Society News

Applications are due March 2, 2018, for the Wylie Scholar Award, co-sponsored by Vascular Cures and the SVS Foundation. 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.

This year's recipient, Dr. Sean English, is conducting research on AAA. Dr. Mohamed Zayed, MD, PhD, the 2015 recipient, is investigating why diabetics develop a unique lipid profile leading to PAD. For each $150,000 award, Wylie Scholars have received $3.3 million in subsequent national research funding, for a return on investment of nearly 22 to 1. 

Applications are due March 2, 2018, for the Wylie Scholar Award, co-sponsored by Vascular Cures and the SVS Foundation. 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.

This year's recipient, Dr. Sean English, is conducting research on AAA. Dr. Mohamed Zayed, MD, PhD, the 2015 recipient, is investigating why diabetics develop a unique lipid profile leading to PAD. For each $150,000 award, Wylie Scholars have received $3.3 million in subsequent national research funding, for a return on investment of nearly 22 to 1. 

Applications are due March 2, 2018, for the Wylie Scholar Award, co-sponsored by Vascular Cures and the SVS Foundation. 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.

This year's recipient, Dr. Sean English, is conducting research on AAA. Dr. Mohamed Zayed, MD, PhD, the 2015 recipient, is investigating why diabetics develop a unique lipid profile leading to PAD. For each $150,000 award, Wylie Scholars have received $3.3 million in subsequent national research funding, for a return on investment of nearly 22 to 1. 

Leaders of the American College of Surgeons (ACS) hosted a Stop the Bleed^® training program on Capitol Hill October 12 for members of Congress and their staffs. The congressional event focused on how early intervention from a Stop the Bleed-trained individual can save the life of someone suffering from a bleeding injury. Participants came to learn more about the ACS’ efforts with Stop the Bleed and engage in the hands-on training in how to control bleeding. The training was led by ACS Fellows, including Lenworth M. Jacobs, Jr., MD, MPH, FACS; Leonard J. Weireter, Jr., MD, FACS; Mark L. Gestring, MD, FACS; John H. Armstrong, MD, FACS; Joseph V. Sakran, MD, MPH, MPA, FACS; and Jack Sava, MD, FACS. Congressional guests included Reps. Ami Bera, MD (D-CA); Phil Roe, MD (R-TN); Raul Ruiz, MD (D-CA); and Brad Wenstrup, DPM (R-OH), who provided opening remarks.

Leaders of the American College of Surgeons (ACS) hosted a Stop the Bleed^® training program on Capitol Hill October 12 for members of Congress and their staffs. The congressional event focused on how early intervention from a Stop the Bleed-trained individual can save the life of someone suffering from a bleeding injury. Participants came to learn more about the ACS’ efforts with Stop the Bleed and engage in the hands-on training in how to control bleeding. The training was led by ACS Fellows, including Lenworth M. Jacobs, Jr., MD, MPH, FACS; Leonard J. Weireter, Jr., MD, FACS; Mark L. Gestring, MD, FACS; John H. Armstrong, MD, FACS; Joseph V. Sakran, MD, MPH, MPA, FACS; and Jack Sava, MD, FACS. Congressional guests included Reps. Ami Bera, MD (D-CA); Phil Roe, MD (R-TN); Raul Ruiz, MD (D-CA); and Brad Wenstrup, DPM (R-OH), who provided opening remarks.

Leaders of the American College of Surgeons (ACS) hosted a Stop the Bleed^® training program on Capitol Hill October 12 for members of Congress and their staffs. The congressional event focused on how early intervention from a Stop the Bleed-trained individual can save the life of someone suffering from a bleeding injury. Participants came to learn more about the ACS’ efforts with Stop the Bleed and engage in the hands-on training in how to control bleeding. The training was led by ACS Fellows, including Lenworth M. Jacobs, Jr., MD, MPH, FACS; Leonard J. Weireter, Jr., MD, FACS; Mark L. Gestring, MD, FACS; John H. Armstrong, MD, FACS; Joseph V. Sakran, MD, MPH, MPA, FACS; and Jack Sava, MD, FACS. Congressional guests included Reps. Ami Bera, MD (D-CA); Phil Roe, MD (R-TN); Raul Ruiz, MD (D-CA); and Brad Wenstrup, DPM (R-OH), who provided opening remarks.

The November issue of the Bulletin of the American College of Surgeons is now available online at bulletin.facs.org. This month’s Bulletin includes the following features, columns, and new stories, among others:

Features

The November issue of the Bulletin of the American College of Surgeons is now available online at bulletin.facs.org. This month’s Bulletin includes the following features, columns, and new stories, among others:

Features

The November issue of the Bulletin of the American College of Surgeons is now available online at bulletin.facs.org. This month’s Bulletin includes the following features, columns, and new stories, among others:

Features

During AGA’s annual Joint Committee weekend, 55 AGA members collectively attended 79 meetings with staff from the offices of their House representatives and senators, lobbying for the top concerns of gastroenterologists across the country, including:

• Continued coverage of patients through either the Affordable Care Act or another bill that has the patient’s best interests in mind. More specifically, one that provides coverage for those with pre-existing conditions and for children under their parents’ plan until 26 years of age, among many other important provisions.
• Changes in health care language that label a colonoscopy for cancer screening as “therapeutic,” which renders a large copay for patients.
• Increased funding for the NIH.

Participants shared experiences from their time on Capitol Hill in the AGA Community forum, and encouraged others to get involved. Here are some of their reasons why.

• Your voice matters: You are constituents – which translates to votes in the minds of representatives and senators – and providing face-to-face conversation with their staffers shows them that you care about your patients and their needs, explains Siddharth Singh, MD.
• Being consistent gets your foot in the door: Some staffers recognized and remembered previous Advocacy Day participants, like Peter Liang, MD, MPH. Personally connecting could lead to follow-up communication and advocacy efforts, says Sarah Streett, MD, AGAF.
• You’re indirectly (and sometimes directly) connecting with decision makers: Staff members from these offices work closely with the legislators who evaluate which policies to support or oppose. “So it’s important to come to Washington, build relationships, and make the case for our science, our specialty, and our patients,” says Kim Barrett, PhD, AGAF.
• Others could be advocating against you on the same issues: “I very strongly believe that it is important to keep letting our legislators know how we feel and what we believe in,” shares Deborah Proctor, MD, AGAF.
• It’s a rewarding experience: “Voice [your] concerns to your representatives who embrace the stories of how their decisions and policies affect your patients, practice, research, and institution,” explains Susan Ramdhaney, MD, AGAF.
• It’s a critical time to take action: With the current health care environment, gastroenterologists need to express the needs of their patients and profession, Dr. Streett explains.

View the full discussion and read updates from colleagues who visited with legislative staffers from California, New York, North Carolina, and Oregon in the forum, community.gastro.org.

Please contact [email protected].
 

[email protected]

During AGA’s annual Joint Committee weekend, 55 AGA members collectively attended 79 meetings with staff from the offices of their House representatives and senators, lobbying for the top concerns of gastroenterologists across the country, including:

• Continued coverage of patients through either the Affordable Care Act or another bill that has the patient’s best interests in mind. More specifically, one that provides coverage for those with pre-existing conditions and for children under their parents’ plan until 26 years of age, among many other important provisions.
• Changes in health care language that label a colonoscopy for cancer screening as “therapeutic,” which renders a large copay for patients.
• Increased funding for the NIH.

Participants shared experiences from their time on Capitol Hill in the AGA Community forum, and encouraged others to get involved. Here are some of their reasons why.

• Your voice matters: You are constituents – which translates to votes in the minds of representatives and senators – and providing face-to-face conversation with their staffers shows them that you care about your patients and their needs, explains Siddharth Singh, MD.
• Being consistent gets your foot in the door: Some staffers recognized and remembered previous Advocacy Day participants, like Peter Liang, MD, MPH. Personally connecting could lead to follow-up communication and advocacy efforts, says Sarah Streett, MD, AGAF.
• You’re indirectly (and sometimes directly) connecting with decision makers: Staff members from these offices work closely with the legislators who evaluate which policies to support or oppose. “So it’s important to come to Washington, build relationships, and make the case for our science, our specialty, and our patients,” says Kim Barrett, PhD, AGAF.
• Others could be advocating against you on the same issues: “I very strongly believe that it is important to keep letting our legislators know how we feel and what we believe in,” shares Deborah Proctor, MD, AGAF.
• It’s a rewarding experience: “Voice [your] concerns to your representatives who embrace the stories of how their decisions and policies affect your patients, practice, research, and institution,” explains Susan Ramdhaney, MD, AGAF.
• It’s a critical time to take action: With the current health care environment, gastroenterologists need to express the needs of their patients and profession, Dr. Streett explains.

View the full discussion and read updates from colleagues who visited with legislative staffers from California, New York, North Carolina, and Oregon in the forum, community.gastro.org.

Please contact [email protected].
 

[email protected]

During AGA’s annual Joint Committee weekend, 55 AGA members collectively attended 79 meetings with staff from the offices of their House representatives and senators, lobbying for the top concerns of gastroenterologists across the country, including:

• Continued coverage of patients through either the Affordable Care Act or another bill that has the patient’s best interests in mind. More specifically, one that provides coverage for those with pre-existing conditions and for children under their parents’ plan until 26 years of age, among many other important provisions.
• Changes in health care language that label a colonoscopy for cancer screening as “therapeutic,” which renders a large copay for patients.
• Increased funding for the NIH.

Participants shared experiences from their time on Capitol Hill in the AGA Community forum, and encouraged others to get involved. Here are some of their reasons why.

• Your voice matters: You are constituents – which translates to votes in the minds of representatives and senators – and providing face-to-face conversation with their staffers shows them that you care about your patients and their needs, explains Siddharth Singh, MD.
• Being consistent gets your foot in the door: Some staffers recognized and remembered previous Advocacy Day participants, like Peter Liang, MD, MPH. Personally connecting could lead to follow-up communication and advocacy efforts, says Sarah Streett, MD, AGAF.
• You’re indirectly (and sometimes directly) connecting with decision makers: Staff members from these offices work closely with the legislators who evaluate which policies to support or oppose. “So it’s important to come to Washington, build relationships, and make the case for our science, our specialty, and our patients,” says Kim Barrett, PhD, AGAF.
• Others could be advocating against you on the same issues: “I very strongly believe that it is important to keep letting our legislators know how we feel and what we believe in,” shares Deborah Proctor, MD, AGAF.
• It’s a rewarding experience: “Voice [your] concerns to your representatives who embrace the stories of how their decisions and policies affect your patients, practice, research, and institution,” explains Susan Ramdhaney, MD, AGAF.
• It’s a critical time to take action: With the current health care environment, gastroenterologists need to express the needs of their patients and profession, Dr. Streett explains.

View the full discussion and read updates from colleagues who visited with legislative staffers from California, New York, North Carolina, and Oregon in the forum, community.gastro.org.

Please contact [email protected].
 

[email protected]

The U.S. is facing an opioid epidemic – 91 Americans die every day from an opioid overdose. While all health care professionals should remain up to date on the risks associated with opioids, it is as important for GIs to understand how opioids can affect diverse parts of the gastrointestinal tract. Patients can experience GI symptoms and side effects related to the intake of opioids, including opioid-induced constipation (OIC), esophageal dysmotility, and delayed gastric emptying, according to a new AGA Clinical Practice Update published in the September 2017 issue of Clinical Gastroenterology and Hepatology.

Because of the common use of opioid medications to treat chronic pain, the authors recommend that physicians should first consider whether any gastrointestinal symptoms are directly related to the intake of opioids. In acute administration of opioids, symptomatic remedies should be used to counter the pharmacologic effects. For OIC, the bowel function index – a clinician assessment tool to appraise severity and responsiveness to current treatment – should be used to identify chronic OIC that is not responding to first-line therapies.

The clinical practice update also outlines:

• Pharmacologic effects of opiates in different regions of the gastrointestinal tract.
• Therapeutic uses of opioid receptor agonists and antagonists in gastroenterology.
• Prevention and treatment of OIC.

[email protected]

The U.S. is facing an opioid epidemic – 91 Americans die every day from an opioid overdose. While all health care professionals should remain up to date on the risks associated with opioids, it is as important for GIs to understand how opioids can affect diverse parts of the gastrointestinal tract. Patients can experience GI symptoms and side effects related to the intake of opioids, including opioid-induced constipation (OIC), esophageal dysmotility, and delayed gastric emptying, according to a new AGA Clinical Practice Update published in the September 2017 issue of Clinical Gastroenterology and Hepatology.

Because of the common use of opioid medications to treat chronic pain, the authors recommend that physicians should first consider whether any gastrointestinal symptoms are directly related to the intake of opioids. In acute administration of opioids, symptomatic remedies should be used to counter the pharmacologic effects. For OIC, the bowel function index – a clinician assessment tool to appraise severity and responsiveness to current treatment – should be used to identify chronic OIC that is not responding to first-line therapies.

The clinical practice update also outlines:

• Pharmacologic effects of opiates in different regions of the gastrointestinal tract.
• Therapeutic uses of opioid receptor agonists and antagonists in gastroenterology.
• Prevention and treatment of OIC.

[email protected]

The U.S. is facing an opioid epidemic – 91 Americans die every day from an opioid overdose. While all health care professionals should remain up to date on the risks associated with opioids, it is as important for GIs to understand how opioids can affect diverse parts of the gastrointestinal tract. Patients can experience GI symptoms and side effects related to the intake of opioids, including opioid-induced constipation (OIC), esophageal dysmotility, and delayed gastric emptying, according to a new AGA Clinical Practice Update published in the September 2017 issue of Clinical Gastroenterology and Hepatology.

Because of the common use of opioid medications to treat chronic pain, the authors recommend that physicians should first consider whether any gastrointestinal symptoms are directly related to the intake of opioids. In acute administration of opioids, symptomatic remedies should be used to counter the pharmacologic effects. For OIC, the bowel function index – a clinician assessment tool to appraise severity and responsiveness to current treatment – should be used to identify chronic OIC that is not responding to first-line therapies.

The clinical practice update also outlines:

• Pharmacologic effects of opiates in different regions of the gastrointestinal tract.
• Therapeutic uses of opioid receptor agonists and antagonists in gastroenterology.
• Prevention and treatment of OIC.

[email protected]

Don't forget that the end of the year is the time to keep up to date with your SVS membership dues. Invoices were emailed to all members earlier this month and are due by Dec. 31.

It's simple to pay your 2018 dues online -- and there's no need to write out a check or find a stamp! Just log on to vascular.org/payinvoice. (While you're at it, please make sure your record is up to date.) You also can make a donation to the SVS Foundation at the same time. For membership help, e-mail the SVS membership department, or call 312-334-2313

Don't forget that the end of the year is the time to keep up to date with your SVS membership dues. Invoices were emailed to all members earlier this month and are due by Dec. 31.

It's simple to pay your 2018 dues online -- and there's no need to write out a check or find a stamp! Just log on to vascular.org/payinvoice. (While you're at it, please make sure your record is up to date.) You also can make a donation to the SVS Foundation at the same time. For membership help, e-mail the SVS membership department, or call 312-334-2313

Don't forget that the end of the year is the time to keep up to date with your SVS membership dues. Invoices were emailed to all members earlier this month and are due by Dec. 31.

It's simple to pay your 2018 dues online -- and there's no need to write out a check or find a stamp! Just log on to vascular.org/payinvoice. (While you're at it, please make sure your record is up to date.) You also can make a donation to the SVS Foundation at the same time. For membership help, e-mail the SVS membership department, or call 312-334-2313

At its recent meeting, the SVS Board of Directors approved establishing a Disaster Relief Fund in response to disasters in Puerto Rico, Florida, Texas and Mexico. This Fund will support vascular surgeons and their patients who have been impacted by these extraordinary events and ensure that their commitment to vascular health is recognized in times of need.  

The Foundation leadership is working to initiate a fundraising campaign and grant application guidelines.

Members are asked to email the SVS Foundation to provide your input on the type of support that would be most helpful to vascular surgeons and their patients in these disaster areas.

At its recent meeting, the SVS Board of Directors approved establishing a Disaster Relief Fund in response to disasters in Puerto Rico, Florida, Texas and Mexico. This Fund will support vascular surgeons and their patients who have been impacted by these extraordinary events and ensure that their commitment to vascular health is recognized in times of need.  

The Foundation leadership is working to initiate a fundraising campaign and grant application guidelines.

Members are asked to email the SVS Foundation to provide your input on the type of support that would be most helpful to vascular surgeons and their patients in these disaster areas.

At its recent meeting, the SVS Board of Directors approved establishing a Disaster Relief Fund in response to disasters in Puerto Rico, Florida, Texas and Mexico. This Fund will support vascular surgeons and their patients who have been impacted by these extraordinary events and ensure that their commitment to vascular health is recognized in times of need.  

The Foundation leadership is working to initiate a fundraising campaign and grant application guidelines.

Members are asked to email the SVS Foundation to provide your input on the type of support that would be most helpful to vascular surgeons and their patients in these disaster areas.

The ACS Clinical Congress will get underway on Saturday, Oct. 21, in San Diego. The vast array of sessions, presentations, and special events can be overwhelming. The best way to manage your time is to download the meeting app and start planning to attend must-see sessions and other events. The app lets you search by day, speaker, track, and type of session, so you can build your daily schedule and connect with colleagues. The ACS Surgery News editorial team, reporters, and videographers will be on site covering many sessions and posting stories and interviews daily on the web page.

Rodrigo Cuel/Thinkstock

Don’t miss these sessions

Acoustic gunshot sensor technology impacts trauma care.

Press Conference:   TUESDAY, OCTOBER 24  - 10:30-11:00 a.m.
Location: Room 21 – San Diego Convention Center (Upper level)

~~~~

Lessons Learned from Las Vegas and other Major Intentional Mass Casualty Events.

Panel Session: TUESDAY, OCTOBER 24 – 8:00 – 9:30 a.m.

Location: 2, Upper Level of the San Diego Convention Center. 

The ACS Surgery News editorial team offers the following picks among the hundreds of panels, sessions, and scientific forums:

•PS101: Controversies in the Management of Complicated Diverticulitis (Monday, Oct. 23, 9:45 am - 11:15 am, Hall F)

•PS104: The Gut Microbiome: Implications for Surgical Complications (Monday, Oct. 23, 9:45 am - 11:15 am, Room 20D)

•PS108: Management of Axilla in Breast Cancer (Monday, Oct. 23, 9:45 am - 11:15 am, 20A)

•PS109: Cholecystectomy: From Lap Chole to Open Common Duct Exploration (Monday, Oct. 23, 11:30 am - 1:00 pm, Hall F)

•PS200: The Impossible Gallbladder: Is Cholecystectomy Always the Answer? (Tuesday, Oct. 24, 8:00 am - 9:30 am, Hall F)

•PS204: What’s New in Hospital Acquired Infections? II (Tuesday, Oct. 24, 8:00 am - 9:30 am, Room 6E)

•PS218: Ergonomics for Surgeons: Preventing Work Related Injuries (Tuesday, Oct. 24, 9:45 am - 11:15 am)

•PS302: Shared Decision Making for Treatment of Uncomplicated Appendicitis (Wednesday, Oct. 25, 8:00 am - 9:30 am, Room 20C)

•PS313: Managing Bariatric Complications: The Role of the Non-Bariatric Surgeon (Wednesday, Oct. 25, 12:45 pm - 2:15 pm, Room 20D)

•PS332: Training Surgeons for Rural Practice (Wednesday, Oct. 25, 4:15 pm - 5:45 pm, Room 20D)

•PS400: Top Hot Topics in General Surgery (Thursday, Oct. 26, 8:00 am - 9:30 am, Room 20BC)


Social media

Follow Therese Borden on Twitter for live tweets during the meeting.
 

[email protected]

On Twitter @ThereseBorden

The ACS Clinical Congress will get underway on Saturday, Oct. 21, in San Diego. The vast array of sessions, presentations, and special events can be overwhelming. The best way to manage your time is to download the meeting app and start planning to attend must-see sessions and other events. The app lets you search by day, speaker, track, and type of session, so you can build your daily schedule and connect with colleagues. The ACS Surgery News editorial team, reporters, and videographers will be on site covering many sessions and posting stories and interviews daily on the web page.

Rodrigo Cuel/Thinkstock

Don’t miss these sessions

Acoustic gunshot sensor technology impacts trauma care.

Press Conference:   TUESDAY, OCTOBER 24  - 10:30-11:00 a.m.
Location: Room 21 – San Diego Convention Center (Upper level)

~~~~

Lessons Learned from Las Vegas and other Major Intentional Mass Casualty Events.

Panel Session: TUESDAY, OCTOBER 24 – 8:00 – 9:30 a.m.

Location: 2, Upper Level of the San Diego Convention Center. 

The ACS Surgery News editorial team offers the following picks among the hundreds of panels, sessions, and scientific forums:

•PS101: Controversies in the Management of Complicated Diverticulitis (Monday, Oct. 23, 9:45 am - 11:15 am, Hall F)

•PS104: The Gut Microbiome: Implications for Surgical Complications (Monday, Oct. 23, 9:45 am - 11:15 am, Room 20D)

•PS108: Management of Axilla in Breast Cancer (Monday, Oct. 23, 9:45 am - 11:15 am, 20A)

•PS109: Cholecystectomy: From Lap Chole to Open Common Duct Exploration (Monday, Oct. 23, 11:30 am - 1:00 pm, Hall F)

•PS200: The Impossible Gallbladder: Is Cholecystectomy Always the Answer? (Tuesday, Oct. 24, 8:00 am - 9:30 am, Hall F)

•PS204: What’s New in Hospital Acquired Infections? II (Tuesday, Oct. 24, 8:00 am - 9:30 am, Room 6E)

•PS218: Ergonomics for Surgeons: Preventing Work Related Injuries (Tuesday, Oct. 24, 9:45 am - 11:15 am)

•PS302: Shared Decision Making for Treatment of Uncomplicated Appendicitis (Wednesday, Oct. 25, 8:00 am - 9:30 am, Room 20C)

•PS313: Managing Bariatric Complications: The Role of the Non-Bariatric Surgeon (Wednesday, Oct. 25, 12:45 pm - 2:15 pm, Room 20D)

•PS332: Training Surgeons for Rural Practice (Wednesday, Oct. 25, 4:15 pm - 5:45 pm, Room 20D)

•PS400: Top Hot Topics in General Surgery (Thursday, Oct. 26, 8:00 am - 9:30 am, Room 20BC)


Social media

Follow Therese Borden on Twitter for live tweets during the meeting.
 

[email protected]

On Twitter @ThereseBorden

The ACS Clinical Congress will get underway on Saturday, Oct. 21, in San Diego. The vast array of sessions, presentations, and special events can be overwhelming. The best way to manage your time is to download the meeting app and start planning to attend must-see sessions and other events. The app lets you search by day, speaker, track, and type of session, so you can build your daily schedule and connect with colleagues. The ACS Surgery News editorial team, reporters, and videographers will be on site covering many sessions and posting stories and interviews daily on the web page.

Rodrigo Cuel/Thinkstock

Don’t miss these sessions

Acoustic gunshot sensor technology impacts trauma care.

Press Conference:   TUESDAY, OCTOBER 24  - 10:30-11:00 a.m.
Location: Room 21 – San Diego Convention Center (Upper level)

~~~~

Lessons Learned from Las Vegas and other Major Intentional Mass Casualty Events.

Panel Session: TUESDAY, OCTOBER 24 – 8:00 – 9:30 a.m.

Location: 2, Upper Level of the San Diego Convention Center. 

The ACS Surgery News editorial team offers the following picks among the hundreds of panels, sessions, and scientific forums:

•PS101: Controversies in the Management of Complicated Diverticulitis (Monday, Oct. 23, 9:45 am - 11:15 am, Hall F)

•PS104: The Gut Microbiome: Implications for Surgical Complications (Monday, Oct. 23, 9:45 am - 11:15 am, Room 20D)

•PS108: Management of Axilla in Breast Cancer (Monday, Oct. 23, 9:45 am - 11:15 am, 20A)

•PS109: Cholecystectomy: From Lap Chole to Open Common Duct Exploration (Monday, Oct. 23, 11:30 am - 1:00 pm, Hall F)

•PS200: The Impossible Gallbladder: Is Cholecystectomy Always the Answer? (Tuesday, Oct. 24, 8:00 am - 9:30 am, Hall F)

•PS204: What’s New in Hospital Acquired Infections? II (Tuesday, Oct. 24, 8:00 am - 9:30 am, Room 6E)

•PS218: Ergonomics for Surgeons: Preventing Work Related Injuries (Tuesday, Oct. 24, 9:45 am - 11:15 am)

•PS302: Shared Decision Making for Treatment of Uncomplicated Appendicitis (Wednesday, Oct. 25, 8:00 am - 9:30 am, Room 20C)

•PS313: Managing Bariatric Complications: The Role of the Non-Bariatric Surgeon (Wednesday, Oct. 25, 12:45 pm - 2:15 pm, Room 20D)

•PS332: Training Surgeons for Rural Practice (Wednesday, Oct. 25, 4:15 pm - 5:45 pm, Room 20D)

•PS400: Top Hot Topics in General Surgery (Thursday, Oct. 26, 8:00 am - 9:30 am, Room 20BC)


Social media

Follow Therese Borden on Twitter for live tweets during the meeting.
 

[email protected]

On Twitter @ThereseBorden

Interventional Chest/Diagnostic Procedures

Cryobiopsy for ILD: Careful stewardship needed

Interest in transbronchial cryobiopsy has accelerated rapidly in recent years. This procedure is performed by advancing a cryoprobe into the peripheral lung via flexible bronchoscopy, where lung tissue freezes and adheres to the probe and is subsequently extracted as a cryobiopsy. The number of cryobiopsy-related publications has increased exponentially since it was described in 2009 (Babiak A, et al. Respiration. 2009;78[2]:203). This interest stems from reports of high diagnostic yields in patients with interstitial lung disease (ILD) while maintaining complication rates similar to that of conventional bronchoscopic biopsy.

Traditional bronchoscopic biopsies are notoriously insensitive; a specific diagnosis can be established in fewer than a third of cases (Sheth JS, et al. Chest. 2017;151[2]:389). As such, surgical lung biopsy continues to be recommended but is associated with significant mortality (2%) and morbidity (30%) in patients with ILD (Hutchinson JP, et al. ARJCCM. 2016;193[10]:1161). Cryobiopsy, which appears to rival surgical lung biopsy in terms of ability to contribute to a specific diagnosis, is, therefore, a highly promising alternative (Tomassetti S, et al. AJRCCM. 2016;193[7]:745).

As cryobiopsy is increasingly adopted around the world, however, troubling reports of serious complications have surfaced. Most notable is the recently reported experience of the initial 25 cases performed at the University of Pennsylvania, in which almost one in four patients suffered serious complications (DiBardino DM, et al. Ann Am Thorac Soc. 2017;14[6]:851). The authors pointed to lack of a predefined procedural protocol, as well as several choices relating to the specific technique used, including inconsistent use of fluoroscopy, lack of prophylactic bronchial blocker placement, and predominant use of laryngeal mask airways as potential contributing factors. Indeed, many variations of the basic cryobiopsy procedure have been described (Lentz RJ, et al. J Thoracic Dis. 2017;9[7]:2186), with no formal guidance or training available to inform advanced bronchoscopists interested in this procedure.

It is incumbent on the interventional pulmonology and ILD specialist communities to be responsible stewards of this promising procedure. Implementation of three parallel efforts to standardize and rigorously study this procedure should be considered as soon as possible: creation of expert consensus guidelines establishing best-practices for safe and effective biopsy technique; a training requirement before independent performance of the procedure; and creation of an international cryobiopsy registry to facilitate higher-quality research into optimal technique and outcomes. We owe this to our patients.

Robert J. Lentz, MD
NetWork Member

Fabien Maldonado, MD, FCCP
NetWork Member

Pediatric Chest Medicine

Chronic cough in children: New guidelines

A chronic cough is a common complaint among children whose parents seek medical evaluation. Chronic wet cough can indicate an underlying illness; therefore, an early diagnosis can lead to prevention of complications of the disease and improvement in quality of life.

CHEST is a leading resource in evidence and consensus-based guidelines on important topics affecting children. The most recent guidelines entitled Management of Children with Chronic Wet Cough and Protracted Bacterial Bronchitis (Chest. 2017;151(4):884-890) and Use of Management Pathways or Algorithms in Children with Chronic Cough (Chest. 2017;151(4):875-873) are updates from the 2006 CHEST guidelines on chronic cough in children.

The present updates utilized the CHEST methodological guidelines with chronic wet or productive cough and Grading of Recommendations Assessment, Development, and Evaluation framework and also performed a systematic review addressing key questions concerning the management of childhood disease for children 14 years and younger.

Guidance provided by the expert panel focused on recommendations to answer six key questions concerning the management of children 14 years and younger with a chronic wet cough unrelated to established chronic lung disease. The recommendations are:

1. Chronic cough is defined as the presence of a cough 4 weeks or longer in duration.

2. Assessment of the effect of the cough on the child and the family be undertaken as part of clinical consultation.

3. Evaluation of a chronic cough should be done with a systematic approach with pediatric-specific cough management protocols or algorithms.

4. Chest radiograph and, when age appropriate, spirometry with bronchodilator be undertaken as evaluation; tests for pertussis infection only to be performed if clinically suspected.

5. Chronic wet cough with no specific clinical features should receive antibiotics for 2 weeks targeted for common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis).

6. When cough persists despite 2 weeks of appropriate antibiotics, it is recommended to continue for an additional 2 weeks.

7. Additional tests (eg skin prick test, Mantoux, bronchoscopy, chest CT scan) should be individualized in accordance with the clinical setting and child’s clinical symptoms and signs.

The panel recognizes the need for prospective studies to assess current algorithms outcomes of children with chronic cough. Both articles can be found on the guidelines section of the CHEST site.

John Bishara, DO
Fellow-in-Training Member

Pulmonary Physiology, Function, and Rehabilitation

Functional imaging of the lung

Quantifying heterogeneity of ventilation and gas exchange in lung diseases remains a clinical challenge. Conventional pulmonary function test is insensitive to regional changes. The multiple inert gas elimination technique can quantify ventilation-perfusion distribution, but it requires invasive instrumentation (eg, pulmonary artery catheterization) and is not practical for clinical use. Computed tomography (CT) scans delineate spatial changes in lung structures but do not directly measure changes in ventilation and gas exchange. With its radiation, it is difficult to apply CT scanning repeatedly in patients. More recently, MR imaging techniques have been developed to directly “visualize” and quantify regional lung function (Kruger SJ, et al. J Magn Reson Imaging. 2016;43(2):295; Roos JE, et al. Magn Reson Imaging Clin N Am. 2015;23(2):217). These techniques employ inhalation of gases, such as oxygen, perfluorinated gases, and hyperpolarized ³He and ¹²⁹Xe. Hyperpolarized ³He has been studied the most; however, the dwindling supply of ³He gas and its rising cost have prevented its further development. ¹²⁹Xe has abundant supply and has emerged to be the inert gas of choice for MR imaging. Hyperpolarized ¹²⁹Xe can measure ventilation, like hyperpolarized ³He. In addition, Xe diffuses into alveolar barrier (interstitium and plasma) and red blood cells, where it exhibits distinct resonant frequency shifts that can be captured by MR. Therefore, in one test, information on pulmonary ventilation and gas transfer can be obtained. To date, the results from MR imaging studies have provided new insights into the pathophysiology of obstructive and restrictive lung diseases. With continuous development, MR imaging of the lung could become a clinically useful tool in the near future.

Yuh-Chin T. Huang, MD, MHS, FCCP

Steering Committee Member

Immune-mediated pneumonitis and PD-1 inhibition

Inhibitors of the programmed cell death 1 receptor (PD-1) have shown significant promise in the treatment of advanced stage malignancy. With the recent expansion of indications for use of these agents, the number of patients treated will continue to grow. Clinicians must be aware of their potential for serious adverse side effects, including dermatitis, colitis, and potentially life-threatening pneumonitis.

The development of pneumonitis secondary to PD-1 inhibitions is reported to occur in 2% to 5% of patients and can present at any time during therapy, with 1% of patients developing grade 3 or higher pneumonitis.^1,2 The most common symptoms are dyspnea and cough, though one-third of patients are asymptomatic at presentation.² Radiographic and pathologic features vary greatly and include organizing pneumonia, interstitial pneumonitis, hypersensitivity pneumonitis, or diffuse alveolar damage.³ While pneumonitis due to PD-1 inhibition is reportedly uncommon, the increasing number of patients expected to receive these medications will predictably result in increasing overall frequency of pneumonitis cases. In addition, the lack of large prospective randomized trials and reliance on radiographic rather than pathologic data in diagnosing immune-mediated pneumonitis gives one pause. Given the variability of presentation, lack of routine pathologic data, and increasing use of dual agents (eg, PD-1 and CTLA-4), chest physicians and medical oncologists should have a high index of suspicion yet practice equipoise in patients receiving immunotherapy who develop unexplained pulmonary symptoms or infiltrates. More research is needed to help improve the multidisciplinary diagnosis and treatment of this potentially serious complication.

David Maurice Chambers, MD
Fellow-in-Training Member

Jason Atticus Akulian, MD, MPH
Steering Committee Member

References

1. Nishino M, et al. Incidence of programmed cell death 1 inhibitor-related pneumonitis in patients with advanced cancer: a systematic review and meta-analysis. JAMA Oncology. 2016;2(12):1607.

2. Naidoo J, et al. Pneumonitis in patients treated with anti-programmed death-1/programmed death ligand 1 therapy. J Clin Oncol. 2017;35(7):709.

3. Nishino M, et al. PD-1 inhibitor-related pneumonitis in advanced cancer patients: radiographic patterns and clinical course. Clin Cancer Res. 2016;22(24):6051.

Pulmonary Vascular Disease

Pulmonary Arterial Hypertension Associated With SLE

While pulmonary arterial hypertension (PAH) commonly complicates scleroderma (SSc), it is a rare complication of other connective tissue diseases (CTD), such as systemic lupus erythematosus (SLE). In the few prospective studies that utilize right-sided heart catheterization (RHC), the estimated prevalence of PAH in SLE is about 4%. However, since the prevalence of SLE is 10 to 15 times greater than SSc in the United States, the true prevalence of SLE-PAH may be higher than previously thought, and, thus, clinically relevant. Despite this, little is known about SLE-PAH.

A recent retrospective study from the French Pulmonary Hypertension Registry has added significantly to our understanding of this complication of SLE. Hachulla and colleagues studied 51 patients with RHC-proven SLE-PAH compared with 101 SLE control subjects without PAH. While the authors did not find any relevant differences in the demographics between groups, they did find a significantly higher prevalence of SSA and SSB antibodies in SLE-PAH. Interestingly, the presence of anti-U1 RNP antibody appeared to be less common in SLE-PAH patients; this lack of association is in contrast to prior studies in mixed CTD patients with anti-U1 RNP antibodies in which the prevalence of PAH can be as high as 60%. Further, none of the SLE-PAH patients demonstrated an acute response to vasodilator challenge during RHC, emphasizing that this maneuver does not need to be performed in SLE patients at risk of PAH. Trends toward improved survival in SLE-PAH patients treated with hydroxychloroquine are preliminary and hypothesis-generating but require confirmation in larger clinical studies.

Stephen Mathai, MD, FCCP
Chair

Leena Palwar, MD
Fellow-in-Training Member

References

Hachulla E, Jais X, Cinquetti G, et al. Pulmonary arterial hypertension associated with SLE: Results from the French pulmonary hypertension registry. Chest. 2017 Aug 26. pii: S0012-3692(17)31430-7. doi: 10.1016/j.chest.2017.08.014. [Epub ahead of print]

Chung L, Liu J, Parsons L, et al. Characterization of connective tissue disease-associated pulmonary arterial hypertension from REVEAL: identifying systemic sclerosis as a unique phenotype. Chest. 2010;138:1383-1394.

Shirai Y, Yasuoka H, Okano Y, Takeuchi T, Satoh T, Kuwana M. Clinical characteristics and survival of Japanese patients with connective tissue disease and pulmonary arterial hypertension: a singlecentre cohort. Rheumatology. 2012;51:1846-1854.

Hao YJ, Jiang X, Zhou W, et al. Connective tissue disease-associated pulmonary arterial hypertension in Chinese patients. Eur Respir J. 2014;44: 963-972.

Huang C, Li M, Liu Y, et al. Baseline characteristics and risk factors of pulmonary arterial hypertension in systemic lupus erythematosus patients. Medicine. 2016;95:e2761.

Pérez-Peñate GM, Rúa-Figueroa I, Juliá- Serdá G, et al. Pulmonary arterial hypertension in systemic lupus erythematosus: prevalence and predictors. J Rheumatol. 2016;43:323-329.

Alpert MA, Goldberg SH, Sindem BH, et al. Cardiovascular manifestations of mixed connective tissue disease in adults. Circulation. 1983;63:1182-1193.

Interventional Chest/Diagnostic Procedures

Cryobiopsy for ILD: Careful stewardship needed

Interest in transbronchial cryobiopsy has accelerated rapidly in recent years. This procedure is performed by advancing a cryoprobe into the peripheral lung via flexible bronchoscopy, where lung tissue freezes and adheres to the probe and is subsequently extracted as a cryobiopsy. The number of cryobiopsy-related publications has increased exponentially since it was described in 2009 (Babiak A, et al. Respiration. 2009;78[2]:203). This interest stems from reports of high diagnostic yields in patients with interstitial lung disease (ILD) while maintaining complication rates similar to that of conventional bronchoscopic biopsy.

Traditional bronchoscopic biopsies are notoriously insensitive; a specific diagnosis can be established in fewer than a third of cases (Sheth JS, et al. Chest. 2017;151[2]:389). As such, surgical lung biopsy continues to be recommended but is associated with significant mortality (2%) and morbidity (30%) in patients with ILD (Hutchinson JP, et al. ARJCCM. 2016;193[10]:1161). Cryobiopsy, which appears to rival surgical lung biopsy in terms of ability to contribute to a specific diagnosis, is, therefore, a highly promising alternative (Tomassetti S, et al. AJRCCM. 2016;193[7]:745).

As cryobiopsy is increasingly adopted around the world, however, troubling reports of serious complications have surfaced. Most notable is the recently reported experience of the initial 25 cases performed at the University of Pennsylvania, in which almost one in four patients suffered serious complications (DiBardino DM, et al. Ann Am Thorac Soc. 2017;14[6]:851). The authors pointed to lack of a predefined procedural protocol, as well as several choices relating to the specific technique used, including inconsistent use of fluoroscopy, lack of prophylactic bronchial blocker placement, and predominant use of laryngeal mask airways as potential contributing factors. Indeed, many variations of the basic cryobiopsy procedure have been described (Lentz RJ, et al. J Thoracic Dis. 2017;9[7]:2186), with no formal guidance or training available to inform advanced bronchoscopists interested in this procedure.

It is incumbent on the interventional pulmonology and ILD specialist communities to be responsible stewards of this promising procedure. Implementation of three parallel efforts to standardize and rigorously study this procedure should be considered as soon as possible: creation of expert consensus guidelines establishing best-practices for safe and effective biopsy technique; a training requirement before independent performance of the procedure; and creation of an international cryobiopsy registry to facilitate higher-quality research into optimal technique and outcomes. We owe this to our patients.

Robert J. Lentz, MD
NetWork Member

Fabien Maldonado, MD, FCCP
NetWork Member

Pediatric Chest Medicine

Chronic cough in children: New guidelines

A chronic cough is a common complaint among children whose parents seek medical evaluation. Chronic wet cough can indicate an underlying illness; therefore, an early diagnosis can lead to prevention of complications of the disease and improvement in quality of life.

CHEST is a leading resource in evidence and consensus-based guidelines on important topics affecting children. The most recent guidelines entitled Management of Children with Chronic Wet Cough and Protracted Bacterial Bronchitis (Chest. 2017;151(4):884-890) and Use of Management Pathways or Algorithms in Children with Chronic Cough (Chest. 2017;151(4):875-873) are updates from the 2006 CHEST guidelines on chronic cough in children.

The present updates utilized the CHEST methodological guidelines with chronic wet or productive cough and Grading of Recommendations Assessment, Development, and Evaluation framework and also performed a systematic review addressing key questions concerning the management of childhood disease for children 14 years and younger.

Guidance provided by the expert panel focused on recommendations to answer six key questions concerning the management of children 14 years and younger with a chronic wet cough unrelated to established chronic lung disease. The recommendations are:

1. Chronic cough is defined as the presence of a cough 4 weeks or longer in duration.

2. Assessment of the effect of the cough on the child and the family be undertaken as part of clinical consultation.

3. Evaluation of a chronic cough should be done with a systematic approach with pediatric-specific cough management protocols or algorithms.

4. Chest radiograph and, when age appropriate, spirometry with bronchodilator be undertaken as evaluation; tests for pertussis infection only to be performed if clinically suspected.

5. Chronic wet cough with no specific clinical features should receive antibiotics for 2 weeks targeted for common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis).

6. When cough persists despite 2 weeks of appropriate antibiotics, it is recommended to continue for an additional 2 weeks.

7. Additional tests (eg skin prick test, Mantoux, bronchoscopy, chest CT scan) should be individualized in accordance with the clinical setting and child’s clinical symptoms and signs.

The panel recognizes the need for prospective studies to assess current algorithms outcomes of children with chronic cough. Both articles can be found on the guidelines section of the CHEST site.

John Bishara, DO
Fellow-in-Training Member

Pulmonary Physiology, Function, and Rehabilitation

Functional imaging of the lung

Quantifying heterogeneity of ventilation and gas exchange in lung diseases remains a clinical challenge. Conventional pulmonary function test is insensitive to regional changes. The multiple inert gas elimination technique can quantify ventilation-perfusion distribution, but it requires invasive instrumentation (eg, pulmonary artery catheterization) and is not practical for clinical use. Computed tomography (CT) scans delineate spatial changes in lung structures but do not directly measure changes in ventilation and gas exchange. With its radiation, it is difficult to apply CT scanning repeatedly in patients. More recently, MR imaging techniques have been developed to directly “visualize” and quantify regional lung function (Kruger SJ, et al. J Magn Reson Imaging. 2016;43(2):295; Roos JE, et al. Magn Reson Imaging Clin N Am. 2015;23(2):217). These techniques employ inhalation of gases, such as oxygen, perfluorinated gases, and hyperpolarized ³He and ¹²⁹Xe. Hyperpolarized ³He has been studied the most; however, the dwindling supply of ³He gas and its rising cost have prevented its further development. ¹²⁹Xe has abundant supply and has emerged to be the inert gas of choice for MR imaging. Hyperpolarized ¹²⁹Xe can measure ventilation, like hyperpolarized ³He. In addition, Xe diffuses into alveolar barrier (interstitium and plasma) and red blood cells, where it exhibits distinct resonant frequency shifts that can be captured by MR. Therefore, in one test, information on pulmonary ventilation and gas transfer can be obtained. To date, the results from MR imaging studies have provided new insights into the pathophysiology of obstructive and restrictive lung diseases. With continuous development, MR imaging of the lung could become a clinically useful tool in the near future.

Yuh-Chin T. Huang, MD, MHS, FCCP

Steering Committee Member

Immune-mediated pneumonitis and PD-1 inhibition

Inhibitors of the programmed cell death 1 receptor (PD-1) have shown significant promise in the treatment of advanced stage malignancy. With the recent expansion of indications for use of these agents, the number of patients treated will continue to grow. Clinicians must be aware of their potential for serious adverse side effects, including dermatitis, colitis, and potentially life-threatening pneumonitis.

The development of pneumonitis secondary to PD-1 inhibitions is reported to occur in 2% to 5% of patients and can present at any time during therapy, with 1% of patients developing grade 3 or higher pneumonitis.^1,2 The most common symptoms are dyspnea and cough, though one-third of patients are asymptomatic at presentation.² Radiographic and pathologic features vary greatly and include organizing pneumonia, interstitial pneumonitis, hypersensitivity pneumonitis, or diffuse alveolar damage.³ While pneumonitis due to PD-1 inhibition is reportedly uncommon, the increasing number of patients expected to receive these medications will predictably result in increasing overall frequency of pneumonitis cases. In addition, the lack of large prospective randomized trials and reliance on radiographic rather than pathologic data in diagnosing immune-mediated pneumonitis gives one pause. Given the variability of presentation, lack of routine pathologic data, and increasing use of dual agents (eg, PD-1 and CTLA-4), chest physicians and medical oncologists should have a high index of suspicion yet practice equipoise in patients receiving immunotherapy who develop unexplained pulmonary symptoms or infiltrates. More research is needed to help improve the multidisciplinary diagnosis and treatment of this potentially serious complication.

David Maurice Chambers, MD
Fellow-in-Training Member

Jason Atticus Akulian, MD, MPH
Steering Committee Member

References

1. Nishino M, et al. Incidence of programmed cell death 1 inhibitor-related pneumonitis in patients with advanced cancer: a systematic review and meta-analysis. JAMA Oncology. 2016;2(12):1607.

2. Naidoo J, et al. Pneumonitis in patients treated with anti-programmed death-1/programmed death ligand 1 therapy. J Clin Oncol. 2017;35(7):709.

3. Nishino M, et al. PD-1 inhibitor-related pneumonitis in advanced cancer patients: radiographic patterns and clinical course. Clin Cancer Res. 2016;22(24):6051.

Pulmonary Vascular Disease

Pulmonary Arterial Hypertension Associated With SLE

While pulmonary arterial hypertension (PAH) commonly complicates scleroderma (SSc), it is a rare complication of other connective tissue diseases (CTD), such as systemic lupus erythematosus (SLE). In the few prospective studies that utilize right-sided heart catheterization (RHC), the estimated prevalence of PAH in SLE is about 4%. However, since the prevalence of SLE is 10 to 15 times greater than SSc in the United States, the true prevalence of SLE-PAH may be higher than previously thought, and, thus, clinically relevant. Despite this, little is known about SLE-PAH.

A recent retrospective study from the French Pulmonary Hypertension Registry has added significantly to our understanding of this complication of SLE. Hachulla and colleagues studied 51 patients with RHC-proven SLE-PAH compared with 101 SLE control subjects without PAH. While the authors did not find any relevant differences in the demographics between groups, they did find a significantly higher prevalence of SSA and SSB antibodies in SLE-PAH. Interestingly, the presence of anti-U1 RNP antibody appeared to be less common in SLE-PAH patients; this lack of association is in contrast to prior studies in mixed CTD patients with anti-U1 RNP antibodies in which the prevalence of PAH can be as high as 60%. Further, none of the SLE-PAH patients demonstrated an acute response to vasodilator challenge during RHC, emphasizing that this maneuver does not need to be performed in SLE patients at risk of PAH. Trends toward improved survival in SLE-PAH patients treated with hydroxychloroquine are preliminary and hypothesis-generating but require confirmation in larger clinical studies.

Stephen Mathai, MD, FCCP
Chair

Leena Palwar, MD
Fellow-in-Training Member

References

Hachulla E, Jais X, Cinquetti G, et al. Pulmonary arterial hypertension associated with SLE: Results from the French pulmonary hypertension registry. Chest. 2017 Aug 26. pii: S0012-3692(17)31430-7. doi: 10.1016/j.chest.2017.08.014. [Epub ahead of print]

Chung L, Liu J, Parsons L, et al. Characterization of connective tissue disease-associated pulmonary arterial hypertension from REVEAL: identifying systemic sclerosis as a unique phenotype. Chest. 2010;138:1383-1394.

Shirai Y, Yasuoka H, Okano Y, Takeuchi T, Satoh T, Kuwana M. Clinical characteristics and survival of Japanese patients with connective tissue disease and pulmonary arterial hypertension: a singlecentre cohort. Rheumatology. 2012;51:1846-1854.

Hao YJ, Jiang X, Zhou W, et al. Connective tissue disease-associated pulmonary arterial hypertension in Chinese patients. Eur Respir J. 2014;44: 963-972.

Huang C, Li M, Liu Y, et al. Baseline characteristics and risk factors of pulmonary arterial hypertension in systemic lupus erythematosus patients. Medicine. 2016;95:e2761.

Pérez-Peñate GM, Rúa-Figueroa I, Juliá- Serdá G, et al. Pulmonary arterial hypertension in systemic lupus erythematosus: prevalence and predictors. J Rheumatol. 2016;43:323-329.

Alpert MA, Goldberg SH, Sindem BH, et al. Cardiovascular manifestations of mixed connective tissue disease in adults. Circulation. 1983;63:1182-1193.

Interventional Chest/Diagnostic Procedures

Cryobiopsy for ILD: Careful stewardship needed

Interest in transbronchial cryobiopsy has accelerated rapidly in recent years. This procedure is performed by advancing a cryoprobe into the peripheral lung via flexible bronchoscopy, where lung tissue freezes and adheres to the probe and is subsequently extracted as a cryobiopsy. The number of cryobiopsy-related publications has increased exponentially since it was described in 2009 (Babiak A, et al. Respiration. 2009;78[2]:203). This interest stems from reports of high diagnostic yields in patients with interstitial lung disease (ILD) while maintaining complication rates similar to that of conventional bronchoscopic biopsy.

Traditional bronchoscopic biopsies are notoriously insensitive; a specific diagnosis can be established in fewer than a third of cases (Sheth JS, et al. Chest. 2017;151[2]:389). As such, surgical lung biopsy continues to be recommended but is associated with significant mortality (2%) and morbidity (30%) in patients with ILD (Hutchinson JP, et al. ARJCCM. 2016;193[10]:1161). Cryobiopsy, which appears to rival surgical lung biopsy in terms of ability to contribute to a specific diagnosis, is, therefore, a highly promising alternative (Tomassetti S, et al. AJRCCM. 2016;193[7]:745).

As cryobiopsy is increasingly adopted around the world, however, troubling reports of serious complications have surfaced. Most notable is the recently reported experience of the initial 25 cases performed at the University of Pennsylvania, in which almost one in four patients suffered serious complications (DiBardino DM, et al. Ann Am Thorac Soc. 2017;14[6]:851). The authors pointed to lack of a predefined procedural protocol, as well as several choices relating to the specific technique used, including inconsistent use of fluoroscopy, lack of prophylactic bronchial blocker placement, and predominant use of laryngeal mask airways as potential contributing factors. Indeed, many variations of the basic cryobiopsy procedure have been described (Lentz RJ, et al. J Thoracic Dis. 2017;9[7]:2186), with no formal guidance or training available to inform advanced bronchoscopists interested in this procedure.

It is incumbent on the interventional pulmonology and ILD specialist communities to be responsible stewards of this promising procedure. Implementation of three parallel efforts to standardize and rigorously study this procedure should be considered as soon as possible: creation of expert consensus guidelines establishing best-practices for safe and effective biopsy technique; a training requirement before independent performance of the procedure; and creation of an international cryobiopsy registry to facilitate higher-quality research into optimal technique and outcomes. We owe this to our patients.

Robert J. Lentz, MD
NetWork Member

Fabien Maldonado, MD, FCCP
NetWork Member

Pediatric Chest Medicine

Chronic cough in children: New guidelines

A chronic cough is a common complaint among children whose parents seek medical evaluation. Chronic wet cough can indicate an underlying illness; therefore, an early diagnosis can lead to prevention of complications of the disease and improvement in quality of life.

CHEST is a leading resource in evidence and consensus-based guidelines on important topics affecting children. The most recent guidelines entitled Management of Children with Chronic Wet Cough and Protracted Bacterial Bronchitis (Chest. 2017;151(4):884-890) and Use of Management Pathways or Algorithms in Children with Chronic Cough (Chest. 2017;151(4):875-873) are updates from the 2006 CHEST guidelines on chronic cough in children.

The present updates utilized the CHEST methodological guidelines with chronic wet or productive cough and Grading of Recommendations Assessment, Development, and Evaluation framework and also performed a systematic review addressing key questions concerning the management of childhood disease for children 14 years and younger.

Guidance provided by the expert panel focused on recommendations to answer six key questions concerning the management of children 14 years and younger with a chronic wet cough unrelated to established chronic lung disease. The recommendations are:

1. Chronic cough is defined as the presence of a cough 4 weeks or longer in duration.

2. Assessment of the effect of the cough on the child and the family be undertaken as part of clinical consultation.

3. Evaluation of a chronic cough should be done with a systematic approach with pediatric-specific cough management protocols or algorithms.

4. Chest radiograph and, when age appropriate, spirometry with bronchodilator be undertaken as evaluation; tests for pertussis infection only to be performed if clinically suspected.

5. Chronic wet cough with no specific clinical features should receive antibiotics for 2 weeks targeted for common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis).

6. When cough persists despite 2 weeks of appropriate antibiotics, it is recommended to continue for an additional 2 weeks.

7. Additional tests (eg skin prick test, Mantoux, bronchoscopy, chest CT scan) should be individualized in accordance with the clinical setting and child’s clinical symptoms and signs.

The panel recognizes the need for prospective studies to assess current algorithms outcomes of children with chronic cough. Both articles can be found on the guidelines section of the CHEST site.

John Bishara, DO
Fellow-in-Training Member

Pulmonary Physiology, Function, and Rehabilitation

Functional imaging of the lung

Quantifying heterogeneity of ventilation and gas exchange in lung diseases remains a clinical challenge. Conventional pulmonary function test is insensitive to regional changes. The multiple inert gas elimination technique can quantify ventilation-perfusion distribution, but it requires invasive instrumentation (eg, pulmonary artery catheterization) and is not practical for clinical use. Computed tomography (CT) scans delineate spatial changes in lung structures but do not directly measure changes in ventilation and gas exchange. With its radiation, it is difficult to apply CT scanning repeatedly in patients. More recently, MR imaging techniques have been developed to directly “visualize” and quantify regional lung function (Kruger SJ, et al. J Magn Reson Imaging. 2016;43(2):295; Roos JE, et al. Magn Reson Imaging Clin N Am. 2015;23(2):217). These techniques employ inhalation of gases, such as oxygen, perfluorinated gases, and hyperpolarized ³He and ¹²⁹Xe. Hyperpolarized ³He has been studied the most; however, the dwindling supply of ³He gas and its rising cost have prevented its further development. ¹²⁹Xe has abundant supply and has emerged to be the inert gas of choice for MR imaging. Hyperpolarized ¹²⁹Xe can measure ventilation, like hyperpolarized ³He. In addition, Xe diffuses into alveolar barrier (interstitium and plasma) and red blood cells, where it exhibits distinct resonant frequency shifts that can be captured by MR. Therefore, in one test, information on pulmonary ventilation and gas transfer can be obtained. To date, the results from MR imaging studies have provided new insights into the pathophysiology of obstructive and restrictive lung diseases. With continuous development, MR imaging of the lung could become a clinically useful tool in the near future.

Yuh-Chin T. Huang, MD, MHS, FCCP

Steering Committee Member

Immune-mediated pneumonitis and PD-1 inhibition

Inhibitors of the programmed cell death 1 receptor (PD-1) have shown significant promise in the treatment of advanced stage malignancy. With the recent expansion of indications for use of these agents, the number of patients treated will continue to grow. Clinicians must be aware of their potential for serious adverse side effects, including dermatitis, colitis, and potentially life-threatening pneumonitis.

The development of pneumonitis secondary to PD-1 inhibitions is reported to occur in 2% to 5% of patients and can present at any time during therapy, with 1% of patients developing grade 3 or higher pneumonitis.^1,2 The most common symptoms are dyspnea and cough, though one-third of patients are asymptomatic at presentation.² Radiographic and pathologic features vary greatly and include organizing pneumonia, interstitial pneumonitis, hypersensitivity pneumonitis, or diffuse alveolar damage.³ While pneumonitis due to PD-1 inhibition is reportedly uncommon, the increasing number of patients expected to receive these medications will predictably result in increasing overall frequency of pneumonitis cases. In addition, the lack of large prospective randomized trials and reliance on radiographic rather than pathologic data in diagnosing immune-mediated pneumonitis gives one pause. Given the variability of presentation, lack of routine pathologic data, and increasing use of dual agents (eg, PD-1 and CTLA-4), chest physicians and medical oncologists should have a high index of suspicion yet practice equipoise in patients receiving immunotherapy who develop unexplained pulmonary symptoms or infiltrates. More research is needed to help improve the multidisciplinary diagnosis and treatment of this potentially serious complication.

David Maurice Chambers, MD
Fellow-in-Training Member

Jason Atticus Akulian, MD, MPH
Steering Committee Member

References

1. Nishino M, et al. Incidence of programmed cell death 1 inhibitor-related pneumonitis in patients with advanced cancer: a systematic review and meta-analysis. JAMA Oncology. 2016;2(12):1607.

2. Naidoo J, et al. Pneumonitis in patients treated with anti-programmed death-1/programmed death ligand 1 therapy. J Clin Oncol. 2017;35(7):709.

3. Nishino M, et al. PD-1 inhibitor-related pneumonitis in advanced cancer patients: radiographic patterns and clinical course. Clin Cancer Res. 2016;22(24):6051.

Pulmonary Vascular Disease

Pulmonary Arterial Hypertension Associated With SLE

While pulmonary arterial hypertension (PAH) commonly complicates scleroderma (SSc), it is a rare complication of other connective tissue diseases (CTD), such as systemic lupus erythematosus (SLE). In the few prospective studies that utilize right-sided heart catheterization (RHC), the estimated prevalence of PAH in SLE is about 4%. However, since the prevalence of SLE is 10 to 15 times greater than SSc in the United States, the true prevalence of SLE-PAH may be higher than previously thought, and, thus, clinically relevant. Despite this, little is known about SLE-PAH.

A recent retrospective study from the French Pulmonary Hypertension Registry has added significantly to our understanding of this complication of SLE. Hachulla and colleagues studied 51 patients with RHC-proven SLE-PAH compared with 101 SLE control subjects without PAH. While the authors did not find any relevant differences in the demographics between groups, they did find a significantly higher prevalence of SSA and SSB antibodies in SLE-PAH. Interestingly, the presence of anti-U1 RNP antibody appeared to be less common in SLE-PAH patients; this lack of association is in contrast to prior studies in mixed CTD patients with anti-U1 RNP antibodies in which the prevalence of PAH can be as high as 60%. Further, none of the SLE-PAH patients demonstrated an acute response to vasodilator challenge during RHC, emphasizing that this maneuver does not need to be performed in SLE patients at risk of PAH. Trends toward improved survival in SLE-PAH patients treated with hydroxychloroquine are preliminary and hypothesis-generating but require confirmation in larger clinical studies.

Stephen Mathai, MD, FCCP
Chair

Leena Palwar, MD
Fellow-in-Training Member

References

Hachulla E, Jais X, Cinquetti G, et al. Pulmonary arterial hypertension associated with SLE: Results from the French pulmonary hypertension registry. Chest. 2017 Aug 26. pii: S0012-3692(17)31430-7. doi: 10.1016/j.chest.2017.08.014. [Epub ahead of print]

Chung L, Liu J, Parsons L, et al. Characterization of connective tissue disease-associated pulmonary arterial hypertension from REVEAL: identifying systemic sclerosis as a unique phenotype. Chest. 2010;138:1383-1394.

Shirai Y, Yasuoka H, Okano Y, Takeuchi T, Satoh T, Kuwana M. Clinical characteristics and survival of Japanese patients with connective tissue disease and pulmonary arterial hypertension: a singlecentre cohort. Rheumatology. 2012;51:1846-1854.

Hao YJ, Jiang X, Zhou W, et al. Connective tissue disease-associated pulmonary arterial hypertension in Chinese patients. Eur Respir J. 2014;44: 963-972.

Huang C, Li M, Liu Y, et al. Baseline characteristics and risk factors of pulmonary arterial hypertension in systemic lupus erythematosus patients. Medicine. 2016;95:e2761.

Pérez-Peñate GM, Rúa-Figueroa I, Juliá- Serdá G, et al. Pulmonary arterial hypertension in systemic lupus erythematosus: prevalence and predictors. J Rheumatol. 2016;43:323-329.

Alpert MA, Goldberg SH, Sindem BH, et al. Cardiovascular manifestations of mixed connective tissue disease in adults. Circulation. 1983;63:1182-1193.