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Treatment of horizontal neck lines
The interplay of the neck subunits, as outlined in the recent article by Friedman and colleagues, requires multiple combination treatments, including fat removal, augmentation of deficient bony prominences, relaxation of hyperkinetic muscles, tissue tightening, suture anchoring, skin resurfacing, and treatment of dyschromia.
Horizontal neck lines are linear etched lines or furrows that commonly appear at a young age and are not caused by the aging process. The anatomy of the neck and the manner in which it bends contributes to their development at an early age. It is hypothesized that variable adipose tissue thickness and fibromuscular bands contribute to deepening of these lines in overweight patients. The widespread use of cell phones, laptops, and tablets has increased their prevalence and this has become one of the most common concerns of patients aged under 30 years in my clinic.
Various treatments have been recommended for neck rejuvenation, including hyaluronic acid and dilute calcium hydroxylapatite. In my experience, neither of these treatments adequately resolves the horizontal neck lines, and more importantly, prevents them from reoccurring. In addition, given the variability in skin and adipose thickness in the anterior neck, side effects including lumps, irregular correction, and the Tyndall effect, are common, particularly with incorrect choice of filler and injection depth.
The fibromuscular bands along the transverse neck lines pose one of the complexities in treatment with injectable filler. I have had significant improvement in the aesthetic outcome of my patients by using subcision along the transverse bands extensively prior to injection with hyaluronic acid fillers. The subcision is done with a 27-gauge needle to release the fibrous bands that tether the tissue down. If a patient has excess adipose tissue on either side of the bands, injectable fillers often do not improve the appearance of the lines and can make the neck appear heavier. The use of subcision followed by one to six treatments of deoxycholic acid in the adjacent adipose tissue prior to injection with a filler will help even out the contour of the neck, decrease adipose tissue bulges, release the fibrous bands, and fill the lines properly.
Working from home and on handheld devices has increased the appearance of neck lines in young populations. Despite the vast array of treatments in the aging neck, none have been very successful for this particular problem in the young. We need an improved understanding of these lines and better studies to investigate treatment options and long-term correction.
References:
Friedman O et al. J Cosmet Dermatol. 2021 Feb;20(2):569-76.
Brandt FS and Boker A. Dermatol Clin. 2004 Apr;22(2):159-66.
Tseng F and Yu H. Plast Reconstr Surg Glob Open. 2019 Aug 19;7(8):e2366.
Dibernardo BE. J Cosmet Laser Ther. 2013 Apr;15(2):56-64.
Jones D et al. Dermatol Surg. 2016 Oct;4 Suppl 1(Suppl 1):S235-42.
Lee SK and Kim HS. J Cosmet Dermatol. 2018 Aug;17(4):590-5.
Chao YY et al. Dermatol Surg. 2011 Oct;37(10):1542-5.
Han TY et al. Dermatol Surg. 2011 Sep;37(9):1291-6.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
The interplay of the neck subunits, as outlined in the recent article by Friedman and colleagues, requires multiple combination treatments, including fat removal, augmentation of deficient bony prominences, relaxation of hyperkinetic muscles, tissue tightening, suture anchoring, skin resurfacing, and treatment of dyschromia.
Horizontal neck lines are linear etched lines or furrows that commonly appear at a young age and are not caused by the aging process. The anatomy of the neck and the manner in which it bends contributes to their development at an early age. It is hypothesized that variable adipose tissue thickness and fibromuscular bands contribute to deepening of these lines in overweight patients. The widespread use of cell phones, laptops, and tablets has increased their prevalence and this has become one of the most common concerns of patients aged under 30 years in my clinic.
Various treatments have been recommended for neck rejuvenation, including hyaluronic acid and dilute calcium hydroxylapatite. In my experience, neither of these treatments adequately resolves the horizontal neck lines, and more importantly, prevents them from reoccurring. In addition, given the variability in skin and adipose thickness in the anterior neck, side effects including lumps, irregular correction, and the Tyndall effect, are common, particularly with incorrect choice of filler and injection depth.
The fibromuscular bands along the transverse neck lines pose one of the complexities in treatment with injectable filler. I have had significant improvement in the aesthetic outcome of my patients by using subcision along the transverse bands extensively prior to injection with hyaluronic acid fillers. The subcision is done with a 27-gauge needle to release the fibrous bands that tether the tissue down. If a patient has excess adipose tissue on either side of the bands, injectable fillers often do not improve the appearance of the lines and can make the neck appear heavier. The use of subcision followed by one to six treatments of deoxycholic acid in the adjacent adipose tissue prior to injection with a filler will help even out the contour of the neck, decrease adipose tissue bulges, release the fibrous bands, and fill the lines properly.
Working from home and on handheld devices has increased the appearance of neck lines in young populations. Despite the vast array of treatments in the aging neck, none have been very successful for this particular problem in the young. We need an improved understanding of these lines and better studies to investigate treatment options and long-term correction.
References:
Friedman O et al. J Cosmet Dermatol. 2021 Feb;20(2):569-76.
Brandt FS and Boker A. Dermatol Clin. 2004 Apr;22(2):159-66.
Tseng F and Yu H. Plast Reconstr Surg Glob Open. 2019 Aug 19;7(8):e2366.
Dibernardo BE. J Cosmet Laser Ther. 2013 Apr;15(2):56-64.
Jones D et al. Dermatol Surg. 2016 Oct;4 Suppl 1(Suppl 1):S235-42.
Lee SK and Kim HS. J Cosmet Dermatol. 2018 Aug;17(4):590-5.
Chao YY et al. Dermatol Surg. 2011 Oct;37(10):1542-5.
Han TY et al. Dermatol Surg. 2011 Sep;37(9):1291-6.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
The interplay of the neck subunits, as outlined in the recent article by Friedman and colleagues, requires multiple combination treatments, including fat removal, augmentation of deficient bony prominences, relaxation of hyperkinetic muscles, tissue tightening, suture anchoring, skin resurfacing, and treatment of dyschromia.
Horizontal neck lines are linear etched lines or furrows that commonly appear at a young age and are not caused by the aging process. The anatomy of the neck and the manner in which it bends contributes to their development at an early age. It is hypothesized that variable adipose tissue thickness and fibromuscular bands contribute to deepening of these lines in overweight patients. The widespread use of cell phones, laptops, and tablets has increased their prevalence and this has become one of the most common concerns of patients aged under 30 years in my clinic.
Various treatments have been recommended for neck rejuvenation, including hyaluronic acid and dilute calcium hydroxylapatite. In my experience, neither of these treatments adequately resolves the horizontal neck lines, and more importantly, prevents them from reoccurring. In addition, given the variability in skin and adipose thickness in the anterior neck, side effects including lumps, irregular correction, and the Tyndall effect, are common, particularly with incorrect choice of filler and injection depth.
The fibromuscular bands along the transverse neck lines pose one of the complexities in treatment with injectable filler. I have had significant improvement in the aesthetic outcome of my patients by using subcision along the transverse bands extensively prior to injection with hyaluronic acid fillers. The subcision is done with a 27-gauge needle to release the fibrous bands that tether the tissue down. If a patient has excess adipose tissue on either side of the bands, injectable fillers often do not improve the appearance of the lines and can make the neck appear heavier. The use of subcision followed by one to six treatments of deoxycholic acid in the adjacent adipose tissue prior to injection with a filler will help even out the contour of the neck, decrease adipose tissue bulges, release the fibrous bands, and fill the lines properly.
Working from home and on handheld devices has increased the appearance of neck lines in young populations. Despite the vast array of treatments in the aging neck, none have been very successful for this particular problem in the young. We need an improved understanding of these lines and better studies to investigate treatment options and long-term correction.
References:
Friedman O et al. J Cosmet Dermatol. 2021 Feb;20(2):569-76.
Brandt FS and Boker A. Dermatol Clin. 2004 Apr;22(2):159-66.
Tseng F and Yu H. Plast Reconstr Surg Glob Open. 2019 Aug 19;7(8):e2366.
Dibernardo BE. J Cosmet Laser Ther. 2013 Apr;15(2):56-64.
Jones D et al. Dermatol Surg. 2016 Oct;4 Suppl 1(Suppl 1):S235-42.
Lee SK and Kim HS. J Cosmet Dermatol. 2018 Aug;17(4):590-5.
Chao YY et al. Dermatol Surg. 2011 Oct;37(10):1542-5.
Han TY et al. Dermatol Surg. 2011 Sep;37(9):1291-6.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
PFO closure reduces migraine: New meta-analysis
A meta-analysis of two randomized studies evaluating patent foramen ovale (PFO) closure as a treatment strategy for migraine has shown significant benefits in several key endpoints, prompting the authors to conclude the approach warrants reevaluation.
The pooled analysis of patient-level data from the PRIMA and PREMIUM studies, both of which evaluated the Amplatzer PFO Occluder device (Abbott Vascular), showed that
The study, led by Mohammad K. Mojadidi, MD, Virginia Commonwealth University, Richmond, was published online in the Journal of the American College of Cardiology on Feb. 8, 2021.
Commenting on the article, the coauthor of an accompanying editorial, Zubair Ahmed, MD, of the Cleveland Clinic said the meta-analysis gave some useful new information but is not enough to recommend PFO closure routinely for patients with migraine.
“This meta-analysis looked at different endpoints that are more relevant to current clinical practice than those in the two original studies, and the results show that we shouldn’t rule out PFO closure as a treatment strategy for some migraine patients,” Dr. Ahmed stated. “But we’re still not sure exactly which patients are most likely to benefit from this approach, and we need additional studies to gain more understanding on that.”
The study authors noted that there is an established link between the presence of PFO and migraine, especially migraine with aura. In observational studies of PFO closure for cryptogenic stroke, the vast majority of patients who also had migraine reported a more than 50% reduction in migraine days per month after PFO closure.
However, two recent randomized clinical trials evaluating the Amplatzer PFO Occluder device for reducing the frequency and duration of episodic migraine headaches did not meet their respective primary endpoints, although they did show significant benefit of PFO closure in most of their secondary endpoints.
The current meta-analysis pooled individual participant data from the two trials to increase the power to detect the effect of percutaneous PFO closure for treating patients with episodic migraine compared with medical therapy alone.
In the two studies including a total of 337 patients, 176 were randomized to PFO closure and 161 to medical treatment only. At 12 months, three of the four efficacy endpoints evaluated in the meta-analysis were significantly reduced in the PFO-closure group. These were mean reduction of monthly migraine days (–3.1 days vs. –1.9 days; P = .02), mean reduction of monthly migraine attacks (–2.0 vs. –1.4; P = .01), and number of patients who experienced complete cessation of migraine (9% vs. 0.7%; P < .001).
The responder rate, defined as more than a 50% reduction in migraine attacks, showed a trend towards an increase in the PFO-closure group but did not achieve statistical significance (38% vs. 29%; P = .13).
For the safety analysis, nine procedure-related and four device-related adverse events occurred in 245 patients who eventually received devices. All events were transient and resolved.
Better effect in patients with aura
Patients with migraine with aura, in particular frequent aura, had a significantly greater reduction in migraine days and a higher incidence of complete migraine cessation following PFO closure versus no closure, the authors reported.
In those without aura, PFO closure did not significantly reduce migraine days or improve complete headache cessation. However, some patients without aura did respond to PFO closure, which was statistically significant for reduction of migraine attacks (–2.0 vs. –1.0; P = .03).
“The interaction between the brain that is susceptible to migraine and the plethora of potential triggers is complex. A PFO may be the potential pathway for a variety of chemical triggers, such as serotonin from platelets, and although less frequent, some people with migraine without aura may trigger their migraine through this mechanism,” the researchers suggested. This hypothesis will be tested in the RELIEF trial, which is now being planned.
In the accompanying editorial, Dr. Ahmed and coauthor Robert J. Sommer, MD, Columbia University Medical Center, New York, pointed out that the meta-analysis demonstrates benefit of PFO closure in the migraine population for the first time.
“Moreover, the investigators defined a population of patients who may benefit most from PFO closure, those with migraine with frequent aura, suggesting that these may be different physiologically than other migraine subtypes. The analysis also places the PRIMA and PREMIUM outcomes in the context of endpoints that are more practical and are more commonly assessed in current clinical trials,” the editorialists noted.
Many unanswered questions
But the editorialists highlighted several significant limitations of the analysis, including “pooling of patient cohorts, methods, and outcome measures that might not be entirely comparable,” which they say could have introduced bias.
They also pointed out that the underlying pathophysiological mechanism linking migraine symptoms to PFO remains unknown. They explain that the mechanism is thought to involve the right-to-left passage of systemic venous blood, with some component – which would normally be eliminated or reduced on passage through the pulmonary vasculature – reaching the cerebral circulation via the PFO in supranormal concentrations and acting as a trigger for migraine activity in patients with susceptible brains.
But not all patients with migraine who have PFO benefit from PFO closure, they noted, and therefore presumably have PFO-unrelated migraines. There is no verified way to distinguish between these two groups at present.
“Once we learn to identify the subset of migraine patients in whom PFOs are actually causal of headache symptoms, screening and treatment of PFO for migraine can become a reality,” they wrote.
Although the meta-analysis is a step in the right direction, “it is not a home run,” Dr. Ahmed elaborated. “This was a post hoc analysis of two studies, neither of which showed significant benefits on their primary endpoints. That weakens the findings somewhat.”
He added: “At present, PFO closure is not routinely recommended as a migraine treatment strategy as we haven’t been sure which patients are most likely to benefit. And while this meta-analysis suggests patients with aura may be more likely to benefit, one quarter of patients without aura in the PREMIUM trial responded to PFO closure, so it’s not just about aura.
“There are still many unanswered questions.
“I don’t think the new information from this meta-analysis is enough to persuade me to change my practice, but it is a small building block in the overall picture and suggests this may be a suitable strategy for some patients in future,” he concluded.
The study had no outside funding. Participant-level data were provided by Abbott. Several coauthors were on the steering committee for the PREMIUM or PRIMA trials. Dr. Ahmed reported receiving consulting fees from, Amgen, AbbVie, electroCore, and Eli Lilly; serving on advisory boards for Amgen and Supernus; serving as a speaker for AbbVie; and receiving funding for an investigator-initiated trial from Teva and Eli Lilly.
A version of this article first appeared on Medscape.com.
A meta-analysis of two randomized studies evaluating patent foramen ovale (PFO) closure as a treatment strategy for migraine has shown significant benefits in several key endpoints, prompting the authors to conclude the approach warrants reevaluation.
The pooled analysis of patient-level data from the PRIMA and PREMIUM studies, both of which evaluated the Amplatzer PFO Occluder device (Abbott Vascular), showed that
The study, led by Mohammad K. Mojadidi, MD, Virginia Commonwealth University, Richmond, was published online in the Journal of the American College of Cardiology on Feb. 8, 2021.
Commenting on the article, the coauthor of an accompanying editorial, Zubair Ahmed, MD, of the Cleveland Clinic said the meta-analysis gave some useful new information but is not enough to recommend PFO closure routinely for patients with migraine.
“This meta-analysis looked at different endpoints that are more relevant to current clinical practice than those in the two original studies, and the results show that we shouldn’t rule out PFO closure as a treatment strategy for some migraine patients,” Dr. Ahmed stated. “But we’re still not sure exactly which patients are most likely to benefit from this approach, and we need additional studies to gain more understanding on that.”
The study authors noted that there is an established link between the presence of PFO and migraine, especially migraine with aura. In observational studies of PFO closure for cryptogenic stroke, the vast majority of patients who also had migraine reported a more than 50% reduction in migraine days per month after PFO closure.
However, two recent randomized clinical trials evaluating the Amplatzer PFO Occluder device for reducing the frequency and duration of episodic migraine headaches did not meet their respective primary endpoints, although they did show significant benefit of PFO closure in most of their secondary endpoints.
The current meta-analysis pooled individual participant data from the two trials to increase the power to detect the effect of percutaneous PFO closure for treating patients with episodic migraine compared with medical therapy alone.
In the two studies including a total of 337 patients, 176 were randomized to PFO closure and 161 to medical treatment only. At 12 months, three of the four efficacy endpoints evaluated in the meta-analysis were significantly reduced in the PFO-closure group. These were mean reduction of monthly migraine days (–3.1 days vs. –1.9 days; P = .02), mean reduction of monthly migraine attacks (–2.0 vs. –1.4; P = .01), and number of patients who experienced complete cessation of migraine (9% vs. 0.7%; P < .001).
The responder rate, defined as more than a 50% reduction in migraine attacks, showed a trend towards an increase in the PFO-closure group but did not achieve statistical significance (38% vs. 29%; P = .13).
For the safety analysis, nine procedure-related and four device-related adverse events occurred in 245 patients who eventually received devices. All events were transient and resolved.
Better effect in patients with aura
Patients with migraine with aura, in particular frequent aura, had a significantly greater reduction in migraine days and a higher incidence of complete migraine cessation following PFO closure versus no closure, the authors reported.
In those without aura, PFO closure did not significantly reduce migraine days or improve complete headache cessation. However, some patients without aura did respond to PFO closure, which was statistically significant for reduction of migraine attacks (–2.0 vs. –1.0; P = .03).
“The interaction between the brain that is susceptible to migraine and the plethora of potential triggers is complex. A PFO may be the potential pathway for a variety of chemical triggers, such as serotonin from platelets, and although less frequent, some people with migraine without aura may trigger their migraine through this mechanism,” the researchers suggested. This hypothesis will be tested in the RELIEF trial, which is now being planned.
In the accompanying editorial, Dr. Ahmed and coauthor Robert J. Sommer, MD, Columbia University Medical Center, New York, pointed out that the meta-analysis demonstrates benefit of PFO closure in the migraine population for the first time.
“Moreover, the investigators defined a population of patients who may benefit most from PFO closure, those with migraine with frequent aura, suggesting that these may be different physiologically than other migraine subtypes. The analysis also places the PRIMA and PREMIUM outcomes in the context of endpoints that are more practical and are more commonly assessed in current clinical trials,” the editorialists noted.
Many unanswered questions
But the editorialists highlighted several significant limitations of the analysis, including “pooling of patient cohorts, methods, and outcome measures that might not be entirely comparable,” which they say could have introduced bias.
They also pointed out that the underlying pathophysiological mechanism linking migraine symptoms to PFO remains unknown. They explain that the mechanism is thought to involve the right-to-left passage of systemic venous blood, with some component – which would normally be eliminated or reduced on passage through the pulmonary vasculature – reaching the cerebral circulation via the PFO in supranormal concentrations and acting as a trigger for migraine activity in patients with susceptible brains.
But not all patients with migraine who have PFO benefit from PFO closure, they noted, and therefore presumably have PFO-unrelated migraines. There is no verified way to distinguish between these two groups at present.
“Once we learn to identify the subset of migraine patients in whom PFOs are actually causal of headache symptoms, screening and treatment of PFO for migraine can become a reality,” they wrote.
Although the meta-analysis is a step in the right direction, “it is not a home run,” Dr. Ahmed elaborated. “This was a post hoc analysis of two studies, neither of which showed significant benefits on their primary endpoints. That weakens the findings somewhat.”
He added: “At present, PFO closure is not routinely recommended as a migraine treatment strategy as we haven’t been sure which patients are most likely to benefit. And while this meta-analysis suggests patients with aura may be more likely to benefit, one quarter of patients without aura in the PREMIUM trial responded to PFO closure, so it’s not just about aura.
“There are still many unanswered questions.
“I don’t think the new information from this meta-analysis is enough to persuade me to change my practice, but it is a small building block in the overall picture and suggests this may be a suitable strategy for some patients in future,” he concluded.
The study had no outside funding. Participant-level data were provided by Abbott. Several coauthors were on the steering committee for the PREMIUM or PRIMA trials. Dr. Ahmed reported receiving consulting fees from, Amgen, AbbVie, electroCore, and Eli Lilly; serving on advisory boards for Amgen and Supernus; serving as a speaker for AbbVie; and receiving funding for an investigator-initiated trial from Teva and Eli Lilly.
A version of this article first appeared on Medscape.com.
A meta-analysis of two randomized studies evaluating patent foramen ovale (PFO) closure as a treatment strategy for migraine has shown significant benefits in several key endpoints, prompting the authors to conclude the approach warrants reevaluation.
The pooled analysis of patient-level data from the PRIMA and PREMIUM studies, both of which evaluated the Amplatzer PFO Occluder device (Abbott Vascular), showed that
The study, led by Mohammad K. Mojadidi, MD, Virginia Commonwealth University, Richmond, was published online in the Journal of the American College of Cardiology on Feb. 8, 2021.
Commenting on the article, the coauthor of an accompanying editorial, Zubair Ahmed, MD, of the Cleveland Clinic said the meta-analysis gave some useful new information but is not enough to recommend PFO closure routinely for patients with migraine.
“This meta-analysis looked at different endpoints that are more relevant to current clinical practice than those in the two original studies, and the results show that we shouldn’t rule out PFO closure as a treatment strategy for some migraine patients,” Dr. Ahmed stated. “But we’re still not sure exactly which patients are most likely to benefit from this approach, and we need additional studies to gain more understanding on that.”
The study authors noted that there is an established link between the presence of PFO and migraine, especially migraine with aura. In observational studies of PFO closure for cryptogenic stroke, the vast majority of patients who also had migraine reported a more than 50% reduction in migraine days per month after PFO closure.
However, two recent randomized clinical trials evaluating the Amplatzer PFO Occluder device for reducing the frequency and duration of episodic migraine headaches did not meet their respective primary endpoints, although they did show significant benefit of PFO closure in most of their secondary endpoints.
The current meta-analysis pooled individual participant data from the two trials to increase the power to detect the effect of percutaneous PFO closure for treating patients with episodic migraine compared with medical therapy alone.
In the two studies including a total of 337 patients, 176 were randomized to PFO closure and 161 to medical treatment only. At 12 months, three of the four efficacy endpoints evaluated in the meta-analysis were significantly reduced in the PFO-closure group. These were mean reduction of monthly migraine days (–3.1 days vs. –1.9 days; P = .02), mean reduction of monthly migraine attacks (–2.0 vs. –1.4; P = .01), and number of patients who experienced complete cessation of migraine (9% vs. 0.7%; P < .001).
The responder rate, defined as more than a 50% reduction in migraine attacks, showed a trend towards an increase in the PFO-closure group but did not achieve statistical significance (38% vs. 29%; P = .13).
For the safety analysis, nine procedure-related and four device-related adverse events occurred in 245 patients who eventually received devices. All events were transient and resolved.
Better effect in patients with aura
Patients with migraine with aura, in particular frequent aura, had a significantly greater reduction in migraine days and a higher incidence of complete migraine cessation following PFO closure versus no closure, the authors reported.
In those without aura, PFO closure did not significantly reduce migraine days or improve complete headache cessation. However, some patients without aura did respond to PFO closure, which was statistically significant for reduction of migraine attacks (–2.0 vs. –1.0; P = .03).
“The interaction between the brain that is susceptible to migraine and the plethora of potential triggers is complex. A PFO may be the potential pathway for a variety of chemical triggers, such as serotonin from platelets, and although less frequent, some people with migraine without aura may trigger their migraine through this mechanism,” the researchers suggested. This hypothesis will be tested in the RELIEF trial, which is now being planned.
In the accompanying editorial, Dr. Ahmed and coauthor Robert J. Sommer, MD, Columbia University Medical Center, New York, pointed out that the meta-analysis demonstrates benefit of PFO closure in the migraine population for the first time.
“Moreover, the investigators defined a population of patients who may benefit most from PFO closure, those with migraine with frequent aura, suggesting that these may be different physiologically than other migraine subtypes. The analysis also places the PRIMA and PREMIUM outcomes in the context of endpoints that are more practical and are more commonly assessed in current clinical trials,” the editorialists noted.
Many unanswered questions
But the editorialists highlighted several significant limitations of the analysis, including “pooling of patient cohorts, methods, and outcome measures that might not be entirely comparable,” which they say could have introduced bias.
They also pointed out that the underlying pathophysiological mechanism linking migraine symptoms to PFO remains unknown. They explain that the mechanism is thought to involve the right-to-left passage of systemic venous blood, with some component – which would normally be eliminated or reduced on passage through the pulmonary vasculature – reaching the cerebral circulation via the PFO in supranormal concentrations and acting as a trigger for migraine activity in patients with susceptible brains.
But not all patients with migraine who have PFO benefit from PFO closure, they noted, and therefore presumably have PFO-unrelated migraines. There is no verified way to distinguish between these two groups at present.
“Once we learn to identify the subset of migraine patients in whom PFOs are actually causal of headache symptoms, screening and treatment of PFO for migraine can become a reality,” they wrote.
Although the meta-analysis is a step in the right direction, “it is not a home run,” Dr. Ahmed elaborated. “This was a post hoc analysis of two studies, neither of which showed significant benefits on their primary endpoints. That weakens the findings somewhat.”
He added: “At present, PFO closure is not routinely recommended as a migraine treatment strategy as we haven’t been sure which patients are most likely to benefit. And while this meta-analysis suggests patients with aura may be more likely to benefit, one quarter of patients without aura in the PREMIUM trial responded to PFO closure, so it’s not just about aura.
“There are still many unanswered questions.
“I don’t think the new information from this meta-analysis is enough to persuade me to change my practice, but it is a small building block in the overall picture and suggests this may be a suitable strategy for some patients in future,” he concluded.
The study had no outside funding. Participant-level data were provided by Abbott. Several coauthors were on the steering committee for the PREMIUM or PRIMA trials. Dr. Ahmed reported receiving consulting fees from, Amgen, AbbVie, electroCore, and Eli Lilly; serving on advisory boards for Amgen and Supernus; serving as a speaker for AbbVie; and receiving funding for an investigator-initiated trial from Teva and Eli Lilly.
A version of this article first appeared on Medscape.com.
Brain connectivity patterns reliably identify ADHD
Functional brain connectivity patterns are a stable biomarker of attention-deficit/hyperactivity disorder, new research suggests.
By applying a machine-learning approach to brain-imaging data, investigators were able to identify with 99% accuracy the adult study participants who had been diagnosed with ADHD in childhood.
“Even though the symptoms of ADHD may be less apparent in adulthood, the brain-wiring signature seems to be persistent,” study investigator Christopher McNorgan, PhD, of the department of psychology, State University of New York at Buffalo told this news organization.
The findings were published online Dec. 17, 2020, in Frontiers of Psychology.
Deep-learning neural networks
The researchers analyzed archived functional magnetic resonance imaging (fMRI) and behavioral data for 80 adults (mean age, 24 years; 64 male). Of these participants, 55 were diagnosed with ADHD in childhood and 25 were not.
The fMRI data were obtained during a response inhibition task that tested the individual’s ability to not respond automatically; for example, not saying “Simon Says” after someone else makes the comment.
The behavioral data included scores on the Iowa Gambling Task (IGT), which is used to measure impulsivity and risk taking.
“Usually, but not always, people with ADHD make riskier choices on this task,” Dr. McNorgan noted.
The investigators measured the amount of interconnectedness among different brain regions during the response inhibition task, which was repeated four times.
Patterns of interconnectivity were then fed into a deep-learning neural network that learned which patterns belonged to the ADHD group vs. those without ADHD (control group) and which patterns belonged to the high vs. low scorers on the IGT.
Caveats, cautionary notes
“The trained models are then tested on brain patterns they had never seen before, and we found the models would make the correct ADHD diagnosis and could tell apart the high and low scorers on the IGT 99% of the time,” Dr. McNorgan reported.
“The trained classifiers make predictions by calculating probabilities, and the neural networks learned how each of the brain connections contributes towards the final classification probability. We identified the set of brain connections that had the greatest influence on these probability calculations,” he noted.
Because the network classified both ADHD diagnosis and gambling task performance, the researchers were able to distinguish between connections that predicted ADHD when gambling performance was poor, as is typical for patients with ADHD, and those predicting ADHD when gambling performance was uncharacteristically good.
While more work is needed, the findings have potential clinical relevance, Dr. McNorgan said.
“ADHD can be difficult to diagnose reliably. If expense wasn’t an issue, fMRI may be able to help make diagnosis more reliable and objective,” he added.
However, because individuals with ADHD have different behavioral profiles, such as scoring atypically well on the IGT, additional studies using this approach may help identify brain networks “that are more or less active in those with ADHD that show a particular diagnostic trait,” he said.
“This could help inform what treatments might be more effective for those individuals,” Dr. McNorgan said.
Of course, he added, “clinicians’ diagnostic expertise is still required, as I would not base an ADHD diagnosis solely on the results of a single brain scan.”
No cross-validation
Commenting on the findings for this news organization, Vince Calhoun, PhD, neuroscientist and founding director of the Center for Translational Research in Neuroimaging and Data Science, Atlanta, a joint effort between Georgia State, Georgia Tech, and Emory University, noted some study limitations.
One cautionary note is that the investigators “appear to select relevant regions to include in the model based on activation to the task, then computed the predictions using the subset of regions that showed strong activation. The issue is this was done on the same data, so there was no cross-validation of this ‘feature selection’ step,” said Dr. Calhoun, who was not involved with the research. “This is a type of circularity which can lead to inflated accuracies,” he added.
Dr. Calhoun also noted that “multiple ADHD classification studies” have reported accuracies above 90%. In addition, there were only 80 participants in the current dataset.
“That’s relatively small for making strong claims about high accuracies as has been reported elsewhere,” he said.
Dr. McNorgan and Dr. Calhoun have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Functional brain connectivity patterns are a stable biomarker of attention-deficit/hyperactivity disorder, new research suggests.
By applying a machine-learning approach to brain-imaging data, investigators were able to identify with 99% accuracy the adult study participants who had been diagnosed with ADHD in childhood.
“Even though the symptoms of ADHD may be less apparent in adulthood, the brain-wiring signature seems to be persistent,” study investigator Christopher McNorgan, PhD, of the department of psychology, State University of New York at Buffalo told this news organization.
The findings were published online Dec. 17, 2020, in Frontiers of Psychology.
Deep-learning neural networks
The researchers analyzed archived functional magnetic resonance imaging (fMRI) and behavioral data for 80 adults (mean age, 24 years; 64 male). Of these participants, 55 were diagnosed with ADHD in childhood and 25 were not.
The fMRI data were obtained during a response inhibition task that tested the individual’s ability to not respond automatically; for example, not saying “Simon Says” after someone else makes the comment.
The behavioral data included scores on the Iowa Gambling Task (IGT), which is used to measure impulsivity and risk taking.
“Usually, but not always, people with ADHD make riskier choices on this task,” Dr. McNorgan noted.
The investigators measured the amount of interconnectedness among different brain regions during the response inhibition task, which was repeated four times.
Patterns of interconnectivity were then fed into a deep-learning neural network that learned which patterns belonged to the ADHD group vs. those without ADHD (control group) and which patterns belonged to the high vs. low scorers on the IGT.
Caveats, cautionary notes
“The trained models are then tested on brain patterns they had never seen before, and we found the models would make the correct ADHD diagnosis and could tell apart the high and low scorers on the IGT 99% of the time,” Dr. McNorgan reported.
“The trained classifiers make predictions by calculating probabilities, and the neural networks learned how each of the brain connections contributes towards the final classification probability. We identified the set of brain connections that had the greatest influence on these probability calculations,” he noted.
Because the network classified both ADHD diagnosis and gambling task performance, the researchers were able to distinguish between connections that predicted ADHD when gambling performance was poor, as is typical for patients with ADHD, and those predicting ADHD when gambling performance was uncharacteristically good.
While more work is needed, the findings have potential clinical relevance, Dr. McNorgan said.
“ADHD can be difficult to diagnose reliably. If expense wasn’t an issue, fMRI may be able to help make diagnosis more reliable and objective,” he added.
However, because individuals with ADHD have different behavioral profiles, such as scoring atypically well on the IGT, additional studies using this approach may help identify brain networks “that are more or less active in those with ADHD that show a particular diagnostic trait,” he said.
“This could help inform what treatments might be more effective for those individuals,” Dr. McNorgan said.
Of course, he added, “clinicians’ diagnostic expertise is still required, as I would not base an ADHD diagnosis solely on the results of a single brain scan.”
No cross-validation
Commenting on the findings for this news organization, Vince Calhoun, PhD, neuroscientist and founding director of the Center for Translational Research in Neuroimaging and Data Science, Atlanta, a joint effort between Georgia State, Georgia Tech, and Emory University, noted some study limitations.
One cautionary note is that the investigators “appear to select relevant regions to include in the model based on activation to the task, then computed the predictions using the subset of regions that showed strong activation. The issue is this was done on the same data, so there was no cross-validation of this ‘feature selection’ step,” said Dr. Calhoun, who was not involved with the research. “This is a type of circularity which can lead to inflated accuracies,” he added.
Dr. Calhoun also noted that “multiple ADHD classification studies” have reported accuracies above 90%. In addition, there were only 80 participants in the current dataset.
“That’s relatively small for making strong claims about high accuracies as has been reported elsewhere,” he said.
Dr. McNorgan and Dr. Calhoun have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Functional brain connectivity patterns are a stable biomarker of attention-deficit/hyperactivity disorder, new research suggests.
By applying a machine-learning approach to brain-imaging data, investigators were able to identify with 99% accuracy the adult study participants who had been diagnosed with ADHD in childhood.
“Even though the symptoms of ADHD may be less apparent in adulthood, the brain-wiring signature seems to be persistent,” study investigator Christopher McNorgan, PhD, of the department of psychology, State University of New York at Buffalo told this news organization.
The findings were published online Dec. 17, 2020, in Frontiers of Psychology.
Deep-learning neural networks
The researchers analyzed archived functional magnetic resonance imaging (fMRI) and behavioral data for 80 adults (mean age, 24 years; 64 male). Of these participants, 55 were diagnosed with ADHD in childhood and 25 were not.
The fMRI data were obtained during a response inhibition task that tested the individual’s ability to not respond automatically; for example, not saying “Simon Says” after someone else makes the comment.
The behavioral data included scores on the Iowa Gambling Task (IGT), which is used to measure impulsivity and risk taking.
“Usually, but not always, people with ADHD make riskier choices on this task,” Dr. McNorgan noted.
The investigators measured the amount of interconnectedness among different brain regions during the response inhibition task, which was repeated four times.
Patterns of interconnectivity were then fed into a deep-learning neural network that learned which patterns belonged to the ADHD group vs. those without ADHD (control group) and which patterns belonged to the high vs. low scorers on the IGT.
Caveats, cautionary notes
“The trained models are then tested on brain patterns they had never seen before, and we found the models would make the correct ADHD diagnosis and could tell apart the high and low scorers on the IGT 99% of the time,” Dr. McNorgan reported.
“The trained classifiers make predictions by calculating probabilities, and the neural networks learned how each of the brain connections contributes towards the final classification probability. We identified the set of brain connections that had the greatest influence on these probability calculations,” he noted.
Because the network classified both ADHD diagnosis and gambling task performance, the researchers were able to distinguish between connections that predicted ADHD when gambling performance was poor, as is typical for patients with ADHD, and those predicting ADHD when gambling performance was uncharacteristically good.
While more work is needed, the findings have potential clinical relevance, Dr. McNorgan said.
“ADHD can be difficult to diagnose reliably. If expense wasn’t an issue, fMRI may be able to help make diagnosis more reliable and objective,” he added.
However, because individuals with ADHD have different behavioral profiles, such as scoring atypically well on the IGT, additional studies using this approach may help identify brain networks “that are more or less active in those with ADHD that show a particular diagnostic trait,” he said.
“This could help inform what treatments might be more effective for those individuals,” Dr. McNorgan said.
Of course, he added, “clinicians’ diagnostic expertise is still required, as I would not base an ADHD diagnosis solely on the results of a single brain scan.”
No cross-validation
Commenting on the findings for this news organization, Vince Calhoun, PhD, neuroscientist and founding director of the Center for Translational Research in Neuroimaging and Data Science, Atlanta, a joint effort between Georgia State, Georgia Tech, and Emory University, noted some study limitations.
One cautionary note is that the investigators “appear to select relevant regions to include in the model based on activation to the task, then computed the predictions using the subset of regions that showed strong activation. The issue is this was done on the same data, so there was no cross-validation of this ‘feature selection’ step,” said Dr. Calhoun, who was not involved with the research. “This is a type of circularity which can lead to inflated accuracies,” he added.
Dr. Calhoun also noted that “multiple ADHD classification studies” have reported accuracies above 90%. In addition, there were only 80 participants in the current dataset.
“That’s relatively small for making strong claims about high accuracies as has been reported elsewhere,” he said.
Dr. McNorgan and Dr. Calhoun have reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Child with yellow nodule
The characteristic orange-yellow color is the tip-off to the diagnosis of juvenile xanthogranuloma (JXG). It manifests as asymptomatic solitary or scattered papules or nodules, congenitally, or most commonly during the first year of life.
JXG is an unusual non-Langerhans cell histiocytosis that more commonly affects males. The etiology of JXG is unclear; it is presumed to be due to physical or infectious stimuli that produce a granulomatous histiocytic reaction. JXG typically manifests on the head, neck, upper extremities, and trunk. The appearance of JXG may be similar to that of Langerhans cell histiocytosis. If necessary, the diagnosis of JXG can be confirmed with a skin biopsy, which will reveal Touton-type giant cells and foamy histiocytes.
JXG is a benign and self-limiting disorder and spontaneously regresses within a few years. In rare cases, it can be systemic. If there are multiple lesions, relevant history, or physical exam features suggesting space-occupying lesions, imaging should be performed to rule out lesions in internal organs or structures. Treatment is indicated when there is systemic or symptomatic ocular involvement and may include surgical excision, radiotherapy, and/or systemic chemotherapy. In this case, the patient’s JXG management involved routine monitoring in anticipation of spontaneous resolution.
Image courtesy of John Durkin, MD, FAAD, Department of Dermatology, University of New Mexico School of Medicine, Albuquerque. Text courtesy of Kerry Song, BS, University of New Mexico School of Medicine, and Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.
Collie JS, Harper CD, Fillman EP. Juvenile Xanthogranuloma. In: StatPearls [Internet]. StatPearls Publishing; 2020 Jan. Accessed January 29, 2021. https://www.ncbi.nlm.nih.gov/books/NBK526103/#_NBK526103_pubdet
The characteristic orange-yellow color is the tip-off to the diagnosis of juvenile xanthogranuloma (JXG). It manifests as asymptomatic solitary or scattered papules or nodules, congenitally, or most commonly during the first year of life.
JXG is an unusual non-Langerhans cell histiocytosis that more commonly affects males. The etiology of JXG is unclear; it is presumed to be due to physical or infectious stimuli that produce a granulomatous histiocytic reaction. JXG typically manifests on the head, neck, upper extremities, and trunk. The appearance of JXG may be similar to that of Langerhans cell histiocytosis. If necessary, the diagnosis of JXG can be confirmed with a skin biopsy, which will reveal Touton-type giant cells and foamy histiocytes.
JXG is a benign and self-limiting disorder and spontaneously regresses within a few years. In rare cases, it can be systemic. If there are multiple lesions, relevant history, or physical exam features suggesting space-occupying lesions, imaging should be performed to rule out lesions in internal organs or structures. Treatment is indicated when there is systemic or symptomatic ocular involvement and may include surgical excision, radiotherapy, and/or systemic chemotherapy. In this case, the patient’s JXG management involved routine monitoring in anticipation of spontaneous resolution.
Image courtesy of John Durkin, MD, FAAD, Department of Dermatology, University of New Mexico School of Medicine, Albuquerque. Text courtesy of Kerry Song, BS, University of New Mexico School of Medicine, and Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.
The characteristic orange-yellow color is the tip-off to the diagnosis of juvenile xanthogranuloma (JXG). It manifests as asymptomatic solitary or scattered papules or nodules, congenitally, or most commonly during the first year of life.
JXG is an unusual non-Langerhans cell histiocytosis that more commonly affects males. The etiology of JXG is unclear; it is presumed to be due to physical or infectious stimuli that produce a granulomatous histiocytic reaction. JXG typically manifests on the head, neck, upper extremities, and trunk. The appearance of JXG may be similar to that of Langerhans cell histiocytosis. If necessary, the diagnosis of JXG can be confirmed with a skin biopsy, which will reveal Touton-type giant cells and foamy histiocytes.
JXG is a benign and self-limiting disorder and spontaneously regresses within a few years. In rare cases, it can be systemic. If there are multiple lesions, relevant history, or physical exam features suggesting space-occupying lesions, imaging should be performed to rule out lesions in internal organs or structures. Treatment is indicated when there is systemic or symptomatic ocular involvement and may include surgical excision, radiotherapy, and/or systemic chemotherapy. In this case, the patient’s JXG management involved routine monitoring in anticipation of spontaneous resolution.
Image courtesy of John Durkin, MD, FAAD, Department of Dermatology, University of New Mexico School of Medicine, Albuquerque. Text courtesy of Kerry Song, BS, University of New Mexico School of Medicine, and Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.
Collie JS, Harper CD, Fillman EP. Juvenile Xanthogranuloma. In: StatPearls [Internet]. StatPearls Publishing; 2020 Jan. Accessed January 29, 2021. https://www.ncbi.nlm.nih.gov/books/NBK526103/#_NBK526103_pubdet
Collie JS, Harper CD, Fillman EP. Juvenile Xanthogranuloma. In: StatPearls [Internet]. StatPearls Publishing; 2020 Jan. Accessed January 29, 2021. https://www.ncbi.nlm.nih.gov/books/NBK526103/#_NBK526103_pubdet
Home O2 in COPD. Eradicating COVID-19. mRNA and beyond. COVID-19 treatment, so far. Awake proning in COVID-19. Home ventilation. Interprofessional team approach to palliative extubation.
Airways disorders
Updated guidelines on the use of home O2 in COPD: A much-needed respite
The use of long-term oxygen therapy (LTOT, oxygen prescribed for at least 15 h/day) in patients with COPD and chronic hypoxemia has been standard of care based on trials from the 1980s that conferred a survival benefit with the use of continuous oxygen (Ann Internal Med. 1980;93[3]:391-8). More recently, LTOT has not shown to improve survival or delay time to the hospitalization in patients with stable COPD and resting or exercise-induced moderate desaturation (N Engl J Med. 2016;375[17]:1617-27). Thus far, existing recommendations had been semi-inclusive in patient selection. A fundamental lack of evidence-based clinical practice guidelines prompted additional research into patient selection, portable oxygen technology, advocacy for improved oxygen therapy financing, and updating of policies (Jacobs et al., Ann Am Thorac Soc. 2018;15[12]:1369-81). With over a million patients in the United States being prescribed home oxygen and reported disconnect in-home oxygen needs/experiences across disease processes, lifestyles, and oxygen supply requirements, the 2020 American Thoracic Society (ATS) workshop on optimizing home oxygen therapy sought to answer critical questions in the use of LTOT for COPD patients (AlMutairi, et al. Respir Care. 2018;63[11]:1321-30; Jacobs, et al. Am J Respir Crit Care Med. 2020;202[10]:e121-e141).
Kadambari Vijaykumar, MD
Fellow-in-Training Member
Dharani Kumari Narendra, MBBS, FCCP
Steering Committee Member
Chest infections
Eradicating COVID-19 scourge: It is up to all of us— get vaccinated!
2021 brings hope, spurred by the availability of several effective COVID-19 vaccines – unprecedented scientific advances, considering that these vaccines were developed in record time. We have stark choices: while some individuals ignore scientific evidence and refuse to take the vaccine, we from the Chest Infections NetWork urge an alternative and imperative choice. As health providers caring for COVID-19 patients, we first-hand witness the horrors of dying alone in a hospital bed – far away from beloved ones. I have a sticker on my car that says: If you do not like your mask, you will not like my ventilator. With the advent of vaccines, I plan on replacing this sticker: If you do not want to get vaccinated, you will not like my ventilator. When the vaccine became available at my institution, I was the first to roll up my sleeve and feel the pinch in my upper arm. I urge you all to do the same. Make a difference, do your part – get vaccinated.
Marcos I. Restrepo, MD, MSc, PhD
Chair
Clinical pulmonary medicine
COVID-19 vaccines – mRNA and beyond
We currently have two COVID-19 mRNA vaccines with US FDA emergency use authorization (EUA) for use in individuals less than or equal to age 18 years – Pfizer and Moderna. They work by introducing mRNA into a muscle cell that instructs the host cell ribosomes to express Sars-CoV-2 spike proteins, thereby triggering a systemic immune response.
Both are two-dose regimens, with Pfizer’s 21 days apart and requires storage at -75 C, and Moderna’s 28 days apart, requiring storage at -20 C.
Presently in development are three more vaccines. AstraZeneca (AZ) and Johnson & Johnson (JnJ) use an adenovirus vector. Both vaccines are stable at standard refrigerator temperatures. AZ’s results were mixed – with two, full-size doses efficacy at 62% effective, but with a half-dose followed by a full dose, efficacy was 90%. Novavax candidate works differently - it’s a protein subunit vaccine and uses a lab-made version of the SARS-CoV-2 spike protein, mixed with an adjuvant to help trigger the immune system. Results from all trials are eagerly awaited.
Mary Jo S. Farmer, MD, PhD, FCCP
Steering Committee Member
Shyam Subramanian, MD, FCCP
Chair
Clinical research and quality improvement
COVID-19 treatment, so far!
COVID-19 has turned rapidly into a fatal illness, causing over 1.8 million deaths worldwide so far. The pandemic has also showed us the power of adaptive trials, multi-arm trials, and the role for collaboration across the global scientific community. A few significant studies are worth mentioning.
Possible future therapies include antiviral monoclonal antibodies, bamlanivimab (Chen P, et al. N Engl J Med. 2020; online ahead of print); early convalescent plasma (Libster R, et al. N Engl J Med. 2021 Jan 6. doi: 10.1056/NEJMoa2033700); and casirivimab-imdevimab (Baum A, et al. Science. 2020 Nov 27 doi: 10.1126/science.abe2402). Development of mRNA COVID-19 vaccines can help with primary prevention and herd immunity (Polack FP, et al. N Engl J Med. 2020;383[27]:2603; Baden LR, et al. N Engl J Med. 2020; Dec 30; doi: 10.1056/NEJMoa2035389).
We are starting to understand why COVID-19 infection is more pathogenic in some, how to predict development of severe disease, and how to best treat respiratory failure. Defeating the pandemic will require ongoing international collaboration in research, development, and resource allocation.
Muhammad Hayat Syed, MBBS
Ankita Agarwal, MD
Fellows-in-Training Members
Critical care
Awake proning in COVID-19
Prone positioning has been shown to improve pulmonary mechanics in intubated patients with acute respiratory distress syndrome (ARDS). Proposed mechanisms for these benefits include shape matching, reversing the pleural pressure gradient, homogenizing distribution of pleural pressures, reducing the impact of the heart and abdomen on the lungs, and maintaining distribution of perfusion. Application of prone positioning has also been shown to reduce mortality in severe ARDS (Guérin, et al. N Engl J Med. 2013;368(23):2159-68). With the COVID-19 pandemic, clinicians have extrapolated that nonintubated patients with severe hypoxia may benefit from awake proning in the hopes of improving oxygenation and decreasing need for intubation. But, what’s the evidence so far?
Kathryn Pendleton, MD
Viren Kaul, MD
Steering Committee Members
Home-Based Mechanical Ventilation and Neuromuscular Disease
New horizons in home ventilation
Phasing out a particular ventilator (Philips Respironics Trilogy 100 ventilator) has everyone on a steep learning curve with the replacement (Trilogy EVO). Most features are replicated in the EVO, including volume/pressure control and pressure-supported modes, mouthpiece ventilation, active/passive circuit capability, and portability (11.5 lb). Upgrades include longer battery life (15 hours; 7.5 hours internal/7.5 hours detachable) and use in pediatric patients now greater than or equal to 2.5 kg.
Other significant improvements include lower flow trigger sensitivity to accommodate patients with severe respiratory muscle weakness, a fast start AVAPS with rapid breath-to-breath 3 cm H20 increases for the first minute to rapidly reach target tidal volume, and breath-to-breath auto-EPAP sensing of upper airway resistance to maintain airway patency for patients with upper airway obstruction.
Internal bluetooth transmission to cloud-based monitoring (Care OrchestratorTM) expands access to patients without wi-fi or cellular service. New monitoring modules, SpO2 and EtCO2, and transcutaneous CO2 monitoring (Sentec), transmit to cloud-based monitoring (EVO EtCs2 spring 2021).
These welcome improvements allow clinicians to better match ventilator settings to the patients’ evolving physiology and provide flexibility and connectivity to optimize long-term care.
Karin Provost, DO, PhD
Steering Committee Member
Janet Hilbert, MD
NetWork Member
Online resources
EVO e-learning curriculum
Interprofessional team
Interprofessional team approach to palliative extubation
The emotional burden of caring for patients at the end of life affects all members of the care team. Palliative (or compassionate) extubation consists of the withdrawal of mechanical ventilation when the absolute priority in care delivery is to afford comfort and allow for natural death to occur. Rapid withdrawal of ventilatory support may lead to significant respiratory distress, and the critical care team has an obligation to ensure patient comfort during the dying process (Truog RD, et al. Crit Care Med. 2008;36[3]:953). Registered nurses (RN) are primarily responsible for the titration of sedation/analgesia and should be included in discussions regarding medication selection. It is imperative that neuromuscular blockade is absent, and benzodiazepines and/or opioids should be initiated prior to palliative extubation (Lanken PN, et al. Am J Respir Crit Care Med. 2008;177:912). Respiratory therapists (RT) are responsible for endotracheal tube removal despite rare participation in end-of-life discussions (Grandhige AP, et al. Respir Care. 2016;61[7]:891). It is recommended that an experienced physician, RN, and RT be readily available to respond quickly to any signs of distress (Downar J, et al. Intensive Care Med. 2016;42:1003). Regular debriefing sessions exploring team actions and communication dynamics are advised following end-of-life care (Ho A, et al. J Interprof Care. 2016;30[6]:795-803). Palliative extubation demands meticulous planning and clear communication among all team members (physician, RN, RT) and the patient’s family. Poor planning may result in physical and emotional suffering for the patient and difficult bereavement for the family (Coradazi A, et al. Hos Pal Med Int J. 2019;3[1]:10-14). Interprofessional team-based care results from intentional teams that exhibit collective identity and shared responsibility for the patients they serve (Core Competencies for Interprofessional Education Collaborative Practice, 2016). An inclusive and interprofessional approach to withdrawal of mechanical ventilation is key to both quality patient care and provider wellbeing.
Rebecca Anna Gersten, MD
Steering Committee Member
Samantha Davis, MS, RRT
Steering Committee Member
Munish Luthra, MD, FCCP
Vice-Chair Committee
Airways disorders
Updated guidelines on the use of home O2 in COPD: A much-needed respite
The use of long-term oxygen therapy (LTOT, oxygen prescribed for at least 15 h/day) in patients with COPD and chronic hypoxemia has been standard of care based on trials from the 1980s that conferred a survival benefit with the use of continuous oxygen (Ann Internal Med. 1980;93[3]:391-8). More recently, LTOT has not shown to improve survival or delay time to the hospitalization in patients with stable COPD and resting or exercise-induced moderate desaturation (N Engl J Med. 2016;375[17]:1617-27). Thus far, existing recommendations had been semi-inclusive in patient selection. A fundamental lack of evidence-based clinical practice guidelines prompted additional research into patient selection, portable oxygen technology, advocacy for improved oxygen therapy financing, and updating of policies (Jacobs et al., Ann Am Thorac Soc. 2018;15[12]:1369-81). With over a million patients in the United States being prescribed home oxygen and reported disconnect in-home oxygen needs/experiences across disease processes, lifestyles, and oxygen supply requirements, the 2020 American Thoracic Society (ATS) workshop on optimizing home oxygen therapy sought to answer critical questions in the use of LTOT for COPD patients (AlMutairi, et al. Respir Care. 2018;63[11]:1321-30; Jacobs, et al. Am J Respir Crit Care Med. 2020;202[10]:e121-e141).
Kadambari Vijaykumar, MD
Fellow-in-Training Member
Dharani Kumari Narendra, MBBS, FCCP
Steering Committee Member
Chest infections
Eradicating COVID-19 scourge: It is up to all of us— get vaccinated!
2021 brings hope, spurred by the availability of several effective COVID-19 vaccines – unprecedented scientific advances, considering that these vaccines were developed in record time. We have stark choices: while some individuals ignore scientific evidence and refuse to take the vaccine, we from the Chest Infections NetWork urge an alternative and imperative choice. As health providers caring for COVID-19 patients, we first-hand witness the horrors of dying alone in a hospital bed – far away from beloved ones. I have a sticker on my car that says: If you do not like your mask, you will not like my ventilator. With the advent of vaccines, I plan on replacing this sticker: If you do not want to get vaccinated, you will not like my ventilator. When the vaccine became available at my institution, I was the first to roll up my sleeve and feel the pinch in my upper arm. I urge you all to do the same. Make a difference, do your part – get vaccinated.
Marcos I. Restrepo, MD, MSc, PhD
Chair
Clinical pulmonary medicine
COVID-19 vaccines – mRNA and beyond
We currently have two COVID-19 mRNA vaccines with US FDA emergency use authorization (EUA) for use in individuals less than or equal to age 18 years – Pfizer and Moderna. They work by introducing mRNA into a muscle cell that instructs the host cell ribosomes to express Sars-CoV-2 spike proteins, thereby triggering a systemic immune response.
Both are two-dose regimens, with Pfizer’s 21 days apart and requires storage at -75 C, and Moderna’s 28 days apart, requiring storage at -20 C.
Presently in development are three more vaccines. AstraZeneca (AZ) and Johnson & Johnson (JnJ) use an adenovirus vector. Both vaccines are stable at standard refrigerator temperatures. AZ’s results were mixed – with two, full-size doses efficacy at 62% effective, but with a half-dose followed by a full dose, efficacy was 90%. Novavax candidate works differently - it’s a protein subunit vaccine and uses a lab-made version of the SARS-CoV-2 spike protein, mixed with an adjuvant to help trigger the immune system. Results from all trials are eagerly awaited.
Mary Jo S. Farmer, MD, PhD, FCCP
Steering Committee Member
Shyam Subramanian, MD, FCCP
Chair
Clinical research and quality improvement
COVID-19 treatment, so far!
COVID-19 has turned rapidly into a fatal illness, causing over 1.8 million deaths worldwide so far. The pandemic has also showed us the power of adaptive trials, multi-arm trials, and the role for collaboration across the global scientific community. A few significant studies are worth mentioning.
Possible future therapies include antiviral monoclonal antibodies, bamlanivimab (Chen P, et al. N Engl J Med. 2020; online ahead of print); early convalescent plasma (Libster R, et al. N Engl J Med. 2021 Jan 6. doi: 10.1056/NEJMoa2033700); and casirivimab-imdevimab (Baum A, et al. Science. 2020 Nov 27 doi: 10.1126/science.abe2402). Development of mRNA COVID-19 vaccines can help with primary prevention and herd immunity (Polack FP, et al. N Engl J Med. 2020;383[27]:2603; Baden LR, et al. N Engl J Med. 2020; Dec 30; doi: 10.1056/NEJMoa2035389).
We are starting to understand why COVID-19 infection is more pathogenic in some, how to predict development of severe disease, and how to best treat respiratory failure. Defeating the pandemic will require ongoing international collaboration in research, development, and resource allocation.
Muhammad Hayat Syed, MBBS
Ankita Agarwal, MD
Fellows-in-Training Members
Critical care
Awake proning in COVID-19
Prone positioning has been shown to improve pulmonary mechanics in intubated patients with acute respiratory distress syndrome (ARDS). Proposed mechanisms for these benefits include shape matching, reversing the pleural pressure gradient, homogenizing distribution of pleural pressures, reducing the impact of the heart and abdomen on the lungs, and maintaining distribution of perfusion. Application of prone positioning has also been shown to reduce mortality in severe ARDS (Guérin, et al. N Engl J Med. 2013;368(23):2159-68). With the COVID-19 pandemic, clinicians have extrapolated that nonintubated patients with severe hypoxia may benefit from awake proning in the hopes of improving oxygenation and decreasing need for intubation. But, what’s the evidence so far?
Kathryn Pendleton, MD
Viren Kaul, MD
Steering Committee Members
Home-Based Mechanical Ventilation and Neuromuscular Disease
New horizons in home ventilation
Phasing out a particular ventilator (Philips Respironics Trilogy 100 ventilator) has everyone on a steep learning curve with the replacement (Trilogy EVO). Most features are replicated in the EVO, including volume/pressure control and pressure-supported modes, mouthpiece ventilation, active/passive circuit capability, and portability (11.5 lb). Upgrades include longer battery life (15 hours; 7.5 hours internal/7.5 hours detachable) and use in pediatric patients now greater than or equal to 2.5 kg.
Other significant improvements include lower flow trigger sensitivity to accommodate patients with severe respiratory muscle weakness, a fast start AVAPS with rapid breath-to-breath 3 cm H20 increases for the first minute to rapidly reach target tidal volume, and breath-to-breath auto-EPAP sensing of upper airway resistance to maintain airway patency for patients with upper airway obstruction.
Internal bluetooth transmission to cloud-based monitoring (Care OrchestratorTM) expands access to patients without wi-fi or cellular service. New monitoring modules, SpO2 and EtCO2, and transcutaneous CO2 monitoring (Sentec), transmit to cloud-based monitoring (EVO EtCs2 spring 2021).
These welcome improvements allow clinicians to better match ventilator settings to the patients’ evolving physiology and provide flexibility and connectivity to optimize long-term care.
Karin Provost, DO, PhD
Steering Committee Member
Janet Hilbert, MD
NetWork Member
Online resources
EVO e-learning curriculum
Interprofessional team
Interprofessional team approach to palliative extubation
The emotional burden of caring for patients at the end of life affects all members of the care team. Palliative (or compassionate) extubation consists of the withdrawal of mechanical ventilation when the absolute priority in care delivery is to afford comfort and allow for natural death to occur. Rapid withdrawal of ventilatory support may lead to significant respiratory distress, and the critical care team has an obligation to ensure patient comfort during the dying process (Truog RD, et al. Crit Care Med. 2008;36[3]:953). Registered nurses (RN) are primarily responsible for the titration of sedation/analgesia and should be included in discussions regarding medication selection. It is imperative that neuromuscular blockade is absent, and benzodiazepines and/or opioids should be initiated prior to palliative extubation (Lanken PN, et al. Am J Respir Crit Care Med. 2008;177:912). Respiratory therapists (RT) are responsible for endotracheal tube removal despite rare participation in end-of-life discussions (Grandhige AP, et al. Respir Care. 2016;61[7]:891). It is recommended that an experienced physician, RN, and RT be readily available to respond quickly to any signs of distress (Downar J, et al. Intensive Care Med. 2016;42:1003). Regular debriefing sessions exploring team actions and communication dynamics are advised following end-of-life care (Ho A, et al. J Interprof Care. 2016;30[6]:795-803). Palliative extubation demands meticulous planning and clear communication among all team members (physician, RN, RT) and the patient’s family. Poor planning may result in physical and emotional suffering for the patient and difficult bereavement for the family (Coradazi A, et al. Hos Pal Med Int J. 2019;3[1]:10-14). Interprofessional team-based care results from intentional teams that exhibit collective identity and shared responsibility for the patients they serve (Core Competencies for Interprofessional Education Collaborative Practice, 2016). An inclusive and interprofessional approach to withdrawal of mechanical ventilation is key to both quality patient care and provider wellbeing.
Rebecca Anna Gersten, MD
Steering Committee Member
Samantha Davis, MS, RRT
Steering Committee Member
Munish Luthra, MD, FCCP
Vice-Chair Committee
Airways disorders
Updated guidelines on the use of home O2 in COPD: A much-needed respite
The use of long-term oxygen therapy (LTOT, oxygen prescribed for at least 15 h/day) in patients with COPD and chronic hypoxemia has been standard of care based on trials from the 1980s that conferred a survival benefit with the use of continuous oxygen (Ann Internal Med. 1980;93[3]:391-8). More recently, LTOT has not shown to improve survival or delay time to the hospitalization in patients with stable COPD and resting or exercise-induced moderate desaturation (N Engl J Med. 2016;375[17]:1617-27). Thus far, existing recommendations had been semi-inclusive in patient selection. A fundamental lack of evidence-based clinical practice guidelines prompted additional research into patient selection, portable oxygen technology, advocacy for improved oxygen therapy financing, and updating of policies (Jacobs et al., Ann Am Thorac Soc. 2018;15[12]:1369-81). With over a million patients in the United States being prescribed home oxygen and reported disconnect in-home oxygen needs/experiences across disease processes, lifestyles, and oxygen supply requirements, the 2020 American Thoracic Society (ATS) workshop on optimizing home oxygen therapy sought to answer critical questions in the use of LTOT for COPD patients (AlMutairi, et al. Respir Care. 2018;63[11]:1321-30; Jacobs, et al. Am J Respir Crit Care Med. 2020;202[10]:e121-e141).
Kadambari Vijaykumar, MD
Fellow-in-Training Member
Dharani Kumari Narendra, MBBS, FCCP
Steering Committee Member
Chest infections
Eradicating COVID-19 scourge: It is up to all of us— get vaccinated!
2021 brings hope, spurred by the availability of several effective COVID-19 vaccines – unprecedented scientific advances, considering that these vaccines were developed in record time. We have stark choices: while some individuals ignore scientific evidence and refuse to take the vaccine, we from the Chest Infections NetWork urge an alternative and imperative choice. As health providers caring for COVID-19 patients, we first-hand witness the horrors of dying alone in a hospital bed – far away from beloved ones. I have a sticker on my car that says: If you do not like your mask, you will not like my ventilator. With the advent of vaccines, I plan on replacing this sticker: If you do not want to get vaccinated, you will not like my ventilator. When the vaccine became available at my institution, I was the first to roll up my sleeve and feel the pinch in my upper arm. I urge you all to do the same. Make a difference, do your part – get vaccinated.
Marcos I. Restrepo, MD, MSc, PhD
Chair
Clinical pulmonary medicine
COVID-19 vaccines – mRNA and beyond
We currently have two COVID-19 mRNA vaccines with US FDA emergency use authorization (EUA) for use in individuals less than or equal to age 18 years – Pfizer and Moderna. They work by introducing mRNA into a muscle cell that instructs the host cell ribosomes to express Sars-CoV-2 spike proteins, thereby triggering a systemic immune response.
Both are two-dose regimens, with Pfizer’s 21 days apart and requires storage at -75 C, and Moderna’s 28 days apart, requiring storage at -20 C.
Presently in development are three more vaccines. AstraZeneca (AZ) and Johnson & Johnson (JnJ) use an adenovirus vector. Both vaccines are stable at standard refrigerator temperatures. AZ’s results were mixed – with two, full-size doses efficacy at 62% effective, but with a half-dose followed by a full dose, efficacy was 90%. Novavax candidate works differently - it’s a protein subunit vaccine and uses a lab-made version of the SARS-CoV-2 spike protein, mixed with an adjuvant to help trigger the immune system. Results from all trials are eagerly awaited.
Mary Jo S. Farmer, MD, PhD, FCCP
Steering Committee Member
Shyam Subramanian, MD, FCCP
Chair
Clinical research and quality improvement
COVID-19 treatment, so far!
COVID-19 has turned rapidly into a fatal illness, causing over 1.8 million deaths worldwide so far. The pandemic has also showed us the power of adaptive trials, multi-arm trials, and the role for collaboration across the global scientific community. A few significant studies are worth mentioning.
Possible future therapies include antiviral monoclonal antibodies, bamlanivimab (Chen P, et al. N Engl J Med. 2020; online ahead of print); early convalescent plasma (Libster R, et al. N Engl J Med. 2021 Jan 6. doi: 10.1056/NEJMoa2033700); and casirivimab-imdevimab (Baum A, et al. Science. 2020 Nov 27 doi: 10.1126/science.abe2402). Development of mRNA COVID-19 vaccines can help with primary prevention and herd immunity (Polack FP, et al. N Engl J Med. 2020;383[27]:2603; Baden LR, et al. N Engl J Med. 2020; Dec 30; doi: 10.1056/NEJMoa2035389).
We are starting to understand why COVID-19 infection is more pathogenic in some, how to predict development of severe disease, and how to best treat respiratory failure. Defeating the pandemic will require ongoing international collaboration in research, development, and resource allocation.
Muhammad Hayat Syed, MBBS
Ankita Agarwal, MD
Fellows-in-Training Members
Critical care
Awake proning in COVID-19
Prone positioning has been shown to improve pulmonary mechanics in intubated patients with acute respiratory distress syndrome (ARDS). Proposed mechanisms for these benefits include shape matching, reversing the pleural pressure gradient, homogenizing distribution of pleural pressures, reducing the impact of the heart and abdomen on the lungs, and maintaining distribution of perfusion. Application of prone positioning has also been shown to reduce mortality in severe ARDS (Guérin, et al. N Engl J Med. 2013;368(23):2159-68). With the COVID-19 pandemic, clinicians have extrapolated that nonintubated patients with severe hypoxia may benefit from awake proning in the hopes of improving oxygenation and decreasing need for intubation. But, what’s the evidence so far?
Kathryn Pendleton, MD
Viren Kaul, MD
Steering Committee Members
Home-Based Mechanical Ventilation and Neuromuscular Disease
New horizons in home ventilation
Phasing out a particular ventilator (Philips Respironics Trilogy 100 ventilator) has everyone on a steep learning curve with the replacement (Trilogy EVO). Most features are replicated in the EVO, including volume/pressure control and pressure-supported modes, mouthpiece ventilation, active/passive circuit capability, and portability (11.5 lb). Upgrades include longer battery life (15 hours; 7.5 hours internal/7.5 hours detachable) and use in pediatric patients now greater than or equal to 2.5 kg.
Other significant improvements include lower flow trigger sensitivity to accommodate patients with severe respiratory muscle weakness, a fast start AVAPS with rapid breath-to-breath 3 cm H20 increases for the first minute to rapidly reach target tidal volume, and breath-to-breath auto-EPAP sensing of upper airway resistance to maintain airway patency for patients with upper airway obstruction.
Internal bluetooth transmission to cloud-based monitoring (Care OrchestratorTM) expands access to patients without wi-fi or cellular service. New monitoring modules, SpO2 and EtCO2, and transcutaneous CO2 monitoring (Sentec), transmit to cloud-based monitoring (EVO EtCs2 spring 2021).
These welcome improvements allow clinicians to better match ventilator settings to the patients’ evolving physiology and provide flexibility and connectivity to optimize long-term care.
Karin Provost, DO, PhD
Steering Committee Member
Janet Hilbert, MD
NetWork Member
Online resources
EVO e-learning curriculum
Interprofessional team
Interprofessional team approach to palliative extubation
The emotional burden of caring for patients at the end of life affects all members of the care team. Palliative (or compassionate) extubation consists of the withdrawal of mechanical ventilation when the absolute priority in care delivery is to afford comfort and allow for natural death to occur. Rapid withdrawal of ventilatory support may lead to significant respiratory distress, and the critical care team has an obligation to ensure patient comfort during the dying process (Truog RD, et al. Crit Care Med. 2008;36[3]:953). Registered nurses (RN) are primarily responsible for the titration of sedation/analgesia and should be included in discussions regarding medication selection. It is imperative that neuromuscular blockade is absent, and benzodiazepines and/or opioids should be initiated prior to palliative extubation (Lanken PN, et al. Am J Respir Crit Care Med. 2008;177:912). Respiratory therapists (RT) are responsible for endotracheal tube removal despite rare participation in end-of-life discussions (Grandhige AP, et al. Respir Care. 2016;61[7]:891). It is recommended that an experienced physician, RN, and RT be readily available to respond quickly to any signs of distress (Downar J, et al. Intensive Care Med. 2016;42:1003). Regular debriefing sessions exploring team actions and communication dynamics are advised following end-of-life care (Ho A, et al. J Interprof Care. 2016;30[6]:795-803). Palliative extubation demands meticulous planning and clear communication among all team members (physician, RN, RT) and the patient’s family. Poor planning may result in physical and emotional suffering for the patient and difficult bereavement for the family (Coradazi A, et al. Hos Pal Med Int J. 2019;3[1]:10-14). Interprofessional team-based care results from intentional teams that exhibit collective identity and shared responsibility for the patients they serve (Core Competencies for Interprofessional Education Collaborative Practice, 2016). An inclusive and interprofessional approach to withdrawal of mechanical ventilation is key to both quality patient care and provider wellbeing.
Rebecca Anna Gersten, MD
Steering Committee Member
Samantha Davis, MS, RRT
Steering Committee Member
Munish Luthra, MD, FCCP
Vice-Chair Committee
In case you missed it ...CHEST Annual Meeting 2020 Award Recipients
ANNUAL AWARDS
Master FCCP
Nancy A. Collop MD, Master FCCP
College Medalist Award
Neil R. MacIntyre, MD, FCCP
Distinguished Service Award
Lisa K. Moores, MD, FCCP
Master Clinician Educator
William F. Kelly, MD, FCCP
David A. Schulman, MD, MPH, FCCP
Early Career Clinician Educator
Subani Chandra, MD, FCCP
Alfred Soffer Award for Editorial Excellence
Barbara Anderson, CHEST Staff
Laura Lipsey, CHEST Staff
Presidential Citation
Mangala Narasimhan, DO, FCCP
Renli Qiao, MD, PhD, FCCP
HONOR LECTURE AND MEMORIAL AWARDS
Edward C. Rosenow III, MD, Master FCCP/Master Teacher Endowed Honor Lecture Evolving Therapies in ANCA-Associated Vasculitides
Joseph P. Lynch, III, MD, FCCP
The lecture is generously funded by the CHEST Foundation.Distinguished Scientist Honor Lecture in Cardiopulmonary PhysiologyHelping the Dyspneic Patient: Clinical Physiology Matters!
Denis E. O’Donnell, MD, MBBCh, FCCP
The lecture is generously funded by the CHEST Foundation.Presidential Honor LectureCOPD Management: We’ve Come So Far
Darcy D. Marciniuk, MD, Master FCCP
Thomas L. Petty, MD, Master FCCP Memorial LectureReal World Research - What Would Dr. Petty Say?
Mary Hart, RRT, MS, FCCP
The lecture is generously funded by the CHEST Foundation.Margaret Pfrommer Endowed Memorial Lecture in Home-Based Mechanical VentilationNavigating to Home NIV Nirvana: What Would Margaret Do?
Peter C. Gay, MD, MS, FCCP
The Margaret Pfrommer Endowed Memorial Lecture in Home-Based Mechanical Ventilation is generously supported by International Ventilator Users Network of Post-Polio Health International and the CHEST Foundation.Pasquale Ciaglia Memorial Lecture in Interventional MedicineRaising the Bar: The Interventional Pulmonary Outcomes Group
Lonny B. Yarmus, DO, MBA, FCCP
The lecture is generously funded by the CHEST Foundation.
Roger C. Bone Memorial Lecture in Critical CareTo SIRS with Love: Dr. Roger Bone’s Continued Influence on Early Sepsis Care
Emanuel P. Rivers, MD, MPH, FCCP
The lecture is generously funded by the CHEST Foundation.Murray Kornfeld Memorial Founders LectureOur Pneumonia Journey: The Lungs and Beyond
Marcos I. Restrepo, MD, PhD, FCCP
The lecture is generously funded by the CHEST Foundation.
CHEST FOUNDATION GRANT AWARDS
The GlaxoSmithKline Distinguished Scholar in Respiratory Health
Deepa Gotur, MD, FCCP
Cytokine Release in SARS COV2 Viral Illness and Trends of Inflammasome Expression in Acute Respiratory Distress Syndrome Manifestations and ManagementThis grant is supported by an endowed fund from GlaxoSmithKline.CHEST Foundation and the Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency
Paul R. Ellis, MBChB
Cardiovascular Outcomes and Phenotypes in Pulmonary Exacerbations of Alpha-1 AntitrypsinThis grant is jointly supported by the CHEST Foundation and the Alpha-1 Foundation.CHEST Foundation Research Grant in Women’s Lung Health
Shannon E. Kay, MD
Sex-specific Gene Expression in AsthmaThis grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease
Davide Biondini, MD, PhD
Role of the Immune Check Points (CTLA-4 and PD-1) in the Development or Evasion of Smoking-Induced Chronic Obstructive Pulmonary Disease
Andrew J. Gangemi, MD
Are Sleep Health, Nicotine Metabolism, and Airway Inflammation Mechanisms for Differences in Lung Function between African American and Non-Hispanic White Smokers? A Proof-of-Concept ExaminationThese grants are supported by AstraZeneca LP.CHEST Foundation Research Grant in Critical Care
Mounica Vallurupalli, MD
Evaluating the Impact of Clonal Hematopoiesis on Host Immune Response During Sepsis
This grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Lung Cancer
Stefanie Mason, MD
Implications of Longitudinal Muscle-Mass Trajectories in Lung CancerThis grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Venous Thromboembolism
Jansen N. Seheult, MD, MBBCh
Untangling the NET: Neutrophil Activation as the Driver of Venous Thromboembolism in Coronavirus Disease 2019This grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Nontuberculous Mycobacteria Diseases
Bryan A. Garcia, MD
Longitudinal Proteomic Endotyping of Patients with Nontuberculous Mycobacterial Lung InfectionsThis grant is supported by Insmed Incorporated.CHEST Foundation Research Grant in Cystic Fibrosis
Jeffrey Barry, MD
Eosinophilia as a Biomarker for Worse Outcomes in Cystic Fibrosis
Kristina Montemayor, MD
The Association of Sex Hormones and Respiratory Morbidity in Individuals with Cystic FibrosisThese grants are supported by Vertex Pharmaceuticals.John R. Addrizzo, MD, FCCP Research Grant in Sarcoidosis
Changwan Ryu, MD
Extracellular Matrix Proteins as a Biomarker for Stage IV SarcoidosisThis grant is in honor of John R. Addrizzo, MD, FCCP and is jointly supported by the Addrizzo family and the CHEST Foundation.CHEST Foundation Research Grant in Severe Asthma
Isaretta L. Riley, MD, MPH
Coping with Asthma through Life Management (CALM)This grant is funded by AstraZeneca LP.CHEST Foundation Research Grant in Pulmonary Fibrosis
Sarah Beshay, MD
COPA Syndrome-Associated Mutations in Lung Transplant Recipients for Pulmonary Fibrosis
Erica D. Farrand, MD
The Future of Telehealth in Interstitial Lung DiseaseThese grants are supported by Boehringer Ingelheim Pharmaceuticals and Genentech, Inc.CHEST Foundation Research Grant in Sleep Medicine
Tetyana Kendzerska, MD, PhD
The Role of Sleep and Circadian Disturbances in Cancer Development and Progression: A Historical Multicenter Clinical Cohort Study
Nancy Stewart, DO
Improving COPD/OSA Overlap Syndrome Pre-Discharge Care DeliveryThese grants are funded by Jazz Pharmaceuticals, Inc.CHEST Foundation and Association of Critical Care Medicine Program Directors Award Research Grant in Medical Education
Ilana R. Krumm, MD
What’s good about Soul Food? Discovering and Analyzing Elements of an ICU Team Group Discussion Which Improve Provider WellnessThis grant is jointly supported by the CHEST Foundation and APCCMPD.CHEST Foundation and American Thoracic Society Research Grant in Diversity
Thomas S. Valley, MD, MSc
Understanding Differences in Delivery of Care Processes for Respiratory Failure by Race/EthnicityThis grant is jointly supported by the CHEST Foundation and ATS.CHEST Foundation Research Grant in COVID-19
David Furfaro, MD
Subphenotypes, Inflammatory Profiles, and Antibody Response in COVID-19 ARDSThis grant is supported by the CHEST Foundation.CHEST Foundation and American Thoracic Society Grant in COVID-19 and Diversity
Peter D. Jackson, MD
The Effect of the COVID-19 Pandemic on Tuberculosis Care in UgandaThis grant is jointly supported by the CHEST Foundation and ATS.CHEST Foundation Research Grant in Ultrasonography and COVID-19
Marjan M. Islam, MD
Thoracic Ultrasound in COVID-19: A Prospective Study Using Lung and Diaphragm Ultrasound in Evaluating Dyspnea in ICU Survivors with COVID-19 in a Post-ICU Clinic
Siddharth Dugar, MBBS
Spontaneous Echo Contrast in Lower Extremity and Correlation with Venous Velocity and Subsequent Deep Venous Thrombosis in Critically Ill COVID-19 PatientsThis grant is jointly supported by the CHEST Foundation and FUJIFILM SonoSite.
CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP
Ivan Nemorin, MBA, MS, RRT
Healthier Homes for Children-Community Asthma Prevention Program
Joseph Huang, MD
East Africa Training Initiative (EATI)
Aninda Das, MD, MBBS
Screening for Childhood Tuberculosis in Children 0-4 years of Age with Moderate to Severe Malnutrition in a Rural District of West Bengal, India
Trishual Siddharthan, MD
Establishing a Pulmonary and Critical Care Training Program in Uganda
Marina Lima, MD, MSc
Asmaland: The First Gamified Pediatric Asthma Educational Program in Portuguese
Roberta M. Kato, MD
Lung Power
These grants are supported by the CHEST Foundation.Alfred Soffer Research Award Winners
Mazen O. Al-Qadi, MD: RESPIRATORY VARIATION IN RIGHT ATRIAL PRESSURE PREDICTS RIGHT VENTRICULAR DYSFUNCTION IN PATIENTS WITH PRE-CAPILLARY PULMONARY HYPERTENSION
Valerie G. Press, MD: COST SAVING SIMULATION FOR THE TRANSITION FROM NEBULIZER TO COMBINATION OF NEBULIZER AND METERED-DOSE INHALERS (MD)
Young Investigator Award Winners
Gabriel E. Ortiz Jaimes, MD: CORRELATION OF CARDIAC OUTPUT MEASUREMENT BY GOAL-DIRECTED ECHOCARDIOGRAPHY PERFORMED BY INTENSIVISTS VS PULMONARY ARTERY CATHETER
Palakkumar Patel, MD: IMPACT OF HAVING PULMONARY HYPERTENSION IN PATIENTS ADMITTED WITH ACUTE EXACERBATION OF COPD IN THEIR HEALTHCARE UTILIZATION AND READMISSION: A US POPULATION COHORT STUDY
Top 5 Abstract Posters
Winner: Amr Alwakeel, MD: IMPACT OF A PLEURAL CARE PROGRAM ON THE PATHWAY TO DEFINITIVE PALLIATION OF MALIGNANT PLEURAL EFFUSIONS: A PRE-AND POST STUDY
Winner: Konstantinos Zorbas, MD: A SIMPLE PREDICTION SCORE FOR POSTOPERATIVE DEATH AFTER DECORTICATION
Winner: Yichen Wang, MD, MSc: CORONAVIRUS-RELATED HOSPITAL ADMISSIONS IN THE UNITED STATES IN 2016-2017
Runner up: Daniel Ospina-Delgado, MD: CHARACTERIZATION OF LARYNGEAL DISORDERS IN PATIENTS WITH EXCESSIVE CENTRAL AIRWAY COLLAPSE
Runner up: Vishal Vashistha, MD: TREATMENT PATTERNS AMONG LOWER-INCOME INDIAN PATIENTS WITH METASTATIC NON-SMALL CELL LUNG CANCER HARBORING EGFR MUTATIONS OR ALK REARRANGEMENTS
Case Report Poster Winners
Faiza Khalid, MD: FORME FUSTE OF INTERMEDIATE SYNDROME (IMS) IN ORGANOPHOSPHATE POISOING (OPP): EXPERT OPINION GUIDELINE WITHOUT CLEAR END-POINT.
William Meng, MD: VINGT MILLE LIEUES SOUS LES MERS: A POISONOUS GUEST FROM THE BLUE SEA TOXIC INHALATION OF CORAL PALYTOXIN
Dhruv Amratia, MD: PULMONARY BLASTOMA: A RARE FORM OF LUNG CANCER
Melinda Becker, MD: ECMO-ASSISTED BRONCHOSCOPY FOR NEAR-COMPLETE TRACHEAL OBSTRUCTION
Brittany Blass, PA-C: A CASE OF AUTOIMMUNE PULMONARY ALVEOLAR PROTEINOSIS WITH UNDERLYING MONOCLONAL B-CELL LYMPHOCYTOSIS
Abigayle Sullivan, MD: BIRD FANCIER’S LUNG: AN UNDERDIAGNOSED CAUSE OF SHORTNESS OF BREATH
Nitin Gupta, DO: SUCCESSFUL EMERGENT CORONARY ARTERY BYPASS IN A WOMAN WITH POSTPARTUM SPONTANEOUS CORONARY ARTERY DISSECTION
Michelle Miles, DO: GI VARIANT OF LEMIERRE SYNDROME: COMPLETE OCCLUSION OF SUPERIOR MESENTERIC VEIN IN A 30-YEAR-OLD WITH APPENDICEAL ABSCESS
Adarsha Ojha, MD: BLEEDING LUNG AND BLOATING GUT: LANE HAMILTON SYNDROME
Abdul Siddiqui, MD: A CASE OF E-CIGARETTE OR VAPING PRODUCT USE-ASSOCIATED LUNG INJURY IN AN INFREQUENT VAPE USER
James Dugan, MD: EMPHYSEMA WITH PLACENTAL TRANSMOGRIFICATION AND LIPOMATOUS CHANGE
Daniel Condit, MD: DUPLICATE INFERIOR VENA CAVA AS A POTENTIAL PATHWAY FOR RECURRENT PULMONARY EMBOLISM
CHEST 2020 CHEST Challenge
1st Place
Case Western Reserve University (MetroHealth)
Enambir Josan, MD
Ishan Lalani, MD, MPH
Faisal Qadir, MD
Program Director: Ziad Shaman, MD, FCCP
2nd Place
SUNY Downstate
Suchit Khanijao, MD
Chetana Pendkar, MBBS
Ayla Zubair, MBBS
Program Director: Robert Foronjy, MD
3rd Place
NYP Brooklyn Methodist Hospital
John Gorski, MD
Sandi Khin, MD
Kinjal Patel, MD
Program Director: Anthony Saleh, MD, FCCP
ANNUAL AWARDS
Master FCCP
Nancy A. Collop MD, Master FCCP
College Medalist Award
Neil R. MacIntyre, MD, FCCP
Distinguished Service Award
Lisa K. Moores, MD, FCCP
Master Clinician Educator
William F. Kelly, MD, FCCP
David A. Schulman, MD, MPH, FCCP
Early Career Clinician Educator
Subani Chandra, MD, FCCP
Alfred Soffer Award for Editorial Excellence
Barbara Anderson, CHEST Staff
Laura Lipsey, CHEST Staff
Presidential Citation
Mangala Narasimhan, DO, FCCP
Renli Qiao, MD, PhD, FCCP
HONOR LECTURE AND MEMORIAL AWARDS
Edward C. Rosenow III, MD, Master FCCP/Master Teacher Endowed Honor Lecture Evolving Therapies in ANCA-Associated Vasculitides
Joseph P. Lynch, III, MD, FCCP
The lecture is generously funded by the CHEST Foundation.Distinguished Scientist Honor Lecture in Cardiopulmonary PhysiologyHelping the Dyspneic Patient: Clinical Physiology Matters!
Denis E. O’Donnell, MD, MBBCh, FCCP
The lecture is generously funded by the CHEST Foundation.Presidential Honor LectureCOPD Management: We’ve Come So Far
Darcy D. Marciniuk, MD, Master FCCP
Thomas L. Petty, MD, Master FCCP Memorial LectureReal World Research - What Would Dr. Petty Say?
Mary Hart, RRT, MS, FCCP
The lecture is generously funded by the CHEST Foundation.Margaret Pfrommer Endowed Memorial Lecture in Home-Based Mechanical VentilationNavigating to Home NIV Nirvana: What Would Margaret Do?
Peter C. Gay, MD, MS, FCCP
The Margaret Pfrommer Endowed Memorial Lecture in Home-Based Mechanical Ventilation is generously supported by International Ventilator Users Network of Post-Polio Health International and the CHEST Foundation.Pasquale Ciaglia Memorial Lecture in Interventional MedicineRaising the Bar: The Interventional Pulmonary Outcomes Group
Lonny B. Yarmus, DO, MBA, FCCP
The lecture is generously funded by the CHEST Foundation.
Roger C. Bone Memorial Lecture in Critical CareTo SIRS with Love: Dr. Roger Bone’s Continued Influence on Early Sepsis Care
Emanuel P. Rivers, MD, MPH, FCCP
The lecture is generously funded by the CHEST Foundation.Murray Kornfeld Memorial Founders LectureOur Pneumonia Journey: The Lungs and Beyond
Marcos I. Restrepo, MD, PhD, FCCP
The lecture is generously funded by the CHEST Foundation.
CHEST FOUNDATION GRANT AWARDS
The GlaxoSmithKline Distinguished Scholar in Respiratory Health
Deepa Gotur, MD, FCCP
Cytokine Release in SARS COV2 Viral Illness and Trends of Inflammasome Expression in Acute Respiratory Distress Syndrome Manifestations and ManagementThis grant is supported by an endowed fund from GlaxoSmithKline.CHEST Foundation and the Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency
Paul R. Ellis, MBChB
Cardiovascular Outcomes and Phenotypes in Pulmonary Exacerbations of Alpha-1 AntitrypsinThis grant is jointly supported by the CHEST Foundation and the Alpha-1 Foundation.CHEST Foundation Research Grant in Women’s Lung Health
Shannon E. Kay, MD
Sex-specific Gene Expression in AsthmaThis grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease
Davide Biondini, MD, PhD
Role of the Immune Check Points (CTLA-4 and PD-1) in the Development or Evasion of Smoking-Induced Chronic Obstructive Pulmonary Disease
Andrew J. Gangemi, MD
Are Sleep Health, Nicotine Metabolism, and Airway Inflammation Mechanisms for Differences in Lung Function between African American and Non-Hispanic White Smokers? A Proof-of-Concept ExaminationThese grants are supported by AstraZeneca LP.CHEST Foundation Research Grant in Critical Care
Mounica Vallurupalli, MD
Evaluating the Impact of Clonal Hematopoiesis on Host Immune Response During Sepsis
This grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Lung Cancer
Stefanie Mason, MD
Implications of Longitudinal Muscle-Mass Trajectories in Lung CancerThis grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Venous Thromboembolism
Jansen N. Seheult, MD, MBBCh
Untangling the NET: Neutrophil Activation as the Driver of Venous Thromboembolism in Coronavirus Disease 2019This grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Nontuberculous Mycobacteria Diseases
Bryan A. Garcia, MD
Longitudinal Proteomic Endotyping of Patients with Nontuberculous Mycobacterial Lung InfectionsThis grant is supported by Insmed Incorporated.CHEST Foundation Research Grant in Cystic Fibrosis
Jeffrey Barry, MD
Eosinophilia as a Biomarker for Worse Outcomes in Cystic Fibrosis
Kristina Montemayor, MD
The Association of Sex Hormones and Respiratory Morbidity in Individuals with Cystic FibrosisThese grants are supported by Vertex Pharmaceuticals.John R. Addrizzo, MD, FCCP Research Grant in Sarcoidosis
Changwan Ryu, MD
Extracellular Matrix Proteins as a Biomarker for Stage IV SarcoidosisThis grant is in honor of John R. Addrizzo, MD, FCCP and is jointly supported by the Addrizzo family and the CHEST Foundation.CHEST Foundation Research Grant in Severe Asthma
Isaretta L. Riley, MD, MPH
Coping with Asthma through Life Management (CALM)This grant is funded by AstraZeneca LP.CHEST Foundation Research Grant in Pulmonary Fibrosis
Sarah Beshay, MD
COPA Syndrome-Associated Mutations in Lung Transplant Recipients for Pulmonary Fibrosis
Erica D. Farrand, MD
The Future of Telehealth in Interstitial Lung DiseaseThese grants are supported by Boehringer Ingelheim Pharmaceuticals and Genentech, Inc.CHEST Foundation Research Grant in Sleep Medicine
Tetyana Kendzerska, MD, PhD
The Role of Sleep and Circadian Disturbances in Cancer Development and Progression: A Historical Multicenter Clinical Cohort Study
Nancy Stewart, DO
Improving COPD/OSA Overlap Syndrome Pre-Discharge Care DeliveryThese grants are funded by Jazz Pharmaceuticals, Inc.CHEST Foundation and Association of Critical Care Medicine Program Directors Award Research Grant in Medical Education
Ilana R. Krumm, MD
What’s good about Soul Food? Discovering and Analyzing Elements of an ICU Team Group Discussion Which Improve Provider WellnessThis grant is jointly supported by the CHEST Foundation and APCCMPD.CHEST Foundation and American Thoracic Society Research Grant in Diversity
Thomas S. Valley, MD, MSc
Understanding Differences in Delivery of Care Processes for Respiratory Failure by Race/EthnicityThis grant is jointly supported by the CHEST Foundation and ATS.CHEST Foundation Research Grant in COVID-19
David Furfaro, MD
Subphenotypes, Inflammatory Profiles, and Antibody Response in COVID-19 ARDSThis grant is supported by the CHEST Foundation.CHEST Foundation and American Thoracic Society Grant in COVID-19 and Diversity
Peter D. Jackson, MD
The Effect of the COVID-19 Pandemic on Tuberculosis Care in UgandaThis grant is jointly supported by the CHEST Foundation and ATS.CHEST Foundation Research Grant in Ultrasonography and COVID-19
Marjan M. Islam, MD
Thoracic Ultrasound in COVID-19: A Prospective Study Using Lung and Diaphragm Ultrasound in Evaluating Dyspnea in ICU Survivors with COVID-19 in a Post-ICU Clinic
Siddharth Dugar, MBBS
Spontaneous Echo Contrast in Lower Extremity and Correlation with Venous Velocity and Subsequent Deep Venous Thrombosis in Critically Ill COVID-19 PatientsThis grant is jointly supported by the CHEST Foundation and FUJIFILM SonoSite.
CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP
Ivan Nemorin, MBA, MS, RRT
Healthier Homes for Children-Community Asthma Prevention Program
Joseph Huang, MD
East Africa Training Initiative (EATI)
Aninda Das, MD, MBBS
Screening for Childhood Tuberculosis in Children 0-4 years of Age with Moderate to Severe Malnutrition in a Rural District of West Bengal, India
Trishual Siddharthan, MD
Establishing a Pulmonary and Critical Care Training Program in Uganda
Marina Lima, MD, MSc
Asmaland: The First Gamified Pediatric Asthma Educational Program in Portuguese
Roberta M. Kato, MD
Lung Power
These grants are supported by the CHEST Foundation.Alfred Soffer Research Award Winners
Mazen O. Al-Qadi, MD: RESPIRATORY VARIATION IN RIGHT ATRIAL PRESSURE PREDICTS RIGHT VENTRICULAR DYSFUNCTION IN PATIENTS WITH PRE-CAPILLARY PULMONARY HYPERTENSION
Valerie G. Press, MD: COST SAVING SIMULATION FOR THE TRANSITION FROM NEBULIZER TO COMBINATION OF NEBULIZER AND METERED-DOSE INHALERS (MD)
Young Investigator Award Winners
Gabriel E. Ortiz Jaimes, MD: CORRELATION OF CARDIAC OUTPUT MEASUREMENT BY GOAL-DIRECTED ECHOCARDIOGRAPHY PERFORMED BY INTENSIVISTS VS PULMONARY ARTERY CATHETER
Palakkumar Patel, MD: IMPACT OF HAVING PULMONARY HYPERTENSION IN PATIENTS ADMITTED WITH ACUTE EXACERBATION OF COPD IN THEIR HEALTHCARE UTILIZATION AND READMISSION: A US POPULATION COHORT STUDY
Top 5 Abstract Posters
Winner: Amr Alwakeel, MD: IMPACT OF A PLEURAL CARE PROGRAM ON THE PATHWAY TO DEFINITIVE PALLIATION OF MALIGNANT PLEURAL EFFUSIONS: A PRE-AND POST STUDY
Winner: Konstantinos Zorbas, MD: A SIMPLE PREDICTION SCORE FOR POSTOPERATIVE DEATH AFTER DECORTICATION
Winner: Yichen Wang, MD, MSc: CORONAVIRUS-RELATED HOSPITAL ADMISSIONS IN THE UNITED STATES IN 2016-2017
Runner up: Daniel Ospina-Delgado, MD: CHARACTERIZATION OF LARYNGEAL DISORDERS IN PATIENTS WITH EXCESSIVE CENTRAL AIRWAY COLLAPSE
Runner up: Vishal Vashistha, MD: TREATMENT PATTERNS AMONG LOWER-INCOME INDIAN PATIENTS WITH METASTATIC NON-SMALL CELL LUNG CANCER HARBORING EGFR MUTATIONS OR ALK REARRANGEMENTS
Case Report Poster Winners
Faiza Khalid, MD: FORME FUSTE OF INTERMEDIATE SYNDROME (IMS) IN ORGANOPHOSPHATE POISOING (OPP): EXPERT OPINION GUIDELINE WITHOUT CLEAR END-POINT.
William Meng, MD: VINGT MILLE LIEUES SOUS LES MERS: A POISONOUS GUEST FROM THE BLUE SEA TOXIC INHALATION OF CORAL PALYTOXIN
Dhruv Amratia, MD: PULMONARY BLASTOMA: A RARE FORM OF LUNG CANCER
Melinda Becker, MD: ECMO-ASSISTED BRONCHOSCOPY FOR NEAR-COMPLETE TRACHEAL OBSTRUCTION
Brittany Blass, PA-C: A CASE OF AUTOIMMUNE PULMONARY ALVEOLAR PROTEINOSIS WITH UNDERLYING MONOCLONAL B-CELL LYMPHOCYTOSIS
Abigayle Sullivan, MD: BIRD FANCIER’S LUNG: AN UNDERDIAGNOSED CAUSE OF SHORTNESS OF BREATH
Nitin Gupta, DO: SUCCESSFUL EMERGENT CORONARY ARTERY BYPASS IN A WOMAN WITH POSTPARTUM SPONTANEOUS CORONARY ARTERY DISSECTION
Michelle Miles, DO: GI VARIANT OF LEMIERRE SYNDROME: COMPLETE OCCLUSION OF SUPERIOR MESENTERIC VEIN IN A 30-YEAR-OLD WITH APPENDICEAL ABSCESS
Adarsha Ojha, MD: BLEEDING LUNG AND BLOATING GUT: LANE HAMILTON SYNDROME
Abdul Siddiqui, MD: A CASE OF E-CIGARETTE OR VAPING PRODUCT USE-ASSOCIATED LUNG INJURY IN AN INFREQUENT VAPE USER
James Dugan, MD: EMPHYSEMA WITH PLACENTAL TRANSMOGRIFICATION AND LIPOMATOUS CHANGE
Daniel Condit, MD: DUPLICATE INFERIOR VENA CAVA AS A POTENTIAL PATHWAY FOR RECURRENT PULMONARY EMBOLISM
CHEST 2020 CHEST Challenge
1st Place
Case Western Reserve University (MetroHealth)
Enambir Josan, MD
Ishan Lalani, MD, MPH
Faisal Qadir, MD
Program Director: Ziad Shaman, MD, FCCP
2nd Place
SUNY Downstate
Suchit Khanijao, MD
Chetana Pendkar, MBBS
Ayla Zubair, MBBS
Program Director: Robert Foronjy, MD
3rd Place
NYP Brooklyn Methodist Hospital
John Gorski, MD
Sandi Khin, MD
Kinjal Patel, MD
Program Director: Anthony Saleh, MD, FCCP
ANNUAL AWARDS
Master FCCP
Nancy A. Collop MD, Master FCCP
College Medalist Award
Neil R. MacIntyre, MD, FCCP
Distinguished Service Award
Lisa K. Moores, MD, FCCP
Master Clinician Educator
William F. Kelly, MD, FCCP
David A. Schulman, MD, MPH, FCCP
Early Career Clinician Educator
Subani Chandra, MD, FCCP
Alfred Soffer Award for Editorial Excellence
Barbara Anderson, CHEST Staff
Laura Lipsey, CHEST Staff
Presidential Citation
Mangala Narasimhan, DO, FCCP
Renli Qiao, MD, PhD, FCCP
HONOR LECTURE AND MEMORIAL AWARDS
Edward C. Rosenow III, MD, Master FCCP/Master Teacher Endowed Honor Lecture Evolving Therapies in ANCA-Associated Vasculitides
Joseph P. Lynch, III, MD, FCCP
The lecture is generously funded by the CHEST Foundation.Distinguished Scientist Honor Lecture in Cardiopulmonary PhysiologyHelping the Dyspneic Patient: Clinical Physiology Matters!
Denis E. O’Donnell, MD, MBBCh, FCCP
The lecture is generously funded by the CHEST Foundation.Presidential Honor LectureCOPD Management: We’ve Come So Far
Darcy D. Marciniuk, MD, Master FCCP
Thomas L. Petty, MD, Master FCCP Memorial LectureReal World Research - What Would Dr. Petty Say?
Mary Hart, RRT, MS, FCCP
The lecture is generously funded by the CHEST Foundation.Margaret Pfrommer Endowed Memorial Lecture in Home-Based Mechanical VentilationNavigating to Home NIV Nirvana: What Would Margaret Do?
Peter C. Gay, MD, MS, FCCP
The Margaret Pfrommer Endowed Memorial Lecture in Home-Based Mechanical Ventilation is generously supported by International Ventilator Users Network of Post-Polio Health International and the CHEST Foundation.Pasquale Ciaglia Memorial Lecture in Interventional MedicineRaising the Bar: The Interventional Pulmonary Outcomes Group
Lonny B. Yarmus, DO, MBA, FCCP
The lecture is generously funded by the CHEST Foundation.
Roger C. Bone Memorial Lecture in Critical CareTo SIRS with Love: Dr. Roger Bone’s Continued Influence on Early Sepsis Care
Emanuel P. Rivers, MD, MPH, FCCP
The lecture is generously funded by the CHEST Foundation.Murray Kornfeld Memorial Founders LectureOur Pneumonia Journey: The Lungs and Beyond
Marcos I. Restrepo, MD, PhD, FCCP
The lecture is generously funded by the CHEST Foundation.
CHEST FOUNDATION GRANT AWARDS
The GlaxoSmithKline Distinguished Scholar in Respiratory Health
Deepa Gotur, MD, FCCP
Cytokine Release in SARS COV2 Viral Illness and Trends of Inflammasome Expression in Acute Respiratory Distress Syndrome Manifestations and ManagementThis grant is supported by an endowed fund from GlaxoSmithKline.CHEST Foundation and the Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency
Paul R. Ellis, MBChB
Cardiovascular Outcomes and Phenotypes in Pulmonary Exacerbations of Alpha-1 AntitrypsinThis grant is jointly supported by the CHEST Foundation and the Alpha-1 Foundation.CHEST Foundation Research Grant in Women’s Lung Health
Shannon E. Kay, MD
Sex-specific Gene Expression in AsthmaThis grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease
Davide Biondini, MD, PhD
Role of the Immune Check Points (CTLA-4 and PD-1) in the Development or Evasion of Smoking-Induced Chronic Obstructive Pulmonary Disease
Andrew J. Gangemi, MD
Are Sleep Health, Nicotine Metabolism, and Airway Inflammation Mechanisms for Differences in Lung Function between African American and Non-Hispanic White Smokers? A Proof-of-Concept ExaminationThese grants are supported by AstraZeneca LP.CHEST Foundation Research Grant in Critical Care
Mounica Vallurupalli, MD
Evaluating the Impact of Clonal Hematopoiesis on Host Immune Response During Sepsis
This grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Lung Cancer
Stefanie Mason, MD
Implications of Longitudinal Muscle-Mass Trajectories in Lung CancerThis grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Venous Thromboembolism
Jansen N. Seheult, MD, MBBCh
Untangling the NET: Neutrophil Activation as the Driver of Venous Thromboembolism in Coronavirus Disease 2019This grant is supported by the CHEST Foundation.CHEST Foundation Research Grant in Nontuberculous Mycobacteria Diseases
Bryan A. Garcia, MD
Longitudinal Proteomic Endotyping of Patients with Nontuberculous Mycobacterial Lung InfectionsThis grant is supported by Insmed Incorporated.CHEST Foundation Research Grant in Cystic Fibrosis
Jeffrey Barry, MD
Eosinophilia as a Biomarker for Worse Outcomes in Cystic Fibrosis
Kristina Montemayor, MD
The Association of Sex Hormones and Respiratory Morbidity in Individuals with Cystic FibrosisThese grants are supported by Vertex Pharmaceuticals.John R. Addrizzo, MD, FCCP Research Grant in Sarcoidosis
Changwan Ryu, MD
Extracellular Matrix Proteins as a Biomarker for Stage IV SarcoidosisThis grant is in honor of John R. Addrizzo, MD, FCCP and is jointly supported by the Addrizzo family and the CHEST Foundation.CHEST Foundation Research Grant in Severe Asthma
Isaretta L. Riley, MD, MPH
Coping with Asthma through Life Management (CALM)This grant is funded by AstraZeneca LP.CHEST Foundation Research Grant in Pulmonary Fibrosis
Sarah Beshay, MD
COPA Syndrome-Associated Mutations in Lung Transplant Recipients for Pulmonary Fibrosis
Erica D. Farrand, MD
The Future of Telehealth in Interstitial Lung DiseaseThese grants are supported by Boehringer Ingelheim Pharmaceuticals and Genentech, Inc.CHEST Foundation Research Grant in Sleep Medicine
Tetyana Kendzerska, MD, PhD
The Role of Sleep and Circadian Disturbances in Cancer Development and Progression: A Historical Multicenter Clinical Cohort Study
Nancy Stewart, DO
Improving COPD/OSA Overlap Syndrome Pre-Discharge Care DeliveryThese grants are funded by Jazz Pharmaceuticals, Inc.CHEST Foundation and Association of Critical Care Medicine Program Directors Award Research Grant in Medical Education
Ilana R. Krumm, MD
What’s good about Soul Food? Discovering and Analyzing Elements of an ICU Team Group Discussion Which Improve Provider WellnessThis grant is jointly supported by the CHEST Foundation and APCCMPD.CHEST Foundation and American Thoracic Society Research Grant in Diversity
Thomas S. Valley, MD, MSc
Understanding Differences in Delivery of Care Processes for Respiratory Failure by Race/EthnicityThis grant is jointly supported by the CHEST Foundation and ATS.CHEST Foundation Research Grant in COVID-19
David Furfaro, MD
Subphenotypes, Inflammatory Profiles, and Antibody Response in COVID-19 ARDSThis grant is supported by the CHEST Foundation.CHEST Foundation and American Thoracic Society Grant in COVID-19 and Diversity
Peter D. Jackson, MD
The Effect of the COVID-19 Pandemic on Tuberculosis Care in UgandaThis grant is jointly supported by the CHEST Foundation and ATS.CHEST Foundation Research Grant in Ultrasonography and COVID-19
Marjan M. Islam, MD
Thoracic Ultrasound in COVID-19: A Prospective Study Using Lung and Diaphragm Ultrasound in Evaluating Dyspnea in ICU Survivors with COVID-19 in a Post-ICU Clinic
Siddharth Dugar, MBBS
Spontaneous Echo Contrast in Lower Extremity and Correlation with Venous Velocity and Subsequent Deep Venous Thrombosis in Critically Ill COVID-19 PatientsThis grant is jointly supported by the CHEST Foundation and FUJIFILM SonoSite.
CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP
Ivan Nemorin, MBA, MS, RRT
Healthier Homes for Children-Community Asthma Prevention Program
Joseph Huang, MD
East Africa Training Initiative (EATI)
Aninda Das, MD, MBBS
Screening for Childhood Tuberculosis in Children 0-4 years of Age with Moderate to Severe Malnutrition in a Rural District of West Bengal, India
Trishual Siddharthan, MD
Establishing a Pulmonary and Critical Care Training Program in Uganda
Marina Lima, MD, MSc
Asmaland: The First Gamified Pediatric Asthma Educational Program in Portuguese
Roberta M. Kato, MD
Lung Power
These grants are supported by the CHEST Foundation.Alfred Soffer Research Award Winners
Mazen O. Al-Qadi, MD: RESPIRATORY VARIATION IN RIGHT ATRIAL PRESSURE PREDICTS RIGHT VENTRICULAR DYSFUNCTION IN PATIENTS WITH PRE-CAPILLARY PULMONARY HYPERTENSION
Valerie G. Press, MD: COST SAVING SIMULATION FOR THE TRANSITION FROM NEBULIZER TO COMBINATION OF NEBULIZER AND METERED-DOSE INHALERS (MD)
Young Investigator Award Winners
Gabriel E. Ortiz Jaimes, MD: CORRELATION OF CARDIAC OUTPUT MEASUREMENT BY GOAL-DIRECTED ECHOCARDIOGRAPHY PERFORMED BY INTENSIVISTS VS PULMONARY ARTERY CATHETER
Palakkumar Patel, MD: IMPACT OF HAVING PULMONARY HYPERTENSION IN PATIENTS ADMITTED WITH ACUTE EXACERBATION OF COPD IN THEIR HEALTHCARE UTILIZATION AND READMISSION: A US POPULATION COHORT STUDY
Top 5 Abstract Posters
Winner: Amr Alwakeel, MD: IMPACT OF A PLEURAL CARE PROGRAM ON THE PATHWAY TO DEFINITIVE PALLIATION OF MALIGNANT PLEURAL EFFUSIONS: A PRE-AND POST STUDY
Winner: Konstantinos Zorbas, MD: A SIMPLE PREDICTION SCORE FOR POSTOPERATIVE DEATH AFTER DECORTICATION
Winner: Yichen Wang, MD, MSc: CORONAVIRUS-RELATED HOSPITAL ADMISSIONS IN THE UNITED STATES IN 2016-2017
Runner up: Daniel Ospina-Delgado, MD: CHARACTERIZATION OF LARYNGEAL DISORDERS IN PATIENTS WITH EXCESSIVE CENTRAL AIRWAY COLLAPSE
Runner up: Vishal Vashistha, MD: TREATMENT PATTERNS AMONG LOWER-INCOME INDIAN PATIENTS WITH METASTATIC NON-SMALL CELL LUNG CANCER HARBORING EGFR MUTATIONS OR ALK REARRANGEMENTS
Case Report Poster Winners
Faiza Khalid, MD: FORME FUSTE OF INTERMEDIATE SYNDROME (IMS) IN ORGANOPHOSPHATE POISOING (OPP): EXPERT OPINION GUIDELINE WITHOUT CLEAR END-POINT.
William Meng, MD: VINGT MILLE LIEUES SOUS LES MERS: A POISONOUS GUEST FROM THE BLUE SEA TOXIC INHALATION OF CORAL PALYTOXIN
Dhruv Amratia, MD: PULMONARY BLASTOMA: A RARE FORM OF LUNG CANCER
Melinda Becker, MD: ECMO-ASSISTED BRONCHOSCOPY FOR NEAR-COMPLETE TRACHEAL OBSTRUCTION
Brittany Blass, PA-C: A CASE OF AUTOIMMUNE PULMONARY ALVEOLAR PROTEINOSIS WITH UNDERLYING MONOCLONAL B-CELL LYMPHOCYTOSIS
Abigayle Sullivan, MD: BIRD FANCIER’S LUNG: AN UNDERDIAGNOSED CAUSE OF SHORTNESS OF BREATH
Nitin Gupta, DO: SUCCESSFUL EMERGENT CORONARY ARTERY BYPASS IN A WOMAN WITH POSTPARTUM SPONTANEOUS CORONARY ARTERY DISSECTION
Michelle Miles, DO: GI VARIANT OF LEMIERRE SYNDROME: COMPLETE OCCLUSION OF SUPERIOR MESENTERIC VEIN IN A 30-YEAR-OLD WITH APPENDICEAL ABSCESS
Adarsha Ojha, MD: BLEEDING LUNG AND BLOATING GUT: LANE HAMILTON SYNDROME
Abdul Siddiqui, MD: A CASE OF E-CIGARETTE OR VAPING PRODUCT USE-ASSOCIATED LUNG INJURY IN AN INFREQUENT VAPE USER
James Dugan, MD: EMPHYSEMA WITH PLACENTAL TRANSMOGRIFICATION AND LIPOMATOUS CHANGE
Daniel Condit, MD: DUPLICATE INFERIOR VENA CAVA AS A POTENTIAL PATHWAY FOR RECURRENT PULMONARY EMBOLISM
CHEST 2020 CHEST Challenge
1st Place
Case Western Reserve University (MetroHealth)
Enambir Josan, MD
Ishan Lalani, MD, MPH
Faisal Qadir, MD
Program Director: Ziad Shaman, MD, FCCP
2nd Place
SUNY Downstate
Suchit Khanijao, MD
Chetana Pendkar, MBBS
Ayla Zubair, MBBS
Program Director: Robert Foronjy, MD
3rd Place
NYP Brooklyn Methodist Hospital
John Gorski, MD
Sandi Khin, MD
Kinjal Patel, MD
Program Director: Anthony Saleh, MD, FCCP
CHEST Foundation vision for 2021 and beyond
In the year of COVID-19, we saw unprecedented changes in our environment and social interactions. Almost nothing was as it should be—sports championships in a “bubble,” social distancing, limited travel, economic hardships, and, of course, the devastating effects on the health of people all over the world. CHEST did not shy away from the challenges of COVID-19. Instead, we accelerated our focus on education, patient care, research, and advocacy to assist clinicians caring for affected patients. The CHEST Foundation, the philanthropic arm of CHEST, contributed to this effort by funding research and community service grants and distributing over 14,000 pieces of PPE to health workers and the public.
Amid social protests, CHEST issued statements supporting inclusion and diversity and called for improving health care disparities. To better understand how these important issues interact, the CHEST Foundation began conducting listening tours across the country
to learn what is important to patients and what barriers they face. These lessons will influence how the foundation implements its current programs and designs future programs. Over the next few months, the CHEST Foundation will set in motion a course of action to support valuable programs in these areas. We will focus on three main themes.
First, we will utilize the strength of CHEST by inviting fellows to participate in CHEST Foundation activities and serve on our committees. By creating an atmosphere of inclusion and collegiality, we believe that fellows will better understand the CHEST Foundation’s goals and commit themselves to strengthening the foundation for years to come.
Second, we want to establish relationships with organizations outside of CHEST. Although our partnerships with health care industry organizations are strong, we have few robust alliances in the non-endemic space. Corporations espouse wellness, and we have experts all over the world who can address the needs and concerns of these companies. Preliminary exploration tells us that non-endemic corporations have an interest in what we can offer.
Third, we want to grow the corpus of the CHEST Foundation. Dreams without funding become only aspirations, but dreams with funding become reality. Without a solid corpus, we operate on a short-term plan. CHEST has some of the most influential leaders in the fields of pulmonary, critical care, and sleep medicine. Together, we can develop programs that can significantly impact the lives of the people we serve.
The CHEST Foundation looks forward to building on past successes and tackling new challenges. On behalf of CHEST’s Board of Trustees and the gifted staff, I invite you to join us to reach these goals.
In the year of COVID-19, we saw unprecedented changes in our environment and social interactions. Almost nothing was as it should be—sports championships in a “bubble,” social distancing, limited travel, economic hardships, and, of course, the devastating effects on the health of people all over the world. CHEST did not shy away from the challenges of COVID-19. Instead, we accelerated our focus on education, patient care, research, and advocacy to assist clinicians caring for affected patients. The CHEST Foundation, the philanthropic arm of CHEST, contributed to this effort by funding research and community service grants and distributing over 14,000 pieces of PPE to health workers and the public.
Amid social protests, CHEST issued statements supporting inclusion and diversity and called for improving health care disparities. To better understand how these important issues interact, the CHEST Foundation began conducting listening tours across the country
to learn what is important to patients and what barriers they face. These lessons will influence how the foundation implements its current programs and designs future programs. Over the next few months, the CHEST Foundation will set in motion a course of action to support valuable programs in these areas. We will focus on three main themes.
First, we will utilize the strength of CHEST by inviting fellows to participate in CHEST Foundation activities and serve on our committees. By creating an atmosphere of inclusion and collegiality, we believe that fellows will better understand the CHEST Foundation’s goals and commit themselves to strengthening the foundation for years to come.
Second, we want to establish relationships with organizations outside of CHEST. Although our partnerships with health care industry organizations are strong, we have few robust alliances in the non-endemic space. Corporations espouse wellness, and we have experts all over the world who can address the needs and concerns of these companies. Preliminary exploration tells us that non-endemic corporations have an interest in what we can offer.
Third, we want to grow the corpus of the CHEST Foundation. Dreams without funding become only aspirations, but dreams with funding become reality. Without a solid corpus, we operate on a short-term plan. CHEST has some of the most influential leaders in the fields of pulmonary, critical care, and sleep medicine. Together, we can develop programs that can significantly impact the lives of the people we serve.
The CHEST Foundation looks forward to building on past successes and tackling new challenges. On behalf of CHEST’s Board of Trustees and the gifted staff, I invite you to join us to reach these goals.
In the year of COVID-19, we saw unprecedented changes in our environment and social interactions. Almost nothing was as it should be—sports championships in a “bubble,” social distancing, limited travel, economic hardships, and, of course, the devastating effects on the health of people all over the world. CHEST did not shy away from the challenges of COVID-19. Instead, we accelerated our focus on education, patient care, research, and advocacy to assist clinicians caring for affected patients. The CHEST Foundation, the philanthropic arm of CHEST, contributed to this effort by funding research and community service grants and distributing over 14,000 pieces of PPE to health workers and the public.
Amid social protests, CHEST issued statements supporting inclusion and diversity and called for improving health care disparities. To better understand how these important issues interact, the CHEST Foundation began conducting listening tours across the country
to learn what is important to patients and what barriers they face. These lessons will influence how the foundation implements its current programs and designs future programs. Over the next few months, the CHEST Foundation will set in motion a course of action to support valuable programs in these areas. We will focus on three main themes.
First, we will utilize the strength of CHEST by inviting fellows to participate in CHEST Foundation activities and serve on our committees. By creating an atmosphere of inclusion and collegiality, we believe that fellows will better understand the CHEST Foundation’s goals and commit themselves to strengthening the foundation for years to come.
Second, we want to establish relationships with organizations outside of CHEST. Although our partnerships with health care industry organizations are strong, we have few robust alliances in the non-endemic space. Corporations espouse wellness, and we have experts all over the world who can address the needs and concerns of these companies. Preliminary exploration tells us that non-endemic corporations have an interest in what we can offer.
Third, we want to grow the corpus of the CHEST Foundation. Dreams without funding become only aspirations, but dreams with funding become reality. Without a solid corpus, we operate on a short-term plan. CHEST has some of the most influential leaders in the fields of pulmonary, critical care, and sleep medicine. Together, we can develop programs that can significantly impact the lives of the people we serve.
The CHEST Foundation looks forward to building on past successes and tackling new challenges. On behalf of CHEST’s Board of Trustees and the gifted staff, I invite you to join us to reach these goals.
Bronchiolitis: Rare diseases, diagnostic challenges, and few proven therapies
What’s in a name?
Bronchiolitis, a group of diseases also referred to as “small airways diseases,” is characterized by inflammation and/or fibrosis in airways less than 2 mm in diameter. In pediatric patients, it is most commonly related to acute viral infections, while in adults, it is often associated with chronic diseases. Bronchiolitis is a well-recognized complication in a significant number of patients who have undergone lung or stem cell transplantation. Common associations also include connective tissue diseases, environmental or occupational inhalation exposures, aspiration, drug toxicity, and infections. Diagnosing bronchiolitis can be challenging for clinicians, and few treatment options exist apart from treating identifiable underlying etiologies. More research is needed into noninvasive diagnostic techniques and treatment modalities.
The terminology used to describe bronchiolitis has evolved over time. Bronchiolitis is now used to describe conditions where the primary pathologic condition is damage to the bronchiolar epithelium not attributable to a larger parenchymal disease (such as hypersensitivity pneumonitis). This change in nomenclature explains why the condition formerly known as “bronchiolitis obliterans organizing pneumonia” (BOOP) is now simply recognized as “organizing pneumonia.” Despite several proposed classification schemes focusing on histopathology, there is no consensus regarding the different subtypes of bronchiolitis, leading to confusion in some cases. Recently, authors have attempted to distinguish cases based on three main histologic patterns (Urisman A, et al. Surg Pathol Clin. 2020;13[1]:189).
- Obliterative/constrictive bronchiolitis (OB) – the terms “obliterative” and “constrictive” are used interchangeably throughout pulmonary literature. It is characterized by fibroblast-rich tissue accumulation in the sub-epithelium of bronchioles leading to progressive narrowing of the lumen. In addition to the transplant setting, it is often seen in patients with rheumatoid arthritis or other connective tissue diseases, inhalational exposures, or acute respiratory infections. More recently, clinicians have recognized diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) as a rare condition causing OB with potentially effective treatment.
- Follicular bronchiolitis (FB) – features peribronchiolar inflammation with subepithelial lymphoid deposits leading to luminal obstruction. FB is chiefly associated with conditions of impaired immunity or chronic airway infection, such as autoimmune connective tissues diseases (especially rheumatoid arthritis and Sjogren’s), severe combined immunodeficiency, HIV, cystic fibrosis, and primary ciliary dyskinesia.
- Diffuse panbronchiolitis (DBP) – features bilateral bronchiolar lesions with lymphocytic inflammation of the bronchiolar wall, as well as peribronchiolar inflammation and accumulation of interstitial foamy macrophages. Patients afflicted with DBP may suffer repeated bacterial colonization or infection. There is a higher prevalence of DBP in Asia where it was first identified in the 1960s, potentially due to several HLA alleles that are more common in Asia.
In addition to the above terminology, the transplant-setting diagnosis “bronchiolitis obliterans syndrome” (BOS) is used to denote progressive obstructive lung disease for which there is not another cause aside from chronic graft rejection. For these patients, clinicians assume the underlying disease entity is OB, but they often lack histopathologic confirmation.
Diagnosis is challenging
Symptoms of bronchiolitis are typically dyspnea and cough, and patients may often be diagnosed with asthma or COPD initially. Pulmonary function testing may show signs of obstruction, restriction, or mixed disease with or without a reduction in Dlco. Chest radiography often appears normal, but high-resolution CT may show expiratory air trapping and centrilobular nodules. Advanced imaging modalities may augment or replace CT imaging in diagnosing bronchiolitis: investigators are evaluating pulmonary MRI and fluoroscopy with computerized ventilation analysis in clinical trials (NCT04080232).
Currently, open or thoracoscopic lung biopsy is typically required to make a definitive diagnosis. Because bronchiolitis is a patchy and heterogeneous process, transbronchial biopsy may provide insufficient yield, with a sensitivity of 29% to 70% reported in lung transplant literature (Urisman A, et al. Surg Pathol Clin. 2020;13[1]:189).
Recent studies have demonstrated transbronchial cryobiopsy to be a promising alternative to surgical biopsy, owing to larger tissue samples than conventional transbronchial lung biopsies. For example, in a recent case series four patients underwent transbronchial cryobiopsy. The procedure yielded adequate tissue for diagnosis of a chronic bronchiolitis in each case (Yamakawa H, et al. Internal Med Advance Publication. doi: 10.2169/internalmedicine.6028-20.
Treatment options are growing
Evidence for treatment of bronchiolitis remains limited. Options are extrapolated from lung transplant patients, where incidence of BOS ranges from 50% at 5 years to 76% at 10 years post transplant. Guidelines recommend a 3-month minimum trial of azithromycin, which has been shown to slow or reverse decline of lung function in some patients. Modification of immunosuppression is also recommended. In patients who have continued lung function decline, a systematic review concluded that extracorporeal photopheresis had the most robust evidence for efficacy with stabilized lung function and improved overall survival (Benden C, et al. J Heart Lung Transplant. 2017;36[9]:921). Other salvage therapies that have lower-quality evidence of benefit include total lymphoid irradiation, montelukast, and aerosolized cyclosporine.
In patients who have undergone hematopoietic stem cell transplant, steroids are typically the first line treatment for OB as it is thought to be a form of chronic graft-vs-host disease (GVHD). Ruxolitinib, a selective JAK1/2 inhibitor, demonstrated significant improvement overall in patients with steroid-refractory acute GVHD in a recent randomized clinical trial, although the trial did not examine its effect on pulmonary manifestations (Zeiser R, et al. N Engl J Med. 2020;382[19]:1800). To date, retrospective observational studies of ruxolitinib in patients with lung GVHD have shown conflicting results regarding benefit. Investigators are currently studying ruxolitinib in a phase II trial for patients with BOS following stem cell transplant (NCT03674047).
DIPNECH is unique from other bronchiolitis entities, as small airways dysfunction develops as a result of neuroendocrine cell proliferation in the airway mucosa, ultimately leading to bronchial narrowing. It most commonly presents in middle-aged nonsmoking women with years of chronic cough and dyspnea. While it has an indolent course in many patients, some patients develop progressive symptoms and obstructive lung disease. DIPNECH is considered a precursor to other pulmonary neuroendocrine tumors. The lesions demonstrate somatostatin receptor expression in many cases, prompting the use of somatostatin analogues as treatment. In the largest published case series, 42 patients from three different institutions were identified who were treated with somatostatin analogues for a mean of 38.8 months at the time of review. Symptomatic improvement was seen in 33 of the 42 (79%), and of the 15 with posttreatment PFT data, 14 (93%) showed improvement in PFTs (Al-Toubah, T, et al. Chest. 2020;158[1]:401). Other small studies have demonstrated varying results with symptomatic improvement in 29% to 76% of patients and improvement or stability of PFTs in 50% to 100% of patients (Samhouri BF, et al. ERJ Open Res. 2020;6[4]:527).
For patients who have not undergone lung transplant, and who do not have an identifiable exposure or underlying rheumatologic condition, a similar 3-month minimum trial of macrolide antibiotics is reasonable. Macrolides have been shown to double long-term survival rates to over 90% in patients with DPB. Evidence in this patient population is quite limited, and further research is needed to determine effective therapies for patients.
What’s next for bronchiolitis
While clinicians currently have few tools for diagnosing and treating these uncommon diseases, in the coming years, we should learn whether novel imaging modalities or less invasive procedures can aid in the diagnosis. Physicians hope these advances will preclude the need for invasive biopsies in more patients going forward. We should also learn whether newer, targeted agents like ruxolitinib are effective for BOS in patients with stem cell transplant. If so, this finding may open it and similar agents to investigation in other forms of bronchiolitis.
Dr. Poole and Dr. Callahan are with University of Utah Health, Salt Lake City, Utah.
What’s in a name?
Bronchiolitis, a group of diseases also referred to as “small airways diseases,” is characterized by inflammation and/or fibrosis in airways less than 2 mm in diameter. In pediatric patients, it is most commonly related to acute viral infections, while in adults, it is often associated with chronic diseases. Bronchiolitis is a well-recognized complication in a significant number of patients who have undergone lung or stem cell transplantation. Common associations also include connective tissue diseases, environmental or occupational inhalation exposures, aspiration, drug toxicity, and infections. Diagnosing bronchiolitis can be challenging for clinicians, and few treatment options exist apart from treating identifiable underlying etiologies. More research is needed into noninvasive diagnostic techniques and treatment modalities.
The terminology used to describe bronchiolitis has evolved over time. Bronchiolitis is now used to describe conditions where the primary pathologic condition is damage to the bronchiolar epithelium not attributable to a larger parenchymal disease (such as hypersensitivity pneumonitis). This change in nomenclature explains why the condition formerly known as “bronchiolitis obliterans organizing pneumonia” (BOOP) is now simply recognized as “organizing pneumonia.” Despite several proposed classification schemes focusing on histopathology, there is no consensus regarding the different subtypes of bronchiolitis, leading to confusion in some cases. Recently, authors have attempted to distinguish cases based on three main histologic patterns (Urisman A, et al. Surg Pathol Clin. 2020;13[1]:189).
- Obliterative/constrictive bronchiolitis (OB) – the terms “obliterative” and “constrictive” are used interchangeably throughout pulmonary literature. It is characterized by fibroblast-rich tissue accumulation in the sub-epithelium of bronchioles leading to progressive narrowing of the lumen. In addition to the transplant setting, it is often seen in patients with rheumatoid arthritis or other connective tissue diseases, inhalational exposures, or acute respiratory infections. More recently, clinicians have recognized diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) as a rare condition causing OB with potentially effective treatment.
- Follicular bronchiolitis (FB) – features peribronchiolar inflammation with subepithelial lymphoid deposits leading to luminal obstruction. FB is chiefly associated with conditions of impaired immunity or chronic airway infection, such as autoimmune connective tissues diseases (especially rheumatoid arthritis and Sjogren’s), severe combined immunodeficiency, HIV, cystic fibrosis, and primary ciliary dyskinesia.
- Diffuse panbronchiolitis (DBP) – features bilateral bronchiolar lesions with lymphocytic inflammation of the bronchiolar wall, as well as peribronchiolar inflammation and accumulation of interstitial foamy macrophages. Patients afflicted with DBP may suffer repeated bacterial colonization or infection. There is a higher prevalence of DBP in Asia where it was first identified in the 1960s, potentially due to several HLA alleles that are more common in Asia.
In addition to the above terminology, the transplant-setting diagnosis “bronchiolitis obliterans syndrome” (BOS) is used to denote progressive obstructive lung disease for which there is not another cause aside from chronic graft rejection. For these patients, clinicians assume the underlying disease entity is OB, but they often lack histopathologic confirmation.
Diagnosis is challenging
Symptoms of bronchiolitis are typically dyspnea and cough, and patients may often be diagnosed with asthma or COPD initially. Pulmonary function testing may show signs of obstruction, restriction, or mixed disease with or without a reduction in Dlco. Chest radiography often appears normal, but high-resolution CT may show expiratory air trapping and centrilobular nodules. Advanced imaging modalities may augment or replace CT imaging in diagnosing bronchiolitis: investigators are evaluating pulmonary MRI and fluoroscopy with computerized ventilation analysis in clinical trials (NCT04080232).
Currently, open or thoracoscopic lung biopsy is typically required to make a definitive diagnosis. Because bronchiolitis is a patchy and heterogeneous process, transbronchial biopsy may provide insufficient yield, with a sensitivity of 29% to 70% reported in lung transplant literature (Urisman A, et al. Surg Pathol Clin. 2020;13[1]:189).
Recent studies have demonstrated transbronchial cryobiopsy to be a promising alternative to surgical biopsy, owing to larger tissue samples than conventional transbronchial lung biopsies. For example, in a recent case series four patients underwent transbronchial cryobiopsy. The procedure yielded adequate tissue for diagnosis of a chronic bronchiolitis in each case (Yamakawa H, et al. Internal Med Advance Publication. doi: 10.2169/internalmedicine.6028-20.
Treatment options are growing
Evidence for treatment of bronchiolitis remains limited. Options are extrapolated from lung transplant patients, where incidence of BOS ranges from 50% at 5 years to 76% at 10 years post transplant. Guidelines recommend a 3-month minimum trial of azithromycin, which has been shown to slow or reverse decline of lung function in some patients. Modification of immunosuppression is also recommended. In patients who have continued lung function decline, a systematic review concluded that extracorporeal photopheresis had the most robust evidence for efficacy with stabilized lung function and improved overall survival (Benden C, et al. J Heart Lung Transplant. 2017;36[9]:921). Other salvage therapies that have lower-quality evidence of benefit include total lymphoid irradiation, montelukast, and aerosolized cyclosporine.
In patients who have undergone hematopoietic stem cell transplant, steroids are typically the first line treatment for OB as it is thought to be a form of chronic graft-vs-host disease (GVHD). Ruxolitinib, a selective JAK1/2 inhibitor, demonstrated significant improvement overall in patients with steroid-refractory acute GVHD in a recent randomized clinical trial, although the trial did not examine its effect on pulmonary manifestations (Zeiser R, et al. N Engl J Med. 2020;382[19]:1800). To date, retrospective observational studies of ruxolitinib in patients with lung GVHD have shown conflicting results regarding benefit. Investigators are currently studying ruxolitinib in a phase II trial for patients with BOS following stem cell transplant (NCT03674047).
DIPNECH is unique from other bronchiolitis entities, as small airways dysfunction develops as a result of neuroendocrine cell proliferation in the airway mucosa, ultimately leading to bronchial narrowing. It most commonly presents in middle-aged nonsmoking women with years of chronic cough and dyspnea. While it has an indolent course in many patients, some patients develop progressive symptoms and obstructive lung disease. DIPNECH is considered a precursor to other pulmonary neuroendocrine tumors. The lesions demonstrate somatostatin receptor expression in many cases, prompting the use of somatostatin analogues as treatment. In the largest published case series, 42 patients from three different institutions were identified who were treated with somatostatin analogues for a mean of 38.8 months at the time of review. Symptomatic improvement was seen in 33 of the 42 (79%), and of the 15 with posttreatment PFT data, 14 (93%) showed improvement in PFTs (Al-Toubah, T, et al. Chest. 2020;158[1]:401). Other small studies have demonstrated varying results with symptomatic improvement in 29% to 76% of patients and improvement or stability of PFTs in 50% to 100% of patients (Samhouri BF, et al. ERJ Open Res. 2020;6[4]:527).
For patients who have not undergone lung transplant, and who do not have an identifiable exposure or underlying rheumatologic condition, a similar 3-month minimum trial of macrolide antibiotics is reasonable. Macrolides have been shown to double long-term survival rates to over 90% in patients with DPB. Evidence in this patient population is quite limited, and further research is needed to determine effective therapies for patients.
What’s next for bronchiolitis
While clinicians currently have few tools for diagnosing and treating these uncommon diseases, in the coming years, we should learn whether novel imaging modalities or less invasive procedures can aid in the diagnosis. Physicians hope these advances will preclude the need for invasive biopsies in more patients going forward. We should also learn whether newer, targeted agents like ruxolitinib are effective for BOS in patients with stem cell transplant. If so, this finding may open it and similar agents to investigation in other forms of bronchiolitis.
Dr. Poole and Dr. Callahan are with University of Utah Health, Salt Lake City, Utah.
What’s in a name?
Bronchiolitis, a group of diseases also referred to as “small airways diseases,” is characterized by inflammation and/or fibrosis in airways less than 2 mm in diameter. In pediatric patients, it is most commonly related to acute viral infections, while in adults, it is often associated with chronic diseases. Bronchiolitis is a well-recognized complication in a significant number of patients who have undergone lung or stem cell transplantation. Common associations also include connective tissue diseases, environmental or occupational inhalation exposures, aspiration, drug toxicity, and infections. Diagnosing bronchiolitis can be challenging for clinicians, and few treatment options exist apart from treating identifiable underlying etiologies. More research is needed into noninvasive diagnostic techniques and treatment modalities.
The terminology used to describe bronchiolitis has evolved over time. Bronchiolitis is now used to describe conditions where the primary pathologic condition is damage to the bronchiolar epithelium not attributable to a larger parenchymal disease (such as hypersensitivity pneumonitis). This change in nomenclature explains why the condition formerly known as “bronchiolitis obliterans organizing pneumonia” (BOOP) is now simply recognized as “organizing pneumonia.” Despite several proposed classification schemes focusing on histopathology, there is no consensus regarding the different subtypes of bronchiolitis, leading to confusion in some cases. Recently, authors have attempted to distinguish cases based on three main histologic patterns (Urisman A, et al. Surg Pathol Clin. 2020;13[1]:189).
- Obliterative/constrictive bronchiolitis (OB) – the terms “obliterative” and “constrictive” are used interchangeably throughout pulmonary literature. It is characterized by fibroblast-rich tissue accumulation in the sub-epithelium of bronchioles leading to progressive narrowing of the lumen. In addition to the transplant setting, it is often seen in patients with rheumatoid arthritis or other connective tissue diseases, inhalational exposures, or acute respiratory infections. More recently, clinicians have recognized diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) as a rare condition causing OB with potentially effective treatment.
- Follicular bronchiolitis (FB) – features peribronchiolar inflammation with subepithelial lymphoid deposits leading to luminal obstruction. FB is chiefly associated with conditions of impaired immunity or chronic airway infection, such as autoimmune connective tissues diseases (especially rheumatoid arthritis and Sjogren’s), severe combined immunodeficiency, HIV, cystic fibrosis, and primary ciliary dyskinesia.
- Diffuse panbronchiolitis (DBP) – features bilateral bronchiolar lesions with lymphocytic inflammation of the bronchiolar wall, as well as peribronchiolar inflammation and accumulation of interstitial foamy macrophages. Patients afflicted with DBP may suffer repeated bacterial colonization or infection. There is a higher prevalence of DBP in Asia where it was first identified in the 1960s, potentially due to several HLA alleles that are more common in Asia.
In addition to the above terminology, the transplant-setting diagnosis “bronchiolitis obliterans syndrome” (BOS) is used to denote progressive obstructive lung disease for which there is not another cause aside from chronic graft rejection. For these patients, clinicians assume the underlying disease entity is OB, but they often lack histopathologic confirmation.
Diagnosis is challenging
Symptoms of bronchiolitis are typically dyspnea and cough, and patients may often be diagnosed with asthma or COPD initially. Pulmonary function testing may show signs of obstruction, restriction, or mixed disease with or without a reduction in Dlco. Chest radiography often appears normal, but high-resolution CT may show expiratory air trapping and centrilobular nodules. Advanced imaging modalities may augment or replace CT imaging in diagnosing bronchiolitis: investigators are evaluating pulmonary MRI and fluoroscopy with computerized ventilation analysis in clinical trials (NCT04080232).
Currently, open or thoracoscopic lung biopsy is typically required to make a definitive diagnosis. Because bronchiolitis is a patchy and heterogeneous process, transbronchial biopsy may provide insufficient yield, with a sensitivity of 29% to 70% reported in lung transplant literature (Urisman A, et al. Surg Pathol Clin. 2020;13[1]:189).
Recent studies have demonstrated transbronchial cryobiopsy to be a promising alternative to surgical biopsy, owing to larger tissue samples than conventional transbronchial lung biopsies. For example, in a recent case series four patients underwent transbronchial cryobiopsy. The procedure yielded adequate tissue for diagnosis of a chronic bronchiolitis in each case (Yamakawa H, et al. Internal Med Advance Publication. doi: 10.2169/internalmedicine.6028-20.
Treatment options are growing
Evidence for treatment of bronchiolitis remains limited. Options are extrapolated from lung transplant patients, where incidence of BOS ranges from 50% at 5 years to 76% at 10 years post transplant. Guidelines recommend a 3-month minimum trial of azithromycin, which has been shown to slow or reverse decline of lung function in some patients. Modification of immunosuppression is also recommended. In patients who have continued lung function decline, a systematic review concluded that extracorporeal photopheresis had the most robust evidence for efficacy with stabilized lung function and improved overall survival (Benden C, et al. J Heart Lung Transplant. 2017;36[9]:921). Other salvage therapies that have lower-quality evidence of benefit include total lymphoid irradiation, montelukast, and aerosolized cyclosporine.
In patients who have undergone hematopoietic stem cell transplant, steroids are typically the first line treatment for OB as it is thought to be a form of chronic graft-vs-host disease (GVHD). Ruxolitinib, a selective JAK1/2 inhibitor, demonstrated significant improvement overall in patients with steroid-refractory acute GVHD in a recent randomized clinical trial, although the trial did not examine its effect on pulmonary manifestations (Zeiser R, et al. N Engl J Med. 2020;382[19]:1800). To date, retrospective observational studies of ruxolitinib in patients with lung GVHD have shown conflicting results regarding benefit. Investigators are currently studying ruxolitinib in a phase II trial for patients with BOS following stem cell transplant (NCT03674047).
DIPNECH is unique from other bronchiolitis entities, as small airways dysfunction develops as a result of neuroendocrine cell proliferation in the airway mucosa, ultimately leading to bronchial narrowing. It most commonly presents in middle-aged nonsmoking women with years of chronic cough and dyspnea. While it has an indolent course in many patients, some patients develop progressive symptoms and obstructive lung disease. DIPNECH is considered a precursor to other pulmonary neuroendocrine tumors. The lesions demonstrate somatostatin receptor expression in many cases, prompting the use of somatostatin analogues as treatment. In the largest published case series, 42 patients from three different institutions were identified who were treated with somatostatin analogues for a mean of 38.8 months at the time of review. Symptomatic improvement was seen in 33 of the 42 (79%), and of the 15 with posttreatment PFT data, 14 (93%) showed improvement in PFTs (Al-Toubah, T, et al. Chest. 2020;158[1]:401). Other small studies have demonstrated varying results with symptomatic improvement in 29% to 76% of patients and improvement or stability of PFTs in 50% to 100% of patients (Samhouri BF, et al. ERJ Open Res. 2020;6[4]:527).
For patients who have not undergone lung transplant, and who do not have an identifiable exposure or underlying rheumatologic condition, a similar 3-month minimum trial of macrolide antibiotics is reasonable. Macrolides have been shown to double long-term survival rates to over 90% in patients with DPB. Evidence in this patient population is quite limited, and further research is needed to determine effective therapies for patients.
What’s next for bronchiolitis
While clinicians currently have few tools for diagnosing and treating these uncommon diseases, in the coming years, we should learn whether novel imaging modalities or less invasive procedures can aid in the diagnosis. Physicians hope these advances will preclude the need for invasive biopsies in more patients going forward. We should also learn whether newer, targeted agents like ruxolitinib are effective for BOS in patients with stem cell transplant. If so, this finding may open it and similar agents to investigation in other forms of bronchiolitis.
Dr. Poole and Dr. Callahan are with University of Utah Health, Salt Lake City, Utah.
Updated WIC in pregnancy boosts infant outcomes
Developmental outcomes in the first 2 years of life improved in children whose mothers received the revised Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) while pregnant, based on data from approximately 1,200 women.
Maternal nutrition is essential to healthy fetal development, and the WIC was revised in 2009 to align with current dietary guidelines and to support the health of women and children in low-income households, wrote Alice Guan, MPH, of the University of California, San Francisco, and colleagues.
“However, no researchers, to our knowledge, have evaluated effects of this revision on downstream child health or development,” they said.
In a study published in Pediatrics, the researchers reviewed data from mothers and their children who participated in the Conditions Affecting Neurocognitive Development and Learning in Early Childhood (CANDLE) longitudinal cohort study conducted in Tennessee between 2006 and 2011. Their quasi-experimental analysis included 700 women who received WIC during pregnancy and 525 women who did not.
The researchers considered core developmental outcomes of child growth, cognitive development, and socioemotional development at age 12 months and 24 months, and age 4-6 years.
Overall, infants of women who received the WIC food package showed significant increases in length-for-age z scores at 12 months of age (.33, representing approximately one-fifth of a standard deviation), compared to infants of women who did not receive the revised WIC package.
In addition, the Bayley Scales of Infant Development cognitive composite score showed a 4.3-point increase at 24 months of age (approximately one-third of a standard deviation) compared to infants of women who did not receive the revised WIC package.
No effects on growth at age 24 months or on cognitive development at age 4-6 years were noted, which suggests that the impact of the WIC program during pregnancy may fade over time, the researchers said.
“The magnitude of the findings in this study represents clinically relevant effect sizes and provides evidence that one of the largest U.S. safety net policies improves developmental outcomes among low-income and marginalized children,” they noted.
The study findings were limited by several factors including the statistical, quasi-experimental design; the reliance on self-reports for information on income, receipt of WIC, and other variables; and a potential lack of generalizability to other states, the researchers noted. However, the results support findings from previous studies and were strengthened by the review of multiple outcomes and use of a longitudinal database, they said.
“These findings provide timely and critical evidence for the role that WIC plays in improving the health of the nation’s most vulnerable populations, suggesting meaningful impacts of the revised WIC food package on child development,” the researchers said. In addition, “considering the relatively modest scope of the 2009 revision, more substantial updates to the program based on up-to-date nutritional guidance may have substantial effects on improving the health of WIC recipients,” they concluded.
Findings support program’s value
“Pediatrics has always had a commitment to reducing disparities in health care, and we are the main clinicians to see many Medicaid patients on a regular basis,” Herschel Lessin, MD, of Children’s Medical Group, Poughkeepsie, N.Y., said in an interview.
“We all know that pregnant women eating nutritiously ought to help child outcomes, but the current study provides an evidence base for something that seems like common sense,” he noted.
Having such an evidence base is helpful to reinforce the value of the WIC program for its intended recipients, especially in the wake of the COVID-19 pandemic when many funding sources are stretched thin, Dr. Lessin said.
The WIC is intended to try to reduce racial and socioeconomic disparities in the most basic form possible, by helping people who are disadvantaged get enough high-quality food to eat, but results of the program’s impact have not been well studied, he said.
“Outcomes are fiendishly difficult to measure,” and the study is subject to the limitations of its statistical nature, he said. But the large sample size adds support to the findings, which are encouraging, Dr. Lessin noted.
Other potential areas for research include comparing the quality of WIC programs in different states, but such research is very difficult, Dr. Lessin noted. However, the findings might encourage states with less robust WIC programs to consider increasing support, he said.
The study was funded by the National Institutes of Health (National Heart, Lung, and Blood Institute); the National Institute on Aging; the University of California, San Francisco, National Center of Excellence in Women’s Health; and the Urban Child Institute. The researchers had no financial conflicts to disclose. Dr. Lessin serves on the editorial advisory board of Pediatric News and had no relevant financial conflicts to disclose.
Developmental outcomes in the first 2 years of life improved in children whose mothers received the revised Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) while pregnant, based on data from approximately 1,200 women.
Maternal nutrition is essential to healthy fetal development, and the WIC was revised in 2009 to align with current dietary guidelines and to support the health of women and children in low-income households, wrote Alice Guan, MPH, of the University of California, San Francisco, and colleagues.
“However, no researchers, to our knowledge, have evaluated effects of this revision on downstream child health or development,” they said.
In a study published in Pediatrics, the researchers reviewed data from mothers and their children who participated in the Conditions Affecting Neurocognitive Development and Learning in Early Childhood (CANDLE) longitudinal cohort study conducted in Tennessee between 2006 and 2011. Their quasi-experimental analysis included 700 women who received WIC during pregnancy and 525 women who did not.
The researchers considered core developmental outcomes of child growth, cognitive development, and socioemotional development at age 12 months and 24 months, and age 4-6 years.
Overall, infants of women who received the WIC food package showed significant increases in length-for-age z scores at 12 months of age (.33, representing approximately one-fifth of a standard deviation), compared to infants of women who did not receive the revised WIC package.
In addition, the Bayley Scales of Infant Development cognitive composite score showed a 4.3-point increase at 24 months of age (approximately one-third of a standard deviation) compared to infants of women who did not receive the revised WIC package.
No effects on growth at age 24 months or on cognitive development at age 4-6 years were noted, which suggests that the impact of the WIC program during pregnancy may fade over time, the researchers said.
“The magnitude of the findings in this study represents clinically relevant effect sizes and provides evidence that one of the largest U.S. safety net policies improves developmental outcomes among low-income and marginalized children,” they noted.
The study findings were limited by several factors including the statistical, quasi-experimental design; the reliance on self-reports for information on income, receipt of WIC, and other variables; and a potential lack of generalizability to other states, the researchers noted. However, the results support findings from previous studies and were strengthened by the review of multiple outcomes and use of a longitudinal database, they said.
“These findings provide timely and critical evidence for the role that WIC plays in improving the health of the nation’s most vulnerable populations, suggesting meaningful impacts of the revised WIC food package on child development,” the researchers said. In addition, “considering the relatively modest scope of the 2009 revision, more substantial updates to the program based on up-to-date nutritional guidance may have substantial effects on improving the health of WIC recipients,” they concluded.
Findings support program’s value
“Pediatrics has always had a commitment to reducing disparities in health care, and we are the main clinicians to see many Medicaid patients on a regular basis,” Herschel Lessin, MD, of Children’s Medical Group, Poughkeepsie, N.Y., said in an interview.
“We all know that pregnant women eating nutritiously ought to help child outcomes, but the current study provides an evidence base for something that seems like common sense,” he noted.
Having such an evidence base is helpful to reinforce the value of the WIC program for its intended recipients, especially in the wake of the COVID-19 pandemic when many funding sources are stretched thin, Dr. Lessin said.
The WIC is intended to try to reduce racial and socioeconomic disparities in the most basic form possible, by helping people who are disadvantaged get enough high-quality food to eat, but results of the program’s impact have not been well studied, he said.
“Outcomes are fiendishly difficult to measure,” and the study is subject to the limitations of its statistical nature, he said. But the large sample size adds support to the findings, which are encouraging, Dr. Lessin noted.
Other potential areas for research include comparing the quality of WIC programs in different states, but such research is very difficult, Dr. Lessin noted. However, the findings might encourage states with less robust WIC programs to consider increasing support, he said.
The study was funded by the National Institutes of Health (National Heart, Lung, and Blood Institute); the National Institute on Aging; the University of California, San Francisco, National Center of Excellence in Women’s Health; and the Urban Child Institute. The researchers had no financial conflicts to disclose. Dr. Lessin serves on the editorial advisory board of Pediatric News and had no relevant financial conflicts to disclose.
Developmental outcomes in the first 2 years of life improved in children whose mothers received the revised Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) while pregnant, based on data from approximately 1,200 women.
Maternal nutrition is essential to healthy fetal development, and the WIC was revised in 2009 to align with current dietary guidelines and to support the health of women and children in low-income households, wrote Alice Guan, MPH, of the University of California, San Francisco, and colleagues.
“However, no researchers, to our knowledge, have evaluated effects of this revision on downstream child health or development,” they said.
In a study published in Pediatrics, the researchers reviewed data from mothers and their children who participated in the Conditions Affecting Neurocognitive Development and Learning in Early Childhood (CANDLE) longitudinal cohort study conducted in Tennessee between 2006 and 2011. Their quasi-experimental analysis included 700 women who received WIC during pregnancy and 525 women who did not.
The researchers considered core developmental outcomes of child growth, cognitive development, and socioemotional development at age 12 months and 24 months, and age 4-6 years.
Overall, infants of women who received the WIC food package showed significant increases in length-for-age z scores at 12 months of age (.33, representing approximately one-fifth of a standard deviation), compared to infants of women who did not receive the revised WIC package.
In addition, the Bayley Scales of Infant Development cognitive composite score showed a 4.3-point increase at 24 months of age (approximately one-third of a standard deviation) compared to infants of women who did not receive the revised WIC package.
No effects on growth at age 24 months or on cognitive development at age 4-6 years were noted, which suggests that the impact of the WIC program during pregnancy may fade over time, the researchers said.
“The magnitude of the findings in this study represents clinically relevant effect sizes and provides evidence that one of the largest U.S. safety net policies improves developmental outcomes among low-income and marginalized children,” they noted.
The study findings were limited by several factors including the statistical, quasi-experimental design; the reliance on self-reports for information on income, receipt of WIC, and other variables; and a potential lack of generalizability to other states, the researchers noted. However, the results support findings from previous studies and were strengthened by the review of multiple outcomes and use of a longitudinal database, they said.
“These findings provide timely and critical evidence for the role that WIC plays in improving the health of the nation’s most vulnerable populations, suggesting meaningful impacts of the revised WIC food package on child development,” the researchers said. In addition, “considering the relatively modest scope of the 2009 revision, more substantial updates to the program based on up-to-date nutritional guidance may have substantial effects on improving the health of WIC recipients,” they concluded.
Findings support program’s value
“Pediatrics has always had a commitment to reducing disparities in health care, and we are the main clinicians to see many Medicaid patients on a regular basis,” Herschel Lessin, MD, of Children’s Medical Group, Poughkeepsie, N.Y., said in an interview.
“We all know that pregnant women eating nutritiously ought to help child outcomes, but the current study provides an evidence base for something that seems like common sense,” he noted.
Having such an evidence base is helpful to reinforce the value of the WIC program for its intended recipients, especially in the wake of the COVID-19 pandemic when many funding sources are stretched thin, Dr. Lessin said.
The WIC is intended to try to reduce racial and socioeconomic disparities in the most basic form possible, by helping people who are disadvantaged get enough high-quality food to eat, but results of the program’s impact have not been well studied, he said.
“Outcomes are fiendishly difficult to measure,” and the study is subject to the limitations of its statistical nature, he said. But the large sample size adds support to the findings, which are encouraging, Dr. Lessin noted.
Other potential areas for research include comparing the quality of WIC programs in different states, but such research is very difficult, Dr. Lessin noted. However, the findings might encourage states with less robust WIC programs to consider increasing support, he said.
The study was funded by the National Institutes of Health (National Heart, Lung, and Blood Institute); the National Institute on Aging; the University of California, San Francisco, National Center of Excellence in Women’s Health; and the Urban Child Institute. The researchers had no financial conflicts to disclose. Dr. Lessin serves on the editorial advisory board of Pediatric News and had no relevant financial conflicts to disclose.
FROM PEDIATRICS
MRI-guided prostate biopsy prevails in PRECISE trial
Here’s welcome news for men of a certain age: New results support a less invasive approach to investigations for suspicion of prostate cancer.
An approach using MRI of the prostate followed by targeted biopsy (TB) in men with images suggesting a high risk beat the conventional approach of using transrectal ultrasound (TRUS)–guided 12-core systematic biopsy.
The results come from the randomized phase 3 PRECISION trial and were published online in JAMA Oncology.
“What the trial showed is that by taking an imaging-first strategy, you could reduce the number of patients needing a biopsy by about 40% and actually find more significant cancer (35% vs. 30%) and reduce the diagnosis of grade group 1 cancers that we don’t want to find by more than half,” lead author Laurence Klotz, CM, MD, of the Sunnybrook Health Sciences Centre in Toronto commented in an interview with this news organization.
These results from the PRECISE trial support and slightly improve upon findings from the European-based PRECISION trial.
The European trial had already provided “compelling evidence in favor of MRI and targeted biopsy,” noted Olivier Rouvière, MD, PhD, from the University of Lyon (France) in an accompanying editorial. But he argued that it was worth duplicating the trial, as “it must not be forgotten that, in science, testing the robustness of an effect and the factors influencing it is are as important as demonstrating this effect in the first place.”
The results from both trials suggest that, instead of replacing TRUS biopsy entirely, MRI results could be used to guide patients to the appropriate diagnostic pathway, Dr. Rouvière commented.
“Using only MRI findings to decide which patients should undergo biopsy is probably insufficient,” he added. “Most likely, MRI findings will be used in conjunction with other biomarkers such as PSA [prostate-specific antigen] density to select, among the patients with positive MRI findings, those who need targeted biopsy (and those who may safely avoid it), and among the patients with negative MRI findings, those who may still deserve systematic biopsy,” he wrote.
Details of PRECISE findings
The Canadian PRECISE study was developed as a noninferiority trial in coordination with the European PRECISION study, but the Canadian version had several additional features. It added risk-based eligibility, systematic follow-up of all patients for 2 years, a repeat MRI in all untreated patients, investigation of fluid- and tissue-based biomarkers in the cohort, and an economic analysis.
PRECISE was conducted in five Canadian academic health sciences centers from January 2017 through November 2019. A total of 453 biopsy-naive men with a clinical suspicion of prostate cancer who were referred for prostate biopsy were enrolled. Of this group, 421 were evaluable per protocol.
The investigators defined clinical suspicion as a 5% or greater chance of grade group 2 or greater prostate cancer. Patients were also required to have serum prostate-specific antigen PSA levels of 20 ng/mL or less and no contraindication to MRI.
The patients randomly assigned to MRI underwent an MRI-targeted biopsy (MRI-TB) only if a lesion with a Prostate Imaging Reporting and Data System (PI-RADS) score of 3 or greater was identified, whereas all men in the other arm of the trial underwent a systematic TRUS-guided 12-core biopsy.
The MRI approach identified more clinically significant cancers. Grade 2 or higher tumors were found in 79 (35%) of 227 men allocated to MRI-TB vs. 67 (30%) of 225 men who underwent TRUS biopsy.
MRI also reduced the need for a biopsy, allowing many men to avoid the associated pain, discomfort, and infection risks. Of 221 men who were randomly assigned to the MRI group, 83 (37%) had a negative MRI result and avoided biopsy. In contrast, all men in the TRUS group had a biopsy.
In addition, MRI was associated with a marked reduction in the diagnosis of clinically insignificant International Society of Urological Pathology (ISUP) grade group 1 cancers (10% with MRI-TB vs. 22% with TRUS). Detection of such early cancers, under conventional protocols, often leads to unnecessary therapies or invasive procedures with significant side effects.
These results led the researchers to conclude that the strategy of MRI followed by MRI-guided biopsy only in men at risk of prostate cancer “offers substantial advantages over an initial systematic biopsy.”
The MRI strategy “results in similar detection rates of clinically significant prostate cancer … while avoiding biopsy in more than one-third of men and reducing the diagnosis of clinically insignificant cancer,” the investigators point out.
The investigators acknowledged that the performance of the MRI-targeted biopsy varied between centers, with differences in both positive MRI rates and target biopsy yields.
“This difference occurred despite the fact that all MRIs were reviewed, and biopsies performed, by experienced radiologists or urologists. This underscores the need for quality control measures to enable the broad application of MRI,” they write.
What’s next?
Dr. Klotz noted that an important addition to PRECISE is the planned follow-up of patients who did not receive treatment on study.
“We know MRI is not perfect, so what happens to the guys who avoid the biopsy? How much at risk are they of having something missed? So the only way to know that really is with long-term follow-up on the patients,” he said in an interview.
In addition to repeating MRI at 2 years, the investigators plan to follow these patients for up to 8 years.
“But certainly, compared to the traditional strategy of systematic biopsy, this looks a lot better,” Dr. Klotz commented.
In his editorial, Dr. Rouvière commented that the intersite variability seen in the study “sounds like a warning to the MRI pathway.”
“Considering that all participating centers were experienced high-volume tertiary centers, the intersite variability is probably much higher among less experienced centers,” he wrote. “Thus, whatever the diagnostic pathway, continuing education and quality insurance programs will become major issues in the future, not only for prostate MRI interpretation, but also for targeted biopsy, which does have a learning curve, even with magnetic resonance and ultrasound fusion systems, and even for systematic biopsy.”
PRECISE was funded by the Ontario Institute of Cancer Research and Prostate Cancer Canada. Dr. Klotz and Dr. Rouvière have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Here’s welcome news for men of a certain age: New results support a less invasive approach to investigations for suspicion of prostate cancer.
An approach using MRI of the prostate followed by targeted biopsy (TB) in men with images suggesting a high risk beat the conventional approach of using transrectal ultrasound (TRUS)–guided 12-core systematic biopsy.
The results come from the randomized phase 3 PRECISION trial and were published online in JAMA Oncology.
“What the trial showed is that by taking an imaging-first strategy, you could reduce the number of patients needing a biopsy by about 40% and actually find more significant cancer (35% vs. 30%) and reduce the diagnosis of grade group 1 cancers that we don’t want to find by more than half,” lead author Laurence Klotz, CM, MD, of the Sunnybrook Health Sciences Centre in Toronto commented in an interview with this news organization.
These results from the PRECISE trial support and slightly improve upon findings from the European-based PRECISION trial.
The European trial had already provided “compelling evidence in favor of MRI and targeted biopsy,” noted Olivier Rouvière, MD, PhD, from the University of Lyon (France) in an accompanying editorial. But he argued that it was worth duplicating the trial, as “it must not be forgotten that, in science, testing the robustness of an effect and the factors influencing it is are as important as demonstrating this effect in the first place.”
The results from both trials suggest that, instead of replacing TRUS biopsy entirely, MRI results could be used to guide patients to the appropriate diagnostic pathway, Dr. Rouvière commented.
“Using only MRI findings to decide which patients should undergo biopsy is probably insufficient,” he added. “Most likely, MRI findings will be used in conjunction with other biomarkers such as PSA [prostate-specific antigen] density to select, among the patients with positive MRI findings, those who need targeted biopsy (and those who may safely avoid it), and among the patients with negative MRI findings, those who may still deserve systematic biopsy,” he wrote.
Details of PRECISE findings
The Canadian PRECISE study was developed as a noninferiority trial in coordination with the European PRECISION study, but the Canadian version had several additional features. It added risk-based eligibility, systematic follow-up of all patients for 2 years, a repeat MRI in all untreated patients, investigation of fluid- and tissue-based biomarkers in the cohort, and an economic analysis.
PRECISE was conducted in five Canadian academic health sciences centers from January 2017 through November 2019. A total of 453 biopsy-naive men with a clinical suspicion of prostate cancer who were referred for prostate biopsy were enrolled. Of this group, 421 were evaluable per protocol.
The investigators defined clinical suspicion as a 5% or greater chance of grade group 2 or greater prostate cancer. Patients were also required to have serum prostate-specific antigen PSA levels of 20 ng/mL or less and no contraindication to MRI.
The patients randomly assigned to MRI underwent an MRI-targeted biopsy (MRI-TB) only if a lesion with a Prostate Imaging Reporting and Data System (PI-RADS) score of 3 or greater was identified, whereas all men in the other arm of the trial underwent a systematic TRUS-guided 12-core biopsy.
The MRI approach identified more clinically significant cancers. Grade 2 or higher tumors were found in 79 (35%) of 227 men allocated to MRI-TB vs. 67 (30%) of 225 men who underwent TRUS biopsy.
MRI also reduced the need for a biopsy, allowing many men to avoid the associated pain, discomfort, and infection risks. Of 221 men who were randomly assigned to the MRI group, 83 (37%) had a negative MRI result and avoided biopsy. In contrast, all men in the TRUS group had a biopsy.
In addition, MRI was associated with a marked reduction in the diagnosis of clinically insignificant International Society of Urological Pathology (ISUP) grade group 1 cancers (10% with MRI-TB vs. 22% with TRUS). Detection of such early cancers, under conventional protocols, often leads to unnecessary therapies or invasive procedures with significant side effects.
These results led the researchers to conclude that the strategy of MRI followed by MRI-guided biopsy only in men at risk of prostate cancer “offers substantial advantages over an initial systematic biopsy.”
The MRI strategy “results in similar detection rates of clinically significant prostate cancer … while avoiding biopsy in more than one-third of men and reducing the diagnosis of clinically insignificant cancer,” the investigators point out.
The investigators acknowledged that the performance of the MRI-targeted biopsy varied between centers, with differences in both positive MRI rates and target biopsy yields.
“This difference occurred despite the fact that all MRIs were reviewed, and biopsies performed, by experienced radiologists or urologists. This underscores the need for quality control measures to enable the broad application of MRI,” they write.
What’s next?
Dr. Klotz noted that an important addition to PRECISE is the planned follow-up of patients who did not receive treatment on study.
“We know MRI is not perfect, so what happens to the guys who avoid the biopsy? How much at risk are they of having something missed? So the only way to know that really is with long-term follow-up on the patients,” he said in an interview.
In addition to repeating MRI at 2 years, the investigators plan to follow these patients for up to 8 years.
“But certainly, compared to the traditional strategy of systematic biopsy, this looks a lot better,” Dr. Klotz commented.
In his editorial, Dr. Rouvière commented that the intersite variability seen in the study “sounds like a warning to the MRI pathway.”
“Considering that all participating centers were experienced high-volume tertiary centers, the intersite variability is probably much higher among less experienced centers,” he wrote. “Thus, whatever the diagnostic pathway, continuing education and quality insurance programs will become major issues in the future, not only for prostate MRI interpretation, but also for targeted biopsy, which does have a learning curve, even with magnetic resonance and ultrasound fusion systems, and even for systematic biopsy.”
PRECISE was funded by the Ontario Institute of Cancer Research and Prostate Cancer Canada. Dr. Klotz and Dr. Rouvière have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Here’s welcome news for men of a certain age: New results support a less invasive approach to investigations for suspicion of prostate cancer.
An approach using MRI of the prostate followed by targeted biopsy (TB) in men with images suggesting a high risk beat the conventional approach of using transrectal ultrasound (TRUS)–guided 12-core systematic biopsy.
The results come from the randomized phase 3 PRECISION trial and were published online in JAMA Oncology.
“What the trial showed is that by taking an imaging-first strategy, you could reduce the number of patients needing a biopsy by about 40% and actually find more significant cancer (35% vs. 30%) and reduce the diagnosis of grade group 1 cancers that we don’t want to find by more than half,” lead author Laurence Klotz, CM, MD, of the Sunnybrook Health Sciences Centre in Toronto commented in an interview with this news organization.
These results from the PRECISE trial support and slightly improve upon findings from the European-based PRECISION trial.
The European trial had already provided “compelling evidence in favor of MRI and targeted biopsy,” noted Olivier Rouvière, MD, PhD, from the University of Lyon (France) in an accompanying editorial. But he argued that it was worth duplicating the trial, as “it must not be forgotten that, in science, testing the robustness of an effect and the factors influencing it is are as important as demonstrating this effect in the first place.”
The results from both trials suggest that, instead of replacing TRUS biopsy entirely, MRI results could be used to guide patients to the appropriate diagnostic pathway, Dr. Rouvière commented.
“Using only MRI findings to decide which patients should undergo biopsy is probably insufficient,” he added. “Most likely, MRI findings will be used in conjunction with other biomarkers such as PSA [prostate-specific antigen] density to select, among the patients with positive MRI findings, those who need targeted biopsy (and those who may safely avoid it), and among the patients with negative MRI findings, those who may still deserve systematic biopsy,” he wrote.
Details of PRECISE findings
The Canadian PRECISE study was developed as a noninferiority trial in coordination with the European PRECISION study, but the Canadian version had several additional features. It added risk-based eligibility, systematic follow-up of all patients for 2 years, a repeat MRI in all untreated patients, investigation of fluid- and tissue-based biomarkers in the cohort, and an economic analysis.
PRECISE was conducted in five Canadian academic health sciences centers from January 2017 through November 2019. A total of 453 biopsy-naive men with a clinical suspicion of prostate cancer who were referred for prostate biopsy were enrolled. Of this group, 421 were evaluable per protocol.
The investigators defined clinical suspicion as a 5% or greater chance of grade group 2 or greater prostate cancer. Patients were also required to have serum prostate-specific antigen PSA levels of 20 ng/mL or less and no contraindication to MRI.
The patients randomly assigned to MRI underwent an MRI-targeted biopsy (MRI-TB) only if a lesion with a Prostate Imaging Reporting and Data System (PI-RADS) score of 3 or greater was identified, whereas all men in the other arm of the trial underwent a systematic TRUS-guided 12-core biopsy.
The MRI approach identified more clinically significant cancers. Grade 2 or higher tumors were found in 79 (35%) of 227 men allocated to MRI-TB vs. 67 (30%) of 225 men who underwent TRUS biopsy.
MRI also reduced the need for a biopsy, allowing many men to avoid the associated pain, discomfort, and infection risks. Of 221 men who were randomly assigned to the MRI group, 83 (37%) had a negative MRI result and avoided biopsy. In contrast, all men in the TRUS group had a biopsy.
In addition, MRI was associated with a marked reduction in the diagnosis of clinically insignificant International Society of Urological Pathology (ISUP) grade group 1 cancers (10% with MRI-TB vs. 22% with TRUS). Detection of such early cancers, under conventional protocols, often leads to unnecessary therapies or invasive procedures with significant side effects.
These results led the researchers to conclude that the strategy of MRI followed by MRI-guided biopsy only in men at risk of prostate cancer “offers substantial advantages over an initial systematic biopsy.”
The MRI strategy “results in similar detection rates of clinically significant prostate cancer … while avoiding biopsy in more than one-third of men and reducing the diagnosis of clinically insignificant cancer,” the investigators point out.
The investigators acknowledged that the performance of the MRI-targeted biopsy varied between centers, with differences in both positive MRI rates and target biopsy yields.
“This difference occurred despite the fact that all MRIs were reviewed, and biopsies performed, by experienced radiologists or urologists. This underscores the need for quality control measures to enable the broad application of MRI,” they write.
What’s next?
Dr. Klotz noted that an important addition to PRECISE is the planned follow-up of patients who did not receive treatment on study.
“We know MRI is not perfect, so what happens to the guys who avoid the biopsy? How much at risk are they of having something missed? So the only way to know that really is with long-term follow-up on the patients,” he said in an interview.
In addition to repeating MRI at 2 years, the investigators plan to follow these patients for up to 8 years.
“But certainly, compared to the traditional strategy of systematic biopsy, this looks a lot better,” Dr. Klotz commented.
In his editorial, Dr. Rouvière commented that the intersite variability seen in the study “sounds like a warning to the MRI pathway.”
“Considering that all participating centers were experienced high-volume tertiary centers, the intersite variability is probably much higher among less experienced centers,” he wrote. “Thus, whatever the diagnostic pathway, continuing education and quality insurance programs will become major issues in the future, not only for prostate MRI interpretation, but also for targeted biopsy, which does have a learning curve, even with magnetic resonance and ultrasound fusion systems, and even for systematic biopsy.”
PRECISE was funded by the Ontario Institute of Cancer Research and Prostate Cancer Canada. Dr. Klotz and Dr. Rouvière have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.