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Women, Apply for Leadership Training Grant
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.
Call from SVS and American Venous Forum
The SVS and American Venous Forum seek to update their joint clinical practice guidelines on the care of patients with varicose veins and associated chronic venous diseases (pdf of full text here). This update will address new research and advances in care since the original guidelines were published in 2011.
The SVS Document Oversight Committee seeks current SVS members with significant relevant practice and research experience to participate. All interested members must complete a conflict of interest disclosure for 2018-2019 to be considered. The SVS requires each volunteer to disclose all relevant financial relationships with commercial interests within the past 12 months. Please indicate your interest here by March 1.
The SVS and American Venous Forum seek to update their joint clinical practice guidelines on the care of patients with varicose veins and associated chronic venous diseases (pdf of full text here). This update will address new research and advances in care since the original guidelines were published in 2011.
The SVS Document Oversight Committee seeks current SVS members with significant relevant practice and research experience to participate. All interested members must complete a conflict of interest disclosure for 2018-2019 to be considered. The SVS requires each volunteer to disclose all relevant financial relationships with commercial interests within the past 12 months. Please indicate your interest here by March 1.
The SVS and American Venous Forum seek to update their joint clinical practice guidelines on the care of patients with varicose veins and associated chronic venous diseases (pdf of full text here). This update will address new research and advances in care since the original guidelines were published in 2011.
The SVS Document Oversight Committee seeks current SVS members with significant relevant practice and research experience to participate. All interested members must complete a conflict of interest disclosure for 2018-2019 to be considered. The SVS requires each volunteer to disclose all relevant financial relationships with commercial interests within the past 12 months. Please indicate your interest here by March 1.
Webinar on Medicare Reimbursement is Thursday; Still Time to Avoid ’17 Penalties
The SVS Patient Safety Organization and the SVS Quality and Performance Measures Committee (QPMC) will hold a webinar at 8 p.m. Eastern Standard Time, Thursday, Feb. 15. It will help unravel the new Quality Payment Program (QPP) under Medicare, including what surgeons still can do for 2017 to avoid reimbursement penalties. Learn more here and register here.
The SVS Patient Safety Organization and the SVS Quality and Performance Measures Committee (QPMC) will hold a webinar at 8 p.m. Eastern Standard Time, Thursday, Feb. 15. It will help unravel the new Quality Payment Program (QPP) under Medicare, including what surgeons still can do for 2017 to avoid reimbursement penalties. Learn more here and register here.
The SVS Patient Safety Organization and the SVS Quality and Performance Measures Committee (QPMC) will hold a webinar at 8 p.m. Eastern Standard Time, Thursday, Feb. 15. It will help unravel the new Quality Payment Program (QPP) under Medicare, including what surgeons still can do for 2017 to avoid reimbursement penalties. Learn more here and register here.
How Will You Champion Lung Health in 2018?
Our CHEST Foundation grantees are doing amazing research and community service projects that are paving the way for change and improvements in chest medicine. How will you help champion lung health?
“This award carries great importance to me as a young clinician who is in the early phase of my career. I’m driven by my passion for researching this disease (PAH). This award helps establish me as a strong clinical researcher – where I see my career heading. It also helps us identify those clues that can lead to changing how this disease state is treated. Everything starts with an idea.”
Sandeep Sahay, MD, FCCP
Houston Methodist Hospital – Houston, Texas
CHEST Foundation Research Grant in Pulmonary Arterial Hypertension
Title: Alterations of Estrogen Metabolism in the Development of Portopulmonary Hypertension
“This grant has allowed me to do this project, period. Having support from the CHEST Foundation automatically gives me credibility at my new institution. As I would meet with people to discuss my project, they would see that a big organization is supporting me, and that is the outside validation to show that this must be a useful project. The grant really helps me hit the ground running, and plants the seed to help us do a larger project in the future.”
Drew Harris, MD
Yale University – New Haven, Connecticut
CHEST Foundation Research Grant in Asthma
Title: Utilizing Medical-Legal Partnership to Promote Asthma Health Equity
“I recently completed my MD, and because of this grant, I am able to do a completely independent research study. I’ve also been recently short-listed for a clinical lecturer post at my university...which positions me to be the lead for quantitative imaging should I receive the post. This grant added gravitas to my project, and, without it, I don’t think I would have had as big of a boost.”
Diana Crossley, MBChB
University Hospital Birmingham – Birmingham, England
CHEST Foundation and the Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency
Title: Functional Magnetic Resonance Lung Imaging Using Inhaled Hyperpolarised 129Xenon: A Pilot Study of the Clinical Utility in Alpha One Antitrypsin Deficiency (AATD).
“Because of this grant, we are able to be effective teachers to Haitian pediatricians, so they can more effectively intervene and save childrens’ lives. We are able to translate these critical care materials into French and provide the best opportunity for learning to our colleagues there.”
Adam Silverman, MD
Connecticut Children’s Medical Center – Hartford, Connecticut
CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP
Title: Haitian Pediatric Critical Care Collaborative Training Course
The CHEST Foundation is accepting grant applications now until March 31 in the following areas:
• CHEST Foundation Research Grant in Lung Cancer – $50,000 - $100,000 2-year grant*
• CHEST Foundation Research Grant in Asthma - $15,000 - $30,000 1-year grant*
• CHEST Foundation Research Grant in Pulmonary Arterial Hypertension - $25,000 - $50,000 1-year grant*
• CHEST Foundation and the Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency - $25,000 1-year grant
• CHEST Foundation Research Grant in Pulmonary Fibrosis – $50,000 1-year grant
• CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease – $50,000 1-year grant
• CHEST Foundation Research Grant in Venous Thromboembolism - $15,000 – $30,000 1-year grant*
• CHEST Foundation Research Grant in Nontuberculous Mycobacteria Disease - $30,000 1-year grant
• CHEST Foundation Research Grant in Women’s Lung Health - $10,000 1-year grant
• CHEST Foundation Research Grant in Cystic Fibrosis – $15,000 – $30,000 1-year grant
• CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP - $2,500- $15,000 1-year grant
*Amount contingent on funding.
Go to chestfoundation.org/grants to apply now.
Our CHEST Foundation grantees are doing amazing research and community service projects that are paving the way for change and improvements in chest medicine. How will you help champion lung health?
“This award carries great importance to me as a young clinician who is in the early phase of my career. I’m driven by my passion for researching this disease (PAH). This award helps establish me as a strong clinical researcher – where I see my career heading. It also helps us identify those clues that can lead to changing how this disease state is treated. Everything starts with an idea.”
Sandeep Sahay, MD, FCCP
Houston Methodist Hospital – Houston, Texas
CHEST Foundation Research Grant in Pulmonary Arterial Hypertension
Title: Alterations of Estrogen Metabolism in the Development of Portopulmonary Hypertension
“This grant has allowed me to do this project, period. Having support from the CHEST Foundation automatically gives me credibility at my new institution. As I would meet with people to discuss my project, they would see that a big organization is supporting me, and that is the outside validation to show that this must be a useful project. The grant really helps me hit the ground running, and plants the seed to help us do a larger project in the future.”
Drew Harris, MD
Yale University – New Haven, Connecticut
CHEST Foundation Research Grant in Asthma
Title: Utilizing Medical-Legal Partnership to Promote Asthma Health Equity
“I recently completed my MD, and because of this grant, I am able to do a completely independent research study. I’ve also been recently short-listed for a clinical lecturer post at my university...which positions me to be the lead for quantitative imaging should I receive the post. This grant added gravitas to my project, and, without it, I don’t think I would have had as big of a boost.”
Diana Crossley, MBChB
University Hospital Birmingham – Birmingham, England
CHEST Foundation and the Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency
Title: Functional Magnetic Resonance Lung Imaging Using Inhaled Hyperpolarised 129Xenon: A Pilot Study of the Clinical Utility in Alpha One Antitrypsin Deficiency (AATD).
“Because of this grant, we are able to be effective teachers to Haitian pediatricians, so they can more effectively intervene and save childrens’ lives. We are able to translate these critical care materials into French and provide the best opportunity for learning to our colleagues there.”
Adam Silverman, MD
Connecticut Children’s Medical Center – Hartford, Connecticut
CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP
Title: Haitian Pediatric Critical Care Collaborative Training Course
The CHEST Foundation is accepting grant applications now until March 31 in the following areas:
• CHEST Foundation Research Grant in Lung Cancer – $50,000 - $100,000 2-year grant*
• CHEST Foundation Research Grant in Asthma - $15,000 - $30,000 1-year grant*
• CHEST Foundation Research Grant in Pulmonary Arterial Hypertension - $25,000 - $50,000 1-year grant*
• CHEST Foundation and the Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency - $25,000 1-year grant
• CHEST Foundation Research Grant in Pulmonary Fibrosis – $50,000 1-year grant
• CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease – $50,000 1-year grant
• CHEST Foundation Research Grant in Venous Thromboembolism - $15,000 – $30,000 1-year grant*
• CHEST Foundation Research Grant in Nontuberculous Mycobacteria Disease - $30,000 1-year grant
• CHEST Foundation Research Grant in Women’s Lung Health - $10,000 1-year grant
• CHEST Foundation Research Grant in Cystic Fibrosis – $15,000 – $30,000 1-year grant
• CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP - $2,500- $15,000 1-year grant
*Amount contingent on funding.
Go to chestfoundation.org/grants to apply now.
Our CHEST Foundation grantees are doing amazing research and community service projects that are paving the way for change and improvements in chest medicine. How will you help champion lung health?
“This award carries great importance to me as a young clinician who is in the early phase of my career. I’m driven by my passion for researching this disease (PAH). This award helps establish me as a strong clinical researcher – where I see my career heading. It also helps us identify those clues that can lead to changing how this disease state is treated. Everything starts with an idea.”
Sandeep Sahay, MD, FCCP
Houston Methodist Hospital – Houston, Texas
CHEST Foundation Research Grant in Pulmonary Arterial Hypertension
Title: Alterations of Estrogen Metabolism in the Development of Portopulmonary Hypertension
“This grant has allowed me to do this project, period. Having support from the CHEST Foundation automatically gives me credibility at my new institution. As I would meet with people to discuss my project, they would see that a big organization is supporting me, and that is the outside validation to show that this must be a useful project. The grant really helps me hit the ground running, and plants the seed to help us do a larger project in the future.”
Drew Harris, MD
Yale University – New Haven, Connecticut
CHEST Foundation Research Grant in Asthma
Title: Utilizing Medical-Legal Partnership to Promote Asthma Health Equity
“I recently completed my MD, and because of this grant, I am able to do a completely independent research study. I’ve also been recently short-listed for a clinical lecturer post at my university...which positions me to be the lead for quantitative imaging should I receive the post. This grant added gravitas to my project, and, without it, I don’t think I would have had as big of a boost.”
Diana Crossley, MBChB
University Hospital Birmingham – Birmingham, England
CHEST Foundation and the Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency
Title: Functional Magnetic Resonance Lung Imaging Using Inhaled Hyperpolarised 129Xenon: A Pilot Study of the Clinical Utility in Alpha One Antitrypsin Deficiency (AATD).
“Because of this grant, we are able to be effective teachers to Haitian pediatricians, so they can more effectively intervene and save childrens’ lives. We are able to translate these critical care materials into French and provide the best opportunity for learning to our colleagues there.”
Adam Silverman, MD
Connecticut Children’s Medical Center – Hartford, Connecticut
CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP
Title: Haitian Pediatric Critical Care Collaborative Training Course
The CHEST Foundation is accepting grant applications now until March 31 in the following areas:
• CHEST Foundation Research Grant in Lung Cancer – $50,000 - $100,000 2-year grant*
• CHEST Foundation Research Grant in Asthma - $15,000 - $30,000 1-year grant*
• CHEST Foundation Research Grant in Pulmonary Arterial Hypertension - $25,000 - $50,000 1-year grant*
• CHEST Foundation and the Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency - $25,000 1-year grant
• CHEST Foundation Research Grant in Pulmonary Fibrosis – $50,000 1-year grant
• CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease – $50,000 1-year grant
• CHEST Foundation Research Grant in Venous Thromboembolism - $15,000 – $30,000 1-year grant*
• CHEST Foundation Research Grant in Nontuberculous Mycobacteria Disease - $30,000 1-year grant
• CHEST Foundation Research Grant in Women’s Lung Health - $10,000 1-year grant
• CHEST Foundation Research Grant in Cystic Fibrosis – $15,000 – $30,000 1-year grant
• CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP - $2,500- $15,000 1-year grant
*Amount contingent on funding.
Go to chestfoundation.org/grants to apply now.
Meet Our CHEST President-Designate
Stephanie M. Levine, MD, FCCP, is an expert in lung transplantation, pulmonary and critical care issues in pregnancy and women’s lung health, and eosinophilic lung disorders. She is a Professor of Medicine in the Division of Pulmonary Diseases and Critical Care Medicine at the University of Texas Health Science Center in San Antonio, Texas; the Program Director of the Pulmonary and Critical Care Fellowship at the University of Texas Health Science Center; and the Director of the Medical Intensive Care Unit and Bronchoscopy Laboratory at the University Hospital. She also is a staff physician at the Audie Murphy Veteran Administration Hospital. Dr. Levine has authored or co-authored over 270 manuscripts, chapters, reviews, editorials, and abstracts, primarily in her major field of interest, lung transplantation. She has been Editor of both Critical Care SEEK and Pulmonary SEEK. 
Stephanie M. Levine, MD, FCCP, is an expert in lung transplantation, pulmonary and critical care issues in pregnancy and women’s lung health, and eosinophilic lung disorders. She is a Professor of Medicine in the Division of Pulmonary Diseases and Critical Care Medicine at the University of Texas Health Science Center in San Antonio, Texas; the Program Director of the Pulmonary and Critical Care Fellowship at the University of Texas Health Science Center; and the Director of the Medical Intensive Care Unit and Bronchoscopy Laboratory at the University Hospital. She also is a staff physician at the Audie Murphy Veteran Administration Hospital. Dr. Levine has authored or co-authored over 270 manuscripts, chapters, reviews, editorials, and abstracts, primarily in her major field of interest, lung transplantation. She has been Editor of both Critical Care SEEK and Pulmonary SEEK.
Stephanie M. Levine, MD, FCCP, is an expert in lung transplantation, pulmonary and critical care issues in pregnancy and women’s lung health, and eosinophilic lung disorders. She is a Professor of Medicine in the Division of Pulmonary Diseases and Critical Care Medicine at the University of Texas Health Science Center in San Antonio, Texas; the Program Director of the Pulmonary and Critical Care Fellowship at the University of Texas Health Science Center; and the Director of the Medical Intensive Care Unit and Bronchoscopy Laboratory at the University Hospital. She also is a staff physician at the Audie Murphy Veteran Administration Hospital. Dr. Levine has authored or co-authored over 270 manuscripts, chapters, reviews, editorials, and abstracts, primarily in her major field of interest, lung transplantation. She has been Editor of both Critical Care SEEK and Pulmonary SEEK.
President’s Report
As I sit here and write this article, it is hard to fathom that a quarter of my year as the President of CHEST has passed by. Thanks again for this incredibly humbling opportunity to serve as your President.
I hope many who read this were able to get to Toronto and experience CHEST 2017. Special thanks to our Program Chair, Peter Mazzone, and to his Co-Chair Diane Lougheed from the Canadian Thoracic Society; the Scientific Program Committee; our excellent and committed CHEST 2017 faculty, who give their valuable time to ensure we are delivering the best clinical education possible; and our incredibly talented CHEST staff for all their work to make this meeting a reality.
What a great opportunity to learn and stay up to date while exposed to such meaningful content from so many outstanding clinical educators in so many traditional and innovative ways. For those who were able to be there, I hope you were able to experience the value of learning in a highly interactive setting while taking the opportunity to build and nurture old and new friendships and relationships.
As we move forward, there is so much going on:
1. The Editor in Chief Search Task Force, under the leadership of Dr.. David Gutterman and Nicki Augustyn, is hard at work with their diverse and talented colleagues on this critically important task.
2. The Scientific Program Committee, under Dr. David Schulman’s direction, is hard at work building October’s CHEST 2018 in San Antonio. It is so exciting to watch this group plan and create, in new and innovative ways, the content for this meeting to be held October 6-10.
3. By the publication date of this article, your Board of Regents most likely will have put the finishing touches, under the leadership of Jenny Nemkovich, our Chief of Staff, on our next 5-year strategic plan.
4. The Board of Regents is also moving forward with a uniform, business-like process and approach in delivering international education offerings and meeting opportunities. Special thanks to Bob Musacchio, our COO and the SVP of Strategy and Innovation, Sue Reimbold, wearing her hat of Market Growth; and Chad Jackson, VP of Innovation and Development, for their direction in this area.
5. Thanks to the Diversity/Inclusion Task Force for their continued work to ensure that the principles of diversity of thought and inclusion permeate all of our conversations and work on the volunteer and professional sides of CHEST.
6. Thanks also to our Training and Transitions Committee and their leadership, Drs. Gabe Bosslet and Matt Miles, and the support of Dr. Richard Irwin and our CHEST® journal for the introduction of the CHEST Teaching, Education, and Career Hub in the journal, which made its debut in January.
7. Also, emphasizing the critical importance of relationships, thanks to our colleagues and partners with so many sister societies with whom we are working closely to help advance the practice of chest medicine. I am confident that we are building better relationships built on common goals, transparency, communication, and trust than we have in many years.
8. Last, and certainly not least, one of the jobs of President I am most looking forward to is serving on the Board of Trustees of the CHEST Foundation as an ex officio member. Having served on this Board for about 10 years, I am so glad to be joining my CF family once again. What an amazing group of volunteers, leaders, and staff serving CHEST and our patients in such amazing ways.
These are but a few of so many things that are transpiring at CHEST. People have asked me if it is intimidating to take on this responsibility. With the support of such diversely talented leaders in our Presidential line; an incredibly mature and engaged BOR; and a CEO, senior leadership, and diverse and talented staff that we have at CHEST, all characterized by incredible intellect and energy, it is pretty easy to be just another member of a great team.
Thanks again for your unwavering support of CHEST and our mission.
As I sit here and write this article, it is hard to fathom that a quarter of my year as the President of CHEST has passed by. Thanks again for this incredibly humbling opportunity to serve as your President.
I hope many who read this were able to get to Toronto and experience CHEST 2017. Special thanks to our Program Chair, Peter Mazzone, and to his Co-Chair Diane Lougheed from the Canadian Thoracic Society; the Scientific Program Committee; our excellent and committed CHEST 2017 faculty, who give their valuable time to ensure we are delivering the best clinical education possible; and our incredibly talented CHEST staff for all their work to make this meeting a reality.
What a great opportunity to learn and stay up to date while exposed to such meaningful content from so many outstanding clinical educators in so many traditional and innovative ways. For those who were able to be there, I hope you were able to experience the value of learning in a highly interactive setting while taking the opportunity to build and nurture old and new friendships and relationships.
As we move forward, there is so much going on:
1. The Editor in Chief Search Task Force, under the leadership of Dr.. David Gutterman and Nicki Augustyn, is hard at work with their diverse and talented colleagues on this critically important task.
2. The Scientific Program Committee, under Dr. David Schulman’s direction, is hard at work building October’s CHEST 2018 in San Antonio. It is so exciting to watch this group plan and create, in new and innovative ways, the content for this meeting to be held October 6-10.
3. By the publication date of this article, your Board of Regents most likely will have put the finishing touches, under the leadership of Jenny Nemkovich, our Chief of Staff, on our next 5-year strategic plan.
4. The Board of Regents is also moving forward with a uniform, business-like process and approach in delivering international education offerings and meeting opportunities. Special thanks to Bob Musacchio, our COO and the SVP of Strategy and Innovation, Sue Reimbold, wearing her hat of Market Growth; and Chad Jackson, VP of Innovation and Development, for their direction in this area.
5. Thanks to the Diversity/Inclusion Task Force for their continued work to ensure that the principles of diversity of thought and inclusion permeate all of our conversations and work on the volunteer and professional sides of CHEST.
6. Thanks also to our Training and Transitions Committee and their leadership, Drs. Gabe Bosslet and Matt Miles, and the support of Dr. Richard Irwin and our CHEST® journal for the introduction of the CHEST Teaching, Education, and Career Hub in the journal, which made its debut in January.
7. Also, emphasizing the critical importance of relationships, thanks to our colleagues and partners with so many sister societies with whom we are working closely to help advance the practice of chest medicine. I am confident that we are building better relationships built on common goals, transparency, communication, and trust than we have in many years.
8. Last, and certainly not least, one of the jobs of President I am most looking forward to is serving on the Board of Trustees of the CHEST Foundation as an ex officio member. Having served on this Board for about 10 years, I am so glad to be joining my CF family once again. What an amazing group of volunteers, leaders, and staff serving CHEST and our patients in such amazing ways.
These are but a few of so many things that are transpiring at CHEST. People have asked me if it is intimidating to take on this responsibility. With the support of such diversely talented leaders in our Presidential line; an incredibly mature and engaged BOR; and a CEO, senior leadership, and diverse and talented staff that we have at CHEST, all characterized by incredible intellect and energy, it is pretty easy to be just another member of a great team.
Thanks again for your unwavering support of CHEST and our mission.
As I sit here and write this article, it is hard to fathom that a quarter of my year as the President of CHEST has passed by. Thanks again for this incredibly humbling opportunity to serve as your President.
I hope many who read this were able to get to Toronto and experience CHEST 2017. Special thanks to our Program Chair, Peter Mazzone, and to his Co-Chair Diane Lougheed from the Canadian Thoracic Society; the Scientific Program Committee; our excellent and committed CHEST 2017 faculty, who give their valuable time to ensure we are delivering the best clinical education possible; and our incredibly talented CHEST staff for all their work to make this meeting a reality.
What a great opportunity to learn and stay up to date while exposed to such meaningful content from so many outstanding clinical educators in so many traditional and innovative ways. For those who were able to be there, I hope you were able to experience the value of learning in a highly interactive setting while taking the opportunity to build and nurture old and new friendships and relationships.
As we move forward, there is so much going on:
1. The Editor in Chief Search Task Force, under the leadership of Dr.. David Gutterman and Nicki Augustyn, is hard at work with their diverse and talented colleagues on this critically important task.
2. The Scientific Program Committee, under Dr. David Schulman’s direction, is hard at work building October’s CHEST 2018 in San Antonio. It is so exciting to watch this group plan and create, in new and innovative ways, the content for this meeting to be held October 6-10.
3. By the publication date of this article, your Board of Regents most likely will have put the finishing touches, under the leadership of Jenny Nemkovich, our Chief of Staff, on our next 5-year strategic plan.
4. The Board of Regents is also moving forward with a uniform, business-like process and approach in delivering international education offerings and meeting opportunities. Special thanks to Bob Musacchio, our COO and the SVP of Strategy and Innovation, Sue Reimbold, wearing her hat of Market Growth; and Chad Jackson, VP of Innovation and Development, for their direction in this area.
5. Thanks to the Diversity/Inclusion Task Force for their continued work to ensure that the principles of diversity of thought and inclusion permeate all of our conversations and work on the volunteer and professional sides of CHEST.
6. Thanks also to our Training and Transitions Committee and their leadership, Drs. Gabe Bosslet and Matt Miles, and the support of Dr. Richard Irwin and our CHEST® journal for the introduction of the CHEST Teaching, Education, and Career Hub in the journal, which made its debut in January.
7. Also, emphasizing the critical importance of relationships, thanks to our colleagues and partners with so many sister societies with whom we are working closely to help advance the practice of chest medicine. I am confident that we are building better relationships built on common goals, transparency, communication, and trust than we have in many years.
8. Last, and certainly not least, one of the jobs of President I am most looking forward to is serving on the Board of Trustees of the CHEST Foundation as an ex officio member. Having served on this Board for about 10 years, I am so glad to be joining my CF family once again. What an amazing group of volunteers, leaders, and staff serving CHEST and our patients in such amazing ways.
These are but a few of so many things that are transpiring at CHEST. People have asked me if it is intimidating to take on this responsibility. With the support of such diversely talented leaders in our Presidential line; an incredibly mature and engaged BOR; and a CEO, senior leadership, and diverse and talented staff that we have at CHEST, all characterized by incredible intellect and energy, it is pretty easy to be just another member of a great team.
Thanks again for your unwavering support of CHEST and our mission.
Adult bronchiectasis, asthma therapy, frailty in ILD
Clinical Research
New guidelines for adult bronchiectasis
Clinically significant bronchiectasis is a combination of radiologic bronchial dilatation with clinical symptoms. Guidelines on management of adult bronchiectasis were recently published (Eur Respir J. 2017; Sep 10;50[3]).
For all adult patients with clinically significant bronchiectasis, the guidelines suggest standardized minimum testing with differential blood count, serum immunoglobulins, and testing for allergic bronchopulmonary aspergillosis with any further workup on an individual basis. Annual sputum surveillance is suggested for clinically stable adult patients; however, the evidence for this recommendation came from studies done on patients with cystic fibrosis.
Inhaled bronchodilators are suggested as the first-line treatment in symptomatic patients. Long-term antibiotics (greater than 3 months) are recommended in patients with greater than 3 exacerbations/year after optimizing airway clearance and disease-specific treatment. Pseudomonas aeruginosa infections are to be treated with inhaled antibiotics (colistin or gentamicin) (Charles SH, et al. Am J Respir Crit Care Med. 2014;189[8]975; Murray P, et al. Am J Respir Crit Care Med. 2011;183[4]:491; and nonpseudomonal infections are to be treated with macrolides (Conroy W, et al. Lancet. 2012;380[9842]:660; Altenburg J, et al. JAMA. 2013;309[12];1251), although interchangeable for intolerance. Sputum cultured early will guide therapy among poor responders. Long-term mucolytic agents are suggested in appropriate tolerating patients. Pulmonary rehabilitation for 6-8 weeks is strongly recommended in adult bronchiectasis with impaired exercise capacity. Surgical interventions for bronchiectasis are reserved for a small group of patients who have localized disease and high exacerbation rates despite maximal medical therapy. Inhaled corticosteroids are suggested not to be used in adult bronchiectasis. Guidelines recommend against the use of statins and recombinant human DNase as it increases exacerbations (Chest. 1998;113[5]:1329. The task force acknowledged the low quality of evidence for their recommendations requiring more research in the field of adult bronchiectasis.
Bharat Bajantri, MD
Fellow-in-Training Member
Airways Disorders
ICS/LABA combo therapy: black box warning removed
Publication of the Salmeterol Multicenter Asthma Research Trial (SMART) in 2006 caused panic among asthmatics and the physicians who treat them (Nelson et al. Chest. 2006;129[1]:15). The study suggested that the long-acting beta-2-agonist (LABA) salmeterol leads to an increased risk of asthma/respiratory-related deaths compared with placebo. This finding was more pronounced in the African American subpopulation. The study left many questions unanswered, including whether or not this risk is present when LABA therapy is combined with inhaled corticosteroids (ICS) (O’Byrne. Chest. 2006;129[1]:3). Subsequent meta-analyses confirmed the increased risk with LABA monotherapy but not with LABA/ICS (Salpeter et al. Ann Inter Med. 2006;144[12]: 904; Jaeschke et al. Am J Respir Crit Care Med. 2008;178[10]:1009). Still, a black box warning relating LABA to asthma-related death was applied to LABA/ICS products.
In 2011, the Food and Drug Administration (FDA) mandated large, randomized controlled trials be performed for LABA/ICS products to assess safety. These trials were recently completed, showing no difference in asthma-related deaths between LABA/ICS and ICS alone. There were 41, 297 patients across four trials, three included teenagers and adults (age ≥ 12) and one enrolled children (ages 4-11). These studies prompted the FDA to remove the black box warning from salmeterol/fluticasone, formoterol/budesonide, and formoterol/mometasone (https://wwwfdagov/downloads/Drugs/DrugSafety/UCM589997pdf).
Conclusion: Because LABA/ICS therapy is effective for asthma, most pulmonologists continue to prescribe it despite the SMART study results and FDA warning. In a practical sense, we don’t expect the FDA findings to radically change asthma care. Still, it seems we can finally put this question to rest – LABA/ICS is indeed safe for asthmatics. Most physicians will continue to avoid LABA monotherapy, and now that tiotropium is included in the 2017 GINA guidelines, it’s only matter of time before we’re debating whether LABA/long-acting muscarinic antagonist (LAMA) is safe for asthmatics.
Aaron Holley, MD, FCCP
Steering Committee Member
Navitha Ramesh, MD, MBBS
Fellow-in-Training Member
Critical Care
Standardized handoffs in the ICU: room for improvement?
Transitions in patient care are commonplace in the ICU. But handoffs are particularly susceptible to error given the complexity of the patient population. Impacts of less-than-ideal handoffs likely include adverse events, delays in medical diagnosis and treatment, redundant communications, redundant activities such as additional procedures and tests, lower provider and patient satisfaction, higher costs, longer hospital stays, more hospital admissions, and less effective training for health -care providers. Yet, there is great heterogeneity in handoff practiced, and the impact of standardized handoffs in the ICU is unclear (Cochran A. JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5468. [Epub ahead of print]).
In a survey of over 600 academic intensivists, 55% of the participants stated that attending handoffs in the ICU should be standardized, yet, only 13% of those participating in handoffs reported using a standardized process (Lane-Fall M. Crit Care Med. 2016;44[4]690). Clinician miscommunication contributes to an estimated 250,000 deaths in US hospitals per year (Makary M. BMJ. 2016 May 3;353:i2139. doi: 10.1136/bmj.i2139). Standardized handoffs may improve outcomes in the ICU.
In many ICUs that do use standardized sign-out templates, higher clinician satisfaction and fewer unexpected patient events have been reported (Bavare AC. J Healthc Qual. 2015;37[5]:267; Nanchal R. BMJ Qual Saf. 2017;26[12]:987). In a recent randomized controlled trial, use of a standardized handoff curriculum in the ICU resulted in a significant 3% decrease in communication errors, without any change in the duration of the handoff. There also was a clinician-reported improvement in team communication and patient safety; but no changes in ICU length of stay, duration of mechanical ventilation, or number of re-intubations were noted (JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5440. [Epub ahead of print]).
Unfortunately, despite interest in improving patient handoffs, there are few tools to evaluate the effectiveness of different handoff strategies. Most studies report clinician perceptions rather than patient-centered outcomes. Further research is required to examine the optimal approach to handover communication. However, based on the available evidence, a standardized approach to handoffs is likely better than a nonstandardized format.
Shruti Gadre, MD
Fellow-in-Training Member
Christopher Carroll, MD, FCCP
Vice-Chair
Home-Based Mechanical Ventilation and Neuromuscular Disease
Update on two recent FDA-approved therapies for ALS and SMA
Amyotrophic lateral sclerosis (ALS) and spinal muscular atrophy (SMA) are neuromuscular diseases often deteriorating to progressive respiratory failure. Two medications received recent FDA approval and are now available in clinical practice – edaravone for ALS and nusinersen for SMA. We present a balanced overview of the favorable data along with realistic challenges.
Edaravone (Radicava) is the second FDA-approved medication for management of ALS (Riluzole was approved over 20 years ago). Edaravone is a free radical scavenger that reduces oxidative stress, resulting in a protective effect on neuronal cells. It originally showed promise in acute ischemic stroke in Japan and was subsequently studied for ALS. A phase 3 randomized, double-blind placebo-controlled study performed in Japan (Lancet Neurol. 2017;16[7]:505) compared ALSFRS-R scores of a specific subset of ALS patients receiving edaravone vs placebo. This study revealed that patients with early ALS (2 years duration or less) with rapid progression (ALSFRS-R score of 7.5 in 6 months) had a 33% decrease in their degree of progression (reducing their ALSFRS-R score to 5) in the edaravone group. Of note, there was also slowing in the decline of FVC, though not clinically significant. Although the drug was rapidly approved by the FDA, there are obvious challenges that must be recognized. First, it is unclear if patients will discern such a mild degree of slowing of disease progression. In addition, the annual cost may be prohibitive, and lifelong IV administration of the medication for 10 days every month may pose logistical barriers.
Nusinersen (Spinraza) is the first FDA-approved therapeutic medication for spinal muscular atrophy (SMA). SMA is a hereditary neuromuscular disorder leading to degeneration of motor neuron cells and ultimately diffuse muscle weakness and often respiratory failure. Nusinersen is an antisense oligonucleotide that modifies splicing of the SMN-2 gene to increase production of normal, full-length SMN protein, which is deficient in SMA. The ENDEAR trial (Finkel RS, et al. N Engl J Med. 2017;377[18]:1723) was a phase 3, multicenter, double-blind study that enrolled SMA infants to receive nusinersen vs sham. Infants who received treatment had improvements in motor milestones (41% vs 0%) and less permanent-assisted ventilation or death in the nusinersen group (39% vs 68%), a 47% reduction in risk of death. The therapy is safe and tolerable, although there is reported risk of bleeding abnormalities, renal toxicity, and constipation. Administered intrathecally, there is a series of four loading doses, followed by maintenance doses every 4 months – presumably lifelong. Although FDA approved all three SMA subtypes, the eventual impact is uncertain, especially in cases of advanced muscle weakness. There are realistic challenges: the high cost ($125,000/dose), limited longitudinal evidence, technical administration, and limited access.
Pulmonologists should be aware of both medications as new therapeutic options for ALS and SMA; however, the long-term impact is yet to be determined.
Ashraf Elsayegh, MD, FCCP
Steering Committee Member
Won Y. Lee, MD
Steering Committee Member
Interstitial and Diffuse Lung Disease
Frailty as a measure of disease activity in ILD
Frailty is a systemic geriatric syndrome characterized by age-related accumulation of physiologic deficits across several systems with an attenuated response to biological stress. Considering that interstitial lung disease (ILD), particularly, idiopathic pulmonary fibrosis (IPF), is a disease of the aging population, frailty is an emerging area of clinical interest. The biological pathways driving the association of frailty with worse prognosis are complex but hinge on cellular senescence, systemic inflammation, and sarcopenia.
There is a high prevalence of frailty in adults with chronic lung diseases and is associated with worse prognosis. The current literature, though, is mostly derived from patients with COPD. Frailty measured using the 42-item patient-reported frailty index is associated with dyspnea severity in patients with fibrotic ILD (Milne et al. Respirology. 2017;22[4]:728) and systemic sclerosis-associated ILD (Guler et al. Respir Med. 2017 Aug;129:1-7. doi: 10.1016/j.rmed.2017.05.012. Epub 2017 May 25.). The SHARE-Frailty and the Edmonton Frail Scale instruments utilized to measure frailty in the University of Alabama at Birmingham IPF cohort detected a high-percentage of frail and pre-frail patients (Luckhardt et al. Am J Respir Crit Care Med. 2017;195:A7012). However, there are differences in targeted domains between the various frailty instruments, and this could affect the identification of the frailty syndrome in patients.
Frailty as a measure of disease activity and progression is not currently employed in clinical trials for ILD, primarily due to lack of standardized tools for this patient population. Future studies designed to utilize the frailty syndrome as outcome measures may further our understanding of the clinical manifestations and underlying mechanisms, as well as identify potential therapeutic interventions for patients with ILD.
Tejaswini Kulkarni MD, MPH
Fellow-in-Training Member
Clinical Research
New guidelines for adult bronchiectasis
Clinically significant bronchiectasis is a combination of radiologic bronchial dilatation with clinical symptoms. Guidelines on management of adult bronchiectasis were recently published (Eur Respir J. 2017; Sep 10;50[3]).
For all adult patients with clinically significant bronchiectasis, the guidelines suggest standardized minimum testing with differential blood count, serum immunoglobulins, and testing for allergic bronchopulmonary aspergillosis with any further workup on an individual basis. Annual sputum surveillance is suggested for clinically stable adult patients; however, the evidence for this recommendation came from studies done on patients with cystic fibrosis.
Inhaled bronchodilators are suggested as the first-line treatment in symptomatic patients. Long-term antibiotics (greater than 3 months) are recommended in patients with greater than 3 exacerbations/year after optimizing airway clearance and disease-specific treatment. Pseudomonas aeruginosa infections are to be treated with inhaled antibiotics (colistin or gentamicin) (Charles SH, et al. Am J Respir Crit Care Med. 2014;189[8]975; Murray P, et al. Am J Respir Crit Care Med. 2011;183[4]:491; and nonpseudomonal infections are to be treated with macrolides (Conroy W, et al. Lancet. 2012;380[9842]:660; Altenburg J, et al. JAMA. 2013;309[12];1251), although interchangeable for intolerance. Sputum cultured early will guide therapy among poor responders. Long-term mucolytic agents are suggested in appropriate tolerating patients. Pulmonary rehabilitation for 6-8 weeks is strongly recommended in adult bronchiectasis with impaired exercise capacity. Surgical interventions for bronchiectasis are reserved for a small group of patients who have localized disease and high exacerbation rates despite maximal medical therapy. Inhaled corticosteroids are suggested not to be used in adult bronchiectasis. Guidelines recommend against the use of statins and recombinant human DNase as it increases exacerbations (Chest. 1998;113[5]:1329. The task force acknowledged the low quality of evidence for their recommendations requiring more research in the field of adult bronchiectasis.
Bharat Bajantri, MD
Fellow-in-Training Member
Airways Disorders
ICS/LABA combo therapy: black box warning removed
Publication of the Salmeterol Multicenter Asthma Research Trial (SMART) in 2006 caused panic among asthmatics and the physicians who treat them (Nelson et al. Chest. 2006;129[1]:15). The study suggested that the long-acting beta-2-agonist (LABA) salmeterol leads to an increased risk of asthma/respiratory-related deaths compared with placebo. This finding was more pronounced in the African American subpopulation. The study left many questions unanswered, including whether or not this risk is present when LABA therapy is combined with inhaled corticosteroids (ICS) (O’Byrne. Chest. 2006;129[1]:3). Subsequent meta-analyses confirmed the increased risk with LABA monotherapy but not with LABA/ICS (Salpeter et al. Ann Inter Med. 2006;144[12]: 904; Jaeschke et al. Am J Respir Crit Care Med. 2008;178[10]:1009). Still, a black box warning relating LABA to asthma-related death was applied to LABA/ICS products.
In 2011, the Food and Drug Administration (FDA) mandated large, randomized controlled trials be performed for LABA/ICS products to assess safety. These trials were recently completed, showing no difference in asthma-related deaths between LABA/ICS and ICS alone. There were 41, 297 patients across four trials, three included teenagers and adults (age ≥ 12) and one enrolled children (ages 4-11). These studies prompted the FDA to remove the black box warning from salmeterol/fluticasone, formoterol/budesonide, and formoterol/mometasone (https://wwwfdagov/downloads/Drugs/DrugSafety/UCM589997pdf).
Conclusion: Because LABA/ICS therapy is effective for asthma, most pulmonologists continue to prescribe it despite the SMART study results and FDA warning. In a practical sense, we don’t expect the FDA findings to radically change asthma care. Still, it seems we can finally put this question to rest – LABA/ICS is indeed safe for asthmatics. Most physicians will continue to avoid LABA monotherapy, and now that tiotropium is included in the 2017 GINA guidelines, it’s only matter of time before we’re debating whether LABA/long-acting muscarinic antagonist (LAMA) is safe for asthmatics.
Aaron Holley, MD, FCCP
Steering Committee Member
Navitha Ramesh, MD, MBBS
Fellow-in-Training Member
Critical Care
Standardized handoffs in the ICU: room for improvement?
Transitions in patient care are commonplace in the ICU. But handoffs are particularly susceptible to error given the complexity of the patient population. Impacts of less-than-ideal handoffs likely include adverse events, delays in medical diagnosis and treatment, redundant communications, redundant activities such as additional procedures and tests, lower provider and patient satisfaction, higher costs, longer hospital stays, more hospital admissions, and less effective training for health -care providers. Yet, there is great heterogeneity in handoff practiced, and the impact of standardized handoffs in the ICU is unclear (Cochran A. JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5468. [Epub ahead of print]).
In a survey of over 600 academic intensivists, 55% of the participants stated that attending handoffs in the ICU should be standardized, yet, only 13% of those participating in handoffs reported using a standardized process (Lane-Fall M. Crit Care Med. 2016;44[4]690). Clinician miscommunication contributes to an estimated 250,000 deaths in US hospitals per year (Makary M. BMJ. 2016 May 3;353:i2139. doi: 10.1136/bmj.i2139). Standardized handoffs may improve outcomes in the ICU.
In many ICUs that do use standardized sign-out templates, higher clinician satisfaction and fewer unexpected patient events have been reported (Bavare AC. J Healthc Qual. 2015;37[5]:267; Nanchal R. BMJ Qual Saf. 2017;26[12]:987). In a recent randomized controlled trial, use of a standardized handoff curriculum in the ICU resulted in a significant 3% decrease in communication errors, without any change in the duration of the handoff. There also was a clinician-reported improvement in team communication and patient safety; but no changes in ICU length of stay, duration of mechanical ventilation, or number of re-intubations were noted (JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5440. [Epub ahead of print]).
Unfortunately, despite interest in improving patient handoffs, there are few tools to evaluate the effectiveness of different handoff strategies. Most studies report clinician perceptions rather than patient-centered outcomes. Further research is required to examine the optimal approach to handover communication. However, based on the available evidence, a standardized approach to handoffs is likely better than a nonstandardized format.
Shruti Gadre, MD
Fellow-in-Training Member
Christopher Carroll, MD, FCCP
Vice-Chair
Home-Based Mechanical Ventilation and Neuromuscular Disease
Update on two recent FDA-approved therapies for ALS and SMA
Amyotrophic lateral sclerosis (ALS) and spinal muscular atrophy (SMA) are neuromuscular diseases often deteriorating to progressive respiratory failure. Two medications received recent FDA approval and are now available in clinical practice – edaravone for ALS and nusinersen for SMA. We present a balanced overview of the favorable data along with realistic challenges.
Edaravone (Radicava) is the second FDA-approved medication for management of ALS (Riluzole was approved over 20 years ago). Edaravone is a free radical scavenger that reduces oxidative stress, resulting in a protective effect on neuronal cells. It originally showed promise in acute ischemic stroke in Japan and was subsequently studied for ALS. A phase 3 randomized, double-blind placebo-controlled study performed in Japan (Lancet Neurol. 2017;16[7]:505) compared ALSFRS-R scores of a specific subset of ALS patients receiving edaravone vs placebo. This study revealed that patients with early ALS (2 years duration or less) with rapid progression (ALSFRS-R score of 7.5 in 6 months) had a 33% decrease in their degree of progression (reducing their ALSFRS-R score to 5) in the edaravone group. Of note, there was also slowing in the decline of FVC, though not clinically significant. Although the drug was rapidly approved by the FDA, there are obvious challenges that must be recognized. First, it is unclear if patients will discern such a mild degree of slowing of disease progression. In addition, the annual cost may be prohibitive, and lifelong IV administration of the medication for 10 days every month may pose logistical barriers.
Nusinersen (Spinraza) is the first FDA-approved therapeutic medication for spinal muscular atrophy (SMA). SMA is a hereditary neuromuscular disorder leading to degeneration of motor neuron cells and ultimately diffuse muscle weakness and often respiratory failure. Nusinersen is an antisense oligonucleotide that modifies splicing of the SMN-2 gene to increase production of normal, full-length SMN protein, which is deficient in SMA. The ENDEAR trial (Finkel RS, et al. N Engl J Med. 2017;377[18]:1723) was a phase 3, multicenter, double-blind study that enrolled SMA infants to receive nusinersen vs sham. Infants who received treatment had improvements in motor milestones (41% vs 0%) and less permanent-assisted ventilation or death in the nusinersen group (39% vs 68%), a 47% reduction in risk of death. The therapy is safe and tolerable, although there is reported risk of bleeding abnormalities, renal toxicity, and constipation. Administered intrathecally, there is a series of four loading doses, followed by maintenance doses every 4 months – presumably lifelong. Although FDA approved all three SMA subtypes, the eventual impact is uncertain, especially in cases of advanced muscle weakness. There are realistic challenges: the high cost ($125,000/dose), limited longitudinal evidence, technical administration, and limited access.
Pulmonologists should be aware of both medications as new therapeutic options for ALS and SMA; however, the long-term impact is yet to be determined.
Ashraf Elsayegh, MD, FCCP
Steering Committee Member
Won Y. Lee, MD
Steering Committee Member
Interstitial and Diffuse Lung Disease
Frailty as a measure of disease activity in ILD
Frailty is a systemic geriatric syndrome characterized by age-related accumulation of physiologic deficits across several systems with an attenuated response to biological stress. Considering that interstitial lung disease (ILD), particularly, idiopathic pulmonary fibrosis (IPF), is a disease of the aging population, frailty is an emerging area of clinical interest. The biological pathways driving the association of frailty with worse prognosis are complex but hinge on cellular senescence, systemic inflammation, and sarcopenia.
There is a high prevalence of frailty in adults with chronic lung diseases and is associated with worse prognosis. The current literature, though, is mostly derived from patients with COPD. Frailty measured using the 42-item patient-reported frailty index is associated with dyspnea severity in patients with fibrotic ILD (Milne et al. Respirology. 2017;22[4]:728) and systemic sclerosis-associated ILD (Guler et al. Respir Med. 2017 Aug;129:1-7. doi: 10.1016/j.rmed.2017.05.012. Epub 2017 May 25.). The SHARE-Frailty and the Edmonton Frail Scale instruments utilized to measure frailty in the University of Alabama at Birmingham IPF cohort detected a high-percentage of frail and pre-frail patients (Luckhardt et al. Am J Respir Crit Care Med. 2017;195:A7012). However, there are differences in targeted domains between the various frailty instruments, and this could affect the identification of the frailty syndrome in patients.
Frailty as a measure of disease activity and progression is not currently employed in clinical trials for ILD, primarily due to lack of standardized tools for this patient population. Future studies designed to utilize the frailty syndrome as outcome measures may further our understanding of the clinical manifestations and underlying mechanisms, as well as identify potential therapeutic interventions for patients with ILD.
Tejaswini Kulkarni MD, MPH
Fellow-in-Training Member
Clinical Research
New guidelines for adult bronchiectasis
Clinically significant bronchiectasis is a combination of radiologic bronchial dilatation with clinical symptoms. Guidelines on management of adult bronchiectasis were recently published (Eur Respir J. 2017; Sep 10;50[3]).
For all adult patients with clinically significant bronchiectasis, the guidelines suggest standardized minimum testing with differential blood count, serum immunoglobulins, and testing for allergic bronchopulmonary aspergillosis with any further workup on an individual basis. Annual sputum surveillance is suggested for clinically stable adult patients; however, the evidence for this recommendation came from studies done on patients with cystic fibrosis.
Inhaled bronchodilators are suggested as the first-line treatment in symptomatic patients. Long-term antibiotics (greater than 3 months) are recommended in patients with greater than 3 exacerbations/year after optimizing airway clearance and disease-specific treatment. Pseudomonas aeruginosa infections are to be treated with inhaled antibiotics (colistin or gentamicin) (Charles SH, et al. Am J Respir Crit Care Med. 2014;189[8]975; Murray P, et al. Am J Respir Crit Care Med. 2011;183[4]:491; and nonpseudomonal infections are to be treated with macrolides (Conroy W, et al. Lancet. 2012;380[9842]:660; Altenburg J, et al. JAMA. 2013;309[12];1251), although interchangeable for intolerance. Sputum cultured early will guide therapy among poor responders. Long-term mucolytic agents are suggested in appropriate tolerating patients. Pulmonary rehabilitation for 6-8 weeks is strongly recommended in adult bronchiectasis with impaired exercise capacity. Surgical interventions for bronchiectasis are reserved for a small group of patients who have localized disease and high exacerbation rates despite maximal medical therapy. Inhaled corticosteroids are suggested not to be used in adult bronchiectasis. Guidelines recommend against the use of statins and recombinant human DNase as it increases exacerbations (Chest. 1998;113[5]:1329. The task force acknowledged the low quality of evidence for their recommendations requiring more research in the field of adult bronchiectasis.
Bharat Bajantri, MD
Fellow-in-Training Member
Airways Disorders
ICS/LABA combo therapy: black box warning removed
Publication of the Salmeterol Multicenter Asthma Research Trial (SMART) in 2006 caused panic among asthmatics and the physicians who treat them (Nelson et al. Chest. 2006;129[1]:15). The study suggested that the long-acting beta-2-agonist (LABA) salmeterol leads to an increased risk of asthma/respiratory-related deaths compared with placebo. This finding was more pronounced in the African American subpopulation. The study left many questions unanswered, including whether or not this risk is present when LABA therapy is combined with inhaled corticosteroids (ICS) (O’Byrne. Chest. 2006;129[1]:3). Subsequent meta-analyses confirmed the increased risk with LABA monotherapy but not with LABA/ICS (Salpeter et al. Ann Inter Med. 2006;144[12]: 904; Jaeschke et al. Am J Respir Crit Care Med. 2008;178[10]:1009). Still, a black box warning relating LABA to asthma-related death was applied to LABA/ICS products.
In 2011, the Food and Drug Administration (FDA) mandated large, randomized controlled trials be performed for LABA/ICS products to assess safety. These trials were recently completed, showing no difference in asthma-related deaths between LABA/ICS and ICS alone. There were 41, 297 patients across four trials, three included teenagers and adults (age ≥ 12) and one enrolled children (ages 4-11). These studies prompted the FDA to remove the black box warning from salmeterol/fluticasone, formoterol/budesonide, and formoterol/mometasone (https://wwwfdagov/downloads/Drugs/DrugSafety/UCM589997pdf).
Conclusion: Because LABA/ICS therapy is effective for asthma, most pulmonologists continue to prescribe it despite the SMART study results and FDA warning. In a practical sense, we don’t expect the FDA findings to radically change asthma care. Still, it seems we can finally put this question to rest – LABA/ICS is indeed safe for asthmatics. Most physicians will continue to avoid LABA monotherapy, and now that tiotropium is included in the 2017 GINA guidelines, it’s only matter of time before we’re debating whether LABA/long-acting muscarinic antagonist (LAMA) is safe for asthmatics.
Aaron Holley, MD, FCCP
Steering Committee Member
Navitha Ramesh, MD, MBBS
Fellow-in-Training Member
Critical Care
Standardized handoffs in the ICU: room for improvement?
Transitions in patient care are commonplace in the ICU. But handoffs are particularly susceptible to error given the complexity of the patient population. Impacts of less-than-ideal handoffs likely include adverse events, delays in medical diagnosis and treatment, redundant communications, redundant activities such as additional procedures and tests, lower provider and patient satisfaction, higher costs, longer hospital stays, more hospital admissions, and less effective training for health -care providers. Yet, there is great heterogeneity in handoff practiced, and the impact of standardized handoffs in the ICU is unclear (Cochran A. JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5468. [Epub ahead of print]).
In a survey of over 600 academic intensivists, 55% of the participants stated that attending handoffs in the ICU should be standardized, yet, only 13% of those participating in handoffs reported using a standardized process (Lane-Fall M. Crit Care Med. 2016;44[4]690). Clinician miscommunication contributes to an estimated 250,000 deaths in US hospitals per year (Makary M. BMJ. 2016 May 3;353:i2139. doi: 10.1136/bmj.i2139). Standardized handoffs may improve outcomes in the ICU.
In many ICUs that do use standardized sign-out templates, higher clinician satisfaction and fewer unexpected patient events have been reported (Bavare AC. J Healthc Qual. 2015;37[5]:267; Nanchal R. BMJ Qual Saf. 2017;26[12]:987). In a recent randomized controlled trial, use of a standardized handoff curriculum in the ICU resulted in a significant 3% decrease in communication errors, without any change in the duration of the handoff. There also was a clinician-reported improvement in team communication and patient safety; but no changes in ICU length of stay, duration of mechanical ventilation, or number of re-intubations were noted (JAMA Surg. 2018 Jan 3. doi: 10.1001/jamasurg.2017.5440. [Epub ahead of print]).
Unfortunately, despite interest in improving patient handoffs, there are few tools to evaluate the effectiveness of different handoff strategies. Most studies report clinician perceptions rather than patient-centered outcomes. Further research is required to examine the optimal approach to handover communication. However, based on the available evidence, a standardized approach to handoffs is likely better than a nonstandardized format.
Shruti Gadre, MD
Fellow-in-Training Member
Christopher Carroll, MD, FCCP
Vice-Chair
Home-Based Mechanical Ventilation and Neuromuscular Disease
Update on two recent FDA-approved therapies for ALS and SMA
Amyotrophic lateral sclerosis (ALS) and spinal muscular atrophy (SMA) are neuromuscular diseases often deteriorating to progressive respiratory failure. Two medications received recent FDA approval and are now available in clinical practice – edaravone for ALS and nusinersen for SMA. We present a balanced overview of the favorable data along with realistic challenges.
Edaravone (Radicava) is the second FDA-approved medication for management of ALS (Riluzole was approved over 20 years ago). Edaravone is a free radical scavenger that reduces oxidative stress, resulting in a protective effect on neuronal cells. It originally showed promise in acute ischemic stroke in Japan and was subsequently studied for ALS. A phase 3 randomized, double-blind placebo-controlled study performed in Japan (Lancet Neurol. 2017;16[7]:505) compared ALSFRS-R scores of a specific subset of ALS patients receiving edaravone vs placebo. This study revealed that patients with early ALS (2 years duration or less) with rapid progression (ALSFRS-R score of 7.5 in 6 months) had a 33% decrease in their degree of progression (reducing their ALSFRS-R score to 5) in the edaravone group. Of note, there was also slowing in the decline of FVC, though not clinically significant. Although the drug was rapidly approved by the FDA, there are obvious challenges that must be recognized. First, it is unclear if patients will discern such a mild degree of slowing of disease progression. In addition, the annual cost may be prohibitive, and lifelong IV administration of the medication for 10 days every month may pose logistical barriers.
Nusinersen (Spinraza) is the first FDA-approved therapeutic medication for spinal muscular atrophy (SMA). SMA is a hereditary neuromuscular disorder leading to degeneration of motor neuron cells and ultimately diffuse muscle weakness and often respiratory failure. Nusinersen is an antisense oligonucleotide that modifies splicing of the SMN-2 gene to increase production of normal, full-length SMN protein, which is deficient in SMA. The ENDEAR trial (Finkel RS, et al. N Engl J Med. 2017;377[18]:1723) was a phase 3, multicenter, double-blind study that enrolled SMA infants to receive nusinersen vs sham. Infants who received treatment had improvements in motor milestones (41% vs 0%) and less permanent-assisted ventilation or death in the nusinersen group (39% vs 68%), a 47% reduction in risk of death. The therapy is safe and tolerable, although there is reported risk of bleeding abnormalities, renal toxicity, and constipation. Administered intrathecally, there is a series of four loading doses, followed by maintenance doses every 4 months – presumably lifelong. Although FDA approved all three SMA subtypes, the eventual impact is uncertain, especially in cases of advanced muscle weakness. There are realistic challenges: the high cost ($125,000/dose), limited longitudinal evidence, technical administration, and limited access.
Pulmonologists should be aware of both medications as new therapeutic options for ALS and SMA; however, the long-term impact is yet to be determined.
Ashraf Elsayegh, MD, FCCP
Steering Committee Member
Won Y. Lee, MD
Steering Committee Member
Interstitial and Diffuse Lung Disease
Frailty as a measure of disease activity in ILD
Frailty is a systemic geriatric syndrome characterized by age-related accumulation of physiologic deficits across several systems with an attenuated response to biological stress. Considering that interstitial lung disease (ILD), particularly, idiopathic pulmonary fibrosis (IPF), is a disease of the aging population, frailty is an emerging area of clinical interest. The biological pathways driving the association of frailty with worse prognosis are complex but hinge on cellular senescence, systemic inflammation, and sarcopenia.
There is a high prevalence of frailty in adults with chronic lung diseases and is associated with worse prognosis. The current literature, though, is mostly derived from patients with COPD. Frailty measured using the 42-item patient-reported frailty index is associated with dyspnea severity in patients with fibrotic ILD (Milne et al. Respirology. 2017;22[4]:728) and systemic sclerosis-associated ILD (Guler et al. Respir Med. 2017 Aug;129:1-7. doi: 10.1016/j.rmed.2017.05.012. Epub 2017 May 25.). The SHARE-Frailty and the Edmonton Frail Scale instruments utilized to measure frailty in the University of Alabama at Birmingham IPF cohort detected a high-percentage of frail and pre-frail patients (Luckhardt et al. Am J Respir Crit Care Med. 2017;195:A7012). However, there are differences in targeted domains between the various frailty instruments, and this could affect the identification of the frailty syndrome in patients.
Frailty as a measure of disease activity and progression is not currently employed in clinical trials for ILD, primarily due to lack of standardized tools for this patient population. Future studies designed to utilize the frailty syndrome as outcome measures may further our understanding of the clinical manifestations and underlying mechanisms, as well as identify potential therapeutic interventions for patients with ILD.
Tejaswini Kulkarni MD, MPH
Fellow-in-Training Member
Shop the CHEST Store
Have you shopped at the CHEST Store lately? We’ve recently updated our merchandise to include several new items perfect for staff gifts or for yourself. Along with our old standbys, including lab coats and scrubs, we now feature CHEST-branded scarves, knit caps (perfect for winter), and insulated hot and cold drink mugs. And don’t forget, most items are customizable for a small, additional fee. For the more education-inclined, the store also features the best in CHEST print, including CHEST SEEKTM volumes, Coding for Chest Medicine, patient education guides, and much more.
Products can be ordered online, and most items are sold on-site at our live learning and board review courses and at the CHEST Annual Meeting. If you can’t purchase in person, visit the store at chestnet.org/store to stock up.
Have you shopped at the CHEST Store lately? We’ve recently updated our merchandise to include several new items perfect for staff gifts or for yourself. Along with our old standbys, including lab coats and scrubs, we now feature CHEST-branded scarves, knit caps (perfect for winter), and insulated hot and cold drink mugs. And don’t forget, most items are customizable for a small, additional fee. For the more education-inclined, the store also features the best in CHEST print, including CHEST SEEKTM volumes, Coding for Chest Medicine, patient education guides, and much more.
Products can be ordered online, and most items are sold on-site at our live learning and board review courses and at the CHEST Annual Meeting. If you can’t purchase in person, visit the store at chestnet.org/store to stock up.
Have you shopped at the CHEST Store lately? We’ve recently updated our merchandise to include several new items perfect for staff gifts or for yourself. Along with our old standbys, including lab coats and scrubs, we now feature CHEST-branded scarves, knit caps (perfect for winter), and insulated hot and cold drink mugs. And don’t forget, most items are customizable for a small, additional fee. For the more education-inclined, the store also features the best in CHEST print, including CHEST SEEKTM volumes, Coding for Chest Medicine, patient education guides, and much more.
Products can be ordered online, and most items are sold on-site at our live learning and board review courses and at the CHEST Annual Meeting. If you can’t purchase in person, visit the store at chestnet.org/store to stock up.
In Memoriam
CHEST has been informed of the following members’ deaths.
We extend our sincere condolences.
Nagesh V Salian, MD, FCCP (2016)
Ted A Calinog, MD, FCCP (2017)
Azam Ansari, MD (2017)
Arthur E. Schmidt, MD, FCCP (2017)
CHEST has been informed of the following members’ deaths.
We extend our sincere condolences.
Nagesh V Salian, MD, FCCP (2016)
Ted A Calinog, MD, FCCP (2017)
Azam Ansari, MD (2017)
Arthur E. Schmidt, MD, FCCP (2017)
CHEST has been informed of the following members’ deaths.
We extend our sincere condolences.
Nagesh V Salian, MD, FCCP (2016)
Ted A Calinog, MD, FCCP (2017)
Azam Ansari, MD (2017)
Arthur E. Schmidt, MD, FCCP (2017)
This Month in the Journal CHEST® Editor’s Picks
Giants In Chest Medicine Professor Nan-shan Zhong, MD.
By Wei-jie Guan.
Original Research
Long-term Use of Inhaled Corticosteroids in COPD and the Risk of Fracture. By Dr. A. V. Gonzalez, et al.
Cardiac Troponin Values in Patients With Acute Coronary Syndrome and Sleep Apnea: A Pilot Study. By Dr. A. Sánchez-de-la-Torre, et al.
CA-125 in Disease Progression and Treatment of Lymphangioleiomyomatosis. By Dr. C. G. Glasgow, et al.
Evidence-Based Medicine
Cough Due to TB and Other Chronic Infections: CHEST Guideline and Expert Panel Report. By Dr. S. K. Field, et al, on behalf of the CHEST Expert Cough Panel.
Giants In Chest Medicine Professor Nan-shan Zhong, MD.
By Wei-jie Guan.
Original Research
Long-term Use of Inhaled Corticosteroids in COPD and the Risk of Fracture. By Dr. A. V. Gonzalez, et al.
Cardiac Troponin Values in Patients With Acute Coronary Syndrome and Sleep Apnea: A Pilot Study. By Dr. A. Sánchez-de-la-Torre, et al.
CA-125 in Disease Progression and Treatment of Lymphangioleiomyomatosis. By Dr. C. G. Glasgow, et al.
Evidence-Based Medicine
Cough Due to TB and Other Chronic Infections: CHEST Guideline and Expert Panel Report. By Dr. S. K. Field, et al, on behalf of the CHEST Expert Cough Panel.
Giants In Chest Medicine Professor Nan-shan Zhong, MD.
By Wei-jie Guan.
Original Research
Long-term Use of Inhaled Corticosteroids in COPD and the Risk of Fracture. By Dr. A. V. Gonzalez, et al.
Cardiac Troponin Values in Patients With Acute Coronary Syndrome and Sleep Apnea: A Pilot Study. By Dr. A. Sánchez-de-la-Torre, et al.
CA-125 in Disease Progression and Treatment of Lymphangioleiomyomatosis. By Dr. C. G. Glasgow, et al.
Evidence-Based Medicine
Cough Due to TB and Other Chronic Infections: CHEST Guideline and Expert Panel Report. By Dr. S. K. Field, et al, on behalf of the CHEST Expert Cough Panel.