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Vaccination: An Important Step in Protecting Health

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Patients with chronic lung conditions, like COPD and asthma, need to take extra steps to manage their condition and ensure the healthiest possible future. One important step that may not always be top of mind is vaccination, which can protect against common preventable diseases that may be very serious for those with respiratory conditions. CDC recommends adults with COPD, asthma, and other lung diseases get an annual flu vaccine, as well as stay up to date with pneumococcal and other recommended vaccines. Additional vaccines may be indicated based on age, job, travel locations, and lifestyle.

COPD and asthma cause airways to swell and become blocked with mucus, making it hard to breathe. Certain vaccine-preventable diseases can make this even worse. Adults with COPD and asthma are at increased risk of complications from influenza, including pneumonia and hospitalization. They are also at higher risk for invasive pneumococcal disease and more likely to develop infections including bacteremia and meningitis. Each year, thousands of adults needlessly suffer, are hospitalized, and even die of diseases that could be prevented by vaccines. Despite increased risks, less than half of adults under 65 years with COPD and asthma have received influenza and pneumococcal vaccination (National Health Information Survey 2015).

Find the latest recommended adult immunization schedule at www.cdc.gov/vaccines/hcp/adults.

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Patients with chronic lung conditions, like COPD and asthma, need to take extra steps to manage their condition and ensure the healthiest possible future. One important step that may not always be top of mind is vaccination, which can protect against common preventable diseases that may be very serious for those with respiratory conditions. CDC recommends adults with COPD, asthma, and other lung diseases get an annual flu vaccine, as well as stay up to date with pneumococcal and other recommended vaccines. Additional vaccines may be indicated based on age, job, travel locations, and lifestyle.

COPD and asthma cause airways to swell and become blocked with mucus, making it hard to breathe. Certain vaccine-preventable diseases can make this even worse. Adults with COPD and asthma are at increased risk of complications from influenza, including pneumonia and hospitalization. They are also at higher risk for invasive pneumococcal disease and more likely to develop infections including bacteremia and meningitis. Each year, thousands of adults needlessly suffer, are hospitalized, and even die of diseases that could be prevented by vaccines. Despite increased risks, less than half of adults under 65 years with COPD and asthma have received influenza and pneumococcal vaccination (National Health Information Survey 2015).

Find the latest recommended adult immunization schedule at www.cdc.gov/vaccines/hcp/adults.

 

Patients with chronic lung conditions, like COPD and asthma, need to take extra steps to manage their condition and ensure the healthiest possible future. One important step that may not always be top of mind is vaccination, which can protect against common preventable diseases that may be very serious for those with respiratory conditions. CDC recommends adults with COPD, asthma, and other lung diseases get an annual flu vaccine, as well as stay up to date with pneumococcal and other recommended vaccines. Additional vaccines may be indicated based on age, job, travel locations, and lifestyle.

COPD and asthma cause airways to swell and become blocked with mucus, making it hard to breathe. Certain vaccine-preventable diseases can make this even worse. Adults with COPD and asthma are at increased risk of complications from influenza, including pneumonia and hospitalization. They are also at higher risk for invasive pneumococcal disease and more likely to develop infections including bacteremia and meningitis. Each year, thousands of adults needlessly suffer, are hospitalized, and even die of diseases that could be prevented by vaccines. Despite increased risks, less than half of adults under 65 years with COPD and asthma have received influenza and pneumococcal vaccination (National Health Information Survey 2015).

Find the latest recommended adult immunization schedule at www.cdc.gov/vaccines/hcp/adults.

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NETWORKS Health-care weaponization, PTSD, depression in caregivers Disaster Response Practice Operations Transplant Women’s Health

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The tragic weaponization of health care

The Syrian conflict has highlighted the dangers to health-care workers (HCWs) in humanitarian crises. The Lancet-American University of Beirut Commission on Syria reports on the weaponization of health care in Syria – a strategy of depriving people of their health-care needs. Targeting of HCWs was recognized early in the Syrian war with targeting of health-care facilities being frequently reported throughout the conflict. HCWs facing extreme supply shortages have been reported to resort to desperate measures: using urine bags with added anticoagulants for blood collection and crafting homemade external fixators for fractures. Sadly, the Syrian conflict is not unique. The International Committee of the Red Cross (ICRC) documented 2,398 episodes of violence directed at health facilities in 11 countries affected by armed conflict between 2012 and 2014 alone. In Syria and elsewhere, the exodus of trained medical personnel, due to lack of medical training in trauma, emergency medicine, and intensive care, puts populations at further risk in these regions. The Inte

rnational Red Cross and Red Crescent Movement has started the Health Care in Danger (http://http://healthcareindanger.org) initiative to highlight this weaponization of health, supporting efforts by HCWs to advocate for their rights and their patients’ rights at a global level. This highlights the needs for CHEST members responding to humanitarian crises to ensure they have appropriate training to work in these environments and deploy with an organization that can provide adequate safeguards.

Dr. Maves is a military service member. The opinions expressed herein are his own and do not necessarily reflect the official opinions of the Department of the Navy, Department of Defense, or the US Government.

Rashmi Mishra, MD

Fellow-in-Training Member

Ryan Maves, MD, FCCP


Steering Committee Member

The House AHCA /Senate BCRA compared with ACA (Affordable Care Act)

Health-care costs are a fundamental driver of insurance costs, which leads to challenges to coverage affordability for millions of families. There is ongoing debate whether the current law (Affordable Care Act [ACA/Obamacare]) and the republican alternatives (American Healthcare Act [AHCA] and Better Care Reconciliation Act [BCRA]) do enough to address the cost challenges. Here is a brief summary of the key similarities and differences.

Similarities: (1) Children will be covered up to age 26. (2) Coverage of pre-existing conditions continues (high risk pools will be subsidized by a state government but premiums are up to twice as much as individual coverage). (3) Tax credit (based on age and family size rather than income level). (4) Insurance can charge older customers more than younger (up to 3X under ACA, 5X under AHCA/BCRA). (5) No annual or lifetime payout limit (but states may apply waivers allowing insurers to apply limits).

Differences: (1) Insurance will no longer be mandatory (no individual or employer mandates, but there is a 30% increase in premiums for 1 year for not maintaining individual continuous coverage). (2) Medicaid expansion (expanded under ACA to 133% of po

verty level income) will stop in 2020. (3) Restriction on “Abortion Funding” (any facility that offers abortion will not receive federal funding) for 1 year. (4) Taxes on health care will be removed (including taxes on prescription drugs, OTC, premiums, and medical devices). (5) Allowing policies for major illness or injury (with elimination of the requirement to cover ten essential health benefits, allowing states to modify).

Health-care reform undoubtedly is complicated, and there are a lot of questions in the air about the future of health care under the Trump Administration. Few certainties: change is coming, MACRA is here to stay.

Adel Bassily-Marcus, MD, FCCP

NetWork Chair

Posttraumatic Stress Disorder Post-Lung Transplant

The majority of transplant physicians are mainly concerned with issues posttransplant that are focused on the graft function. But recently, neurocognition and posttransplant posttraumatic stress disorder have been found to have significant impact on quality of life and mortality after transplantation. Posttraumatic stress disorder (PTSD) is described as re-experiencing a traumatic event in addition to having avoidant and hyperarousal symptoms, which last for a period of at least 1 month. Studies of PTSD in solid organ transplant recipients have revealed a significantly higher prevalence of PTSD symptoms (10% to 17%) compared with the general population (prevalence of 3.5% to 6%). In one study of heart transplant recipients, patients who met the criteria for PTSD in the first year posttransplant had a higher risk for 3-year mortality (OR=13.74) [Dew et al. J Heart Lung Transplant. 1999;18[6]:549-562].

Lung transplant recipients are at a high risk for developing PTSD due to exposure to several traumatic events, such as a life-threatening exacerbation of the underlying lung disease, undergoing transplant surgery, intensive care unit stay, delirium and episodes of infection, and acute and chronic rejection. However, data regarding the prevalence and risk factors for PTSD post-lung transplant are limited.

The prevalence of PTSD post lung transplantation has been reported to be 12.6% to 15.8%. In lung transplant recipients with clinically significant PTSD symptomatology; the presence of symptoms of re-experiencing (29.5%) and arousal (33.8%) were more common than avoidant symptoms (18.4%) [Gries et al. J Heart Lung Transplant. 2013; 32[5]: 525-532]. In another study by Dew et al, in 178 lung transplant recipients, all PTSD occurred in the early months posttransplant with a median duration of symptoms of 12 months (IQR 7.2 to 18.5 months) [Dew et al. Gen. Hosp Psychiatry. 2012;34:127-138]. A higher burden of PTSD is noted in patients who are younger, have a lo

wer income, have a previous history of a traumatic event, and have bronchiolitis obliterans (Gries et al. J Heart Lung Transplant. 2013;32[5]:525-532).

The challenges that remain include determining the true prevalence of PTSD in the lung transplant recipient in the LAS era using standard diagnostic criteria, documenting the adverse effects of PTSD on medical compliance, morbidity, and mortality; and developing interventions to mitigate the adverse effects of PTSD through well-designed multicenter prospective studies.

 

 

Vivek Ahya, MD

Steering Committee Member

Caregiver Burden in the ICU and Beyond

Family members of patients in the ICU who transition to the role of caregivers following discharge are at high risk for psychosocial distress. Post-intensive care syndrome-family (PICS-F) describes the symptoms of depression, posttraumatic stress, and anxiety commonly found in this population (Davidson et al. Crit Care Med. 2012;4(2):618-624). Women are more commonly called upon to adopt the role of caregiver for family members with chronic medical conditions or mental illnesses. Worldwide estimates indicate that 57% to 81% of all caregivers are women (Sharma et al. World J Psych. 2016;6[2]:7-17).

Family burden begins during the acute phase of critical illness. As surrogate decision-makers, they frequently face decisional conflict and decisional regret, especially in scenarios that limit life-sustaining therapies (Long et al. Curr Opin Crit Care. 2016;22:613-620). The prevalence of PICS-F is high as family members attempt to balance their role in the ICU with personal obligations (Choi et al. J Korean Acad Nurs. 2016;[46]2:159-167). Those who perceive that they are not receiving complete information from the medical team, and who do not find their physician comforting, have been shown to suffer a greater symptom burden (Davidson et al).

With the growing older adult population, and increased ICU survival, family members are often called upon to serve as caretakers to the chronically critically ill (Choi et al.). These caregivers have more depressive symptoms, worse health outcomes, and significant professional and personal lifestyle disruptions (Cameron, et al. N Engl J Med. 2016;[374]19:1831-1841). In many caregivers, depressive symptoms persist at 1 year after ICU admission, with rates comparable to caretakers of patients with dementia (Haines et al. Crit Care Med. 2015;(43)5:1112-1120). Caregivers who are younger, female, minorities, and those with pre-existing depression are at especially high risk for worse mental health outcomes (Davidson et al; Cameron et al).


Caregivers of ICU survivors are vulnerable and undersupported. Interventions such as ICU diaries, telephone-based mindfulness exercises, and stress management strategies have shown promise in alleviating PICS-F symptoms (Choi et al.). During the acute ICU stay, how medical providers communicate, and how we help family members make sense of what has happened and their new roles as caregivers have an impact (Davidson et al.). From an individual in a study of psychosocial morbidity in caregivers of ICU survivors: “Leaving the hospital is not the end for some people. The next place is just as hard, sometimes worse” (Haines et al. Further studies are needed to identify interventions that will truly address this population’s unique needs.

Margaret Pisani, MD, FCCP

Steering Committee Member

Nicole Bournival, MD

Fellow-in-Training Member

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The tragic weaponization of health care

The Syrian conflict has highlighted the dangers to health-care workers (HCWs) in humanitarian crises. The Lancet-American University of Beirut Commission on Syria reports on the weaponization of health care in Syria – a strategy of depriving people of their health-care needs. Targeting of HCWs was recognized early in the Syrian war with targeting of health-care facilities being frequently reported throughout the conflict. HCWs facing extreme supply shortages have been reported to resort to desperate measures: using urine bags with added anticoagulants for blood collection and crafting homemade external fixators for fractures. Sadly, the Syrian conflict is not unique. The International Committee of the Red Cross (ICRC) documented 2,398 episodes of violence directed at health facilities in 11 countries affected by armed conflict between 2012 and 2014 alone. In Syria and elsewhere, the exodus of trained medical personnel, due to lack of medical training in trauma, emergency medicine, and intensive care, puts populations at further risk in these regions. The Inte

rnational Red Cross and Red Crescent Movement has started the Health Care in Danger (http://http://healthcareindanger.org) initiative to highlight this weaponization of health, supporting efforts by HCWs to advocate for their rights and their patients’ rights at a global level. This highlights the needs for CHEST members responding to humanitarian crises to ensure they have appropriate training to work in these environments and deploy with an organization that can provide adequate safeguards.

Dr. Maves is a military service member. The opinions expressed herein are his own and do not necessarily reflect the official opinions of the Department of the Navy, Department of Defense, or the US Government.

Rashmi Mishra, MD

Fellow-in-Training Member

Ryan Maves, MD, FCCP


Steering Committee Member

The House AHCA /Senate BCRA compared with ACA (Affordable Care Act)

Health-care costs are a fundamental driver of insurance costs, which leads to challenges to coverage affordability for millions of families. There is ongoing debate whether the current law (Affordable Care Act [ACA/Obamacare]) and the republican alternatives (American Healthcare Act [AHCA] and Better Care Reconciliation Act [BCRA]) do enough to address the cost challenges. Here is a brief summary of the key similarities and differences.

Similarities: (1) Children will be covered up to age 26. (2) Coverage of pre-existing conditions continues (high risk pools will be subsidized by a state government but premiums are up to twice as much as individual coverage). (3) Tax credit (based on age and family size rather than income level). (4) Insurance can charge older customers more than younger (up to 3X under ACA, 5X under AHCA/BCRA). (5) No annual or lifetime payout limit (but states may apply waivers allowing insurers to apply limits).

Differences: (1) Insurance will no longer be mandatory (no individual or employer mandates, but there is a 30% increase in premiums for 1 year for not maintaining individual continuous coverage). (2) Medicaid expansion (expanded under ACA to 133% of po

verty level income) will stop in 2020. (3) Restriction on “Abortion Funding” (any facility that offers abortion will not receive federal funding) for 1 year. (4) Taxes on health care will be removed (including taxes on prescription drugs, OTC, premiums, and medical devices). (5) Allowing policies for major illness or injury (with elimination of the requirement to cover ten essential health benefits, allowing states to modify).

Health-care reform undoubtedly is complicated, and there are a lot of questions in the air about the future of health care under the Trump Administration. Few certainties: change is coming, MACRA is here to stay.

Adel Bassily-Marcus, MD, FCCP

NetWork Chair

Posttraumatic Stress Disorder Post-Lung Transplant

The majority of transplant physicians are mainly concerned with issues posttransplant that are focused on the graft function. But recently, neurocognition and posttransplant posttraumatic stress disorder have been found to have significant impact on quality of life and mortality after transplantation. Posttraumatic stress disorder (PTSD) is described as re-experiencing a traumatic event in addition to having avoidant and hyperarousal symptoms, which last for a period of at least 1 month. Studies of PTSD in solid organ transplant recipients have revealed a significantly higher prevalence of PTSD symptoms (10% to 17%) compared with the general population (prevalence of 3.5% to 6%). In one study of heart transplant recipients, patients who met the criteria for PTSD in the first year posttransplant had a higher risk for 3-year mortality (OR=13.74) [Dew et al. J Heart Lung Transplant. 1999;18[6]:549-562].

Lung transplant recipients are at a high risk for developing PTSD due to exposure to several traumatic events, such as a life-threatening exacerbation of the underlying lung disease, undergoing transplant surgery, intensive care unit stay, delirium and episodes of infection, and acute and chronic rejection. However, data regarding the prevalence and risk factors for PTSD post-lung transplant are limited.

The prevalence of PTSD post lung transplantation has been reported to be 12.6% to 15.8%. In lung transplant recipients with clinically significant PTSD symptomatology; the presence of symptoms of re-experiencing (29.5%) and arousal (33.8%) were more common than avoidant symptoms (18.4%) [Gries et al. J Heart Lung Transplant. 2013; 32[5]: 525-532]. In another study by Dew et al, in 178 lung transplant recipients, all PTSD occurred in the early months posttransplant with a median duration of symptoms of 12 months (IQR 7.2 to 18.5 months) [Dew et al. Gen. Hosp Psychiatry. 2012;34:127-138]. A higher burden of PTSD is noted in patients who are younger, have a lo

wer income, have a previous history of a traumatic event, and have bronchiolitis obliterans (Gries et al. J Heart Lung Transplant. 2013;32[5]:525-532).

The challenges that remain include determining the true prevalence of PTSD in the lung transplant recipient in the LAS era using standard diagnostic criteria, documenting the adverse effects of PTSD on medical compliance, morbidity, and mortality; and developing interventions to mitigate the adverse effects of PTSD through well-designed multicenter prospective studies.

 

 

Vivek Ahya, MD

Steering Committee Member

Caregiver Burden in the ICU and Beyond

Family members of patients in the ICU who transition to the role of caregivers following discharge are at high risk for psychosocial distress. Post-intensive care syndrome-family (PICS-F) describes the symptoms of depression, posttraumatic stress, and anxiety commonly found in this population (Davidson et al. Crit Care Med. 2012;4(2):618-624). Women are more commonly called upon to adopt the role of caregiver for family members with chronic medical conditions or mental illnesses. Worldwide estimates indicate that 57% to 81% of all caregivers are women (Sharma et al. World J Psych. 2016;6[2]:7-17).

Family burden begins during the acute phase of critical illness. As surrogate decision-makers, they frequently face decisional conflict and decisional regret, especially in scenarios that limit life-sustaining therapies (Long et al. Curr Opin Crit Care. 2016;22:613-620). The prevalence of PICS-F is high as family members attempt to balance their role in the ICU with personal obligations (Choi et al. J Korean Acad Nurs. 2016;[46]2:159-167). Those who perceive that they are not receiving complete information from the medical team, and who do not find their physician comforting, have been shown to suffer a greater symptom burden (Davidson et al).

With the growing older adult population, and increased ICU survival, family members are often called upon to serve as caretakers to the chronically critically ill (Choi et al.). These caregivers have more depressive symptoms, worse health outcomes, and significant professional and personal lifestyle disruptions (Cameron, et al. N Engl J Med. 2016;[374]19:1831-1841). In many caregivers, depressive symptoms persist at 1 year after ICU admission, with rates comparable to caretakers of patients with dementia (Haines et al. Crit Care Med. 2015;(43)5:1112-1120). Caregivers who are younger, female, minorities, and those with pre-existing depression are at especially high risk for worse mental health outcomes (Davidson et al; Cameron et al).


Caregivers of ICU survivors are vulnerable and undersupported. Interventions such as ICU diaries, telephone-based mindfulness exercises, and stress management strategies have shown promise in alleviating PICS-F symptoms (Choi et al.). During the acute ICU stay, how medical providers communicate, and how we help family members make sense of what has happened and their new roles as caregivers have an impact (Davidson et al.). From an individual in a study of psychosocial morbidity in caregivers of ICU survivors: “Leaving the hospital is not the end for some people. The next place is just as hard, sometimes worse” (Haines et al. Further studies are needed to identify interventions that will truly address this population’s unique needs.

Margaret Pisani, MD, FCCP

Steering Committee Member

Nicole Bournival, MD

Fellow-in-Training Member

 

The tragic weaponization of health care

The Syrian conflict has highlighted the dangers to health-care workers (HCWs) in humanitarian crises. The Lancet-American University of Beirut Commission on Syria reports on the weaponization of health care in Syria – a strategy of depriving people of their health-care needs. Targeting of HCWs was recognized early in the Syrian war with targeting of health-care facilities being frequently reported throughout the conflict. HCWs facing extreme supply shortages have been reported to resort to desperate measures: using urine bags with added anticoagulants for blood collection and crafting homemade external fixators for fractures. Sadly, the Syrian conflict is not unique. The International Committee of the Red Cross (ICRC) documented 2,398 episodes of violence directed at health facilities in 11 countries affected by armed conflict between 2012 and 2014 alone. In Syria and elsewhere, the exodus of trained medical personnel, due to lack of medical training in trauma, emergency medicine, and intensive care, puts populations at further risk in these regions. The Inte

rnational Red Cross and Red Crescent Movement has started the Health Care in Danger (http://http://healthcareindanger.org) initiative to highlight this weaponization of health, supporting efforts by HCWs to advocate for their rights and their patients’ rights at a global level. This highlights the needs for CHEST members responding to humanitarian crises to ensure they have appropriate training to work in these environments and deploy with an organization that can provide adequate safeguards.

Dr. Maves is a military service member. The opinions expressed herein are his own and do not necessarily reflect the official opinions of the Department of the Navy, Department of Defense, or the US Government.

Rashmi Mishra, MD

Fellow-in-Training Member

Ryan Maves, MD, FCCP


Steering Committee Member

The House AHCA /Senate BCRA compared with ACA (Affordable Care Act)

Health-care costs are a fundamental driver of insurance costs, which leads to challenges to coverage affordability for millions of families. There is ongoing debate whether the current law (Affordable Care Act [ACA/Obamacare]) and the republican alternatives (American Healthcare Act [AHCA] and Better Care Reconciliation Act [BCRA]) do enough to address the cost challenges. Here is a brief summary of the key similarities and differences.

Similarities: (1) Children will be covered up to age 26. (2) Coverage of pre-existing conditions continues (high risk pools will be subsidized by a state government but premiums are up to twice as much as individual coverage). (3) Tax credit (based on age and family size rather than income level). (4) Insurance can charge older customers more than younger (up to 3X under ACA, 5X under AHCA/BCRA). (5) No annual or lifetime payout limit (but states may apply waivers allowing insurers to apply limits).

Differences: (1) Insurance will no longer be mandatory (no individual or employer mandates, but there is a 30% increase in premiums for 1 year for not maintaining individual continuous coverage). (2) Medicaid expansion (expanded under ACA to 133% of po

verty level income) will stop in 2020. (3) Restriction on “Abortion Funding” (any facility that offers abortion will not receive federal funding) for 1 year. (4) Taxes on health care will be removed (including taxes on prescription drugs, OTC, premiums, and medical devices). (5) Allowing policies for major illness or injury (with elimination of the requirement to cover ten essential health benefits, allowing states to modify).

Health-care reform undoubtedly is complicated, and there are a lot of questions in the air about the future of health care under the Trump Administration. Few certainties: change is coming, MACRA is here to stay.

Adel Bassily-Marcus, MD, FCCP

NetWork Chair

Posttraumatic Stress Disorder Post-Lung Transplant

The majority of transplant physicians are mainly concerned with issues posttransplant that are focused on the graft function. But recently, neurocognition and posttransplant posttraumatic stress disorder have been found to have significant impact on quality of life and mortality after transplantation. Posttraumatic stress disorder (PTSD) is described as re-experiencing a traumatic event in addition to having avoidant and hyperarousal symptoms, which last for a period of at least 1 month. Studies of PTSD in solid organ transplant recipients have revealed a significantly higher prevalence of PTSD symptoms (10% to 17%) compared with the general population (prevalence of 3.5% to 6%). In one study of heart transplant recipients, patients who met the criteria for PTSD in the first year posttransplant had a higher risk for 3-year mortality (OR=13.74) [Dew et al. J Heart Lung Transplant. 1999;18[6]:549-562].

Lung transplant recipients are at a high risk for developing PTSD due to exposure to several traumatic events, such as a life-threatening exacerbation of the underlying lung disease, undergoing transplant surgery, intensive care unit stay, delirium and episodes of infection, and acute and chronic rejection. However, data regarding the prevalence and risk factors for PTSD post-lung transplant are limited.

The prevalence of PTSD post lung transplantation has been reported to be 12.6% to 15.8%. In lung transplant recipients with clinically significant PTSD symptomatology; the presence of symptoms of re-experiencing (29.5%) and arousal (33.8%) were more common than avoidant symptoms (18.4%) [Gries et al. J Heart Lung Transplant. 2013; 32[5]: 525-532]. In another study by Dew et al, in 178 lung transplant recipients, all PTSD occurred in the early months posttransplant with a median duration of symptoms of 12 months (IQR 7.2 to 18.5 months) [Dew et al. Gen. Hosp Psychiatry. 2012;34:127-138]. A higher burden of PTSD is noted in patients who are younger, have a lo

wer income, have a previous history of a traumatic event, and have bronchiolitis obliterans (Gries et al. J Heart Lung Transplant. 2013;32[5]:525-532).

The challenges that remain include determining the true prevalence of PTSD in the lung transplant recipient in the LAS era using standard diagnostic criteria, documenting the adverse effects of PTSD on medical compliance, morbidity, and mortality; and developing interventions to mitigate the adverse effects of PTSD through well-designed multicenter prospective studies.

 

 

Vivek Ahya, MD

Steering Committee Member

Caregiver Burden in the ICU and Beyond

Family members of patients in the ICU who transition to the role of caregivers following discharge are at high risk for psychosocial distress. Post-intensive care syndrome-family (PICS-F) describes the symptoms of depression, posttraumatic stress, and anxiety commonly found in this population (Davidson et al. Crit Care Med. 2012;4(2):618-624). Women are more commonly called upon to adopt the role of caregiver for family members with chronic medical conditions or mental illnesses. Worldwide estimates indicate that 57% to 81% of all caregivers are women (Sharma et al. World J Psych. 2016;6[2]:7-17).

Family burden begins during the acute phase of critical illness. As surrogate decision-makers, they frequently face decisional conflict and decisional regret, especially in scenarios that limit life-sustaining therapies (Long et al. Curr Opin Crit Care. 2016;22:613-620). The prevalence of PICS-F is high as family members attempt to balance their role in the ICU with personal obligations (Choi et al. J Korean Acad Nurs. 2016;[46]2:159-167). Those who perceive that they are not receiving complete information from the medical team, and who do not find their physician comforting, have been shown to suffer a greater symptom burden (Davidson et al).

With the growing older adult population, and increased ICU survival, family members are often called upon to serve as caretakers to the chronically critically ill (Choi et al.). These caregivers have more depressive symptoms, worse health outcomes, and significant professional and personal lifestyle disruptions (Cameron, et al. N Engl J Med. 2016;[374]19:1831-1841). In many caregivers, depressive symptoms persist at 1 year after ICU admission, with rates comparable to caretakers of patients with dementia (Haines et al. Crit Care Med. 2015;(43)5:1112-1120). Caregivers who are younger, female, minorities, and those with pre-existing depression are at especially high risk for worse mental health outcomes (Davidson et al; Cameron et al).


Caregivers of ICU survivors are vulnerable and undersupported. Interventions such as ICU diaries, telephone-based mindfulness exercises, and stress management strategies have shown promise in alleviating PICS-F symptoms (Choi et al.). During the acute ICU stay, how medical providers communicate, and how we help family members make sense of what has happened and their new roles as caregivers have an impact (Davidson et al.). From an individual in a study of psychosocial morbidity in caregivers of ICU survivors: “Leaving the hospital is not the end for some people. The next place is just as hard, sometimes worse” (Haines et al. Further studies are needed to identify interventions that will truly address this population’s unique needs.

Margaret Pisani, MD, FCCP

Steering Committee Member

Nicole Bournival, MD

Fellow-in-Training Member

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Learn What's New in Billing, Coding

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Learn the latest in billing, coding and reimbursement at the 2017 Coding and Reimbursement Workshop for vascular surgeons, Oct. 13-14 in Chicago.

Cost is $880 for SVS members or staff; $955 for non-members and $250 for residents and trainees.

The program will address and review 2018 updates and include information about the global surgical package and how it impacts billing and reimbursement, along with the application of modifiers for streamlined reimbursement.

An optional workshop on Evaluation and Management (E&M) coding will be held from 9 a.m. to noon Oct. 13.

Learn more and register here

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Learn the latest in billing, coding and reimbursement at the 2017 Coding and Reimbursement Workshop for vascular surgeons, Oct. 13-14 in Chicago.

Cost is $880 for SVS members or staff; $955 for non-members and $250 for residents and trainees.

The program will address and review 2018 updates and include information about the global surgical package and how it impacts billing and reimbursement, along with the application of modifiers for streamlined reimbursement.

An optional workshop on Evaluation and Management (E&M) coding will be held from 9 a.m. to noon Oct. 13.

Learn more and register here

Learn the latest in billing, coding and reimbursement at the 2017 Coding and Reimbursement Workshop for vascular surgeons, Oct. 13-14 in Chicago.

Cost is $880 for SVS members or staff; $955 for non-members and $250 for residents and trainees.

The program will address and review 2018 updates and include information about the global surgical package and how it impacts billing and reimbursement, along with the application of modifiers for streamlined reimbursement.

An optional workshop on Evaluation and Management (E&M) coding will be held from 9 a.m. to noon Oct. 13.

Learn more and register here

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Review Course is This Month

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Mon, 08/07/2017 - 10:34

Get an in-depth review of vascular surgery at the Second Annual UCLA/SVS Symposium: “A Comprehensive Review and Update of What’s New in Vascular and Endovascular Surgery," Aug. 26 to 28 in Beverly Hills, Calif.

This joint effort between UCLA and SVS is aimed at those preparing to take the vascular board examinations and also provides the basic didactic education for vascular residents and fellows in training.

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Get an in-depth review of vascular surgery at the Second Annual UCLA/SVS Symposium: “A Comprehensive Review and Update of What’s New in Vascular and Endovascular Surgery," Aug. 26 to 28 in Beverly Hills, Calif.

This joint effort between UCLA and SVS is aimed at those preparing to take the vascular board examinations and also provides the basic didactic education for vascular residents and fellows in training.

Get an in-depth review of vascular surgery at the Second Annual UCLA/SVS Symposium: “A Comprehensive Review and Update of What’s New in Vascular and Endovascular Surgery," Aug. 26 to 28 in Beverly Hills, Calif.

This joint effort between UCLA and SVS is aimed at those preparing to take the vascular board examinations and also provides the basic didactic education for vascular residents and fellows in training.

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VESAP4 Now Available

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Mon, 08/07/2017 - 10:32

The updated and improved VESAP4 is now available for purchase, in time for those preparing for qualification, certification and recertification exams.

A major enhancement of this fourth edition of the Vascular Education and Self-Assessment Program (VESAP) is the companion app – Apple products only – which lets users access the program off-line, in virtually any setting, and then later sync with the desktop version. The companion app will be available later this month.

VESAP4 also includes improved and simplified navigation, expanded bookmarking and annotation and easier certificate tracking.

Please note: VESAP3 expires at 11:59 p.m. Eastern Daylight Time on Sept. 1. Owners can continue to use it in learning mode until Sept. 15, but will no longer be able to claim credits. VESAP4 will expire July 31, 2020.

Purchase VESAP4 here.

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The updated and improved VESAP4 is now available for purchase, in time for those preparing for qualification, certification and recertification exams.

A major enhancement of this fourth edition of the Vascular Education and Self-Assessment Program (VESAP) is the companion app – Apple products only – which lets users access the program off-line, in virtually any setting, and then later sync with the desktop version. The companion app will be available later this month.

VESAP4 also includes improved and simplified navigation, expanded bookmarking and annotation and easier certificate tracking.

Please note: VESAP3 expires at 11:59 p.m. Eastern Daylight Time on Sept. 1. Owners can continue to use it in learning mode until Sept. 15, but will no longer be able to claim credits. VESAP4 will expire July 31, 2020.

Purchase VESAP4 here.

The updated and improved VESAP4 is now available for purchase, in time for those preparing for qualification, certification and recertification exams.

A major enhancement of this fourth edition of the Vascular Education and Self-Assessment Program (VESAP) is the companion app – Apple products only – which lets users access the program off-line, in virtually any setting, and then later sync with the desktop version. The companion app will be available later this month.

VESAP4 also includes improved and simplified navigation, expanded bookmarking and annotation and easier certificate tracking.

Please note: VESAP3 expires at 11:59 p.m. Eastern Daylight Time on Sept. 1. Owners can continue to use it in learning mode until Sept. 15, but will no longer be able to claim credits. VESAP4 will expire July 31, 2020.

Purchase VESAP4 here.

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This Month in CHEST: Editor’s picks

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Tue, 10/23/2018 - 16:10

Giants in Chest Medicine:

Steven E. Weinberger, MD, FCCP

By Dr. J. Mandel

Editorial

Precision Medicine Urgency: The Case of Inhaled Corticosteroids in COPD By Drs. S. Suissa and P. Ernst

Original Research

Physician Assessment of Pretest Probability of Malignancy and Adherence With Guidelines for Pulmonary Nodule Evaluation By Dr. N. T. Tanner, et al.

The Long-Term Effect of Bacille Calmette-Guérin Vaccination on Tuberculin Skin Testing: A 55-Year Follow-Up Study By Dr. J. D. Mancuso, et al.

Clinical Characteristics of Pertussis-Associated Cough in Adults and Children: A Diagnostic Systematic Review and Meta-Analysis By Dr. A. Moore, et al.

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Giants in Chest Medicine:

Steven E. Weinberger, MD, FCCP

By Dr. J. Mandel

Editorial

Precision Medicine Urgency: The Case of Inhaled Corticosteroids in COPD By Drs. S. Suissa and P. Ernst

Original Research

Physician Assessment of Pretest Probability of Malignancy and Adherence With Guidelines for Pulmonary Nodule Evaluation By Dr. N. T. Tanner, et al.

The Long-Term Effect of Bacille Calmette-Guérin Vaccination on Tuberculin Skin Testing: A 55-Year Follow-Up Study By Dr. J. D. Mancuso, et al.

Clinical Characteristics of Pertussis-Associated Cough in Adults and Children: A Diagnostic Systematic Review and Meta-Analysis By Dr. A. Moore, et al.

Giants in Chest Medicine:

Steven E. Weinberger, MD, FCCP

By Dr. J. Mandel

Editorial

Precision Medicine Urgency: The Case of Inhaled Corticosteroids in COPD By Drs. S. Suissa and P. Ernst

Original Research

Physician Assessment of Pretest Probability of Malignancy and Adherence With Guidelines for Pulmonary Nodule Evaluation By Dr. N. T. Tanner, et al.

The Long-Term Effect of Bacille Calmette-Guérin Vaccination on Tuberculin Skin Testing: A 55-Year Follow-Up Study By Dr. J. D. Mancuso, et al.

Clinical Characteristics of Pertussis-Associated Cough in Adults and Children: A Diagnostic Systematic Review and Meta-Analysis By Dr. A. Moore, et al.

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CHEST Membership News

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Tue, 10/23/2018 - 16:10
We’re Rewarding You

 

Introducing CHEST Participation Points

Everyday, you commit your time to helping patients. We recognize your dedication not only to your profession but to the CHEST community.

We’re happy to introduce CHEST Participation Points, designed to increase member recognition and reward you for participating and contributing to our diverse community. Wherever you are in your career, you can earn points for the things you do within the CHEST community.

Members can now earn 10, 20, or 30 points for participating in eligible activities such as attending CHEST Annual Meeting, submitting abstracts, participating in a CHEST Twitter chat, becoming a Fellow of the American College of Chest Physicians (FCCP), and more!

Once you receive 50, 100, or 150 points, you can redeem your points for CHEST-branded apparel or discounts on courses and products.

Point accrual started on July 5, so you’ve already been earning points. If you are an FCCP, you began with 30 points awarded for becoming FCCP—that’s only 20 points away from the first tier of prizes. To accrue or redeem points, you must be an active member and current with your dues.

Log in to your CHEST account, and access Participation Points in the left column to see your points.

Start earning more points today! Learn more at chestnet.org/participationpoints.

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We’re Rewarding You
We’re Rewarding You

 

Introducing CHEST Participation Points

Everyday, you commit your time to helping patients. We recognize your dedication not only to your profession but to the CHEST community.

We’re happy to introduce CHEST Participation Points, designed to increase member recognition and reward you for participating and contributing to our diverse community. Wherever you are in your career, you can earn points for the things you do within the CHEST community.

Members can now earn 10, 20, or 30 points for participating in eligible activities such as attending CHEST Annual Meeting, submitting abstracts, participating in a CHEST Twitter chat, becoming a Fellow of the American College of Chest Physicians (FCCP), and more!

Once you receive 50, 100, or 150 points, you can redeem your points for CHEST-branded apparel or discounts on courses and products.

Point accrual started on July 5, so you’ve already been earning points. If you are an FCCP, you began with 30 points awarded for becoming FCCP—that’s only 20 points away from the first tier of prizes. To accrue or redeem points, you must be an active member and current with your dues.

Log in to your CHEST account, and access Participation Points in the left column to see your points.

Start earning more points today! Learn more at chestnet.org/participationpoints.

 

Introducing CHEST Participation Points

Everyday, you commit your time to helping patients. We recognize your dedication not only to your profession but to the CHEST community.

We’re happy to introduce CHEST Participation Points, designed to increase member recognition and reward you for participating and contributing to our diverse community. Wherever you are in your career, you can earn points for the things you do within the CHEST community.

Members can now earn 10, 20, or 30 points for participating in eligible activities such as attending CHEST Annual Meeting, submitting abstracts, participating in a CHEST Twitter chat, becoming a Fellow of the American College of Chest Physicians (FCCP), and more!

Once you receive 50, 100, or 150 points, you can redeem your points for CHEST-branded apparel or discounts on courses and products.

Point accrual started on July 5, so you’ve already been earning points. If you are an FCCP, you began with 30 points awarded for becoming FCCP—that’s only 20 points away from the first tier of prizes. To accrue or redeem points, you must be an active member and current with your dues.

Log in to your CHEST account, and access Participation Points in the left column to see your points.

Start earning more points today! Learn more at chestnet.org/participationpoints.

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CHEST ® journal — new online home

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Tue, 10/23/2018 - 16:10

 

We are excited to share that the journal CHEST® has a new website with improved navigation, better search capabilities, alert sign-ups, and more multimedia elements. We are asking members to take a few minutes to activate their new account.
 

In order to maintain continuous access to the online journal, members will have to register for a free account and claim their subscription. If you go to chestjournal.org, CHEST members can then complete a 1- to 2-minute registration process.

“This is an exciting time for the journal, and I personally believe that online users will be very pleased with what the new web version has to offer,” says Dr. Richard Irwin, CHEST’s Editor in Chief.

CHEST members should have received an email with step-by-step instructions. Still have questions or need help? Contact Online Journal Support at 800/654-2452 (US and Canada) or +44 (0) 1865-843177 (Europe).

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We are excited to share that the journal CHEST® has a new website with improved navigation, better search capabilities, alert sign-ups, and more multimedia elements. We are asking members to take a few minutes to activate their new account.
 

In order to maintain continuous access to the online journal, members will have to register for a free account and claim their subscription. If you go to chestjournal.org, CHEST members can then complete a 1- to 2-minute registration process.

“This is an exciting time for the journal, and I personally believe that online users will be very pleased with what the new web version has to offer,” says Dr. Richard Irwin, CHEST’s Editor in Chief.

CHEST members should have received an email with step-by-step instructions. Still have questions or need help? Contact Online Journal Support at 800/654-2452 (US and Canada) or +44 (0) 1865-843177 (Europe).

 

We are excited to share that the journal CHEST® has a new website with improved navigation, better search capabilities, alert sign-ups, and more multimedia elements. We are asking members to take a few minutes to activate their new account.
 

In order to maintain continuous access to the online journal, members will have to register for a free account and claim their subscription. If you go to chestjournal.org, CHEST members can then complete a 1- to 2-minute registration process.

“This is an exciting time for the journal, and I personally believe that online users will be very pleased with what the new web version has to offer,” says Dr. Richard Irwin, CHEST’s Editor in Chief.

CHEST members should have received an email with step-by-step instructions. Still have questions or need help? Contact Online Journal Support at 800/654-2452 (US and Canada) or +44 (0) 1865-843177 (Europe).

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New Tools in Campaign to Fight Asthma

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Tue, 10/23/2018 - 16:10

 

The Allergy & Asthma NetWork, the nation’s leading patient education and advocacy organization for people with allergy and asthma, has once again joined forces with the CHEST Foundation in an effort to empower patients suffering from severe asthma.

The campaign’s focus is to educate health-care providers, patients, parents of asthmatics, and the public about the most current treatment options for asthma, highlight the importance of referring to specialists to improve patient outcomes, and bring to light the role of the entire health-care team in the care of a patient with severe or difficult-to-control asthma.

This is the second year of this growing campaign, and there are several new and exciting materials.

Severity Assessment Tool

Available online and in print, the severity assessment tool was designed to help a patient, and the clinician, understand the severity of their asthma. Not only does the tool evaluate the severity of their condition, but it also helps the patient become more aware of their symptoms. The seven-question assessment includes questions on usage of quick-relief or rescue inhalers, visits to the ED/hospital, physical activity, controller medication, and quality of sleep.

Patient and Caregiver Testimonials

The campaign features several patient and caregiver testimonials that tell the stories of patients and parents of children with severe asthma.

“What we want people to understand, is that at the time of Ben’s passing, he was on a preventive med. He was going to the doctor routinely. We had actually just been to the asthma doctor. We were seeing somebody, had an action plan, and everybody knew what they had to do. Even with all of that, it still came to this. Benjamin still lost his life, and we never knew this was something that could happen,” stated Cristin Buckley, mother of Benjamin Buckley who was 7 years old at the time of his death. These testimonial videos will be used to raise awareness of the condition, and the importance of managing and monitoring symptoms.

Shared Decision Making Tool

The American College of Allergy, Asthma, and Immunology (ACAAI), the Allergy & Asthma Network, and CHEST Foundation have partnered to develop a shared decision-making tool for adults with severe asthma. This tool will be launched at CHEST 2017 in October. Available online and in print, it was created for patients and clinicians to work together to improve self-management skills, choose the best treatment plan for the patient, and increase adherence. This patient-centered approach in clinical settings improves patient satisfaction of care and overall outcomes.

Thank You to Our Supporters

The CHEST Foundation and Allergy and Asthma Network would like to thank our generous supporters, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Novartis for making this campaign possible. It is through supporters, who are active participants in helping grow this campaign, that these important materials are able to have an impact on patient outcomes and create long-lasting social change.

To view the campaign materials, visit us at asthma.chestnet.org.

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The Allergy & Asthma NetWork, the nation’s leading patient education and advocacy organization for people with allergy and asthma, has once again joined forces with the CHEST Foundation in an effort to empower patients suffering from severe asthma.

The campaign’s focus is to educate health-care providers, patients, parents of asthmatics, and the public about the most current treatment options for asthma, highlight the importance of referring to specialists to improve patient outcomes, and bring to light the role of the entire health-care team in the care of a patient with severe or difficult-to-control asthma.

This is the second year of this growing campaign, and there are several new and exciting materials.

Severity Assessment Tool

Available online and in print, the severity assessment tool was designed to help a patient, and the clinician, understand the severity of their asthma. Not only does the tool evaluate the severity of their condition, but it also helps the patient become more aware of their symptoms. The seven-question assessment includes questions on usage of quick-relief or rescue inhalers, visits to the ED/hospital, physical activity, controller medication, and quality of sleep.

Patient and Caregiver Testimonials

The campaign features several patient and caregiver testimonials that tell the stories of patients and parents of children with severe asthma.

“What we want people to understand, is that at the time of Ben’s passing, he was on a preventive med. He was going to the doctor routinely. We had actually just been to the asthma doctor. We were seeing somebody, had an action plan, and everybody knew what they had to do. Even with all of that, it still came to this. Benjamin still lost his life, and we never knew this was something that could happen,” stated Cristin Buckley, mother of Benjamin Buckley who was 7 years old at the time of his death. These testimonial videos will be used to raise awareness of the condition, and the importance of managing and monitoring symptoms.

Shared Decision Making Tool

The American College of Allergy, Asthma, and Immunology (ACAAI), the Allergy & Asthma Network, and CHEST Foundation have partnered to develop a shared decision-making tool for adults with severe asthma. This tool will be launched at CHEST 2017 in October. Available online and in print, it was created for patients and clinicians to work together to improve self-management skills, choose the best treatment plan for the patient, and increase adherence. This patient-centered approach in clinical settings improves patient satisfaction of care and overall outcomes.

Thank You to Our Supporters

The CHEST Foundation and Allergy and Asthma Network would like to thank our generous supporters, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Novartis for making this campaign possible. It is through supporters, who are active participants in helping grow this campaign, that these important materials are able to have an impact on patient outcomes and create long-lasting social change.

To view the campaign materials, visit us at asthma.chestnet.org.

 

The Allergy & Asthma NetWork, the nation’s leading patient education and advocacy organization for people with allergy and asthma, has once again joined forces with the CHEST Foundation in an effort to empower patients suffering from severe asthma.

The campaign’s focus is to educate health-care providers, patients, parents of asthmatics, and the public about the most current treatment options for asthma, highlight the importance of referring to specialists to improve patient outcomes, and bring to light the role of the entire health-care team in the care of a patient with severe or difficult-to-control asthma.

This is the second year of this growing campaign, and there are several new and exciting materials.

Severity Assessment Tool

Available online and in print, the severity assessment tool was designed to help a patient, and the clinician, understand the severity of their asthma. Not only does the tool evaluate the severity of their condition, but it also helps the patient become more aware of their symptoms. The seven-question assessment includes questions on usage of quick-relief or rescue inhalers, visits to the ED/hospital, physical activity, controller medication, and quality of sleep.

Patient and Caregiver Testimonials

The campaign features several patient and caregiver testimonials that tell the stories of patients and parents of children with severe asthma.

“What we want people to understand, is that at the time of Ben’s passing, he was on a preventive med. He was going to the doctor routinely. We had actually just been to the asthma doctor. We were seeing somebody, had an action plan, and everybody knew what they had to do. Even with all of that, it still came to this. Benjamin still lost his life, and we never knew this was something that could happen,” stated Cristin Buckley, mother of Benjamin Buckley who was 7 years old at the time of his death. These testimonial videos will be used to raise awareness of the condition, and the importance of managing and monitoring symptoms.

Shared Decision Making Tool

The American College of Allergy, Asthma, and Immunology (ACAAI), the Allergy & Asthma Network, and CHEST Foundation have partnered to develop a shared decision-making tool for adults with severe asthma. This tool will be launched at CHEST 2017 in October. Available online and in print, it was created for patients and clinicians to work together to improve self-management skills, choose the best treatment plan for the patient, and increase adherence. This patient-centered approach in clinical settings improves patient satisfaction of care and overall outcomes.

Thank You to Our Supporters

The CHEST Foundation and Allergy and Asthma Network would like to thank our generous supporters, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Novartis for making this campaign possible. It is through supporters, who are active participants in helping grow this campaign, that these important materials are able to have an impact on patient outcomes and create long-lasting social change.

To view the campaign materials, visit us at asthma.chestnet.org.

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CHEST Joint Congress in Basel, Switzerland

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Tue, 10/23/2018 - 16:10

 

Members of CHEST leadership, faculty, and staff traveled to Basel, Switzerland, in June, to participate in the CHEST Joint Congress, which was co-hosted with the Swiss Respiratory Society, Schweizersche Gesellschaft Fur Pneumologie (SPG). Overall, there were approximately 1,100 total attendees, representing over 40 countries, who enjoyed the scientific program and gained valuable chest medicine knowledge.

Among the many topics presented were diagnosis and treatment of ILD; biologics for severe asthma; EBUS for molecular analysis; and ICS in COPD. Plus, hands-on, interactive workshops were offered for learning or reviewing more procedural skills. We invite you to view webcasts of five of the Basel sessions at bit.ly/chestsgp2017.

The CHEST Joint Congress in Basel represented the second collaborative scientific conference endeavor with a third party, the first being the CHEST Conference held in Amsterdam May 6-9, COPD: Current Excellence and Future Development.

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Members of CHEST leadership, faculty, and staff traveled to Basel, Switzerland, in June, to participate in the CHEST Joint Congress, which was co-hosted with the Swiss Respiratory Society, Schweizersche Gesellschaft Fur Pneumologie (SPG). Overall, there were approximately 1,100 total attendees, representing over 40 countries, who enjoyed the scientific program and gained valuable chest medicine knowledge.

Among the many topics presented were diagnosis and treatment of ILD; biologics for severe asthma; EBUS for molecular analysis; and ICS in COPD. Plus, hands-on, interactive workshops were offered for learning or reviewing more procedural skills. We invite you to view webcasts of five of the Basel sessions at bit.ly/chestsgp2017.

The CHEST Joint Congress in Basel represented the second collaborative scientific conference endeavor with a third party, the first being the CHEST Conference held in Amsterdam May 6-9, COPD: Current Excellence and Future Development.

 

Members of CHEST leadership, faculty, and staff traveled to Basel, Switzerland, in June, to participate in the CHEST Joint Congress, which was co-hosted with the Swiss Respiratory Society, Schweizersche Gesellschaft Fur Pneumologie (SPG). Overall, there were approximately 1,100 total attendees, representing over 40 countries, who enjoyed the scientific program and gained valuable chest medicine knowledge.

Among the many topics presented were diagnosis and treatment of ILD; biologics for severe asthma; EBUS for molecular analysis; and ICS in COPD. Plus, hands-on, interactive workshops were offered for learning or reviewing more procedural skills. We invite you to view webcasts of five of the Basel sessions at bit.ly/chestsgp2017.

The CHEST Joint Congress in Basel represented the second collaborative scientific conference endeavor with a third party, the first being the CHEST Conference held in Amsterdam May 6-9, COPD: Current Excellence and Future Development.

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