Society News

One of the primary goals of the American College of Surgeons (ACS) is to provide surgeons with knowledge and skills to deliver the highest quality of patient care. The guidelines and statements developed by the ACS are intended to inform and guide Fellows in the care of their patients and to educate their patients and their institutions on best practices in those situations that may warrant specific guidance and direction.

Guidelines

Over the last decade, the College has participated in the development of guidelines and “point of care” modules that address those diagnoses most relevant to general surgeons. The Evidence-Based Decisions in Surgery (EBDS) are clinical guideline summaries that provide recommendations based on the latest practice guidelines in an easy-to-use, widely accessible format, including mobile devices and tablets. Module development involves a rigorous multi-step process, including contributions from experts on the ACS Board of Governors and the ACS Advisory Council for General Surgery. It is important to note that EBDS is not intended to reflect standards of care as defined by the ACS, but rather to serve as educational resources that practicing surgeons can use within the context of their respective practices. These guidelines should be used when appropriate based on the surgical condition and the surgeon’s experience, as well as the patient’s needs and preferences.

EBDS now comprises more than 70 point of care modules covering the following categories—bariatric surgery, biliary tract and pancreas, breast disease, colon, rectum and anus, critical care, endocrine, gastrointestinal surgery, geriatrics and palliative care, miscellaneous surgical conditions, perioperative care, surgical oncology, and vascular.

The complete list of guidelines is available at ebds.facs.org/topics, and new modules are released regularly. To access individual guidelines, members are required to log in. Contact [email protected] for member log-in information, and go to facs.org/ebds for more information about the program.

The Trauma Quality Improvement Program (TQIP^®) generates the ACS TQIP Best Practice Guidelines to provide recommendations for managing patient populations or injury types. The TQIP Best Practices Project Team and a panel of guest experts from appropriate specialties work together over the course of the year to create each guideline. The guidelines are created from evidence-based literature when available and the consensus of the group when evidence is lacking. To date, the following guidelines have been created for use by trauma centers and are available for download at facs.org/quality-programs/trauma/tqip/best-practice:

• Geriatric Trauma Management

• Massive Transfusion in Trauma

• Management of Traumatic Brain Injury

• Management of Orthopaedic Trauma

• Palliative Care

The College’s National Surgical Quality Improvement Program (ACS NSQIP®) and the American Geriatrics Society’s Geriatrics for Specialists Initiative have developed two best practice guidelines that address management of older patients: Optimal Preoperative Assessment of the Geriatric Surgical Patient and Optimal Perioperative Management of the Geriatric Patient. These consensus-based recommendations were developed with support from the John A. Hartford Foundation and are available for download at facs.org/quality-programs/acs-nsqip/geriatric-periop-guideline.



Statements

Founded to provide opportunities for the continuing education of surgeons, the ACS has had a deep concern for the improvement of patient care and for the ethical practice of medicine. These values are reflected in the ACS Statements on Principles, which serve as the guidepost resource for all ACS Fellows. In addition to the Fellowship Pledge and Code of Professional Conduct, the Statements on Principles address the qualifications of the responsible surgeon, the surgeon-patient relationship, interprofessional relations, medical education, and surgeons and society. Fellows are encouraged to familiarize themselves with the contents of the Statements on Principles, which can be accessed at facs.org/about-acs/statements/stonprin.

In addition to the Statements on Principles, the ACS has issued more than 90 statements that have been adopted by the Board of Regents and address topics of importance to surgeons and the surgical profession. These statements have been developed by a range of volunteer committees and workgroups within the College, including the ACS Board of Governors, the ACS Advisory Councils, and various ACS standing committees. Statements are reviewed and updated annually, and new statements are created as appropriate. Statements are generally communicated to the membership via the Bulletin and are posted to the ACS website. Thus far in 2018, the Board of Regents has approved seven new statements and two revised statements. To review the complete list of ACS statements, go to facs.org/about-acs/statements and share those of interest with your colleagues and your institution.



Ms. Bura is Associate Director, ACS Division of Member Services, Chicago, IL.

One of the primary goals of the American College of Surgeons (ACS) is to provide surgeons with knowledge and skills to deliver the highest quality of patient care. The guidelines and statements developed by the ACS are intended to inform and guide Fellows in the care of their patients and to educate their patients and their institutions on best practices in those situations that may warrant specific guidance and direction.

Guidelines

Over the last decade, the College has participated in the development of guidelines and “point of care” modules that address those diagnoses most relevant to general surgeons. The Evidence-Based Decisions in Surgery (EBDS) are clinical guideline summaries that provide recommendations based on the latest practice guidelines in an easy-to-use, widely accessible format, including mobile devices and tablets. Module development involves a rigorous multi-step process, including contributions from experts on the ACS Board of Governors and the ACS Advisory Council for General Surgery. It is important to note that EBDS is not intended to reflect standards of care as defined by the ACS, but rather to serve as educational resources that practicing surgeons can use within the context of their respective practices. These guidelines should be used when appropriate based on the surgical condition and the surgeon’s experience, as well as the patient’s needs and preferences.

EBDS now comprises more than 70 point of care modules covering the following categories—bariatric surgery, biliary tract and pancreas, breast disease, colon, rectum and anus, critical care, endocrine, gastrointestinal surgery, geriatrics and palliative care, miscellaneous surgical conditions, perioperative care, surgical oncology, and vascular.

The complete list of guidelines is available at ebds.facs.org/topics, and new modules are released regularly. To access individual guidelines, members are required to log in. Contact [email protected] for member log-in information, and go to facs.org/ebds for more information about the program.

The Trauma Quality Improvement Program (TQIP^®) generates the ACS TQIP Best Practice Guidelines to provide recommendations for managing patient populations or injury types. The TQIP Best Practices Project Team and a panel of guest experts from appropriate specialties work together over the course of the year to create each guideline. The guidelines are created from evidence-based literature when available and the consensus of the group when evidence is lacking. To date, the following guidelines have been created for use by trauma centers and are available for download at facs.org/quality-programs/trauma/tqip/best-practice:

• Geriatric Trauma Management

• Massive Transfusion in Trauma

• Management of Traumatic Brain Injury

• Management of Orthopaedic Trauma

• Palliative Care

The College’s National Surgical Quality Improvement Program (ACS NSQIP®) and the American Geriatrics Society’s Geriatrics for Specialists Initiative have developed two best practice guidelines that address management of older patients: Optimal Preoperative Assessment of the Geriatric Surgical Patient and Optimal Perioperative Management of the Geriatric Patient. These consensus-based recommendations were developed with support from the John A. Hartford Foundation and are available for download at facs.org/quality-programs/acs-nsqip/geriatric-periop-guideline.



Statements

Founded to provide opportunities for the continuing education of surgeons, the ACS has had a deep concern for the improvement of patient care and for the ethical practice of medicine. These values are reflected in the ACS Statements on Principles, which serve as the guidepost resource for all ACS Fellows. In addition to the Fellowship Pledge and Code of Professional Conduct, the Statements on Principles address the qualifications of the responsible surgeon, the surgeon-patient relationship, interprofessional relations, medical education, and surgeons and society. Fellows are encouraged to familiarize themselves with the contents of the Statements on Principles, which can be accessed at facs.org/about-acs/statements/stonprin.

In addition to the Statements on Principles, the ACS has issued more than 90 statements that have been adopted by the Board of Regents and address topics of importance to surgeons and the surgical profession. These statements have been developed by a range of volunteer committees and workgroups within the College, including the ACS Board of Governors, the ACS Advisory Councils, and various ACS standing committees. Statements are reviewed and updated annually, and new statements are created as appropriate. Statements are generally communicated to the membership via the Bulletin and are posted to the ACS website. Thus far in 2018, the Board of Regents has approved seven new statements and two revised statements. To review the complete list of ACS statements, go to facs.org/about-acs/statements and share those of interest with your colleagues and your institution.



Ms. Bura is Associate Director, ACS Division of Member Services, Chicago, IL.

One of the primary goals of the American College of Surgeons (ACS) is to provide surgeons with knowledge and skills to deliver the highest quality of patient care. The guidelines and statements developed by the ACS are intended to inform and guide Fellows in the care of their patients and to educate their patients and their institutions on best practices in those situations that may warrant specific guidance and direction.

Guidelines

Over the last decade, the College has participated in the development of guidelines and “point of care” modules that address those diagnoses most relevant to general surgeons. The Evidence-Based Decisions in Surgery (EBDS) are clinical guideline summaries that provide recommendations based on the latest practice guidelines in an easy-to-use, widely accessible format, including mobile devices and tablets. Module development involves a rigorous multi-step process, including contributions from experts on the ACS Board of Governors and the ACS Advisory Council for General Surgery. It is important to note that EBDS is not intended to reflect standards of care as defined by the ACS, but rather to serve as educational resources that practicing surgeons can use within the context of their respective practices. These guidelines should be used when appropriate based on the surgical condition and the surgeon’s experience, as well as the patient’s needs and preferences.

EBDS now comprises more than 70 point of care modules covering the following categories—bariatric surgery, biliary tract and pancreas, breast disease, colon, rectum and anus, critical care, endocrine, gastrointestinal surgery, geriatrics and palliative care, miscellaneous surgical conditions, perioperative care, surgical oncology, and vascular.

The complete list of guidelines is available at ebds.facs.org/topics, and new modules are released regularly. To access individual guidelines, members are required to log in. Contact [email protected] for member log-in information, and go to facs.org/ebds for more information about the program.

The Trauma Quality Improvement Program (TQIP^®) generates the ACS TQIP Best Practice Guidelines to provide recommendations for managing patient populations or injury types. The TQIP Best Practices Project Team and a panel of guest experts from appropriate specialties work together over the course of the year to create each guideline. The guidelines are created from evidence-based literature when available and the consensus of the group when evidence is lacking. To date, the following guidelines have been created for use by trauma centers and are available for download at facs.org/quality-programs/trauma/tqip/best-practice:

• Geriatric Trauma Management

• Massive Transfusion in Trauma

• Management of Traumatic Brain Injury

• Management of Orthopaedic Trauma

• Palliative Care

The College’s National Surgical Quality Improvement Program (ACS NSQIP®) and the American Geriatrics Society’s Geriatrics for Specialists Initiative have developed two best practice guidelines that address management of older patients: Optimal Preoperative Assessment of the Geriatric Surgical Patient and Optimal Perioperative Management of the Geriatric Patient. These consensus-based recommendations were developed with support from the John A. Hartford Foundation and are available for download at facs.org/quality-programs/acs-nsqip/geriatric-periop-guideline.



Statements

Founded to provide opportunities for the continuing education of surgeons, the ACS has had a deep concern for the improvement of patient care and for the ethical practice of medicine. These values are reflected in the ACS Statements on Principles, which serve as the guidepost resource for all ACS Fellows. In addition to the Fellowship Pledge and Code of Professional Conduct, the Statements on Principles address the qualifications of the responsible surgeon, the surgeon-patient relationship, interprofessional relations, medical education, and surgeons and society. Fellows are encouraged to familiarize themselves with the contents of the Statements on Principles, which can be accessed at facs.org/about-acs/statements/stonprin.

In addition to the Statements on Principles, the ACS has issued more than 90 statements that have been adopted by the Board of Regents and address topics of importance to surgeons and the surgical profession. These statements have been developed by a range of volunteer committees and workgroups within the College, including the ACS Board of Governors, the ACS Advisory Councils, and various ACS standing committees. Statements are reviewed and updated annually, and new statements are created as appropriate. Statements are generally communicated to the membership via the Bulletin and are posted to the ACS website. Thus far in 2018, the Board of Regents has approved seven new statements and two revised statements. To review the complete list of ACS statements, go to facs.org/about-acs/statements and share those of interest with your colleagues and your institution.



Ms. Bura is Associate Director, ACS Division of Member Services, Chicago, IL.

Make the most of your American College of Surgeons (ACS) Clinical Congress experience by visiting ACS Central in the Exhibit Hall. Open 9:00 am–4:30 pm Monday, October 22, to Wednesday, October 24, ACS Central is the place to meet with staff, learn about ACS products and programs, purchase ACS-branded items and publications, and relax during the meeting. Other select ACS programs will have a presence in the main lobby of the center, including ACSPA-SurgeonsPAC, Wi-fi and Clinical Congress App Support, Become a Member/Member Services, MyCME, SESAP^® (Surgical Education and Self-Assessment Program), and Webcast Sales.

Featured areas in ACS Central include the following:

• ACS Foundation

• ACS Store

• Advocacy and Regulatory Affairs

• Education

• Manage Your Profile (receive a free professional photo)

• Member Engagement

• My Specialty and Quality Programs

• Publications and Online Resources

• Surgeon Specific Registry (SSR)



ACS Central also features the ACS Theatre. The following programs will take place during the lunch hour, so grab a bite to eat and stop by to listen.



Monday, October 22: 1:15 pm–2:15 pm
Life Skills for the Surgeon: Savings Advice for Retirement
Mark Aeder, MD, FACS, will provide advice on how to handle your debt, how to find the right financial advisor, and how to protect your family and your income?

Special Considerations for a Successful Simulation Program
Rick Feins, MD, FACS, will explain why surgical simulation is an important pathway for achieving competency in surgical resident performance and adoption of new technology by established surgeons.

Tuesday, October 23: 11:30 am–12:30 pm
Efforts to Reduce Administrative Burdens and Regulations and State Level Advocacy
Come listen to how the ACS is addressing the increasing administrative burdens and regulations that are frustrating our Fellows across the country with Vinita Ollapally, JD, ACS Manager of Regulatory Affairs.

Wednesday, October 24: 11:30 am–12:30 pm
Addressing Intimate Partner Violence in the Surgical Community: Is there a need?
ACS President Barbara Lee Bass, MD, FACS, formed an ACS Task Force earlier this year to begin to consider what the ACS should do to address and prevent intimate partner violence (IPV) within the surgical community. Dr. Bass will address the work of the task force and the resources that have been developed to address this issue.

Make the most of your American College of Surgeons (ACS) Clinical Congress experience by visiting ACS Central in the Exhibit Hall. Open 9:00 am–4:30 pm Monday, October 22, to Wednesday, October 24, ACS Central is the place to meet with staff, learn about ACS products and programs, purchase ACS-branded items and publications, and relax during the meeting. Other select ACS programs will have a presence in the main lobby of the center, including ACSPA-SurgeonsPAC, Wi-fi and Clinical Congress App Support, Become a Member/Member Services, MyCME, SESAP^® (Surgical Education and Self-Assessment Program), and Webcast Sales.

Featured areas in ACS Central include the following:

• ACS Foundation

• ACS Store

• Advocacy and Regulatory Affairs

• Education

• Manage Your Profile (receive a free professional photo)

• Member Engagement

• My Specialty and Quality Programs

• Publications and Online Resources

• Surgeon Specific Registry (SSR)



ACS Central also features the ACS Theatre. The following programs will take place during the lunch hour, so grab a bite to eat and stop by to listen.



Monday, October 22: 1:15 pm–2:15 pm
Life Skills for the Surgeon: Savings Advice for Retirement
Mark Aeder, MD, FACS, will provide advice on how to handle your debt, how to find the right financial advisor, and how to protect your family and your income?

Special Considerations for a Successful Simulation Program
Rick Feins, MD, FACS, will explain why surgical simulation is an important pathway for achieving competency in surgical resident performance and adoption of new technology by established surgeons.

Tuesday, October 23: 11:30 am–12:30 pm
Efforts to Reduce Administrative Burdens and Regulations and State Level Advocacy
Come listen to how the ACS is addressing the increasing administrative burdens and regulations that are frustrating our Fellows across the country with Vinita Ollapally, JD, ACS Manager of Regulatory Affairs.

Wednesday, October 24: 11:30 am–12:30 pm
Addressing Intimate Partner Violence in the Surgical Community: Is there a need?
ACS President Barbara Lee Bass, MD, FACS, formed an ACS Task Force earlier this year to begin to consider what the ACS should do to address and prevent intimate partner violence (IPV) within the surgical community. Dr. Bass will address the work of the task force and the resources that have been developed to address this issue.

Make the most of your American College of Surgeons (ACS) Clinical Congress experience by visiting ACS Central in the Exhibit Hall. Open 9:00 am–4:30 pm Monday, October 22, to Wednesday, October 24, ACS Central is the place to meet with staff, learn about ACS products and programs, purchase ACS-branded items and publications, and relax during the meeting. Other select ACS programs will have a presence in the main lobby of the center, including ACSPA-SurgeonsPAC, Wi-fi and Clinical Congress App Support, Become a Member/Member Services, MyCME, SESAP^® (Surgical Education and Self-Assessment Program), and Webcast Sales.

Featured areas in ACS Central include the following:

• ACS Foundation

• ACS Store

• Advocacy and Regulatory Affairs

• Education

• Manage Your Profile (receive a free professional photo)

• Member Engagement

• My Specialty and Quality Programs

• Publications and Online Resources

• Surgeon Specific Registry (SSR)



ACS Central also features the ACS Theatre. The following programs will take place during the lunch hour, so grab a bite to eat and stop by to listen.



Monday, October 22: 1:15 pm–2:15 pm
Life Skills for the Surgeon: Savings Advice for Retirement
Mark Aeder, MD, FACS, will provide advice on how to handle your debt, how to find the right financial advisor, and how to protect your family and your income?

Special Considerations for a Successful Simulation Program
Rick Feins, MD, FACS, will explain why surgical simulation is an important pathway for achieving competency in surgical resident performance and adoption of new technology by established surgeons.

Tuesday, October 23: 11:30 am–12:30 pm
Efforts to Reduce Administrative Burdens and Regulations and State Level Advocacy
Come listen to how the ACS is addressing the increasing administrative burdens and regulations that are frustrating our Fellows across the country with Vinita Ollapally, JD, ACS Manager of Regulatory Affairs.

Wednesday, October 24: 11:30 am–12:30 pm
Addressing Intimate Partner Violence in the Surgical Community: Is there a need?
ACS President Barbara Lee Bass, MD, FACS, formed an ACS Task Force earlier this year to begin to consider what the ACS should do to address and prevent intimate partner violence (IPV) within the surgical community. Dr. Bass will address the work of the task force and the resources that have been developed to address this issue.

Operative Standards for Cancer Surgery, Volume 2, a collaborative manual from the American College of Surgeons (ACS) and the Alliance for Clinical Trials in Oncology, is now available for print and electronic purchase. This second volume focuses on thyroid cancer, gastric cancer, rectal cancer, esophageal cancer, and melanoma. The goal of the manual is to recommend the steps that need to occur in the operating room, from skin incision to skin closure, that ensure the best oncological outcomes for patients. Recommendations from the first two volumes serve as an initial point of discussion as the ACS Commission on Cancer (CoC) works to revise its accreditation manual and requirements. Preliminary work is being done to incorporate a portion of the recommendations into the new CoC standards for implementation by 2020.

The recommendations in the manual are part of a shift in the way surgeons perform cancer operations to ensure the procedures are guided by the strongest available evidence, according to the leadership of the Alliance/ACS Clinical Research Program (ACS CRP) Cancer Care Standards Development Committee, which led development of both volumes.

Similar to the first volume of the manual, which covered cancer of the breast, colon, lung, and pancreas, this volume breaks down the major cancer operations for each of the five disease sites into the critical steps that teams of experts and stakeholders around the country have identified as having the most significant influence on outcomes.

“We hope that the recommendations become actively used and achieve greater legitimacy,” said Committee Chair Mathew H. G. Katz, MD, FACS.

Operative Standards for Cancer Surgery, Volume 2, is available for purchase on the Wolters Kluwer website at bit.ly/2PCHUCn. For more information, contact [email protected].

Operative Standards for Cancer Surgery, Volume 2, a collaborative manual from the American College of Surgeons (ACS) and the Alliance for Clinical Trials in Oncology, is now available for print and electronic purchase. This second volume focuses on thyroid cancer, gastric cancer, rectal cancer, esophageal cancer, and melanoma. The goal of the manual is to recommend the steps that need to occur in the operating room, from skin incision to skin closure, that ensure the best oncological outcomes for patients. Recommendations from the first two volumes serve as an initial point of discussion as the ACS Commission on Cancer (CoC) works to revise its accreditation manual and requirements. Preliminary work is being done to incorporate a portion of the recommendations into the new CoC standards for implementation by 2020.

The recommendations in the manual are part of a shift in the way surgeons perform cancer operations to ensure the procedures are guided by the strongest available evidence, according to the leadership of the Alliance/ACS Clinical Research Program (ACS CRP) Cancer Care Standards Development Committee, which led development of both volumes.

Similar to the first volume of the manual, which covered cancer of the breast, colon, lung, and pancreas, this volume breaks down the major cancer operations for each of the five disease sites into the critical steps that teams of experts and stakeholders around the country have identified as having the most significant influence on outcomes.

“We hope that the recommendations become actively used and achieve greater legitimacy,” said Committee Chair Mathew H. G. Katz, MD, FACS.

Operative Standards for Cancer Surgery, Volume 2, is available for purchase on the Wolters Kluwer website at bit.ly/2PCHUCn. For more information, contact [email protected].

Operative Standards for Cancer Surgery, Volume 2, a collaborative manual from the American College of Surgeons (ACS) and the Alliance for Clinical Trials in Oncology, is now available for print and electronic purchase. This second volume focuses on thyroid cancer, gastric cancer, rectal cancer, esophageal cancer, and melanoma. The goal of the manual is to recommend the steps that need to occur in the operating room, from skin incision to skin closure, that ensure the best oncological outcomes for patients. Recommendations from the first two volumes serve as an initial point of discussion as the ACS Commission on Cancer (CoC) works to revise its accreditation manual and requirements. Preliminary work is being done to incorporate a portion of the recommendations into the new CoC standards for implementation by 2020.

The recommendations in the manual are part of a shift in the way surgeons perform cancer operations to ensure the procedures are guided by the strongest available evidence, according to the leadership of the Alliance/ACS Clinical Research Program (ACS CRP) Cancer Care Standards Development Committee, which led development of both volumes.

Similar to the first volume of the manual, which covered cancer of the breast, colon, lung, and pancreas, this volume breaks down the major cancer operations for each of the five disease sites into the critical steps that teams of experts and stakeholders around the country have identified as having the most significant influence on outcomes.

“We hope that the recommendations become actively used and achieve greater legitimacy,” said Committee Chair Mathew H. G. Katz, MD, FACS.

Operative Standards for Cancer Surgery, Volume 2, is available for purchase on the Wolters Kluwer website at bit.ly/2PCHUCn. For more information, contact [email protected].

The Scientific Forum of the American College of Surgeons (ACS) Clinical Congress has evolved since the concept was first introduced as the Surgical Forum in 1951. This year’s Scientific Forum will build on these transformations and will offer attendees greater exposure to the surgical research conducted by the ACS community.

Background

The Surgical Forum was established in 1951 to provide a supportive venue for trainees and junior faculty to present and discuss their research. Presenting at the Forum has always been a rite of passage for aspiring academic surgeon-scientists. In 1993, the Surgical Forum was renamed to honor the program founder, Owen H. Wangensteen, MD, PhD, FACS, past-chair, department of surgery, University of Minnesota, Minneapolis.

As surgical science evolved, the Program Committee developed a separate Scientific Papers session for established investigators and Fellows who were not early in their career. As these two programs evolved, it became increasingly clear that there was substantial overlap. In 2014, the Surgical Forum and Scientific Papers merged into a single entity under the oversight of the existing Surgical Forum Committee.

The merged program was renamed the Scientific Forum to reflect the contributions of the Surgical Forum and the Scientific Papers, and the committee was renamed the Scientific Forum Committee. Because of the increase in scientific abstracts resulting from this merger, the committee expanded its membership to reflect the type of scientific abstracts in the broader program. The basic and translational research focus of the Surgical Forum was expanded to include clinical research in health services, education, global surgery, ethics, and other evolving areas of surgical science.

These changes have revitalized the scientific effort. The number and quality of the abstracts submitted to the Scientific Forum has grown significantly—more than 2,000 abstracts were submitted for review for Clinical Congress 2018.

The spirit of the Surgical Forum has been maintained in the new Scientific Forum, continuing with the clustering of focused areas of research to encourage discussion and collaboration among the attendees. The Program Committee continues to place great emphasis on highlighting the work of young investigators while incorporating the expertise of senior investigators into the sessions.
 

Changes at Clinical Congress 2017

Quick Shots and e-Posters were introduced at Clinical Congress 2017 in San Diego, CA. Quick Shots are three-minute oral abstract presentations, which were incorporated into the Scientific Forum sessions. This addition, which allowed for more presenters in a session, was met with a positive reception.

The poster sessions were restructured to an electronic format. The e-Posters were placed in a central, dedicated location among the Scientific Forum sessions rather than the Exhibit Hall. The modern e-Poster sessions brought greater visibility to the poster presentations and energized the format. In the e-Poster room, special sessions were scheduled to highlight the exceptional research efforts of the surgical trainees through the Excellence in Research Awards and the Posters of Exceptional Merit. In addition, the Scientific Forum is dedicated to a senior surgeon-scientist who has demonstrated a career-long commitment to training surgeon-scientists and the academic mission.

To further promote and support surgical research, the Scientific Forum Committee partnered with the Journal of the American College of Surgeons (JACS) to solicit the highest-rated abstracts for publication in JACS. In the first year, the top 5 percent of abstracts in the clinical sciences were solicited for manuscript submissions. More than half of those authors submitted a manuscript for review. All accepted manuscripts will be electronically published concurrently with the ACS Clinical Congress 2018 to provide greater visibility to the high-quality research being generated by the ACS community.
 

Clinical trials session added in 2018

The Scientific Forum Committee strongly believes the Clinical Congress is the premier venue to present practice-changing research. New for 2018, a call for late-breaking clinical trials abstracts was issued, and the committee selected six clinical trials that have the potential to change practice and improve patient care. This new clinical trials session will be presented at Clinical Congress 2018 Monday, October 22, at 9:45 am.

The ACS Clinical Congress is the largest surgical meeting in the U.S. The vision of the Scientific Forum Committee is for leaders of surgical trials to view the Clinical Congress as the premier venue to present their results. These exciting and transformative changes to the Scientific Forum will bring greater exposure to the leading-edge research in clinical care, while continuing to support and encourage young surgeon-scientists—the future of the study and practice of surgery—in their work. ♦
 

Note

The authors of this article are part of the Owen H. Wangensteen Scientific Forum Committee—Mary T. Hawn, MD, FACS; Edith Tzeng, MD, FACS; and Valerie W. Rusch, MD, FACS, are members, and M. Jane Burns, MJHL; Richard V. King, PhD; and Ajit K. Sachdeva, MD, FACS, FRCSC, are ACS staff.



Dr. Hawn is professor of surgery and chair, department of surgery, Stanford University, CA. She is Chair, ACS Scientific Forum Committee.

Dr. Tzeng is professor of surgery, University of Pittsburgh, and chief, vascular surgery, Veterans Affairs Pittsburgh Healthcare System, University Drive Campus, PA. She is Vice-Chair, ACS Scientific Forum Committee.

Dr. Rusch is vice-chair, clinical research, department of surgery; Miner Family Chair in Intrathoracic Cancers; attending surgeon, thoracic service, department of surgery, Memorial Sloan-Kettering Cancer Center; and professor of surgery, Weill Cornell Medical College. She is a consultant for the ACS Program Committee.

Ms. Burns is Senior Manager, Clinical Congress Program, ACS Division of Education, Chicago.

Mr. King is Assistant Director, Clinical Congress Program and Skills Courses, ACS Division of Education.

Dr. Sachdeva is Director, ACS Division of Education.






 

The Scientific Forum of the American College of Surgeons (ACS) Clinical Congress has evolved since the concept was first introduced as the Surgical Forum in 1951. This year’s Scientific Forum will build on these transformations and will offer attendees greater exposure to the surgical research conducted by the ACS community.

Background

The Surgical Forum was established in 1951 to provide a supportive venue for trainees and junior faculty to present and discuss their research. Presenting at the Forum has always been a rite of passage for aspiring academic surgeon-scientists. In 1993, the Surgical Forum was renamed to honor the program founder, Owen H. Wangensteen, MD, PhD, FACS, past-chair, department of surgery, University of Minnesota, Minneapolis.

As surgical science evolved, the Program Committee developed a separate Scientific Papers session for established investigators and Fellows who were not early in their career. As these two programs evolved, it became increasingly clear that there was substantial overlap. In 2014, the Surgical Forum and Scientific Papers merged into a single entity under the oversight of the existing Surgical Forum Committee.

The merged program was renamed the Scientific Forum to reflect the contributions of the Surgical Forum and the Scientific Papers, and the committee was renamed the Scientific Forum Committee. Because of the increase in scientific abstracts resulting from this merger, the committee expanded its membership to reflect the type of scientific abstracts in the broader program. The basic and translational research focus of the Surgical Forum was expanded to include clinical research in health services, education, global surgery, ethics, and other evolving areas of surgical science.

These changes have revitalized the scientific effort. The number and quality of the abstracts submitted to the Scientific Forum has grown significantly—more than 2,000 abstracts were submitted for review for Clinical Congress 2018.

The spirit of the Surgical Forum has been maintained in the new Scientific Forum, continuing with the clustering of focused areas of research to encourage discussion and collaboration among the attendees. The Program Committee continues to place great emphasis on highlighting the work of young investigators while incorporating the expertise of senior investigators into the sessions.
 

Changes at Clinical Congress 2017

Quick Shots and e-Posters were introduced at Clinical Congress 2017 in San Diego, CA. Quick Shots are three-minute oral abstract presentations, which were incorporated into the Scientific Forum sessions. This addition, which allowed for more presenters in a session, was met with a positive reception.

The poster sessions were restructured to an electronic format. The e-Posters were placed in a central, dedicated location among the Scientific Forum sessions rather than the Exhibit Hall. The modern e-Poster sessions brought greater visibility to the poster presentations and energized the format. In the e-Poster room, special sessions were scheduled to highlight the exceptional research efforts of the surgical trainees through the Excellence in Research Awards and the Posters of Exceptional Merit. In addition, the Scientific Forum is dedicated to a senior surgeon-scientist who has demonstrated a career-long commitment to training surgeon-scientists and the academic mission.

To further promote and support surgical research, the Scientific Forum Committee partnered with the Journal of the American College of Surgeons (JACS) to solicit the highest-rated abstracts for publication in JACS. In the first year, the top 5 percent of abstracts in the clinical sciences were solicited for manuscript submissions. More than half of those authors submitted a manuscript for review. All accepted manuscripts will be electronically published concurrently with the ACS Clinical Congress 2018 to provide greater visibility to the high-quality research being generated by the ACS community.
 

Clinical trials session added in 2018

The Scientific Forum Committee strongly believes the Clinical Congress is the premier venue to present practice-changing research. New for 2018, a call for late-breaking clinical trials abstracts was issued, and the committee selected six clinical trials that have the potential to change practice and improve patient care. This new clinical trials session will be presented at Clinical Congress 2018 Monday, October 22, at 9:45 am.

The ACS Clinical Congress is the largest surgical meeting in the U.S. The vision of the Scientific Forum Committee is for leaders of surgical trials to view the Clinical Congress as the premier venue to present their results. These exciting and transformative changes to the Scientific Forum will bring greater exposure to the leading-edge research in clinical care, while continuing to support and encourage young surgeon-scientists—the future of the study and practice of surgery—in their work. ♦
 

Note

The authors of this article are part of the Owen H. Wangensteen Scientific Forum Committee—Mary T. Hawn, MD, FACS; Edith Tzeng, MD, FACS; and Valerie W. Rusch, MD, FACS, are members, and M. Jane Burns, MJHL; Richard V. King, PhD; and Ajit K. Sachdeva, MD, FACS, FRCSC, are ACS staff.



Dr. Hawn is professor of surgery and chair, department of surgery, Stanford University, CA. She is Chair, ACS Scientific Forum Committee.

Dr. Tzeng is professor of surgery, University of Pittsburgh, and chief, vascular surgery, Veterans Affairs Pittsburgh Healthcare System, University Drive Campus, PA. She is Vice-Chair, ACS Scientific Forum Committee.

Dr. Rusch is vice-chair, clinical research, department of surgery; Miner Family Chair in Intrathoracic Cancers; attending surgeon, thoracic service, department of surgery, Memorial Sloan-Kettering Cancer Center; and professor of surgery, Weill Cornell Medical College. She is a consultant for the ACS Program Committee.

Ms. Burns is Senior Manager, Clinical Congress Program, ACS Division of Education, Chicago.

Mr. King is Assistant Director, Clinical Congress Program and Skills Courses, ACS Division of Education.

Dr. Sachdeva is Director, ACS Division of Education.






 

The Scientific Forum of the American College of Surgeons (ACS) Clinical Congress has evolved since the concept was first introduced as the Surgical Forum in 1951. This year’s Scientific Forum will build on these transformations and will offer attendees greater exposure to the surgical research conducted by the ACS community.

Background

The Surgical Forum was established in 1951 to provide a supportive venue for trainees and junior faculty to present and discuss their research. Presenting at the Forum has always been a rite of passage for aspiring academic surgeon-scientists. In 1993, the Surgical Forum was renamed to honor the program founder, Owen H. Wangensteen, MD, PhD, FACS, past-chair, department of surgery, University of Minnesota, Minneapolis.

As surgical science evolved, the Program Committee developed a separate Scientific Papers session for established investigators and Fellows who were not early in their career. As these two programs evolved, it became increasingly clear that there was substantial overlap. In 2014, the Surgical Forum and Scientific Papers merged into a single entity under the oversight of the existing Surgical Forum Committee.

The merged program was renamed the Scientific Forum to reflect the contributions of the Surgical Forum and the Scientific Papers, and the committee was renamed the Scientific Forum Committee. Because of the increase in scientific abstracts resulting from this merger, the committee expanded its membership to reflect the type of scientific abstracts in the broader program. The basic and translational research focus of the Surgical Forum was expanded to include clinical research in health services, education, global surgery, ethics, and other evolving areas of surgical science.

These changes have revitalized the scientific effort. The number and quality of the abstracts submitted to the Scientific Forum has grown significantly—more than 2,000 abstracts were submitted for review for Clinical Congress 2018.

The spirit of the Surgical Forum has been maintained in the new Scientific Forum, continuing with the clustering of focused areas of research to encourage discussion and collaboration among the attendees. The Program Committee continues to place great emphasis on highlighting the work of young investigators while incorporating the expertise of senior investigators into the sessions.
 

Changes at Clinical Congress 2017

Quick Shots and e-Posters were introduced at Clinical Congress 2017 in San Diego, CA. Quick Shots are three-minute oral abstract presentations, which were incorporated into the Scientific Forum sessions. This addition, which allowed for more presenters in a session, was met with a positive reception.

The poster sessions were restructured to an electronic format. The e-Posters were placed in a central, dedicated location among the Scientific Forum sessions rather than the Exhibit Hall. The modern e-Poster sessions brought greater visibility to the poster presentations and energized the format. In the e-Poster room, special sessions were scheduled to highlight the exceptional research efforts of the surgical trainees through the Excellence in Research Awards and the Posters of Exceptional Merit. In addition, the Scientific Forum is dedicated to a senior surgeon-scientist who has demonstrated a career-long commitment to training surgeon-scientists and the academic mission.

To further promote and support surgical research, the Scientific Forum Committee partnered with the Journal of the American College of Surgeons (JACS) to solicit the highest-rated abstracts for publication in JACS. In the first year, the top 5 percent of abstracts in the clinical sciences were solicited for manuscript submissions. More than half of those authors submitted a manuscript for review. All accepted manuscripts will be electronically published concurrently with the ACS Clinical Congress 2018 to provide greater visibility to the high-quality research being generated by the ACS community.
 

Clinical trials session added in 2018

The Scientific Forum Committee strongly believes the Clinical Congress is the premier venue to present practice-changing research. New for 2018, a call for late-breaking clinical trials abstracts was issued, and the committee selected six clinical trials that have the potential to change practice and improve patient care. This new clinical trials session will be presented at Clinical Congress 2018 Monday, October 22, at 9:45 am.

The ACS Clinical Congress is the largest surgical meeting in the U.S. The vision of the Scientific Forum Committee is for leaders of surgical trials to view the Clinical Congress as the premier venue to present their results. These exciting and transformative changes to the Scientific Forum will bring greater exposure to the leading-edge research in clinical care, while continuing to support and encourage young surgeon-scientists—the future of the study and practice of surgery—in their work. ♦
 

Note

The authors of this article are part of the Owen H. Wangensteen Scientific Forum Committee—Mary T. Hawn, MD, FACS; Edith Tzeng, MD, FACS; and Valerie W. Rusch, MD, FACS, are members, and M. Jane Burns, MJHL; Richard V. King, PhD; and Ajit K. Sachdeva, MD, FACS, FRCSC, are ACS staff.



Dr. Hawn is professor of surgery and chair, department of surgery, Stanford University, CA. She is Chair, ACS Scientific Forum Committee.

Dr. Tzeng is professor of surgery, University of Pittsburgh, and chief, vascular surgery, Veterans Affairs Pittsburgh Healthcare System, University Drive Campus, PA. She is Vice-Chair, ACS Scientific Forum Committee.

Dr. Rusch is vice-chair, clinical research, department of surgery; Miner Family Chair in Intrathoracic Cancers; attending surgeon, thoracic service, department of surgery, Memorial Sloan-Kettering Cancer Center; and professor of surgery, Weill Cornell Medical College. She is a consultant for the ACS Program Committee.

Ms. Burns is Senior Manager, Clinical Congress Program, ACS Division of Education, Chicago.

Mr. King is Assistant Director, Clinical Congress Program and Skills Courses, ACS Division of Education.

Dr. Sachdeva is Director, ACS Division of Education.






 

The American Venous Forum Foundation will accept applications until Oct. 21 for the $100,000 BSN-JOBST Research Grant. The grant is for original, basic or clinical research in venous or lymphatic disease and provides $50,000 for each of two years. It is named after patient Conrad Jobst, who suffered from vascular disease and developed gradient compression garments to help relieve symptoms of venous disease.

The American Venous Forum Foundation will accept applications until Oct. 21 for the $100,000 BSN-JOBST Research Grant. The grant is for original, basic or clinical research in venous or lymphatic disease and provides $50,000 for each of two years. It is named after patient Conrad Jobst, who suffered from vascular disease and developed gradient compression garments to help relieve symptoms of venous disease.

The American Venous Forum Foundation will accept applications until Oct. 21 for the $100,000 BSN-JOBST Research Grant. The grant is for original, basic or clinical research in venous or lymphatic disease and provides $50,000 for each of two years. It is named after patient Conrad Jobst, who suffered from vascular disease and developed gradient compression garments to help relieve symptoms of venous disease.

The National Heart, Lung and Blood institute has extended the combined number of years of K training support from six to eight years for the K08 and K23 grants. Clinician scientists who have received either award can stay on a K12 or KL2 program for up to three years and then request a five-year individual K award. This will help support the transition from training to independent investigators for those clinicians.

The National Heart, Lung and Blood institute has extended the combined number of years of K training support from six to eight years for the K08 and K23 grants. Clinician scientists who have received either award can stay on a K12 or KL2 program for up to three years and then request a five-year individual K award. This will help support the transition from training to independent investigators for those clinicians.

The National Heart, Lung and Blood institute has extended the combined number of years of K training support from six to eight years for the K08 and K23 grants. Clinician scientists who have received either award can stay on a K12 or KL2 program for up to three years and then request a five-year individual K award. This will help support the transition from training to independent investigators for those clinicians.

PARIS – A one-way endobronchial valve placed in the lungs of emphysema patients with hyperinflation provides acceptable safety and clinically significant improvement in lung function at 12 months, according to results from a multicenter trial presented as a late-breaker at the annual congress of the European Respiratory Society.

Ted Bosworth/MDedge News

Six-month results have been presented previously, but the 12-month results suggest that lung volume reduction associated with placement of the valves provides “durable effectiveness in appropriately selected hyperinflated emphysema patients,” according to Gerard Criner, MD, chair of the thoracic medicine department at Temple University, Philadelphia.

In this randomized controlled trial, called EMPROVE, 172 emphysema patients with severe dyspnea were randomized in a 2:1 fashion to receive a proprietary endobronchial valve or medical therapy alone. The valve, marketed under the brand name Spiration Valve System (SVS), is currently indicated for the treatment of air leaks after lung surgery.

“The valve serves to block airflow from edematous lungs with the objective of blocking hyperinflation and improving lung function,” Dr. Criner explained. The valves are retrievable, if necessary, with bronchoscopy.

High resolution computed tomography (HRCT) was used to identify emphysema obstruction and target valve placement to the most diseased lobes. The average number of valves placed per patient was slightly less than four. Most of the valves (70%) were placed in an upper lobe.

When reported at 6 months, the responder rate, defined as at least 15% improvement in forced expiratory volume in 1 second (FEV₁) was 36.8% and 10% in the SVS and control groups, respectively, a difference of 25.7% that Dr. Criner reported as statistically significant although he did not provide P values. At 12 months, the rates were 37.2% and 5.1%, respectively, demonstrating a persistent effect.

Thoracic adverse events were higher at both 6 months (31% vs. 11.9%) and 12 months (21.4% vs. 10.6%) in the treatment group relative to the control group. At 6 months, pneumothorax, which Dr. Criner characterized as “a recognized marker of target lobe volume reduction,” was the only event that occurred significantly more commonly (14.2% vs. 0%) in the SVS group.

Between 6 and 12 months, there were no pneumothorax events in either arm. The higher numerical rates of thoracic adverse events in the treatment arm were acute exacerbations (13.6% vs. 8.5%) and pneumonia in nontreated lobes (7.8% vs. 2.1%), but these rates were not statistically different.

At 6 months, there was a numerically higher rate of all-cause mortality in the treatment group (5.3% vs. 1.7%) but the rate was numerically lower between 6 and 12 months (2.9% vs. 6.4%). The differences were not significantly different at either time point or overall.

A significant reduction in hyperinflation favoring valve placement was accompanied by improvement in objective measures of lung function, such as FEV₁, and dyspnea, as measured with the Modified Medical Research Council (mMRC) Dyspnea Scale, at 6 and 12 months. These improvements translated into persistent quality of life benefits as measured with the St. George Respiratory Questionnaire (SGRQ). At 12 months, the SGRQ changes from baseline were a 5.5-point reduction and a four-point gain in the treatment and control groups, respectively. This absolute difference of 9.5 points is slightly more modest than the 13-point difference at 6 months (–8 vs. +5 points), but demonstrates a durable effect, Dr. Criner reported.

According to Dr. Criner, EMPROVE reinforces the principle that HRCT is effective “for selecting the lobe for therapy and which patients may benefit,” but the most important message from the 12-month results is persistent clinical benefit.

The endobronchial values “provide statistically and clinically meaningful improvements in FEV₁, reductions in lobe volume and dyspnea, and improvements in quality of life with an acceptable safety profile,” Dr. Criner reported.

On June 29, 2018, the Food and Drug Administration approved the first endobronchial valve for treatment of emphysema. This valve, marketed under the name Zephyr, was approved on the basis of the pivotal LIBERATE trial, also led by Dr. Criner and published earlier this year (Am J Respir Crit Care Med. 2018 May 22. doi: 10.1164/rccm.201803-0590OC.). The results of EMPROVE are consistent with previous evidence that a one-way valve, by preventing air from entering diseased lobes of patients with emphysema to exacerbate hyperinflation, improves lung function and reduces clinical symptoms.

Dr. Criner reports financial relationships with Olympus, the sponsor of this trial.

PARIS – A one-way endobronchial valve placed in the lungs of emphysema patients with hyperinflation provides acceptable safety and clinically significant improvement in lung function at 12 months, according to results from a multicenter trial presented as a late-breaker at the annual congress of the European Respiratory Society.

Ted Bosworth/MDedge News

Six-month results have been presented previously, but the 12-month results suggest that lung volume reduction associated with placement of the valves provides “durable effectiveness in appropriately selected hyperinflated emphysema patients,” according to Gerard Criner, MD, chair of the thoracic medicine department at Temple University, Philadelphia.

In this randomized controlled trial, called EMPROVE, 172 emphysema patients with severe dyspnea were randomized in a 2:1 fashion to receive a proprietary endobronchial valve or medical therapy alone. The valve, marketed under the brand name Spiration Valve System (SVS), is currently indicated for the treatment of air leaks after lung surgery.

“The valve serves to block airflow from edematous lungs with the objective of blocking hyperinflation and improving lung function,” Dr. Criner explained. The valves are retrievable, if necessary, with bronchoscopy.

High resolution computed tomography (HRCT) was used to identify emphysema obstruction and target valve placement to the most diseased lobes. The average number of valves placed per patient was slightly less than four. Most of the valves (70%) were placed in an upper lobe.

When reported at 6 months, the responder rate, defined as at least 15% improvement in forced expiratory volume in 1 second (FEV₁) was 36.8% and 10% in the SVS and control groups, respectively, a difference of 25.7% that Dr. Criner reported as statistically significant although he did not provide P values. At 12 months, the rates were 37.2% and 5.1%, respectively, demonstrating a persistent effect.

Thoracic adverse events were higher at both 6 months (31% vs. 11.9%) and 12 months (21.4% vs. 10.6%) in the treatment group relative to the control group. At 6 months, pneumothorax, which Dr. Criner characterized as “a recognized marker of target lobe volume reduction,” was the only event that occurred significantly more commonly (14.2% vs. 0%) in the SVS group.

Between 6 and 12 months, there were no pneumothorax events in either arm. The higher numerical rates of thoracic adverse events in the treatment arm were acute exacerbations (13.6% vs. 8.5%) and pneumonia in nontreated lobes (7.8% vs. 2.1%), but these rates were not statistically different.

At 6 months, there was a numerically higher rate of all-cause mortality in the treatment group (5.3% vs. 1.7%) but the rate was numerically lower between 6 and 12 months (2.9% vs. 6.4%). The differences were not significantly different at either time point or overall.

A significant reduction in hyperinflation favoring valve placement was accompanied by improvement in objective measures of lung function, such as FEV₁, and dyspnea, as measured with the Modified Medical Research Council (mMRC) Dyspnea Scale, at 6 and 12 months. These improvements translated into persistent quality of life benefits as measured with the St. George Respiratory Questionnaire (SGRQ). At 12 months, the SGRQ changes from baseline were a 5.5-point reduction and a four-point gain in the treatment and control groups, respectively. This absolute difference of 9.5 points is slightly more modest than the 13-point difference at 6 months (–8 vs. +5 points), but demonstrates a durable effect, Dr. Criner reported.

According to Dr. Criner, EMPROVE reinforces the principle that HRCT is effective “for selecting the lobe for therapy and which patients may benefit,” but the most important message from the 12-month results is persistent clinical benefit.

The endobronchial values “provide statistically and clinically meaningful improvements in FEV₁, reductions in lobe volume and dyspnea, and improvements in quality of life with an acceptable safety profile,” Dr. Criner reported.

On June 29, 2018, the Food and Drug Administration approved the first endobronchial valve for treatment of emphysema. This valve, marketed under the name Zephyr, was approved on the basis of the pivotal LIBERATE trial, also led by Dr. Criner and published earlier this year (Am J Respir Crit Care Med. 2018 May 22. doi: 10.1164/rccm.201803-0590OC.). The results of EMPROVE are consistent with previous evidence that a one-way valve, by preventing air from entering diseased lobes of patients with emphysema to exacerbate hyperinflation, improves lung function and reduces clinical symptoms.

Dr. Criner reports financial relationships with Olympus, the sponsor of this trial.

PARIS – A one-way endobronchial valve placed in the lungs of emphysema patients with hyperinflation provides acceptable safety and clinically significant improvement in lung function at 12 months, according to results from a multicenter trial presented as a late-breaker at the annual congress of the European Respiratory Society.

Ted Bosworth/MDedge News

Six-month results have been presented previously, but the 12-month results suggest that lung volume reduction associated with placement of the valves provides “durable effectiveness in appropriately selected hyperinflated emphysema patients,” according to Gerard Criner, MD, chair of the thoracic medicine department at Temple University, Philadelphia.

In this randomized controlled trial, called EMPROVE, 172 emphysema patients with severe dyspnea were randomized in a 2:1 fashion to receive a proprietary endobronchial valve or medical therapy alone. The valve, marketed under the brand name Spiration Valve System (SVS), is currently indicated for the treatment of air leaks after lung surgery.

“The valve serves to block airflow from edematous lungs with the objective of blocking hyperinflation and improving lung function,” Dr. Criner explained. The valves are retrievable, if necessary, with bronchoscopy.

High resolution computed tomography (HRCT) was used to identify emphysema obstruction and target valve placement to the most diseased lobes. The average number of valves placed per patient was slightly less than four. Most of the valves (70%) were placed in an upper lobe.

When reported at 6 months, the responder rate, defined as at least 15% improvement in forced expiratory volume in 1 second (FEV₁) was 36.8% and 10% in the SVS and control groups, respectively, a difference of 25.7% that Dr. Criner reported as statistically significant although he did not provide P values. At 12 months, the rates were 37.2% and 5.1%, respectively, demonstrating a persistent effect.

Thoracic adverse events were higher at both 6 months (31% vs. 11.9%) and 12 months (21.4% vs. 10.6%) in the treatment group relative to the control group. At 6 months, pneumothorax, which Dr. Criner characterized as “a recognized marker of target lobe volume reduction,” was the only event that occurred significantly more commonly (14.2% vs. 0%) in the SVS group.

Between 6 and 12 months, there were no pneumothorax events in either arm. The higher numerical rates of thoracic adverse events in the treatment arm were acute exacerbations (13.6% vs. 8.5%) and pneumonia in nontreated lobes (7.8% vs. 2.1%), but these rates were not statistically different.

At 6 months, there was a numerically higher rate of all-cause mortality in the treatment group (5.3% vs. 1.7%) but the rate was numerically lower between 6 and 12 months (2.9% vs. 6.4%). The differences were not significantly different at either time point or overall.

A significant reduction in hyperinflation favoring valve placement was accompanied by improvement in objective measures of lung function, such as FEV₁, and dyspnea, as measured with the Modified Medical Research Council (mMRC) Dyspnea Scale, at 6 and 12 months. These improvements translated into persistent quality of life benefits as measured with the St. George Respiratory Questionnaire (SGRQ). At 12 months, the SGRQ changes from baseline were a 5.5-point reduction and a four-point gain in the treatment and control groups, respectively. This absolute difference of 9.5 points is slightly more modest than the 13-point difference at 6 months (–8 vs. +5 points), but demonstrates a durable effect, Dr. Criner reported.

According to Dr. Criner, EMPROVE reinforces the principle that HRCT is effective “for selecting the lobe for therapy and which patients may benefit,” but the most important message from the 12-month results is persistent clinical benefit.

The endobronchial values “provide statistically and clinically meaningful improvements in FEV₁, reductions in lobe volume and dyspnea, and improvements in quality of life with an acceptable safety profile,” Dr. Criner reported.

On June 29, 2018, the Food and Drug Administration approved the first endobronchial valve for treatment of emphysema. This valve, marketed under the name Zephyr, was approved on the basis of the pivotal LIBERATE trial, also led by Dr. Criner and published earlier this year (Am J Respir Crit Care Med. 2018 May 22. doi: 10.1164/rccm.201803-0590OC.). The results of EMPROVE are consistent with previous evidence that a one-way valve, by preventing air from entering diseased lobes of patients with emphysema to exacerbate hyperinflation, improves lung function and reduces clinical symptoms.

Dr. Criner reports financial relationships with Olympus, the sponsor of this trial.

The American College of Chest Physicians® announced updates to the evidence-based guidelines on antithrombotic therapy for atrial fibrillation. The guideline panel submitted the manuscript, Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report, for publication in the journal CHEST®.

Key recommendations and shifts from previous guidelines include:

• For patients with atrial fibrillation without valvular heart disease, including those with paroxysmal atrial fibrillation who are at low risk of stroke (eg, CHA2DS2VASc score of 0 in males or 1 in females), we suggest no antithrombotic therapy.

• For patients with a single non-sex CHA2DS2VASc stroke risk factor, we suggest oral anticoagulation rather than no therapy, aspirin or combination therapy with aspirin and clopidogrel.

• For those at high risk of stroke, we recommend oral anticoagulation rather than no therapy, aspirin or combination therapy with aspirin and clopidogrel.

• Where we recommend or suggest in favor of oral anticoagulation, we suggest using a novel oral anticoagulant (NOAC) rather than adjusted-dose vitamin K antagonist therapy. With the latter, it is important to aim for good quality anticoagulation control with a time in therapeutic range (TTR) >70%.

• Attention to modifiable bleeding risk factors should be made at each patient contact, and HAS-BLED score should be used to assess the risk of bleeding where high-risk patients (>=3) can be identified for earlier review and follow-up visits.

The complete guideline article is free to view in the Online First section of the journal CHEST.

The American College of Chest Physicians® announced updates to the evidence-based guidelines on antithrombotic therapy for atrial fibrillation. The guideline panel submitted the manuscript, Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report, for publication in the journal CHEST®.

Key recommendations and shifts from previous guidelines include:

• For patients with atrial fibrillation without valvular heart disease, including those with paroxysmal atrial fibrillation who are at low risk of stroke (eg, CHA2DS2VASc score of 0 in males or 1 in females), we suggest no antithrombotic therapy.

• For patients with a single non-sex CHA2DS2VASc stroke risk factor, we suggest oral anticoagulation rather than no therapy, aspirin or combination therapy with aspirin and clopidogrel.

• For those at high risk of stroke, we recommend oral anticoagulation rather than no therapy, aspirin or combination therapy with aspirin and clopidogrel.

• Where we recommend or suggest in favor of oral anticoagulation, we suggest using a novel oral anticoagulant (NOAC) rather than adjusted-dose vitamin K antagonist therapy. With the latter, it is important to aim for good quality anticoagulation control with a time in therapeutic range (TTR) >70%.

• Attention to modifiable bleeding risk factors should be made at each patient contact, and HAS-BLED score should be used to assess the risk of bleeding where high-risk patients (>=3) can be identified for earlier review and follow-up visits.

The complete guideline article is free to view in the Online First section of the journal CHEST.

The American College of Chest Physicians® announced updates to the evidence-based guidelines on antithrombotic therapy for atrial fibrillation. The guideline panel submitted the manuscript, Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report, for publication in the journal CHEST®.

Key recommendations and shifts from previous guidelines include:

• For patients with atrial fibrillation without valvular heart disease, including those with paroxysmal atrial fibrillation who are at low risk of stroke (eg, CHA2DS2VASc score of 0 in males or 1 in females), we suggest no antithrombotic therapy.

• For patients with a single non-sex CHA2DS2VASc stroke risk factor, we suggest oral anticoagulation rather than no therapy, aspirin or combination therapy with aspirin and clopidogrel.

• For those at high risk of stroke, we recommend oral anticoagulation rather than no therapy, aspirin or combination therapy with aspirin and clopidogrel.

• Where we recommend or suggest in favor of oral anticoagulation, we suggest using a novel oral anticoagulant (NOAC) rather than adjusted-dose vitamin K antagonist therapy. With the latter, it is important to aim for good quality anticoagulation control with a time in therapeutic range (TTR) >70%.

• Attention to modifiable bleeding risk factors should be made at each patient contact, and HAS-BLED score should be used to assess the risk of bleeding where high-risk patients (>=3) can be identified for earlier review and follow-up visits.

The complete guideline article is free to view in the Online First section of the journal CHEST.

Extracorporeal membrane oxygenation (ECMO) has become increasingly accepted as a rescue therapy for severe respiratory failure from a variety of conditions, though most commonly, the acute respiratory distress syndrome (ARDS) (Thiagarajan R, et al. ASAIO. 2017;63[1]:60). ECMO can provide respiratory or cardiorespiratory support for failing lungs, heart, or both. The most common ECMO configuration used in ARDS is venovenous ECMO, in which blood is withdrawn from a catheter placed in a central vein, pumped through a gas exchange device known as an oxygenator, and returned to the venous system via another catheter. The blood flowing through the oxygenator is separated from a continuous supply of oxygen-rich sweep gas by a semipermeable membrane, across which diffusion-mediated gas exchange occurs, so that the blood exiting it is rich in oxygen and low in carbon dioxide. As venovenous ECMO functions in series with the native circulation, the well-oxygenated blood exiting the ECMO circuit mixes with poorly oxygenated blood flowing through the lungs. Therefore, oxygenation is dependent on native cardiac output to achieve systemic oxygen delivery (Figure 1).

ECMO been used successfully in adults with ARDS since the early 1970s (Hill JD, et al. N Engl J Med. 1972;286[12]:629-34) but, until recently, was limited to small numbers of patients at select global centers and associated with a high-risk profile. In the last decade, however, driven by improvements in ECMO circuit components making the device safer and easier to use, encouraging worldwide experience during the 2009 influenza A (H1N1) pandemic (Davies A, et al. JAMA. 2009;302[17]1888-95), and publication of the Efficacy and Economic Assessment of Conventional Ventilatory Support versus Extracorporeal Membrane Oxygenation for Severe Adult Respiratory Failure (CESAR) trial (Peek GJ, et al. Lancet. 2009;374[9698]:1351-63), ECMO use has markedly increased.

Despite its rapid growth, however, rigorous evidence supporting the use of ECMO has been lacking. The CESAR trial, while impressive in execution, had methodological issues that limited the strength of its conclusions. CESAR was a pragmatic trial that randomized 180 adults with severe respiratory failure from multiple etiologies to conventional management or transfer to an experienced, ECMO-capable center. CESAR met its primary outcome of improved survival without disability in the ECMO-referred group (63% vs 47%, relative risk [RR] 0.69; 95% confidence interval [CI] 0.05 to 0.97, P=.03), but not all patients in that group ultimately received ECMO. In addition, the use of lung protective ventilation was significantly higher in the ECMO-referred group, making it difficult to separate its benefit from that of ECMO. A conservative interpretation is that CESAR showed the clinical benefit of treatment at an ECMO-capable center, experienced in the management of patients with severe respiratory failure.

Not until the release of the Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome (EOLIA) trial earlier this year (Combes A, et al. N Engl J Med. 2018;378[21]:1965-75), did a modern, randomized controlled trial evaluating the use of ECMO itself exist. The EOLIA trial addressed the limitations of CESAR and randomized adult patients with early, severe ARDS to conventional, standard of care management that included a protocolized lung protective strategy in the control group vs immediate initiation of ECMO combined with an ultra-lung protective strategy (targeting end-inspiratory plateau pressure ≤24 cmH2O) in the intervention group. The primary outcome was all-cause mortality at 60 days. Of note, patients enrolled in EOLIA met entry criteria despite greater than 90% of patients receiving neuromuscular blockade and around 60% treated with prone positioning at the time of randomization (importantly, 90% of control group patients ultimately underwent prone positioning).

EOLIA was powered to detect a 20% decrease in mortality in the ECMO group. Based on trial design and the results of the fourth interim analysis, the trial was stopped for futility to reach that endpoint after enrollment of 249 of a maximum 331 patients. Although a 20% mortality reduction was not achieved, 60-day mortality was notably lower in the ECMO-treated group (35% vs 46%, RR 0.76, 95% CI 0.55 to 1.04, P=.09). The key secondary outcome of risk of treatment failure (defined as death in the ECMO group and death or crossover to ECMO in the control group) favored the ECMO group with a RR for mortality of 0.62 (95% CI, 0.47 to 0.82; P<.001), as did other secondary endpoints such as days free of renal and other organ failure.

A major limitation of the trial was that 35 (28%) of control group patients ultimately crossed over to ECMO, which diluted the effect of ECMO observed in the intention-to-treat analysis. Crossover occurred at clinician discretion an average of 6.5 days after randomization and after stringent criteria for crossover was met. These patients were incredibly ill, with a median oxygen saturation of 77%, rapidly worsening inotropic scores, and lactic acidosis; nine individuals had already suffered cardiac arrest, and six had received ECMO as part of extracorporeal cardiopulmonary resuscitation (ECPR), the initiation of venoarterial ECMO during cardiac arrest in attempt to restore spontaneous circulation. Mortality was considerably worse in the crossover group than in conventionally managed cohort overall, and, notably, 33% of patients crossed over to ECMO still survived.

In order to estimate the effect of ECMO on survival times if crossover had not occurred, the authors performed a post-hoc, rank-preserving structural failure time analysis. Though this relies on some assessment regarding the effect of the treatment itself, it showed a hazard ratio for mortality in the ECMO group of 0.51 (95% CI 0.24 to 1.02, P=.055). Although the EOLIA trial was not positive by traditional interpretation, all three major analyses and all secondary endpoints suggest some degree of benefit in patients with severe ARDS managed with ECMO.

Importantly, ECMO was well tolerated (at least when performed at expert centers, as done in this trial). There were significantly more bleeding events and cases of severe thrombocytopenia in the ECMO-treated group, but massive hemorrhage, ischemic and hemorrhagic stroke, arrhythmias, and other complications were similar.

Where do we go from here? Based on the totality of information, it is reasonable to consider ECMO for cases of severe ARDS not responsive to conventional measures, such as a lung protective ventilator strategy, neuromuscular blockade, and prone positioning. Initiation of ECMO may be reasonable prior to implementation of standard of care therapies, in order to permit safe transfer to an experienced center from a center not able to provide them.

Two take-away points: First, it is important to recognize that much of the clinical benefit derived from ECMO may be beyond its ability to normalize gas exchange and be due, at least in part, to the fact that ECMO allows the enhancement of proven lung protective ventilatory strategies. Initiation of ECMO and the “lung rest” it permits reduce the mechanical power applied to the injured alveoli and may attenuate ventilator-induced lung injury, cytokine release, and multiorgan failure that portend poor clinical outcomes in ARDS. Second, ECMO in EOLIA was conducted at expert centers with relatively low rates of complications.

It is too early to know how the critical care community will view ECMO for ARDS in light of EOLIA as well as a growing body of global ECMO experience, or how its wider application may impact the distribution and organization of ECMO centers. Regardless, of paramount importance in using ECMO as a treatment modality is optimizing patient management both prior to and after its initiation.

Dr. Agerstrand is Assistant Professor of Medicine, Director of the Medical ECMO Program, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital.


 

Extracorporeal membrane oxygenation (ECMO) has become increasingly accepted as a rescue therapy for severe respiratory failure from a variety of conditions, though most commonly, the acute respiratory distress syndrome (ARDS) (Thiagarajan R, et al. ASAIO. 2017;63[1]:60). ECMO can provide respiratory or cardiorespiratory support for failing lungs, heart, or both. The most common ECMO configuration used in ARDS is venovenous ECMO, in which blood is withdrawn from a catheter placed in a central vein, pumped through a gas exchange device known as an oxygenator, and returned to the venous system via another catheter. The blood flowing through the oxygenator is separated from a continuous supply of oxygen-rich sweep gas by a semipermeable membrane, across which diffusion-mediated gas exchange occurs, so that the blood exiting it is rich in oxygen and low in carbon dioxide. As venovenous ECMO functions in series with the native circulation, the well-oxygenated blood exiting the ECMO circuit mixes with poorly oxygenated blood flowing through the lungs. Therefore, oxygenation is dependent on native cardiac output to achieve systemic oxygen delivery (Figure 1).

ECMO been used successfully in adults with ARDS since the early 1970s (Hill JD, et al. N Engl J Med. 1972;286[12]:629-34) but, until recently, was limited to small numbers of patients at select global centers and associated with a high-risk profile. In the last decade, however, driven by improvements in ECMO circuit components making the device safer and easier to use, encouraging worldwide experience during the 2009 influenza A (H1N1) pandemic (Davies A, et al. JAMA. 2009;302[17]1888-95), and publication of the Efficacy and Economic Assessment of Conventional Ventilatory Support versus Extracorporeal Membrane Oxygenation for Severe Adult Respiratory Failure (CESAR) trial (Peek GJ, et al. Lancet. 2009;374[9698]:1351-63), ECMO use has markedly increased.

Despite its rapid growth, however, rigorous evidence supporting the use of ECMO has been lacking. The CESAR trial, while impressive in execution, had methodological issues that limited the strength of its conclusions. CESAR was a pragmatic trial that randomized 180 adults with severe respiratory failure from multiple etiologies to conventional management or transfer to an experienced, ECMO-capable center. CESAR met its primary outcome of improved survival without disability in the ECMO-referred group (63% vs 47%, relative risk [RR] 0.69; 95% confidence interval [CI] 0.05 to 0.97, P=.03), but not all patients in that group ultimately received ECMO. In addition, the use of lung protective ventilation was significantly higher in the ECMO-referred group, making it difficult to separate its benefit from that of ECMO. A conservative interpretation is that CESAR showed the clinical benefit of treatment at an ECMO-capable center, experienced in the management of patients with severe respiratory failure.

Not until the release of the Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome (EOLIA) trial earlier this year (Combes A, et al. N Engl J Med. 2018;378[21]:1965-75), did a modern, randomized controlled trial evaluating the use of ECMO itself exist. The EOLIA trial addressed the limitations of CESAR and randomized adult patients with early, severe ARDS to conventional, standard of care management that included a protocolized lung protective strategy in the control group vs immediate initiation of ECMO combined with an ultra-lung protective strategy (targeting end-inspiratory plateau pressure ≤24 cmH2O) in the intervention group. The primary outcome was all-cause mortality at 60 days. Of note, patients enrolled in EOLIA met entry criteria despite greater than 90% of patients receiving neuromuscular blockade and around 60% treated with prone positioning at the time of randomization (importantly, 90% of control group patients ultimately underwent prone positioning).

EOLIA was powered to detect a 20% decrease in mortality in the ECMO group. Based on trial design and the results of the fourth interim analysis, the trial was stopped for futility to reach that endpoint after enrollment of 249 of a maximum 331 patients. Although a 20% mortality reduction was not achieved, 60-day mortality was notably lower in the ECMO-treated group (35% vs 46%, RR 0.76, 95% CI 0.55 to 1.04, P=.09). The key secondary outcome of risk of treatment failure (defined as death in the ECMO group and death or crossover to ECMO in the control group) favored the ECMO group with a RR for mortality of 0.62 (95% CI, 0.47 to 0.82; P<.001), as did other secondary endpoints such as days free of renal and other organ failure.

A major limitation of the trial was that 35 (28%) of control group patients ultimately crossed over to ECMO, which diluted the effect of ECMO observed in the intention-to-treat analysis. Crossover occurred at clinician discretion an average of 6.5 days after randomization and after stringent criteria for crossover was met. These patients were incredibly ill, with a median oxygen saturation of 77%, rapidly worsening inotropic scores, and lactic acidosis; nine individuals had already suffered cardiac arrest, and six had received ECMO as part of extracorporeal cardiopulmonary resuscitation (ECPR), the initiation of venoarterial ECMO during cardiac arrest in attempt to restore spontaneous circulation. Mortality was considerably worse in the crossover group than in conventionally managed cohort overall, and, notably, 33% of patients crossed over to ECMO still survived.

In order to estimate the effect of ECMO on survival times if crossover had not occurred, the authors performed a post-hoc, rank-preserving structural failure time analysis. Though this relies on some assessment regarding the effect of the treatment itself, it showed a hazard ratio for mortality in the ECMO group of 0.51 (95% CI 0.24 to 1.02, P=.055). Although the EOLIA trial was not positive by traditional interpretation, all three major analyses and all secondary endpoints suggest some degree of benefit in patients with severe ARDS managed with ECMO.

Importantly, ECMO was well tolerated (at least when performed at expert centers, as done in this trial). There were significantly more bleeding events and cases of severe thrombocytopenia in the ECMO-treated group, but massive hemorrhage, ischemic and hemorrhagic stroke, arrhythmias, and other complications were similar.

Where do we go from here? Based on the totality of information, it is reasonable to consider ECMO for cases of severe ARDS not responsive to conventional measures, such as a lung protective ventilator strategy, neuromuscular blockade, and prone positioning. Initiation of ECMO may be reasonable prior to implementation of standard of care therapies, in order to permit safe transfer to an experienced center from a center not able to provide them.

Two take-away points: First, it is important to recognize that much of the clinical benefit derived from ECMO may be beyond its ability to normalize gas exchange and be due, at least in part, to the fact that ECMO allows the enhancement of proven lung protective ventilatory strategies. Initiation of ECMO and the “lung rest” it permits reduce the mechanical power applied to the injured alveoli and may attenuate ventilator-induced lung injury, cytokine release, and multiorgan failure that portend poor clinical outcomes in ARDS. Second, ECMO in EOLIA was conducted at expert centers with relatively low rates of complications.

It is too early to know how the critical care community will view ECMO for ARDS in light of EOLIA as well as a growing body of global ECMO experience, or how its wider application may impact the distribution and organization of ECMO centers. Regardless, of paramount importance in using ECMO as a treatment modality is optimizing patient management both prior to and after its initiation.

Dr. Agerstrand is Assistant Professor of Medicine, Director of the Medical ECMO Program, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital.


 

Extracorporeal membrane oxygenation (ECMO) has become increasingly accepted as a rescue therapy for severe respiratory failure from a variety of conditions, though most commonly, the acute respiratory distress syndrome (ARDS) (Thiagarajan R, et al. ASAIO. 2017;63[1]:60). ECMO can provide respiratory or cardiorespiratory support for failing lungs, heart, or both. The most common ECMO configuration used in ARDS is venovenous ECMO, in which blood is withdrawn from a catheter placed in a central vein, pumped through a gas exchange device known as an oxygenator, and returned to the venous system via another catheter. The blood flowing through the oxygenator is separated from a continuous supply of oxygen-rich sweep gas by a semipermeable membrane, across which diffusion-mediated gas exchange occurs, so that the blood exiting it is rich in oxygen and low in carbon dioxide. As venovenous ECMO functions in series with the native circulation, the well-oxygenated blood exiting the ECMO circuit mixes with poorly oxygenated blood flowing through the lungs. Therefore, oxygenation is dependent on native cardiac output to achieve systemic oxygen delivery (Figure 1).

ECMO been used successfully in adults with ARDS since the early 1970s (Hill JD, et al. N Engl J Med. 1972;286[12]:629-34) but, until recently, was limited to small numbers of patients at select global centers and associated with a high-risk profile. In the last decade, however, driven by improvements in ECMO circuit components making the device safer and easier to use, encouraging worldwide experience during the 2009 influenza A (H1N1) pandemic (Davies A, et al. JAMA. 2009;302[17]1888-95), and publication of the Efficacy and Economic Assessment of Conventional Ventilatory Support versus Extracorporeal Membrane Oxygenation for Severe Adult Respiratory Failure (CESAR) trial (Peek GJ, et al. Lancet. 2009;374[9698]:1351-63), ECMO use has markedly increased.

Despite its rapid growth, however, rigorous evidence supporting the use of ECMO has been lacking. The CESAR trial, while impressive in execution, had methodological issues that limited the strength of its conclusions. CESAR was a pragmatic trial that randomized 180 adults with severe respiratory failure from multiple etiologies to conventional management or transfer to an experienced, ECMO-capable center. CESAR met its primary outcome of improved survival without disability in the ECMO-referred group (63% vs 47%, relative risk [RR] 0.69; 95% confidence interval [CI] 0.05 to 0.97, P=.03), but not all patients in that group ultimately received ECMO. In addition, the use of lung protective ventilation was significantly higher in the ECMO-referred group, making it difficult to separate its benefit from that of ECMO. A conservative interpretation is that CESAR showed the clinical benefit of treatment at an ECMO-capable center, experienced in the management of patients with severe respiratory failure.

Not until the release of the Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome (EOLIA) trial earlier this year (Combes A, et al. N Engl J Med. 2018;378[21]:1965-75), did a modern, randomized controlled trial evaluating the use of ECMO itself exist. The EOLIA trial addressed the limitations of CESAR and randomized adult patients with early, severe ARDS to conventional, standard of care management that included a protocolized lung protective strategy in the control group vs immediate initiation of ECMO combined with an ultra-lung protective strategy (targeting end-inspiratory plateau pressure ≤24 cmH2O) in the intervention group. The primary outcome was all-cause mortality at 60 days. Of note, patients enrolled in EOLIA met entry criteria despite greater than 90% of patients receiving neuromuscular blockade and around 60% treated with prone positioning at the time of randomization (importantly, 90% of control group patients ultimately underwent prone positioning).

EOLIA was powered to detect a 20% decrease in mortality in the ECMO group. Based on trial design and the results of the fourth interim analysis, the trial was stopped for futility to reach that endpoint after enrollment of 249 of a maximum 331 patients. Although a 20% mortality reduction was not achieved, 60-day mortality was notably lower in the ECMO-treated group (35% vs 46%, RR 0.76, 95% CI 0.55 to 1.04, P=.09). The key secondary outcome of risk of treatment failure (defined as death in the ECMO group and death or crossover to ECMO in the control group) favored the ECMO group with a RR for mortality of 0.62 (95% CI, 0.47 to 0.82; P<.001), as did other secondary endpoints such as days free of renal and other organ failure.

A major limitation of the trial was that 35 (28%) of control group patients ultimately crossed over to ECMO, which diluted the effect of ECMO observed in the intention-to-treat analysis. Crossover occurred at clinician discretion an average of 6.5 days after randomization and after stringent criteria for crossover was met. These patients were incredibly ill, with a median oxygen saturation of 77%, rapidly worsening inotropic scores, and lactic acidosis; nine individuals had already suffered cardiac arrest, and six had received ECMO as part of extracorporeal cardiopulmonary resuscitation (ECPR), the initiation of venoarterial ECMO during cardiac arrest in attempt to restore spontaneous circulation. Mortality was considerably worse in the crossover group than in conventionally managed cohort overall, and, notably, 33% of patients crossed over to ECMO still survived.

In order to estimate the effect of ECMO on survival times if crossover had not occurred, the authors performed a post-hoc, rank-preserving structural failure time analysis. Though this relies on some assessment regarding the effect of the treatment itself, it showed a hazard ratio for mortality in the ECMO group of 0.51 (95% CI 0.24 to 1.02, P=.055). Although the EOLIA trial was not positive by traditional interpretation, all three major analyses and all secondary endpoints suggest some degree of benefit in patients with severe ARDS managed with ECMO.

Importantly, ECMO was well tolerated (at least when performed at expert centers, as done in this trial). There were significantly more bleeding events and cases of severe thrombocytopenia in the ECMO-treated group, but massive hemorrhage, ischemic and hemorrhagic stroke, arrhythmias, and other complications were similar.

Where do we go from here? Based on the totality of information, it is reasonable to consider ECMO for cases of severe ARDS not responsive to conventional measures, such as a lung protective ventilator strategy, neuromuscular blockade, and prone positioning. Initiation of ECMO may be reasonable prior to implementation of standard of care therapies, in order to permit safe transfer to an experienced center from a center not able to provide them.

Two take-away points: First, it is important to recognize that much of the clinical benefit derived from ECMO may be beyond its ability to normalize gas exchange and be due, at least in part, to the fact that ECMO allows the enhancement of proven lung protective ventilatory strategies. Initiation of ECMO and the “lung rest” it permits reduce the mechanical power applied to the injured alveoli and may attenuate ventilator-induced lung injury, cytokine release, and multiorgan failure that portend poor clinical outcomes in ARDS. Second, ECMO in EOLIA was conducted at expert centers with relatively low rates of complications.

It is too early to know how the critical care community will view ECMO for ARDS in light of EOLIA as well as a growing body of global ECMO experience, or how its wider application may impact the distribution and organization of ECMO centers. Regardless, of paramount importance in using ECMO as a treatment modality is optimizing patient management both prior to and after its initiation.

Dr. Agerstrand is Assistant Professor of Medicine, Director of the Medical ECMO Program, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital.


 

Due to significant interest in the pulmonary/critical care community, the National Board of Echocardiography (NBE) has opened registration for a board examination as a requirement for national level certification in advanced critical care echocardiography (ACCE). The examination has been developed by the National Board of Medical Examiners; CHEST and the other professional societies are well represented on the writing committee. The first examination is scheduled to be given on January 15, 2019.

The board of the NBE will be the final arbiter for other requirements for certification. We anticipate that these will be available in 2019.

A few essential questions about the certification:

1. Who will be eligible for certification in ACCE?

The policy of the NBE is that any licensed physician may take the examination. Passing the examination confers testamur status, which is only one of several requirements for certification. The board of the NBE will make the final decision as to how to define the clinical background of the candidate that will be required for certification.

2. What will be the requirements for demonstration of competence at image acquisition for ACCE?

Competence at ACCE requires that the intensivist be expert at image acquisition of a comprehensive image set. The board of the NBE will make the final decision as to what constitutes a full ACCE image set, how many studies must be performed by the candidate, and how the studies will be documented. Regarding the latter question, it is likely that there will be a need for identification of qualified mentors to guide the candidate through the process of demonstrating competence in image acquisition.

3. What resources exist to learn more about the examination?

For some suggestions regarding mastery of the cognitive base, Dr. Yonatan Greenstein has set up an independent website that has recommendations about study material and an example of the full ACCE image set (advancedcriticalcareecho.org). The NBE website has a list of subjects that will be covered in the examination. In addition to passing the examination, there will be other elements required for ACCE certification. The NBE has not yet made final decision on the additional requirements. As soon as they are available, they will be posted on the NBE website (echoboards.org).

There is keen interest amongst fellows and junior attendings in the NBE certification who are already competent in whole body ultrasonography. They see ACCE as a natural and necessary extension of their scope of practice, as a means of better helping their critically ill patients, and as a means of acquiring a unique skill that defines them as having a special skill compared with other intensivists. A smaller group of senior attending intensivists are primarily motivated by a well-defined practice-related need of skill at ACCE and/or a strong perception that knowledge of ACCE may directly improve their ability to care for the critically ill patient. Interest in certification extends across the various specialties that provide critical care services. The NBE has indicated that there has been a strong showing of registrations for the examination thus far.

We recommend that candidates for certification consider that passing the examination should be the priority. Collection of the image set may occur in parallel, as the two will complement each other. Preparation for the examination requires intensive study of the cognitive base of ACCE and mastery of image interpretation.

To aid in preparation for the ACCE examination, CHEST is offering a comprehensive review course, Advanced Critical Care Echocardiography Board Review Exam Course, being held at the CHEST Innovation, Simulation, and Training Center, December 7-8, 2018, in Glenview, Illinois.




 

Due to significant interest in the pulmonary/critical care community, the National Board of Echocardiography (NBE) has opened registration for a board examination as a requirement for national level certification in advanced critical care echocardiography (ACCE). The examination has been developed by the National Board of Medical Examiners; CHEST and the other professional societies are well represented on the writing committee. The first examination is scheduled to be given on January 15, 2019.

The board of the NBE will be the final arbiter for other requirements for certification. We anticipate that these will be available in 2019.

A few essential questions about the certification:

1. Who will be eligible for certification in ACCE?

The policy of the NBE is that any licensed physician may take the examination. Passing the examination confers testamur status, which is only one of several requirements for certification. The board of the NBE will make the final decision as to how to define the clinical background of the candidate that will be required for certification.

2. What will be the requirements for demonstration of competence at image acquisition for ACCE?

Competence at ACCE requires that the intensivist be expert at image acquisition of a comprehensive image set. The board of the NBE will make the final decision as to what constitutes a full ACCE image set, how many studies must be performed by the candidate, and how the studies will be documented. Regarding the latter question, it is likely that there will be a need for identification of qualified mentors to guide the candidate through the process of demonstrating competence in image acquisition.

3. What resources exist to learn more about the examination?

For some suggestions regarding mastery of the cognitive base, Dr. Yonatan Greenstein has set up an independent website that has recommendations about study material and an example of the full ACCE image set (advancedcriticalcareecho.org). The NBE website has a list of subjects that will be covered in the examination. In addition to passing the examination, there will be other elements required for ACCE certification. The NBE has not yet made final decision on the additional requirements. As soon as they are available, they will be posted on the NBE website (echoboards.org).

There is keen interest amongst fellows and junior attendings in the NBE certification who are already competent in whole body ultrasonography. They see ACCE as a natural and necessary extension of their scope of practice, as a means of better helping their critically ill patients, and as a means of acquiring a unique skill that defines them as having a special skill compared with other intensivists. A smaller group of senior attending intensivists are primarily motivated by a well-defined practice-related need of skill at ACCE and/or a strong perception that knowledge of ACCE may directly improve their ability to care for the critically ill patient. Interest in certification extends across the various specialties that provide critical care services. The NBE has indicated that there has been a strong showing of registrations for the examination thus far.

We recommend that candidates for certification consider that passing the examination should be the priority. Collection of the image set may occur in parallel, as the two will complement each other. Preparation for the examination requires intensive study of the cognitive base of ACCE and mastery of image interpretation.

To aid in preparation for the ACCE examination, CHEST is offering a comprehensive review course, Advanced Critical Care Echocardiography Board Review Exam Course, being held at the CHEST Innovation, Simulation, and Training Center, December 7-8, 2018, in Glenview, Illinois.




 

Due to significant interest in the pulmonary/critical care community, the National Board of Echocardiography (NBE) has opened registration for a board examination as a requirement for national level certification in advanced critical care echocardiography (ACCE). The examination has been developed by the National Board of Medical Examiners; CHEST and the other professional societies are well represented on the writing committee. The first examination is scheduled to be given on January 15, 2019.

The board of the NBE will be the final arbiter for other requirements for certification. We anticipate that these will be available in 2019.

A few essential questions about the certification:

1. Who will be eligible for certification in ACCE?

The policy of the NBE is that any licensed physician may take the examination. Passing the examination confers testamur status, which is only one of several requirements for certification. The board of the NBE will make the final decision as to how to define the clinical background of the candidate that will be required for certification.

2. What will be the requirements for demonstration of competence at image acquisition for ACCE?

Competence at ACCE requires that the intensivist be expert at image acquisition of a comprehensive image set. The board of the NBE will make the final decision as to what constitutes a full ACCE image set, how many studies must be performed by the candidate, and how the studies will be documented. Regarding the latter question, it is likely that there will be a need for identification of qualified mentors to guide the candidate through the process of demonstrating competence in image acquisition.

3. What resources exist to learn more about the examination?

For some suggestions regarding mastery of the cognitive base, Dr. Yonatan Greenstein has set up an independent website that has recommendations about study material and an example of the full ACCE image set (advancedcriticalcareecho.org). The NBE website has a list of subjects that will be covered in the examination. In addition to passing the examination, there will be other elements required for ACCE certification. The NBE has not yet made final decision on the additional requirements. As soon as they are available, they will be posted on the NBE website (echoboards.org).

There is keen interest amongst fellows and junior attendings in the NBE certification who are already competent in whole body ultrasonography. They see ACCE as a natural and necessary extension of their scope of practice, as a means of better helping their critically ill patients, and as a means of acquiring a unique skill that defines them as having a special skill compared with other intensivists. A smaller group of senior attending intensivists are primarily motivated by a well-defined practice-related need of skill at ACCE and/or a strong perception that knowledge of ACCE may directly improve their ability to care for the critically ill patient. Interest in certification extends across the various specialties that provide critical care services. The NBE has indicated that there has been a strong showing of registrations for the examination thus far.

We recommend that candidates for certification consider that passing the examination should be the priority. Collection of the image set may occur in parallel, as the two will complement each other. Preparation for the examination requires intensive study of the cognitive base of ACCE and mastery of image interpretation.

To aid in preparation for the ACCE examination, CHEST is offering a comprehensive review course, Advanced Critical Care Echocardiography Board Review Exam Course, being held at the CHEST Innovation, Simulation, and Training Center, December 7-8, 2018, in Glenview, Illinois.