Society News

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.

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.

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.

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.

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.

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

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 SEEK^TM 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 SEEK^TM 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 SEEK^TM 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.

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)

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.

“BLACK PATIENTS PRESENT WITH MORE SEVERE VASCULAR DISEASE AND A GREATER BURDEN OF RISK FACTORS THAN WHITE PATIENTS AT TIME OF MAJOR VASCULAR INTERVENTION.” Journal of Vascular Surgery, February 2018.

African Americans come into the vascular operating room with significant co-morbidities that may explain their more severe level of disease and higher risk factors, report researchers who reviewed 76,000 vascular cases for their report in the February edition of the Journal of Vascular Surgery.

This study drills deeper into the severity of vascular disease in African Americans, adding more fuel to the discussion of health disparities between racial and ethnic groups explored by the American Medical Association, which found that minorities are less likely to receive routine medical care and face higher rates of morbidity and mortality than non-minorities.

Invited commentator Dr. William R. Flinn found the study so profound he stated, “It should be read by every vascular surgeon, in fact, by every physician.”

Researchers have observed similar outcomes in vascular surgical procedures, but determining the cause of these disparities is difficult, since databases do not provide detail on disease severity.

For this report, a multi-institutional team of vascular surgeons led by vascular surgeon Dr. Marc Schermerhorn from Beth Israel Deaconess Medical Center took direct aim at this problem. Using de-identified data from the Vascular Quality Initiative gathered between 2009 and 2014, they found that compared to white patients, black patients were:

• Younger
• More likely to smoke
• More often diagnosed with insulin-dependent diabetes, hypertension, congestive heart failure and end-stage renal disease
• Less often medicated with statins
• Less often insured

Black patients also were sicker at the time of surgery. Compared with whites, black patients had more severe:

• Carotid disease (36% versus 31% symptomatic lesions)
• AAA (27% versus 16% symptoms/rupture, and more iliac aneurysm)
• PAD (73% versus 62% critical limb ischemia)

Furthermore, black patients were less likely to be discharged on aspirin and statin therapy after treatment for AAA and PAD than whites.

The authors note that their study is limited by factors common to all database studies including missing data, variability in definitions, and no way to adjust for socio-economic factors, compliance, family support, hospital type and timing of referral.

“Even in hospitals invested in quality improvement – as evidenced by participation in the VQI – black patients present with more advanced disease and more comorbidities compared with whites, despite presenting at a younger age,” states first author Dr. Peter Soden.  “And these disparities were uniform across the spectrum of vascular disease, including carotids, AAA and PAD.” 

The increase in presenting risk factors, along with disparity in medical management, offers clues as to the well-reported worse outcomes for black patients after major vascular procedures.

“The majority of the disparities highlighted in this manuscript are not from biologic differences, but instead from social, economic and health care delivery factors,” noted Dr. Flinn. “What this most clearly suggests is that there are untold numbers of black [patients] throughout the country with undiagnosed and untreated carotid disease, abdominal aortic aneurysm and PAD (and hypertension, and diabetes, and chronic kidney disease) because they do not have equitable access to health care in the United States in the 21^st century.

“The vascular community has a unique opportunity to contribute to the health care debate in this country,” he added. “I hope we have both the scientific rigor and the political courage to pursue it aggressively.”

To download the complete article (freely available Jan.  22 - March 31), click: vsweb.org/JVS-Severe.

“BLACK PATIENTS PRESENT WITH MORE SEVERE VASCULAR DISEASE AND A GREATER BURDEN OF RISK FACTORS THAN WHITE PATIENTS AT TIME OF MAJOR VASCULAR INTERVENTION.” Journal of Vascular Surgery, February 2018.

African Americans come into the vascular operating room with significant co-morbidities that may explain their more severe level of disease and higher risk factors, report researchers who reviewed 76,000 vascular cases for their report in the February edition of the Journal of Vascular Surgery.

This study drills deeper into the severity of vascular disease in African Americans, adding more fuel to the discussion of health disparities between racial and ethnic groups explored by the American Medical Association, which found that minorities are less likely to receive routine medical care and face higher rates of morbidity and mortality than non-minorities.

Invited commentator Dr. William R. Flinn found the study so profound he stated, “It should be read by every vascular surgeon, in fact, by every physician.”

Researchers have observed similar outcomes in vascular surgical procedures, but determining the cause of these disparities is difficult, since databases do not provide detail on disease severity.

For this report, a multi-institutional team of vascular surgeons led by vascular surgeon Dr. Marc Schermerhorn from Beth Israel Deaconess Medical Center took direct aim at this problem. Using de-identified data from the Vascular Quality Initiative gathered between 2009 and 2014, they found that compared to white patients, black patients were:

• Younger
• More likely to smoke
• More often diagnosed with insulin-dependent diabetes, hypertension, congestive heart failure and end-stage renal disease
• Less often medicated with statins
• Less often insured

Black patients also were sicker at the time of surgery. Compared with whites, black patients had more severe:

• Carotid disease (36% versus 31% symptomatic lesions)
• AAA (27% versus 16% symptoms/rupture, and more iliac aneurysm)
• PAD (73% versus 62% critical limb ischemia)

Furthermore, black patients were less likely to be discharged on aspirin and statin therapy after treatment for AAA and PAD than whites.

The authors note that their study is limited by factors common to all database studies including missing data, variability in definitions, and no way to adjust for socio-economic factors, compliance, family support, hospital type and timing of referral.

“Even in hospitals invested in quality improvement – as evidenced by participation in the VQI – black patients present with more advanced disease and more comorbidities compared with whites, despite presenting at a younger age,” states first author Dr. Peter Soden.  “And these disparities were uniform across the spectrum of vascular disease, including carotids, AAA and PAD.” 

The increase in presenting risk factors, along with disparity in medical management, offers clues as to the well-reported worse outcomes for black patients after major vascular procedures.

“The majority of the disparities highlighted in this manuscript are not from biologic differences, but instead from social, economic and health care delivery factors,” noted Dr. Flinn. “What this most clearly suggests is that there are untold numbers of black [patients] throughout the country with undiagnosed and untreated carotid disease, abdominal aortic aneurysm and PAD (and hypertension, and diabetes, and chronic kidney disease) because they do not have equitable access to health care in the United States in the 21^st century.

“The vascular community has a unique opportunity to contribute to the health care debate in this country,” he added. “I hope we have both the scientific rigor and the political courage to pursue it aggressively.”

To download the complete article (freely available Jan.  22 - March 31), click: vsweb.org/JVS-Severe.

“BLACK PATIENTS PRESENT WITH MORE SEVERE VASCULAR DISEASE AND A GREATER BURDEN OF RISK FACTORS THAN WHITE PATIENTS AT TIME OF MAJOR VASCULAR INTERVENTION.” Journal of Vascular Surgery, February 2018.

African Americans come into the vascular operating room with significant co-morbidities that may explain their more severe level of disease and higher risk factors, report researchers who reviewed 76,000 vascular cases for their report in the February edition of the Journal of Vascular Surgery.

This study drills deeper into the severity of vascular disease in African Americans, adding more fuel to the discussion of health disparities between racial and ethnic groups explored by the American Medical Association, which found that minorities are less likely to receive routine medical care and face higher rates of morbidity and mortality than non-minorities.

Invited commentator Dr. William R. Flinn found the study so profound he stated, “It should be read by every vascular surgeon, in fact, by every physician.”

Researchers have observed similar outcomes in vascular surgical procedures, but determining the cause of these disparities is difficult, since databases do not provide detail on disease severity.

For this report, a multi-institutional team of vascular surgeons led by vascular surgeon Dr. Marc Schermerhorn from Beth Israel Deaconess Medical Center took direct aim at this problem. Using de-identified data from the Vascular Quality Initiative gathered between 2009 and 2014, they found that compared to white patients, black patients were:

• Younger
• More likely to smoke
• More often diagnosed with insulin-dependent diabetes, hypertension, congestive heart failure and end-stage renal disease
• Less often medicated with statins
• Less often insured

Black patients also were sicker at the time of surgery. Compared with whites, black patients had more severe:

• Carotid disease (36% versus 31% symptomatic lesions)
• AAA (27% versus 16% symptoms/rupture, and more iliac aneurysm)
• PAD (73% versus 62% critical limb ischemia)

Furthermore, black patients were less likely to be discharged on aspirin and statin therapy after treatment for AAA and PAD than whites.

The authors note that their study is limited by factors common to all database studies including missing data, variability in definitions, and no way to adjust for socio-economic factors, compliance, family support, hospital type and timing of referral.

“Even in hospitals invested in quality improvement – as evidenced by participation in the VQI – black patients present with more advanced disease and more comorbidities compared with whites, despite presenting at a younger age,” states first author Dr. Peter Soden.  “And these disparities were uniform across the spectrum of vascular disease, including carotids, AAA and PAD.” 

The increase in presenting risk factors, along with disparity in medical management, offers clues as to the well-reported worse outcomes for black patients after major vascular procedures.

“The majority of the disparities highlighted in this manuscript are not from biologic differences, but instead from social, economic and health care delivery factors,” noted Dr. Flinn. “What this most clearly suggests is that there are untold numbers of black [patients] throughout the country with undiagnosed and untreated carotid disease, abdominal aortic aneurysm and PAD (and hypertension, and diabetes, and chronic kidney disease) because they do not have equitable access to health care in the United States in the 21^st century.

“The vascular community has a unique opportunity to contribute to the health care debate in this country,” he added. “I hope we have both the scientific rigor and the political courage to pursue it aggressively.”

To download the complete article (freely available Jan.  22 - March 31), click: vsweb.org/JVS-Severe.

Applications are due March 2 for the Wylie Scholar Award, co-sponsored by the SVS Foundation and Vascular Cures. The three-year, $150,000 grant is awarded to a promising vascular surgeon-scientist in North America and is designed to support outstanding surgeon-scientists conducting innovative academic research in the early stages of their careers.

Applications are due March 2 for the Wylie Scholar Award, co-sponsored by the SVS Foundation and Vascular Cures. The three-year, $150,000 grant is awarded to a promising vascular surgeon-scientist in North America and is designed to support outstanding surgeon-scientists conducting innovative academic research in the early stages of their careers.

Applications are due March 2 for the Wylie Scholar Award, co-sponsored by the SVS Foundation and Vascular Cures. The three-year, $150,000 grant is awarded to a promising vascular surgeon-scientist in North America and is designed to support outstanding surgeon-scientists conducting innovative academic research in the early stages of their careers.

SVS members, please remind any vascular PAs with whom you work to consider submitting an abstract for the inaugural PA programming or be a speaker during our 2018 Vascular Annual Meeting. More information is here -- please forward to your PAs!

SVS members, please remind any vascular PAs with whom you work to consider submitting an abstract for the inaugural PA programming or be a speaker during our 2018 Vascular Annual Meeting. More information is here -- please forward to your PAs!

SVS members, please remind any vascular PAs with whom you work to consider submitting an abstract for the inaugural PA programming or be a speaker during our 2018 Vascular Annual Meeting. More information is here -- please forward to your PAs!

The Society for Vascular Ultrasound (SVU), the Society for Vascular Surgery (SVS), and Medstreaming-M2S, announce the development of the Vascular Quality Initiative (VQI) Vascular Ultrasound Registry.  This Registry represents an expansion of the SVS VQI which will combine noninvasive (vascular ultrasound) testing data with vascular treatment and outcomes data, making it possible to analyze the relationships between diagnosis and care provided to patients with vascular disease.

The Vascular Ultrasound Registry’s initial efforts will focus on collection and analysis of data associated with the diagnosis and treatment of carotid artery disease. The development of the registry and ongoing research related activities are being led by a VQI Vascular Ultrasound Registry Task Force, chaired by Drs. David Dawson and Gregory Moneta. Groundbreaking in this registry will be the inclusion of actual ultrasound images which will make future machine analysis and learning possible from the collected registry, which currently does not exist.

It is anticipated that the registry will provide the means and an impetus to promote vascular laboratory standardization and thereby improve patient care. “Non-invasive vascular testing has evolved to the point where it is being relied upon heavily to direct patient medical management decisions”, said James Wilkinson, SVU Executive Director. “With the rapid growth and diversification in the number of medical specialties providing testing, there is a lack of standardization in the delivery of testing and the reporting of results. Targeted, yet broad based research will significantly contribute to standardization efforts.”

Fundamental to the VQI Vascular Ultrasound Registry is the ability to link technical data and images to the clinical data collected from the SVS VQI’s existing registries. “The addition of the VQI Vascular Ultrasound Registry, to the existing VQI registries, will further aid the VQI’s mission of improving vascular care by enhancing the data we can make available to our members.  We are also pleased that this registry expands the reach of the VQI to include vascular technologists, sonographers and other professionals in the vascular laboratory setting. The VQI has long embraced a team-approach to care with 59% of VQI membership coming from specialties outside of Vascular Surgery, including Cardiology and Radiology,” said Dr. Jens Eldrup-Jorgensen, Medical Director of the SVS Patient Safety Organization.

A key to the success of any registry is providing means for efficient data capture. The VQI Vascular Ultrasound Registry leverages the infrastructure of the preexisting registry with linkages to ultrasound images from the vascular laboratory. “Medstreaming-M2S’s specialty based workflow solutions, along with its clinical data management system for structured data aggregation can be used for uploading of data and images,” noted Wael Elseaidy, Medstreaming-M2S CEO. Initially, only a select number of current VQI sites will participate, but Vascular Ultrasound Registry participation is expected to be broadly available in the next phase of the program, along with an increase in registry content and scope of projects.

 “Unique to the VQI Vascular Ultrasound Registry is the inclusion of an imaged based registry component, which will include the actual ultrasound images acquired during patient studies. When combined with powerful analytics and potential for machine learning, we foresee opportunity to normalize ultrasound image data submitted from different sites, develop new benchmarking standards, further explore and promote utilization of all the information embedded in the images, and provide the ultrasound industry with an entirely new platform from which to conduct research and drive product development,” Elseaidy continued.

Ultimately, the Registry will provide opportunity for VQI members to improve quality and conduct additional research regarding vascular ultrasound. “The Registry will provide greater opportunity for members to participate in research, whether through contribution of data pertaining to Society sponsored research projects or their own projects utilizing Registry data, all with the overall objective of quality improvement and better patient care,” Wilkinson concluded.

The Society for Vascular Ultrasound (SVU), the Society for Vascular Surgery (SVS), and Medstreaming-M2S, announce the development of the Vascular Quality Initiative (VQI) Vascular Ultrasound Registry.  This Registry represents an expansion of the SVS VQI which will combine noninvasive (vascular ultrasound) testing data with vascular treatment and outcomes data, making it possible to analyze the relationships between diagnosis and care provided to patients with vascular disease.

The Vascular Ultrasound Registry’s initial efforts will focus on collection and analysis of data associated with the diagnosis and treatment of carotid artery disease. The development of the registry and ongoing research related activities are being led by a VQI Vascular Ultrasound Registry Task Force, chaired by Drs. David Dawson and Gregory Moneta. Groundbreaking in this registry will be the inclusion of actual ultrasound images which will make future machine analysis and learning possible from the collected registry, which currently does not exist.

It is anticipated that the registry will provide the means and an impetus to promote vascular laboratory standardization and thereby improve patient care. “Non-invasive vascular testing has evolved to the point where it is being relied upon heavily to direct patient medical management decisions”, said James Wilkinson, SVU Executive Director. “With the rapid growth and diversification in the number of medical specialties providing testing, there is a lack of standardization in the delivery of testing and the reporting of results. Targeted, yet broad based research will significantly contribute to standardization efforts.”

Fundamental to the VQI Vascular Ultrasound Registry is the ability to link technical data and images to the clinical data collected from the SVS VQI’s existing registries. “The addition of the VQI Vascular Ultrasound Registry, to the existing VQI registries, will further aid the VQI’s mission of improving vascular care by enhancing the data we can make available to our members.  We are also pleased that this registry expands the reach of the VQI to include vascular technologists, sonographers and other professionals in the vascular laboratory setting. The VQI has long embraced a team-approach to care with 59% of VQI membership coming from specialties outside of Vascular Surgery, including Cardiology and Radiology,” said Dr. Jens Eldrup-Jorgensen, Medical Director of the SVS Patient Safety Organization.

A key to the success of any registry is providing means for efficient data capture. The VQI Vascular Ultrasound Registry leverages the infrastructure of the preexisting registry with linkages to ultrasound images from the vascular laboratory. “Medstreaming-M2S’s specialty based workflow solutions, along with its clinical data management system for structured data aggregation can be used for uploading of data and images,” noted Wael Elseaidy, Medstreaming-M2S CEO. Initially, only a select number of current VQI sites will participate, but Vascular Ultrasound Registry participation is expected to be broadly available in the next phase of the program, along with an increase in registry content and scope of projects.

 “Unique to the VQI Vascular Ultrasound Registry is the inclusion of an imaged based registry component, which will include the actual ultrasound images acquired during patient studies. When combined with powerful analytics and potential for machine learning, we foresee opportunity to normalize ultrasound image data submitted from different sites, develop new benchmarking standards, further explore and promote utilization of all the information embedded in the images, and provide the ultrasound industry with an entirely new platform from which to conduct research and drive product development,” Elseaidy continued.

Ultimately, the Registry will provide opportunity for VQI members to improve quality and conduct additional research regarding vascular ultrasound. “The Registry will provide greater opportunity for members to participate in research, whether through contribution of data pertaining to Society sponsored research projects or their own projects utilizing Registry data, all with the overall objective of quality improvement and better patient care,” Wilkinson concluded.

The Society for Vascular Ultrasound (SVU), the Society for Vascular Surgery (SVS), and Medstreaming-M2S, announce the development of the Vascular Quality Initiative (VQI) Vascular Ultrasound Registry.  This Registry represents an expansion of the SVS VQI which will combine noninvasive (vascular ultrasound) testing data with vascular treatment and outcomes data, making it possible to analyze the relationships between diagnosis and care provided to patients with vascular disease.

The Vascular Ultrasound Registry’s initial efforts will focus on collection and analysis of data associated with the diagnosis and treatment of carotid artery disease. The development of the registry and ongoing research related activities are being led by a VQI Vascular Ultrasound Registry Task Force, chaired by Drs. David Dawson and Gregory Moneta. Groundbreaking in this registry will be the inclusion of actual ultrasound images which will make future machine analysis and learning possible from the collected registry, which currently does not exist.

It is anticipated that the registry will provide the means and an impetus to promote vascular laboratory standardization and thereby improve patient care. “Non-invasive vascular testing has evolved to the point where it is being relied upon heavily to direct patient medical management decisions”, said James Wilkinson, SVU Executive Director. “With the rapid growth and diversification in the number of medical specialties providing testing, there is a lack of standardization in the delivery of testing and the reporting of results. Targeted, yet broad based research will significantly contribute to standardization efforts.”

Fundamental to the VQI Vascular Ultrasound Registry is the ability to link technical data and images to the clinical data collected from the SVS VQI’s existing registries. “The addition of the VQI Vascular Ultrasound Registry, to the existing VQI registries, will further aid the VQI’s mission of improving vascular care by enhancing the data we can make available to our members.  We are also pleased that this registry expands the reach of the VQI to include vascular technologists, sonographers and other professionals in the vascular laboratory setting. The VQI has long embraced a team-approach to care with 59% of VQI membership coming from specialties outside of Vascular Surgery, including Cardiology and Radiology,” said Dr. Jens Eldrup-Jorgensen, Medical Director of the SVS Patient Safety Organization.

A key to the success of any registry is providing means for efficient data capture. The VQI Vascular Ultrasound Registry leverages the infrastructure of the preexisting registry with linkages to ultrasound images from the vascular laboratory. “Medstreaming-M2S’s specialty based workflow solutions, along with its clinical data management system for structured data aggregation can be used for uploading of data and images,” noted Wael Elseaidy, Medstreaming-M2S CEO. Initially, only a select number of current VQI sites will participate, but Vascular Ultrasound Registry participation is expected to be broadly available in the next phase of the program, along with an increase in registry content and scope of projects.

 “Unique to the VQI Vascular Ultrasound Registry is the inclusion of an imaged based registry component, which will include the actual ultrasound images acquired during patient studies. When combined with powerful analytics and potential for machine learning, we foresee opportunity to normalize ultrasound image data submitted from different sites, develop new benchmarking standards, further explore and promote utilization of all the information embedded in the images, and provide the ultrasound industry with an entirely new platform from which to conduct research and drive product development,” Elseaidy continued.

Ultimately, the Registry will provide opportunity for VQI members to improve quality and conduct additional research regarding vascular ultrasound. “The Registry will provide greater opportunity for members to participate in research, whether through contribution of data pertaining to Society sponsored research projects or their own projects utilizing Registry data, all with the overall objective of quality improvement and better patient care,” Wilkinson concluded.