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Disaster Response
A Natural Disaster Creates Nationwide Threat
Hurricane Maria devastated Puerto Rico in late September 2017, and the lessons learned endure as the storm exposed the vulnerability of an increasingly interconnected and fragile medical community across the continental United States. According to the US Food and Drug Administration (FDA), Puerto Rico manufactures more drug products than any US state and just under 10% of all drugs consumed by Americans, some of which do not have therapeutic alternatives. In addition, certain medical devices are only produced in Puerto Rico. The humanitarian crisis caused by Hurricane Maria consequently created critical medication and medical device shortages across the United States (FDA. https://www.fda.gov/NewsEvents/. Accessed Feb 01, 2018).
The disruption and disorganization caused by Hurricane Maria was perhaps best exemplified by the resultant shortage of small-volume 0.9% saline injection bags, which coincided with a particularly bad flu season. The FDA temporarily allowed import of saline bags from outside the United States while concurrently expediting the approval of IV solutions from new manufacturers. The American Society for Health-System Pharmacists (ASHP), meanwhile, contributed guidance on managing fluid shortages (ASHP. https://www.ashp.org/Drug-Shortages/. Accessed Feb 01, 2018).
Hurricane Maria was a wake-up call for medical professionals across the United States to modernize institutional procedures and to develop contingency plans to deal with medication shortages, particularly IV fluids, since this is a recurring problem across the United States since 2014. Ultimately, the goal of health-care providers across the United States is to manage natural catastrophes, however distant, by effectively planning for and adapting to medical product shortages to ensure patient care is not interrupted and that critical shortages remain invisible to patients themselves.
Cristian Madar, MD
Steering Committee Member
Practice Operations
Are All Regulations Well Thought Out? Point of View!
Current medicine is complex, with patients presenting in the ICU with multiorgan dysfunction. The art and science of medicine is being replaced by protocolized medicine. To help streamline the care, societies and colleges are coming up with guidelines. The guideline, though, changes from year to year what has been practiced in the past has been obsolete, and what is current may not hold true in the future. With increasing health-care costs affecting physician and hospital practices, innovations are being undertaken on a daily basis. The payers, on the other hand, are trying to come up with regulations, whether one likes it or not, that have become the beacon for penalty and reward. Sometimes those regulations conflict with what is sound judgment and prudent care, cornering the providers in the box with unnecessary penalties.
Approximately 250,000 bloodstream infections occur in the United States yearly, mostly attributed to the presence of intravascular devices. The rate of central line-associated blood stream infection (CLABSI) in the United States is 0.8 per 1,000 central line days. The desirable rate is zero rate of CLABSI. The hospitals are being pushed to be prudent with the use of central lines and removal if not needed. The technique and sterile field along with appropriate innovation in dressing technique have been effective in reducing the CLABSI by 46% from 2008 to 2013. The hospitals and ICUs are being very vigilant in trying to avoid CLABSI and are striving to achieve the goal of a zero percentage CLABSI rate, leading to almost a state of paranoia. The efforts are being undertaken in many institutions to get all the cultures on admission to identify the organism on admission so as to be designated as a bloodstream infection (BSI) due to other causes and to avoid the CLABSI attribution. The CLABSI attribution follows a complex algorithm with no waiver for the exception outside the strict definition that is changing (The 2015 definition change resulted in an 83% increase in CLABSI rate.).
We hereby present a simple scenario for point of view, where there is very clear-cut evidence of the bloodstream infection due to abdominal sources but that BSI would be designated as CLABSI as defined by National Healthcare Safety Network (NHSN). The patient postoperatively presents with fever, nausea, and abdominal discomfort. The CT scan showed fluid collection suggestive of infection. Culture from the abscess grew Escherichia coli and the blood culture grew Bacteroides fargilis. This patient was labeled as BSI due to intra-abdominal cause. On the other hand, patient has pus pockets in the abdominal wall with swelling and tenderness. Cultures from the pustule grew Streptococcus Group B and the blood culture grew Staphylococcus aureus. This would be classified as soft tissue infection and primary BSI and if the patient has the central line for 2 days, it would be classified as CLABSI, even though there was a clear cut source from where the infection originated. On the other hand, if a patient has a CT scan of the abdomen or any imaging study done, which showed the pus pocket, and even if there is no abscess culture done, and if there is BSI, it would be labelled as BSI due to intra-abdominal cause rather than CLABSI.
This is one of the many examples where there is unnecessary imaging needed to avoid the designation of CLABSI, or, in other instances, unnecessary cultures on admission to avoid the CLABSI or catheter-related urinary tract infection (CAUTI) when patient is coming in from other institutions or nursing facilities to avoid the attribution of CLABSI and CAUTI, rather than what is good for the patient. We are in the time of protocol-driven medicine, which has helped in improving the patient care in certain aspects, but where are the days when the physical examination meant something rather than having to prove it by imaging and laboratory studies? Are the guidelines and regulations a solution to health-care cost and waste, or are they part of problem? You be the judge.
Adel Bassily-Marcus, MD, FCCP
Chair
Salim Surani, MD, FCCP
Vice-Chair
References
Grimes L, McMullen KM, Leone C, et al. Impact of 2015 National Healthcare Safety Network (NHSN) Definition Changes on Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection (CLABSI) at a Large Healthcare System. Open Forum Infectious Diseases. 2016;3(suppl1):946-946.
Central line related blood infection. Center for Disease Control and Prevention. https://www.cdc.gov/hai/bsi/bsi.html. Accessed on 1/28/2018
Preventing central line related blood infections. A Global challenge and Global perspective. https://www.jointcommission.org/assets/1/18/CLABSI_Monograph.pdf. Accessed on 1/28/2018
Transplant
Radius of Change: Will Expanding Organ Sharing Beyond Donor Service Area Enhance Access in Lung Transplantation?
In November 2017, the US Department of Health and Human Services (HHS) prompted the United Network for Organ Sharing Organ Procurement and Transplant Network (UNOS/OPTN) to reconsider geographical boundaries of donor allocation. The impetus for change was driven by a recent litigation and data that challenged the current organ allocation algorithm on the premise that it overlooked potential high acuity candidates listed at centers outside the primary DSA (donor service area) of the donor hospital, in favor of less sick local recipients. In response, the UNOS/OPTN Executive Committee recommended the adoption of a 250-nautical mile radius from the donor hospital in lieu of the DSA as the first circle or zone A of distribution for lungs. The putative merits of this change, due to last an experimental year, is intended to provide sicker candidates with access to a broader geographic range of donors. Its impact will then be evaluated by the Thoracic Organ Transplantation Committee to make further recommendations, including possibly extending zone A to 500 miles.
The extended geographical limits have organ-specific implications. In contrast to other organs, constraints of cold ischemia limit the duration within which lungs and hearts must be transplanted. Indeed, this latter point is the basis for using a radius from the donor hospital, rather than the region, as the first circle of distribution. Furthermore, DSAs vary substantially in both size and population and performance, leading to considerable variation in access to organs for candidates based on their region of residence. Currently, more than 50% of the lung allocation in the United States occurs locally to recipients with lung allocation scores (LAS) less than 50 (Iribarne et al. Chest. 2009;135[4]:923). In addition, waiting time mortality remains high and actuarial survival remains low for those with higher LAS (Russo et al. Chest. 2010;137[3]:651). The new recommendations broaden the concentric circle approach and potentially provide enhanced access for the sickest candidates on the waiting list. However, this may increase duration of waitlist time for those with lower LAS, certain disease groups such as COPD and those listed in more conservative centers. It may conversely, however, drive transplantation in the sickest patients and increase the use of bridging strategies in high volume centers and those with ECMO capabilities, as there will now be a greater reassurance of donor offers with the wider catchment area. The implications are unclear at this time, and over the next year, the efficacy and the potential unintended consequences of this newly implemented directive should become more apparent.
Anupam Kumar, MD
Fellow-in-Training Member
J. W. Awori Hayanga, MD, MPH
Steering Committee Member
Women’s Health
Lung Cancer and Steroid Hormones: An Evolving Paradigm
Lung cancer remains to be the second most common cancer and the leading cause of cancer-related mortality in women. The risk for developing lung cancer in women is 1/17 and increases with age and smoking history. Women with stage I NSLC have better prognosis after surgical treatment compared with men (Graham et al. South Med J. 2013;106[10]:582); however. they are less likely to have undergone a low dose screening CT scan, even after meeting high risk criteria (Lamb et al. Chest. 2017;152[suppl]A623). The prognosis in advanced stage lung cancer at diagnosis does not differ among the genders or age groups (Santoro et al. J Bras Pneumol. 2017;43[6]:431).
There is increasing interest in the role of steroid hormones in lung biology in health and disease with estrogen and progesterone receptors identified in both healthy and malignant tissue. The role of hormone receptors as a prognostication tool and a therapeutic target is being actively investigated.
Estrogen receptor Beta (ER-Beta) is the predominantly expressed estrogen receptor in lung cancer cells (Raso et al. Clin Cancer Res. 2009;15[17]:5359). Increased cytoplasmic ER-alpha and ER-beta is associated with tobacco smoking and likely indicates a hormonal-smoking interaction (Siegfried. Mol Cancer Res. 2014;12[1]:24). A higher nuclear expression ER-beta in women may be protective against hormone-related lung cancer (Schwartz et al. J Clin Oncol. 2007; 25[36]:5785), whereas higher cytoplasmic expression of ER-alpha and ER-beta was associated with worse lung cancer survival (Cheng. J Natl Cancer Inst. 2018; Jan 13). Therapies targeting ER-beta1 and its downregulation resulted in sensitizing the cells to epidermal growth factor receptor-tyrosine kinase inhibitors and may result in reversing EGFR-TK resistance (Fu et al. Oncol Rep. 2018;39[3]:1313).
The presence of progesterone receptors is associated with longer survival in NSCLC, and treatment with progesterone has been shown to induce apoptosis and inhibit migration and invasion of lung cancer cell lines (Ishibashi et al. Cancer Res. 2005;65[14]:6450). Women over the age of 60 were found to have significant survival benefit when compared with both men and younger women (Wakelee et al. J Thoracic Oncol. 2007b; 2:S570), whereas a worse survival and earlier age of occurrence of lung cancer was associated with the exposure to HRT (Ganti et al. J Clin Oncol. 2006;24[1]:59).
The future of hormone receptor targets in lung cancer may provide new therapeutic options for patients with lung adenocarcinoma, especially those with acquired resistance to the EGFR antagonists (Hsu et al. Int J Mol Sci. 2017; 18[8] pii: E1713. doi: 10.3390/ijms18081713).
Fidaa Shaib, MD, FCCP
Steering Committee Member
Ali Jiwani, MD
NetWork Member
Disaster Response
A Natural Disaster Creates Nationwide Threat
Hurricane Maria devastated Puerto Rico in late September 2017, and the lessons learned endure as the storm exposed the vulnerability of an increasingly interconnected and fragile medical community across the continental United States. According to the US Food and Drug Administration (FDA), Puerto Rico manufactures more drug products than any US state and just under 10% of all drugs consumed by Americans, some of which do not have therapeutic alternatives. In addition, certain medical devices are only produced in Puerto Rico. The humanitarian crisis caused by Hurricane Maria consequently created critical medication and medical device shortages across the United States (FDA. https://www.fda.gov/NewsEvents/. Accessed Feb 01, 2018).
The disruption and disorganization caused by Hurricane Maria was perhaps best exemplified by the resultant shortage of small-volume 0.9% saline injection bags, which coincided with a particularly bad flu season. The FDA temporarily allowed import of saline bags from outside the United States while concurrently expediting the approval of IV solutions from new manufacturers. The American Society for Health-System Pharmacists (ASHP), meanwhile, contributed guidance on managing fluid shortages (ASHP. https://www.ashp.org/Drug-Shortages/. Accessed Feb 01, 2018).
Hurricane Maria was a wake-up call for medical professionals across the United States to modernize institutional procedures and to develop contingency plans to deal with medication shortages, particularly IV fluids, since this is a recurring problem across the United States since 2014. Ultimately, the goal of health-care providers across the United States is to manage natural catastrophes, however distant, by effectively planning for and adapting to medical product shortages to ensure patient care is not interrupted and that critical shortages remain invisible to patients themselves.
Cristian Madar, MD
Steering Committee Member
Practice Operations
Are All Regulations Well Thought Out? Point of View!
Current medicine is complex, with patients presenting in the ICU with multiorgan dysfunction. The art and science of medicine is being replaced by protocolized medicine. To help streamline the care, societies and colleges are coming up with guidelines. The guideline, though, changes from year to year what has been practiced in the past has been obsolete, and what is current may not hold true in the future. With increasing health-care costs affecting physician and hospital practices, innovations are being undertaken on a daily basis. The payers, on the other hand, are trying to come up with regulations, whether one likes it or not, that have become the beacon for penalty and reward. Sometimes those regulations conflict with what is sound judgment and prudent care, cornering the providers in the box with unnecessary penalties.
Approximately 250,000 bloodstream infections occur in the United States yearly, mostly attributed to the presence of intravascular devices. The rate of central line-associated blood stream infection (CLABSI) in the United States is 0.8 per 1,000 central line days. The desirable rate is zero rate of CLABSI. The hospitals are being pushed to be prudent with the use of central lines and removal if not needed. The technique and sterile field along with appropriate innovation in dressing technique have been effective in reducing the CLABSI by 46% from 2008 to 2013. The hospitals and ICUs are being very vigilant in trying to avoid CLABSI and are striving to achieve the goal of a zero percentage CLABSI rate, leading to almost a state of paranoia. The efforts are being undertaken in many institutions to get all the cultures on admission to identify the organism on admission so as to be designated as a bloodstream infection (BSI) due to other causes and to avoid the CLABSI attribution. The CLABSI attribution follows a complex algorithm with no waiver for the exception outside the strict definition that is changing (The 2015 definition change resulted in an 83% increase in CLABSI rate.).
We hereby present a simple scenario for point of view, where there is very clear-cut evidence of the bloodstream infection due to abdominal sources but that BSI would be designated as CLABSI as defined by National Healthcare Safety Network (NHSN). The patient postoperatively presents with fever, nausea, and abdominal discomfort. The CT scan showed fluid collection suggestive of infection. Culture from the abscess grew Escherichia coli and the blood culture grew Bacteroides fargilis. This patient was labeled as BSI due to intra-abdominal cause. On the other hand, patient has pus pockets in the abdominal wall with swelling and tenderness. Cultures from the pustule grew Streptococcus Group B and the blood culture grew Staphylococcus aureus. This would be classified as soft tissue infection and primary BSI and if the patient has the central line for 2 days, it would be classified as CLABSI, even though there was a clear cut source from where the infection originated. On the other hand, if a patient has a CT scan of the abdomen or any imaging study done, which showed the pus pocket, and even if there is no abscess culture done, and if there is BSI, it would be labelled as BSI due to intra-abdominal cause rather than CLABSI.
This is one of the many examples where there is unnecessary imaging needed to avoid the designation of CLABSI, or, in other instances, unnecessary cultures on admission to avoid the CLABSI or catheter-related urinary tract infection (CAUTI) when patient is coming in from other institutions or nursing facilities to avoid the attribution of CLABSI and CAUTI, rather than what is good for the patient. We are in the time of protocol-driven medicine, which has helped in improving the patient care in certain aspects, but where are the days when the physical examination meant something rather than having to prove it by imaging and laboratory studies? Are the guidelines and regulations a solution to health-care cost and waste, or are they part of problem? You be the judge.
Adel Bassily-Marcus, MD, FCCP
Chair
Salim Surani, MD, FCCP
Vice-Chair
References
Grimes L, McMullen KM, Leone C, et al. Impact of 2015 National Healthcare Safety Network (NHSN) Definition Changes on Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection (CLABSI) at a Large Healthcare System. Open Forum Infectious Diseases. 2016;3(suppl1):946-946.
Central line related blood infection. Center for Disease Control and Prevention. https://www.cdc.gov/hai/bsi/bsi.html. Accessed on 1/28/2018
Preventing central line related blood infections. A Global challenge and Global perspective. https://www.jointcommission.org/assets/1/18/CLABSI_Monograph.pdf. Accessed on 1/28/2018
Transplant
Radius of Change: Will Expanding Organ Sharing Beyond Donor Service Area Enhance Access in Lung Transplantation?
In November 2017, the US Department of Health and Human Services (HHS) prompted the United Network for Organ Sharing Organ Procurement and Transplant Network (UNOS/OPTN) to reconsider geographical boundaries of donor allocation. The impetus for change was driven by a recent litigation and data that challenged the current organ allocation algorithm on the premise that it overlooked potential high acuity candidates listed at centers outside the primary DSA (donor service area) of the donor hospital, in favor of less sick local recipients. In response, the UNOS/OPTN Executive Committee recommended the adoption of a 250-nautical mile radius from the donor hospital in lieu of the DSA as the first circle or zone A of distribution for lungs. The putative merits of this change, due to last an experimental year, is intended to provide sicker candidates with access to a broader geographic range of donors. Its impact will then be evaluated by the Thoracic Organ Transplantation Committee to make further recommendations, including possibly extending zone A to 500 miles.
The extended geographical limits have organ-specific implications. In contrast to other organs, constraints of cold ischemia limit the duration within which lungs and hearts must be transplanted. Indeed, this latter point is the basis for using a radius from the donor hospital, rather than the region, as the first circle of distribution. Furthermore, DSAs vary substantially in both size and population and performance, leading to considerable variation in access to organs for candidates based on their region of residence. Currently, more than 50% of the lung allocation in the United States occurs locally to recipients with lung allocation scores (LAS) less than 50 (Iribarne et al. Chest. 2009;135[4]:923). In addition, waiting time mortality remains high and actuarial survival remains low for those with higher LAS (Russo et al. Chest. 2010;137[3]:651). The new recommendations broaden the concentric circle approach and potentially provide enhanced access for the sickest candidates on the waiting list. However, this may increase duration of waitlist time for those with lower LAS, certain disease groups such as COPD and those listed in more conservative centers. It may conversely, however, drive transplantation in the sickest patients and increase the use of bridging strategies in high volume centers and those with ECMO capabilities, as there will now be a greater reassurance of donor offers with the wider catchment area. The implications are unclear at this time, and over the next year, the efficacy and the potential unintended consequences of this newly implemented directive should become more apparent.
Anupam Kumar, MD
Fellow-in-Training Member
J. W. Awori Hayanga, MD, MPH
Steering Committee Member
Women’s Health
Lung Cancer and Steroid Hormones: An Evolving Paradigm
Lung cancer remains to be the second most common cancer and the leading cause of cancer-related mortality in women. The risk for developing lung cancer in women is 1/17 and increases with age and smoking history. Women with stage I NSLC have better prognosis after surgical treatment compared with men (Graham et al. South Med J. 2013;106[10]:582); however. they are less likely to have undergone a low dose screening CT scan, even after meeting high risk criteria (Lamb et al. Chest. 2017;152[suppl]A623). The prognosis in advanced stage lung cancer at diagnosis does not differ among the genders or age groups (Santoro et al. J Bras Pneumol. 2017;43[6]:431).
There is increasing interest in the role of steroid hormones in lung biology in health and disease with estrogen and progesterone receptors identified in both healthy and malignant tissue. The role of hormone receptors as a prognostication tool and a therapeutic target is being actively investigated.
Estrogen receptor Beta (ER-Beta) is the predominantly expressed estrogen receptor in lung cancer cells (Raso et al. Clin Cancer Res. 2009;15[17]:5359). Increased cytoplasmic ER-alpha and ER-beta is associated with tobacco smoking and likely indicates a hormonal-smoking interaction (Siegfried. Mol Cancer Res. 2014;12[1]:24). A higher nuclear expression ER-beta in women may be protective against hormone-related lung cancer (Schwartz et al. J Clin Oncol. 2007; 25[36]:5785), whereas higher cytoplasmic expression of ER-alpha and ER-beta was associated with worse lung cancer survival (Cheng. J Natl Cancer Inst. 2018; Jan 13). Therapies targeting ER-beta1 and its downregulation resulted in sensitizing the cells to epidermal growth factor receptor-tyrosine kinase inhibitors and may result in reversing EGFR-TK resistance (Fu et al. Oncol Rep. 2018;39[3]:1313).
The presence of progesterone receptors is associated with longer survival in NSCLC, and treatment with progesterone has been shown to induce apoptosis and inhibit migration and invasion of lung cancer cell lines (Ishibashi et al. Cancer Res. 2005;65[14]:6450). Women over the age of 60 were found to have significant survival benefit when compared with both men and younger women (Wakelee et al. J Thoracic Oncol. 2007b; 2:S570), whereas a worse survival and earlier age of occurrence of lung cancer was associated with the exposure to HRT (Ganti et al. J Clin Oncol. 2006;24[1]:59).
The future of hormone receptor targets in lung cancer may provide new therapeutic options for patients with lung adenocarcinoma, especially those with acquired resistance to the EGFR antagonists (Hsu et al. Int J Mol Sci. 2017; 18[8] pii: E1713. doi: 10.3390/ijms18081713).
Fidaa Shaib, MD, FCCP
Steering Committee Member
Ali Jiwani, MD
NetWork Member
Disaster Response
A Natural Disaster Creates Nationwide Threat
Hurricane Maria devastated Puerto Rico in late September 2017, and the lessons learned endure as the storm exposed the vulnerability of an increasingly interconnected and fragile medical community across the continental United States. According to the US Food and Drug Administration (FDA), Puerto Rico manufactures more drug products than any US state and just under 10% of all drugs consumed by Americans, some of which do not have therapeutic alternatives. In addition, certain medical devices are only produced in Puerto Rico. The humanitarian crisis caused by Hurricane Maria consequently created critical medication and medical device shortages across the United States (FDA. https://www.fda.gov/NewsEvents/. Accessed Feb 01, 2018).
The disruption and disorganization caused by Hurricane Maria was perhaps best exemplified by the resultant shortage of small-volume 0.9% saline injection bags, which coincided with a particularly bad flu season. The FDA temporarily allowed import of saline bags from outside the United States while concurrently expediting the approval of IV solutions from new manufacturers. The American Society for Health-System Pharmacists (ASHP), meanwhile, contributed guidance on managing fluid shortages (ASHP. https://www.ashp.org/Drug-Shortages/. Accessed Feb 01, 2018).
Hurricane Maria was a wake-up call for medical professionals across the United States to modernize institutional procedures and to develop contingency plans to deal with medication shortages, particularly IV fluids, since this is a recurring problem across the United States since 2014. Ultimately, the goal of health-care providers across the United States is to manage natural catastrophes, however distant, by effectively planning for and adapting to medical product shortages to ensure patient care is not interrupted and that critical shortages remain invisible to patients themselves.
Cristian Madar, MD
Steering Committee Member
Practice Operations
Are All Regulations Well Thought Out? Point of View!
Current medicine is complex, with patients presenting in the ICU with multiorgan dysfunction. The art and science of medicine is being replaced by protocolized medicine. To help streamline the care, societies and colleges are coming up with guidelines. The guideline, though, changes from year to year what has been practiced in the past has been obsolete, and what is current may not hold true in the future. With increasing health-care costs affecting physician and hospital practices, innovations are being undertaken on a daily basis. The payers, on the other hand, are trying to come up with regulations, whether one likes it or not, that have become the beacon for penalty and reward. Sometimes those regulations conflict with what is sound judgment and prudent care, cornering the providers in the box with unnecessary penalties.
Approximately 250,000 bloodstream infections occur in the United States yearly, mostly attributed to the presence of intravascular devices. The rate of central line-associated blood stream infection (CLABSI) in the United States is 0.8 per 1,000 central line days. The desirable rate is zero rate of CLABSI. The hospitals are being pushed to be prudent with the use of central lines and removal if not needed. The technique and sterile field along with appropriate innovation in dressing technique have been effective in reducing the CLABSI by 46% from 2008 to 2013. The hospitals and ICUs are being very vigilant in trying to avoid CLABSI and are striving to achieve the goal of a zero percentage CLABSI rate, leading to almost a state of paranoia. The efforts are being undertaken in many institutions to get all the cultures on admission to identify the organism on admission so as to be designated as a bloodstream infection (BSI) due to other causes and to avoid the CLABSI attribution. The CLABSI attribution follows a complex algorithm with no waiver for the exception outside the strict definition that is changing (The 2015 definition change resulted in an 83% increase in CLABSI rate.).
We hereby present a simple scenario for point of view, where there is very clear-cut evidence of the bloodstream infection due to abdominal sources but that BSI would be designated as CLABSI as defined by National Healthcare Safety Network (NHSN). The patient postoperatively presents with fever, nausea, and abdominal discomfort. The CT scan showed fluid collection suggestive of infection. Culture from the abscess grew Escherichia coli and the blood culture grew Bacteroides fargilis. This patient was labeled as BSI due to intra-abdominal cause. On the other hand, patient has pus pockets in the abdominal wall with swelling and tenderness. Cultures from the pustule grew Streptococcus Group B and the blood culture grew Staphylococcus aureus. This would be classified as soft tissue infection and primary BSI and if the patient has the central line for 2 days, it would be classified as CLABSI, even though there was a clear cut source from where the infection originated. On the other hand, if a patient has a CT scan of the abdomen or any imaging study done, which showed the pus pocket, and even if there is no abscess culture done, and if there is BSI, it would be labelled as BSI due to intra-abdominal cause rather than CLABSI.
This is one of the many examples where there is unnecessary imaging needed to avoid the designation of CLABSI, or, in other instances, unnecessary cultures on admission to avoid the CLABSI or catheter-related urinary tract infection (CAUTI) when patient is coming in from other institutions or nursing facilities to avoid the attribution of CLABSI and CAUTI, rather than what is good for the patient. We are in the time of protocol-driven medicine, which has helped in improving the patient care in certain aspects, but where are the days when the physical examination meant something rather than having to prove it by imaging and laboratory studies? Are the guidelines and regulations a solution to health-care cost and waste, or are they part of problem? You be the judge.
Adel Bassily-Marcus, MD, FCCP
Chair
Salim Surani, MD, FCCP
Vice-Chair
References
Grimes L, McMullen KM, Leone C, et al. Impact of 2015 National Healthcare Safety Network (NHSN) Definition Changes on Intensive Care Unit (ICU) Central Line-Associated Bloodstream Infection (CLABSI) at a Large Healthcare System. Open Forum Infectious Diseases. 2016;3(suppl1):946-946.
Central line related blood infection. Center for Disease Control and Prevention. https://www.cdc.gov/hai/bsi/bsi.html. Accessed on 1/28/2018
Preventing central line related blood infections. A Global challenge and Global perspective. https://www.jointcommission.org/assets/1/18/CLABSI_Monograph.pdf. Accessed on 1/28/2018
Transplant
Radius of Change: Will Expanding Organ Sharing Beyond Donor Service Area Enhance Access in Lung Transplantation?
In November 2017, the US Department of Health and Human Services (HHS) prompted the United Network for Organ Sharing Organ Procurement and Transplant Network (UNOS/OPTN) to reconsider geographical boundaries of donor allocation. The impetus for change was driven by a recent litigation and data that challenged the current organ allocation algorithm on the premise that it overlooked potential high acuity candidates listed at centers outside the primary DSA (donor service area) of the donor hospital, in favor of less sick local recipients. In response, the UNOS/OPTN Executive Committee recommended the adoption of a 250-nautical mile radius from the donor hospital in lieu of the DSA as the first circle or zone A of distribution for lungs. The putative merits of this change, due to last an experimental year, is intended to provide sicker candidates with access to a broader geographic range of donors. Its impact will then be evaluated by the Thoracic Organ Transplantation Committee to make further recommendations, including possibly extending zone A to 500 miles.
The extended geographical limits have organ-specific implications. In contrast to other organs, constraints of cold ischemia limit the duration within which lungs and hearts must be transplanted. Indeed, this latter point is the basis for using a radius from the donor hospital, rather than the region, as the first circle of distribution. Furthermore, DSAs vary substantially in both size and population and performance, leading to considerable variation in access to organs for candidates based on their region of residence. Currently, more than 50% of the lung allocation in the United States occurs locally to recipients with lung allocation scores (LAS) less than 50 (Iribarne et al. Chest. 2009;135[4]:923). In addition, waiting time mortality remains high and actuarial survival remains low for those with higher LAS (Russo et al. Chest. 2010;137[3]:651). The new recommendations broaden the concentric circle approach and potentially provide enhanced access for the sickest candidates on the waiting list. However, this may increase duration of waitlist time for those with lower LAS, certain disease groups such as COPD and those listed in more conservative centers. It may conversely, however, drive transplantation in the sickest patients and increase the use of bridging strategies in high volume centers and those with ECMO capabilities, as there will now be a greater reassurance of donor offers with the wider catchment area. The implications are unclear at this time, and over the next year, the efficacy and the potential unintended consequences of this newly implemented directive should become more apparent.
Anupam Kumar, MD
Fellow-in-Training Member
J. W. Awori Hayanga, MD, MPH
Steering Committee Member
Women’s Health
Lung Cancer and Steroid Hormones: An Evolving Paradigm
Lung cancer remains to be the second most common cancer and the leading cause of cancer-related mortality in women. The risk for developing lung cancer in women is 1/17 and increases with age and smoking history. Women with stage I NSLC have better prognosis after surgical treatment compared with men (Graham et al. South Med J. 2013;106[10]:582); however. they are less likely to have undergone a low dose screening CT scan, even after meeting high risk criteria (Lamb et al. Chest. 2017;152[suppl]A623). The prognosis in advanced stage lung cancer at diagnosis does not differ among the genders or age groups (Santoro et al. J Bras Pneumol. 2017;43[6]:431).
There is increasing interest in the role of steroid hormones in lung biology in health and disease with estrogen and progesterone receptors identified in both healthy and malignant tissue. The role of hormone receptors as a prognostication tool and a therapeutic target is being actively investigated.
Estrogen receptor Beta (ER-Beta) is the predominantly expressed estrogen receptor in lung cancer cells (Raso et al. Clin Cancer Res. 2009;15[17]:5359). Increased cytoplasmic ER-alpha and ER-beta is associated with tobacco smoking and likely indicates a hormonal-smoking interaction (Siegfried. Mol Cancer Res. 2014;12[1]:24). A higher nuclear expression ER-beta in women may be protective against hormone-related lung cancer (Schwartz et al. J Clin Oncol. 2007; 25[36]:5785), whereas higher cytoplasmic expression of ER-alpha and ER-beta was associated with worse lung cancer survival (Cheng. J Natl Cancer Inst. 2018; Jan 13). Therapies targeting ER-beta1 and its downregulation resulted in sensitizing the cells to epidermal growth factor receptor-tyrosine kinase inhibitors and may result in reversing EGFR-TK resistance (Fu et al. Oncol Rep. 2018;39[3]:1313).
The presence of progesterone receptors is associated with longer survival in NSCLC, and treatment with progesterone has been shown to induce apoptosis and inhibit migration and invasion of lung cancer cell lines (Ishibashi et al. Cancer Res. 2005;65[14]:6450). Women over the age of 60 were found to have significant survival benefit when compared with both men and younger women (Wakelee et al. J Thoracic Oncol. 2007b; 2:S570), whereas a worse survival and earlier age of occurrence of lung cancer was associated with the exposure to HRT (Ganti et al. J Clin Oncol. 2006;24[1]:59).
The future of hormone receptor targets in lung cancer may provide new therapeutic options for patients with lung adenocarcinoma, especially those with acquired resistance to the EGFR antagonists (Hsu et al. Int J Mol Sci. 2017; 18[8] pii: E1713. doi: 10.3390/ijms18081713).
Fidaa Shaib, MD, FCCP
Steering Committee Member
Ali Jiwani, MD
NetWork Member