $5,000 or more per year for 5 years ($25,000 total) or $50,000 or more in a planned gift, such as a bequest. All Legacy Society contributions go directly to support research awards.

AGA members support young researchers at a critical decision point in their lives – when many consider giving up their research careers due to a lack of funding. “I am honored to be a recipient of the Research Scholar Award. I would like to thank the foundation for their generous contribution that will fund a crucial transition in my career,” said Jose Saenz, MD, PhD, Washington University School of Medicine and 2017 AGA – Gastric Cancer Foundation Research Scholar Award recipient.

The makings of a grand celebration

Beginning with a memorable gathering at the United States Library of Congress in 2007, the AGA Benefactors’ Dinner has welcomed members of the AGA Legacy Society and other AGA dignitaries to special locations nationwide. The Folger Shakespeare Library will be the location of the 2018 AGA Research Foundation Benefactors Dinner during DDW in Washington, DC. Just steps from the Capitol, the Great Hall and Pastor Reading room are a spectacular setting for an enjoyable evening with friends. Members of the AGA Legacy Society will be among the distinguished honorees at the annual event.

[email protected]

AGA Legacy Society members share a desire to guarantee long-term support for digestive disease research. Through their foresight and generosity, they help ensure the continued momentum of discovery and patient education that has characterized GI medicine in recent decades. Legacy Society member donations directly support young GI investigators as they establish independent research careers.

Legacy Society members are the most generous individual donors to the AGA Research Foundation. Members of the AGA Legacy Society provide tax-deductible gifts to the AGA Research Foundation of $5,000 or more per year for 5 years ($25,000 total) or $50,000 or more in a planned gift, such as a bequest. All Legacy Society contributions go directly to support research awards.

AGA members support young researchers at a critical decision point in their lives – when many consider giving up their research careers due to a lack of funding. “I am honored to be a recipient of the Research Scholar Award. I would like to thank the foundation for their generous contribution that will fund a crucial transition in my career,” said Jose Saenz, MD, PhD, Washington University School of Medicine and 2017 AGA – Gastric Cancer Foundation Research Scholar Award recipient.

The makings of a grand celebration

Beginning with a memorable gathering at the United States Library of Congress in 2007, the AGA Benefactors’ Dinner has welcomed members of the AGA Legacy Society and other AGA dignitaries to special locations nationwide. The Folger Shakespeare Library will be the location of the 2018 AGA Research Foundation Benefactors Dinner during DDW in Washington, DC. Just steps from the Capitol, the Great Hall and Pastor Reading room are a spectacular setting for an enjoyable evening with friends. Members of the AGA Legacy Society will be among the distinguished honorees at the annual event.

[email protected]

AGA President Sheila Crowe, MD, FRCPC, FACP, FACG, AGAF, recently spent the day on Capitol Hill meeting with lawmakers to advocate for AGA legislative priorities including increasing funding for NIH and biomedical research, support for the Removing Barriers to Colorectal Cancer Screening Act, and support for the Restoring the Patient’s Voice Act. Dr. Crowe met with eight congressional offices and received helpful feedback on the upcoming agenda in Congress and how it impacts AGA’s priorities.

NIH funding

Removing Barriers to Colorectal Cancer Screening Act

Fixing the current coinsurance problem for Medicare beneficiaries who undergo a screening colonoscopy that becomes therapeutic remains a top AGA priority. Most of the offices that Dr. Crowe met with were cosponsors of the legislation, the Removing Barriers to Colorectal Cancer Screening Act (HR 1017/S.479), that would waive coinsurance payment regardless of the screening outcome. Dr. Crowe shared her experience with patients and the financial burden this places on beneficiaries who need to be screened. Rep. Raul Ruiz, D-CA, and Rep. Scott Peters, D-CA, both members of the House Energy and Commerce Committee and supporters of the bill, will continue to advocate that the bill receive a hearing this year to help move it through Congress. The bill continues to have wide bipartisan support. Read more about the issue and how you can explain it to your patients.

Step therapy

More and more patients are being subject to step therapy protocols, also known as “fail first” under which they are required to try and fail sometimes two or three therapies before receiving coverage of the initial therapy recommended by their physician. With the emergence of new biologics to treat diseases like inflammatory bowel disease, more and more digestive disease patients are being subject to these protocols, which can have adverse effects on their health. Restoring the Patient’s Voice Act (HR 2077) would provide patients and providers with a fair and equitable appeals process when step therapy has been imposed and provides common sense exceptions for the provider to appeal. Dr. Crowe spoke of the impact this policy is having on digestive disease patients and the burden it puts on physician practices that have to take time away from patients to navigate the convoluted insurance appeals process. We are hopeful that many of the offices that we met with will support HR 2077. Read more about the issue.

Food is Medicine Working Group

Dr. Crowe also had a productive meeting with Rep. Jim McGovern’s, D-MA, office and learned more about the recently created Food is Medicine Working Group that he has initiated. McGovern is the Ranking Member of the Agriculture Committee’s Subcommittee on Nutrition which is responsible for our nation’s nutrition guidelines and the Supplemental Nutrition Assistance Program. The Working Group will focus on costs related to hunger and the importance of nutrition in treating chronic illness and disease. AGA looks forward to working with McGovern and members of the Working Group on this bipartisan initiative.

Capitol Hill needs to hear the voice of GI

In conjunction with Dr. Crowe’s visit, AGA launched a Virtual Advocacy Day to encourage members to contact their legislators in support of the issues that Dr. Crowe was advocating during her meetings. We thank those members who took time out of their schedules to take action.

AGA President Sheila Crowe, MD, FRCPC, FACP, FACG, AGAF, recently spent the day on Capitol Hill meeting with lawmakers to advocate for AGA legislative priorities including increasing funding for NIH and biomedical research, support for the Removing Barriers to Colorectal Cancer Screening Act, and support for the Restoring the Patient’s Voice Act. Dr. Crowe met with eight congressional offices and received helpful feedback on the upcoming agenda in Congress and how it impacts AGA’s priorities.

NIH funding

Removing Barriers to Colorectal Cancer Screening Act

Fixing the current coinsurance problem for Medicare beneficiaries who undergo a screening colonoscopy that becomes therapeutic remains a top AGA priority. Most of the offices that Dr. Crowe met with were cosponsors of the legislation, the Removing Barriers to Colorectal Cancer Screening Act (HR 1017/S.479), that would waive coinsurance payment regardless of the screening outcome. Dr. Crowe shared her experience with patients and the financial burden this places on beneficiaries who need to be screened. Rep. Raul Ruiz, D-CA, and Rep. Scott Peters, D-CA, both members of the House Energy and Commerce Committee and supporters of the bill, will continue to advocate that the bill receive a hearing this year to help move it through Congress. The bill continues to have wide bipartisan support. Read more about the issue and how you can explain it to your patients.

Step therapy

More and more patients are being subject to step therapy protocols, also known as “fail first” under which they are required to try and fail sometimes two or three therapies before receiving coverage of the initial therapy recommended by their physician. With the emergence of new biologics to treat diseases like inflammatory bowel disease, more and more digestive disease patients are being subject to these protocols, which can have adverse effects on their health. Restoring the Patient’s Voice Act (HR 2077) would provide patients and providers with a fair and equitable appeals process when step therapy has been imposed and provides common sense exceptions for the provider to appeal. Dr. Crowe spoke of the impact this policy is having on digestive disease patients and the burden it puts on physician practices that have to take time away from patients to navigate the convoluted insurance appeals process. We are hopeful that many of the offices that we met with will support HR 2077. Read more about the issue.

Food is Medicine Working Group

Dr. Crowe also had a productive meeting with Rep. Jim McGovern’s, D-MA, office and learned more about the recently created Food is Medicine Working Group that he has initiated. McGovern is the Ranking Member of the Agriculture Committee’s Subcommittee on Nutrition which is responsible for our nation’s nutrition guidelines and the Supplemental Nutrition Assistance Program. The Working Group will focus on costs related to hunger and the importance of nutrition in treating chronic illness and disease. AGA looks forward to working with McGovern and members of the Working Group on this bipartisan initiative.

Capitol Hill needs to hear the voice of GI

In conjunction with Dr. Crowe’s visit, AGA launched a Virtual Advocacy Day to encourage members to contact their legislators in support of the issues that Dr. Crowe was advocating during her meetings. We thank those members who took time out of their schedules to take action.

AGA President Sheila Crowe, MD, FRCPC, FACP, FACG, AGAF, recently spent the day on Capitol Hill meeting with lawmakers to advocate for AGA legislative priorities including increasing funding for NIH and biomedical research, support for the Removing Barriers to Colorectal Cancer Screening Act, and support for the Restoring the Patient’s Voice Act. Dr. Crowe met with eight congressional offices and received helpful feedback on the upcoming agenda in Congress and how it impacts AGA’s priorities.

NIH funding

Removing Barriers to Colorectal Cancer Screening Act

Fixing the current coinsurance problem for Medicare beneficiaries who undergo a screening colonoscopy that becomes therapeutic remains a top AGA priority. Most of the offices that Dr. Crowe met with were cosponsors of the legislation, the Removing Barriers to Colorectal Cancer Screening Act (HR 1017/S.479), that would waive coinsurance payment regardless of the screening outcome. Dr. Crowe shared her experience with patients and the financial burden this places on beneficiaries who need to be screened. Rep. Raul Ruiz, D-CA, and Rep. Scott Peters, D-CA, both members of the House Energy and Commerce Committee and supporters of the bill, will continue to advocate that the bill receive a hearing this year to help move it through Congress. The bill continues to have wide bipartisan support. Read more about the issue and how you can explain it to your patients.

Step therapy

More and more patients are being subject to step therapy protocols, also known as “fail first” under which they are required to try and fail sometimes two or three therapies before receiving coverage of the initial therapy recommended by their physician. With the emergence of new biologics to treat diseases like inflammatory bowel disease, more and more digestive disease patients are being subject to these protocols, which can have adverse effects on their health. Restoring the Patient’s Voice Act (HR 2077) would provide patients and providers with a fair and equitable appeals process when step therapy has been imposed and provides common sense exceptions for the provider to appeal. Dr. Crowe spoke of the impact this policy is having on digestive disease patients and the burden it puts on physician practices that have to take time away from patients to navigate the convoluted insurance appeals process. We are hopeful that many of the offices that we met with will support HR 2077. Read more about the issue.

Food is Medicine Working Group

Dr. Crowe also had a productive meeting with Rep. Jim McGovern’s, D-MA, office and learned more about the recently created Food is Medicine Working Group that he has initiated. McGovern is the Ranking Member of the Agriculture Committee’s Subcommittee on Nutrition which is responsible for our nation’s nutrition guidelines and the Supplemental Nutrition Assistance Program. The Working Group will focus on costs related to hunger and the importance of nutrition in treating chronic illness and disease. AGA looks forward to working with McGovern and members of the Working Group on this bipartisan initiative.

Capitol Hill needs to hear the voice of GI

In conjunction with Dr. Crowe’s visit, AGA launched a Virtual Advocacy Day to encourage members to contact their legislators in support of the issues that Dr. Crowe was advocating during her meetings. We thank those members who took time out of their schedules to take action.

The 2018 Gastrointestinal Cancers Symposium took place Jan. 18-20, 2018, in San Francisco. During the meeting, investigators presented groundbreaking research designed to improve the diagnosis and treatment of GI cancers. Here are some of the most noteworthy headlines from the 2018 meeting.

Promising Results Using Liquid Biopsy to Improve CRC Early Detection

Researchers in Taiwan developed a screening test for early colorectal cancer (CRC) detection that requires a simple blood draw to assess for circulating tumor cells in the blood. The test demonstrates 88% accuracy to detect all stages of colorectal illness, including precancerous lesions. If validated and made commercially available, this test could be readily integrated into a patient’s routine physical exam, thereby increasing CRC screening compliance.

CELESTIAL Results May Lead to Cabozantinib Approval in Second-Line HCC

The phase III CELESTIAL trial met its primary endpoint by demonstrating a survival advantage with cabozantinib in patients with advanced hepatocellular carcinoma (HCC) that progressed following prior systemic therapy. Other outcomes included improvements in progression-free survival and objective response rate, as well as an acceptable safety profile, thus positioning cabozantinib for potential approval in the second-line setting in HCC.

RAINFALL Meets Primary Endpoint, But Ramucirumab Will Not Be Pursued for a First-Line Indication in G-GEJ Cancer

Results of the global, randomized, double-blind, placebo-controlled, phase III RAINFALL trial established the statistical benefit of ramucirumab, a monoclonal antibody targeting VEGFR-2, added to standard chemotherapy for patients with previously untreated metastatic gastric or gastroesophageal junction (G-GEJ) adenocarcinoma. The findings revealed a significant 25% reduction in the risk of disease progression or death for the primary endpoint of progression-free survival (PFS). However, the reduction corresponded to only a 9-day improvement in median PFS, so the clinical benefit of frontline ramucirumab is debatable.

The Gastrointestinal Cancers Symposium is cosponsored by AGA, the American Society of Clinical Oncology (ASCO), the American Society for Radiation Oncology (ASTRO) and the Society of Surgical Oncology (SSO).

More news from the 2018 Gastrointestinal Cancers Symposium is available at gicasym.org/daily-news.

[email protected]

The 2018 Gastrointestinal Cancers Symposium took place Jan. 18-20, 2018, in San Francisco. During the meeting, investigators presented groundbreaking research designed to improve the diagnosis and treatment of GI cancers. Here are some of the most noteworthy headlines from the 2018 meeting.

Promising Results Using Liquid Biopsy to Improve CRC Early Detection

Researchers in Taiwan developed a screening test for early colorectal cancer (CRC) detection that requires a simple blood draw to assess for circulating tumor cells in the blood. The test demonstrates 88% accuracy to detect all stages of colorectal illness, including precancerous lesions. If validated and made commercially available, this test could be readily integrated into a patient’s routine physical exam, thereby increasing CRC screening compliance.

CELESTIAL Results May Lead to Cabozantinib Approval in Second-Line HCC

The phase III CELESTIAL trial met its primary endpoint by demonstrating a survival advantage with cabozantinib in patients with advanced hepatocellular carcinoma (HCC) that progressed following prior systemic therapy. Other outcomes included improvements in progression-free survival and objective response rate, as well as an acceptable safety profile, thus positioning cabozantinib for potential approval in the second-line setting in HCC.

RAINFALL Meets Primary Endpoint, But Ramucirumab Will Not Be Pursued for a First-Line Indication in G-GEJ Cancer

Results of the global, randomized, double-blind, placebo-controlled, phase III RAINFALL trial established the statistical benefit of ramucirumab, a monoclonal antibody targeting VEGFR-2, added to standard chemotherapy for patients with previously untreated metastatic gastric or gastroesophageal junction (G-GEJ) adenocarcinoma. The findings revealed a significant 25% reduction in the risk of disease progression or death for the primary endpoint of progression-free survival (PFS). However, the reduction corresponded to only a 9-day improvement in median PFS, so the clinical benefit of frontline ramucirumab is debatable.

The Gastrointestinal Cancers Symposium is cosponsored by AGA, the American Society of Clinical Oncology (ASCO), the American Society for Radiation Oncology (ASTRO) and the Society of Surgical Oncology (SSO).

More news from the 2018 Gastrointestinal Cancers Symposium is available at gicasym.org/daily-news.

[email protected]

The 2018 Gastrointestinal Cancers Symposium took place Jan. 18-20, 2018, in San Francisco. During the meeting, investigators presented groundbreaking research designed to improve the diagnosis and treatment of GI cancers. Here are some of the most noteworthy headlines from the 2018 meeting.

Promising Results Using Liquid Biopsy to Improve CRC Early Detection

Researchers in Taiwan developed a screening test for early colorectal cancer (CRC) detection that requires a simple blood draw to assess for circulating tumor cells in the blood. The test demonstrates 88% accuracy to detect all stages of colorectal illness, including precancerous lesions. If validated and made commercially available, this test could be readily integrated into a patient’s routine physical exam, thereby increasing CRC screening compliance.

CELESTIAL Results May Lead to Cabozantinib Approval in Second-Line HCC

The phase III CELESTIAL trial met its primary endpoint by demonstrating a survival advantage with cabozantinib in patients with advanced hepatocellular carcinoma (HCC) that progressed following prior systemic therapy. Other outcomes included improvements in progression-free survival and objective response rate, as well as an acceptable safety profile, thus positioning cabozantinib for potential approval in the second-line setting in HCC.

RAINFALL Meets Primary Endpoint, But Ramucirumab Will Not Be Pursued for a First-Line Indication in G-GEJ Cancer

Results of the global, randomized, double-blind, placebo-controlled, phase III RAINFALL trial established the statistical benefit of ramucirumab, a monoclonal antibody targeting VEGFR-2, added to standard chemotherapy for patients with previously untreated metastatic gastric or gastroesophageal junction (G-GEJ) adenocarcinoma. The findings revealed a significant 25% reduction in the risk of disease progression or death for the primary endpoint of progression-free survival (PFS). However, the reduction corresponded to only a 9-day improvement in median PFS, so the clinical benefit of frontline ramucirumab is debatable.

The Gastrointestinal Cancers Symposium is cosponsored by AGA, the American Society of Clinical Oncology (ASCO), the American Society for Radiation Oncology (ASTRO) and the Society of Surgical Oncology (SSO).

More news from the 2018 Gastrointestinal Cancers Symposium is available at gicasym.org/daily-news.

[email protected]

2017 was a busy year in the AGA Community, our member-only discussion forum. Some of our favorite discussions included challenging clinical cases you shared, remembering your colleague Dr. Marv Sleisenger and first-hand recaps of AGA’s Advocacy Day experiences.

Thank you to everyone who contributed to the conversations in 2017, making the AGA Community a hub for collaboration to ever-expand the field of GI.

Tied for the title of top contributor in 2017 were Dmitriy Kedrin, MD, PhD, of Elliot Hospital in Manchester, N.H., and Sunanda Kane, MD, MSPH, AGAF, of Mayo Clinic in Rochester, MN.

Both are key influencers in the forum, especially with helping colleagues manage challenging patient cases. Learn more about each contributor and why keeping up with the Community is an important part of their regular routines in this brief Q&A.

Thanks for being such an active member of the AGA Community! Why do you contribute?

Dr. Kane: “You are welcome! I contribute because I feel I have helpful suggestions and recommendations for managing difficult patient scenarios as well as for professional issues.”

Dr. Kedrin: “I think it is important for GI docs to be a part of a larger community, stay informed on latest guidelines, research publications and approaches to difficult cases, where more than one road can be taken. I feel that it is a great forum for someone like me, relatively junior gastroenterologist.”

Why do you enjoy being part of the AGA Community?

Kane: “I feel engaged with my colleagues who I otherwise do not see on a regular basis, and get to ‘meet’ new ones.”

Kedrin: “I find the case discussions informative. I learn a great deal about current trends and opinions on important topics in the GI world.”

What do you like to do in your free time?

Kane: “I enjoy cooking and binge-watching Netflix.”

Kedrin: “I bake bread and run a gastroenterology literature review podcast called ‘GI Pearls.’”

What’s your approach to handling a difficult patient case you come across in your practice?

Kane: “I reach out to as many of my colleagues as I think appropriate who may have some experience or thoughts about how to help a difficult patient.”

Kedrin: “I often seek advice of other clinicians, some with more expertise in a particular area. I also go to the literature and try to learn more that way, help expand my differential as well as figure out the best therapeutic approach.”

Was there a conversation in the AGA Community in 2017 that was your favorite?

Kane: “All conversations have merit, none stick out as a favorite.”

Kedrin: “Oh, there are several. I recall a patient case where there were several thought leaders in the field who had a disagreement about the best approach to treatment. The work-life balance conversation [Early Career Group members only] was also very good. I also enjoyed reading about different opinions regarding the values of randomized versus observational trials that happened a while back.”

View the top discussions and contributors from 2017 on the AGA Community homepage, for a limited time.

[email protected]

2017 was a busy year in the AGA Community, our member-only discussion forum. Some of our favorite discussions included challenging clinical cases you shared, remembering your colleague Dr. Marv Sleisenger and first-hand recaps of AGA’s Advocacy Day experiences.

Thank you to everyone who contributed to the conversations in 2017, making the AGA Community a hub for collaboration to ever-expand the field of GI.

Tied for the title of top contributor in 2017 were Dmitriy Kedrin, MD, PhD, of Elliot Hospital in Manchester, N.H., and Sunanda Kane, MD, MSPH, AGAF, of Mayo Clinic in Rochester, MN.

Both are key influencers in the forum, especially with helping colleagues manage challenging patient cases. Learn more about each contributor and why keeping up with the Community is an important part of their regular routines in this brief Q&A.

Thanks for being such an active member of the AGA Community! Why do you contribute?

Dr. Kane: “You are welcome! I contribute because I feel I have helpful suggestions and recommendations for managing difficult patient scenarios as well as for professional issues.”

Dr. Kedrin: “I think it is important for GI docs to be a part of a larger community, stay informed on latest guidelines, research publications and approaches to difficult cases, where more than one road can be taken. I feel that it is a great forum for someone like me, relatively junior gastroenterologist.”

Why do you enjoy being part of the AGA Community?

Kane: “I feel engaged with my colleagues who I otherwise do not see on a regular basis, and get to ‘meet’ new ones.”

Kedrin: “I find the case discussions informative. I learn a great deal about current trends and opinions on important topics in the GI world.”

What do you like to do in your free time?

Kane: “I enjoy cooking and binge-watching Netflix.”

Kedrin: “I bake bread and run a gastroenterology literature review podcast called ‘GI Pearls.’”

What’s your approach to handling a difficult patient case you come across in your practice?

Kane: “I reach out to as many of my colleagues as I think appropriate who may have some experience or thoughts about how to help a difficult patient.”

Kedrin: “I often seek advice of other clinicians, some with more expertise in a particular area. I also go to the literature and try to learn more that way, help expand my differential as well as figure out the best therapeutic approach.”

Was there a conversation in the AGA Community in 2017 that was your favorite?

Kane: “All conversations have merit, none stick out as a favorite.”

Kedrin: “Oh, there are several. I recall a patient case where there were several thought leaders in the field who had a disagreement about the best approach to treatment. The work-life balance conversation [Early Career Group members only] was also very good. I also enjoyed reading about different opinions regarding the values of randomized versus observational trials that happened a while back.”

View the top discussions and contributors from 2017 on the AGA Community homepage, for a limited time.

[email protected]

2017 was a busy year in the AGA Community, our member-only discussion forum. Some of our favorite discussions included challenging clinical cases you shared, remembering your colleague Dr. Marv Sleisenger and first-hand recaps of AGA’s Advocacy Day experiences.

Thank you to everyone who contributed to the conversations in 2017, making the AGA Community a hub for collaboration to ever-expand the field of GI.

Tied for the title of top contributor in 2017 were Dmitriy Kedrin, MD, PhD, of Elliot Hospital in Manchester, N.H., and Sunanda Kane, MD, MSPH, AGAF, of Mayo Clinic in Rochester, MN.

Both are key influencers in the forum, especially with helping colleagues manage challenging patient cases. Learn more about each contributor and why keeping up with the Community is an important part of their regular routines in this brief Q&A.

Thanks for being such an active member of the AGA Community! Why do you contribute?

Dr. Kane: “You are welcome! I contribute because I feel I have helpful suggestions and recommendations for managing difficult patient scenarios as well as for professional issues.”

Dr. Kedrin: “I think it is important for GI docs to be a part of a larger community, stay informed on latest guidelines, research publications and approaches to difficult cases, where more than one road can be taken. I feel that it is a great forum for someone like me, relatively junior gastroenterologist.”

Why do you enjoy being part of the AGA Community?

Kane: “I feel engaged with my colleagues who I otherwise do not see on a regular basis, and get to ‘meet’ new ones.”

Kedrin: “I find the case discussions informative. I learn a great deal about current trends and opinions on important topics in the GI world.”

What do you like to do in your free time?

Kane: “I enjoy cooking and binge-watching Netflix.”

Kedrin: “I bake bread and run a gastroenterology literature review podcast called ‘GI Pearls.’”

What’s your approach to handling a difficult patient case you come across in your practice?

Kane: “I reach out to as many of my colleagues as I think appropriate who may have some experience or thoughts about how to help a difficult patient.”

Kedrin: “I often seek advice of other clinicians, some with more expertise in a particular area. I also go to the literature and try to learn more that way, help expand my differential as well as figure out the best therapeutic approach.”

Was there a conversation in the AGA Community in 2017 that was your favorite?

Kane: “All conversations have merit, none stick out as a favorite.”

Kedrin: “Oh, there are several. I recall a patient case where there were several thought leaders in the field who had a disagreement about the best approach to treatment. The work-life balance conversation [Early Career Group members only] was also very good. I also enjoyed reading about different opinions regarding the values of randomized versus observational trials that happened a while back.”

View the top discussions and contributors from 2017 on the AGA Community homepage, for a limited time.

[email protected]