Clinical utility of the acute bronchodilator response

Recently, numerous articles evaluating the acute bronchodilator (BD) response in various disease states have appeared in the literature (Chest. 2015;148[6]:1489; J Thorac Dis. 2016;8[1]:14; Int J Chron Obstruct Pulmon Dis. 2016;11:93; Respir Med. 2016;112:45). New algorithms have been proposed to improve quality control in BD (Eur Clin Respir J. 2015;30;2).

In our lab, requests for pre- and post-BD spirometry continue unabated. Undoubtedly, many labs comply with these requests without regard for pre-BD values. The number of these requests far exceeds the number needed to confirm asthma diagnosis, or to assure that post-BD FEV1/FVC ratio remains below 0.7 for COPD diagnosis, which are the only universally accepted indications for BD testing.

Acute BD testing technique, interpretation, and clinical application involve important issues that remain unresolved, even in COPD where this test has been studied more than any other disease state except asthma (Chest. 2011;140[4]:1055; Int J Chron Obstruct Pulmon Dis. 2015;10:407). There remains no clear consensus for a clinically relevant BD response. The ACCP definition proposed in 1974 (FEV1 improvement by greater than 15%) has not been updated, and the widely used ATS/ERS definition (FEV1 and/or FVC improvement by greater than 12% and 200 mL) is felt to be arbitrary and based more on expert opinion than scientific evidence (Respir Care. 2012;57[10]:1564). Literature review (excluding asthma) reveals no well-done, reproducible studies that demonstrate meaningful or widely applicable uses for the acute BD response.

Overcoming the many factors influencing acute bronchodilator testing, developing a unified definition for a positive test, and then showing a predictive significance to the acute-BD response is an extremely difficult task. Until this test is further studied in a rigorous manner, any meaning attached to a positive response outside of asthma is purely arbitrary.

Dr. Oleh Hnatiuk, FCCP

Steering Committee Member

Gun violence in the hospital

Thirty-one thousand fatal gunshot wounds (GSW) occur in the United States each year and are increasing; 55% are self-inflicted, mostly isolated incidents. However, mass shooting events (MSE = more than 3 victims) are rising with 355 events in 2015 (462 deaths and 1,314 injuries). The mortality of GSW has risen due to the use of high caliber automatic handguns. Health-care providers, facilities, and systems need to include preparation for primary prevention and secondary mitigation for violent acts of this nature.

MSE attacker demographics reveal a male predominance (90%) with ethnicity mirroring the US population (65% Caucasian, 16% black, and 9% Asian) and mainly occurring in urban settings. The psychosocial basis of these changes is complex and multifactorial. Two-thirds of mass shooters have a history of mental illness with paranoid schizophrenia predominating. Motives are shifting from self-destruction to grievance-related events. Targets and victims of GSW violence also seem to be changing, and health-care workers are potential targets for GSW violence.

A 12-year review of hospital shooting events (HSE) found 154 events with 235 victims. There is a rise in this type of violent act. Grievance motives are dominant in these events. Most HSE occur in the ED or at the entrance to the hospital or parking lot (77%). The case fatality rate in HSE averages 50%. The perpetrators are injured in 85% of cases. Nurses are the most common victims of HSE.

Prevention strategies such as metal detectors, camera surveillance, strengthened security staff, and emergency protocols are vital. However, in many hospitals, these strategies are inadequate or not considered. Secondary mitigation requires special education and training and some material preparation to be successful. Providers must consider themselves potential gun violence victims. We encourage all medical providers to engage in planning and preparation for HSE, as well as advocate for gun safety laws

Dr. Dennis Amundson, FCCP

NetWork Member

Critical violent injury in the United States: A review and call to action. Crit Care Med. 2015;43(11):2460-2466.

Hospital-based shooting in the United States: 2000-2011. Ann Emerg Med. 2012;60(6):790-798.

The epidemiology of trauma-related mortality in the United States From 2002-2012. J Trauma Acute Care Surg. 2014;76(4):913-920.

Balloon pulmonary angioplasty for CTEPH

The gold-standard treatment for chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary thromboendarterectomy (PTE). However, not every patient is a surgical candidate, including those who are deemed technically inoperable (after review by a multidisciplinary, experienced CTEPH team) or those whose goals of care are more palliative.

Such factors created an opportunity for an alternative procedure to manage CTEPH: catheter-based balloon pulmonary angioplasty (BPA). Despite the limited success with early BPA experience, with initial set-backs including high reperfusion edema rates and other procedure complications, BPA has become more refined over time. Initially led by the efforts of several groups based in Japan, modifications included greater precision in “right-sizing” balloons, staging the procedure (average two to five sessions/patient), and better vascular imaging techniques with advancing technical capabilities.

BPA has received attention due to the favorable hemodynamic and functional outcomes reported in select patients. Despite a lack of consensus regarding who might benefit most, these preliminary results have stimulated considerable interest for acquiring this technique worldwide.

Caution should be exercised when BPA is considered for CTEPH treatment. Critical to success is the selection of patients who might benefit, and adequate training and technical expertise is essential for BPA performance. For those with operable CTEPH who are otherwise surgical candidates, data do not yet exist to suggest BPA as a comparable alternative to PTE. Furthermore, the absence of head-to-head comparison between medical therapy and BPA for inoperable CTEPH further blurs the role BPA will have in this unique patient population. But, it holds promise, awaiting further trials data.

Dr. Wassim H. Fares, FCCP, NetWork Member

Dr. William R. Auger, FCCP, Steering Committee Member

Pulmonary nodules: Are you seeing spots?

Pulmonary nodules are increasingly being identified in clinical practice. A recent study estimated that 1.5 million nodules are identified annually in the United States (Gould et al. 2015; Am J Respir Crit Care Med. 192[10], 1208). This 10-fold increase in number over prior estimates reflects the steep escalation in utilization of CT scanning over the past several decades, and is likely to rise further as lung cancer screening is implemented. While the majority of nodules are benign, evaluation necessarily includes an assessment of the probability of malignancy, since this is a major driver of the decision as to whether no further intervention is required, or whether watchful surveillance or further noninvasive or invasive evaluation is appropriate (Gould et al., 2013). It is reassuring that experienced chest physicians perform well in the assessment of the probability of malignancy (Gould et al., 2013; Swensen et al., 1999), but also important to recognize that evidence-based guidelines for nodule evaluation as well as validated tools for assessing the likelihood of malignancy are readily available (Gould, Ananth, Barnett, & Veterans Affairs, 2007; Gould et al., 2013; McWilliams et al., 2013; Swensen, Silverstein, Ilstrup, Schleck, & Edell, 1997). It is important to engage our radiology colleagues in this discussion; guidelines from the Fleischner Society and the American College of Radiology for reporting on incidentally identified small solid nodules, incidentally identified subsolid nodules, and screening-detected nodules are individually distinct in definitions of abnormality as well as recommendations for follow up, and should be applied appropriately in the context of the individual patient as well as the situation for which the CT was performed (“Lung-RADS Version 1.0 Assessment Categories Release date: April 28, 2014,” 2014; MacMahon et al., 2005; Naidich et al., 2013). All of these potential sources of variation highlight the value of standardizing the approach to nodule evaluation, to ensure that appropriate evaluation will be done to maximize the likelihood of identifying nodules that are actually cancer, and minimize harm potentially incurred by unnecessary invasive and noninvasive testing of nodules that are actually benign.

Dr. Lynn Tanoue, FCCP

NetWork Chair

Gould MK, Ananth L, Barnett PG, and Veterans Affairs, S. C. S. G. A clinical model to estimate the pretest probability of lung cancer in patients with solitary pulmonary nodules. Chest. 2007;131(2):383-388.

Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013; 143(5 suppl):e93S.

Gould MK, Tang T, Liu IL, et al. Recent trends in the identification of incidental pulmonary nodules. Am J Respir Crit Care Med. 2015; 192(10):1208-1214.

Lung-RADS Version 1.0 Assessment Categories Release date: April 28,2014. http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/LungRADS/AssessmentCategories.pdf. Accessed Oct 31, 2014.

MacMahon H, Austin JH, Gamsu G, et al. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology. 2005;237(2):395-400.

McWilliams A, Tammemagi MC, Mayo JR, et al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med. 2013;369(10):910-919.

Naidich DP, Bankier AA, MacMahon H, et al. Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society. Radiology. 2013;266(1):304-317.

Swensen SJ, Silverstein MD, Edell ES, et al. Solitary pulmonary nodules: clinical prediction model versus physicians. Mayo Clin Proc. 1999;74(4):319-329.

Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES. The probability of malignancy in solitary pulmonary nodules: Application to small radiologically indeterminate nodules. Arch Intern Med. 1997;157(8): 849-855.

Clinical utility of the acute bronchodilator response

Recently, numerous articles evaluating the acute bronchodilator (BD) response in various disease states have appeared in the literature (Chest. 2015;148[6]:1489; J Thorac Dis. 2016;8[1]:14; Int J Chron Obstruct Pulmon Dis. 2016;11:93; Respir Med. 2016;112:45). New algorithms have been proposed to improve quality control in BD (Eur Clin Respir J. 2015;30;2).

In our lab, requests for pre- and post-BD spirometry continue unabated. Undoubtedly, many labs comply with these requests without regard for pre-BD values. The number of these requests far exceeds the number needed to confirm asthma diagnosis, or to assure that post-BD FEV1/FVC ratio remains below 0.7 for COPD diagnosis, which are the only universally accepted indications for BD testing.

Acute BD testing technique, interpretation, and clinical application involve important issues that remain unresolved, even in COPD where this test has been studied more than any other disease state except asthma (Chest. 2011;140[4]:1055; Int J Chron Obstruct Pulmon Dis. 2015;10:407). There remains no clear consensus for a clinically relevant BD response. The ACCP definition proposed in 1974 (FEV1 improvement by greater than 15%) has not been updated, and the widely used ATS/ERS definition (FEV1 and/or FVC improvement by greater than 12% and 200 mL) is felt to be arbitrary and based more on expert opinion than scientific evidence (Respir Care. 2012;57[10]:1564). Literature review (excluding asthma) reveals no well-done, reproducible studies that demonstrate meaningful or widely applicable uses for the acute BD response.

Overcoming the many factors influencing acute bronchodilator testing, developing a unified definition for a positive test, and then showing a predictive significance to the acute-BD response is an extremely difficult task. Until this test is further studied in a rigorous manner, any meaning attached to a positive response outside of asthma is purely arbitrary.

Dr. Oleh Hnatiuk, FCCP

Steering Committee Member

Gun violence in the hospital

Thirty-one thousand fatal gunshot wounds (GSW) occur in the United States each year and are increasing; 55% are self-inflicted, mostly isolated incidents. However, mass shooting events (MSE = more than 3 victims) are rising with 355 events in 2015 (462 deaths and 1,314 injuries). The mortality of GSW has risen due to the use of high caliber automatic handguns. Health-care providers, facilities, and systems need to include preparation for primary prevention and secondary mitigation for violent acts of this nature.

MSE attacker demographics reveal a male predominance (90%) with ethnicity mirroring the US population (65% Caucasian, 16% black, and 9% Asian) and mainly occurring in urban settings. The psychosocial basis of these changes is complex and multifactorial. Two-thirds of mass shooters have a history of mental illness with paranoid schizophrenia predominating. Motives are shifting from self-destruction to grievance-related events. Targets and victims of GSW violence also seem to be changing, and health-care workers are potential targets for GSW violence.

A 12-year review of hospital shooting events (HSE) found 154 events with 235 victims. There is a rise in this type of violent act. Grievance motives are dominant in these events. Most HSE occur in the ED or at the entrance to the hospital or parking lot (77%). The case fatality rate in HSE averages 50%. The perpetrators are injured in 85% of cases. Nurses are the most common victims of HSE.

Prevention strategies such as metal detectors, camera surveillance, strengthened security staff, and emergency protocols are vital. However, in many hospitals, these strategies are inadequate or not considered. Secondary mitigation requires special education and training and some material preparation to be successful. Providers must consider themselves potential gun violence victims. We encourage all medical providers to engage in planning and preparation for HSE, as well as advocate for gun safety laws

Dr. Dennis Amundson, FCCP

NetWork Member

Critical violent injury in the United States: A review and call to action. Crit Care Med. 2015;43(11):2460-2466.

Hospital-based shooting in the United States: 2000-2011. Ann Emerg Med. 2012;60(6):790-798.

The epidemiology of trauma-related mortality in the United States From 2002-2012. J Trauma Acute Care Surg. 2014;76(4):913-920.

Balloon pulmonary angioplasty for CTEPH

The gold-standard treatment for chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary thromboendarterectomy (PTE). However, not every patient is a surgical candidate, including those who are deemed technically inoperable (after review by a multidisciplinary, experienced CTEPH team) or those whose goals of care are more palliative.

Such factors created an opportunity for an alternative procedure to manage CTEPH: catheter-based balloon pulmonary angioplasty (BPA). Despite the limited success with early BPA experience, with initial set-backs including high reperfusion edema rates and other procedure complications, BPA has become more refined over time. Initially led by the efforts of several groups based in Japan, modifications included greater precision in “right-sizing” balloons, staging the procedure (average two to five sessions/patient), and better vascular imaging techniques with advancing technical capabilities.

BPA has received attention due to the favorable hemodynamic and functional outcomes reported in select patients. Despite a lack of consensus regarding who might benefit most, these preliminary results have stimulated considerable interest for acquiring this technique worldwide.

Caution should be exercised when BPA is considered for CTEPH treatment. Critical to success is the selection of patients who might benefit, and adequate training and technical expertise is essential for BPA performance. For those with operable CTEPH who are otherwise surgical candidates, data do not yet exist to suggest BPA as a comparable alternative to PTE. Furthermore, the absence of head-to-head comparison between medical therapy and BPA for inoperable CTEPH further blurs the role BPA will have in this unique patient population. But, it holds promise, awaiting further trials data.

Dr. Wassim H. Fares, FCCP, NetWork Member

Dr. William R. Auger, FCCP, Steering Committee Member

Pulmonary nodules: Are you seeing spots?

Pulmonary nodules are increasingly being identified in clinical practice. A recent study estimated that 1.5 million nodules are identified annually in the United States (Gould et al. 2015; Am J Respir Crit Care Med. 192[10], 1208). This 10-fold increase in number over prior estimates reflects the steep escalation in utilization of CT scanning over the past several decades, and is likely to rise further as lung cancer screening is implemented. While the majority of nodules are benign, evaluation necessarily includes an assessment of the probability of malignancy, since this is a major driver of the decision as to whether no further intervention is required, or whether watchful surveillance or further noninvasive or invasive evaluation is appropriate (Gould et al., 2013). It is reassuring that experienced chest physicians perform well in the assessment of the probability of malignancy (Gould et al., 2013; Swensen et al., 1999), but also important to recognize that evidence-based guidelines for nodule evaluation as well as validated tools for assessing the likelihood of malignancy are readily available (Gould, Ananth, Barnett, & Veterans Affairs, 2007; Gould et al., 2013; McWilliams et al., 2013; Swensen, Silverstein, Ilstrup, Schleck, & Edell, 1997). It is important to engage our radiology colleagues in this discussion; guidelines from the Fleischner Society and the American College of Radiology for reporting on incidentally identified small solid nodules, incidentally identified subsolid nodules, and screening-detected nodules are individually distinct in definitions of abnormality as well as recommendations for follow up, and should be applied appropriately in the context of the individual patient as well as the situation for which the CT was performed (“Lung-RADS Version 1.0 Assessment Categories Release date: April 28, 2014,” 2014; MacMahon et al., 2005; Naidich et al., 2013). All of these potential sources of variation highlight the value of standardizing the approach to nodule evaluation, to ensure that appropriate evaluation will be done to maximize the likelihood of identifying nodules that are actually cancer, and minimize harm potentially incurred by unnecessary invasive and noninvasive testing of nodules that are actually benign.

Dr. Lynn Tanoue, FCCP

NetWork Chair

Gould MK, Ananth L, Barnett PG, and Veterans Affairs, S. C. S. G. A clinical model to estimate the pretest probability of lung cancer in patients with solitary pulmonary nodules. Chest. 2007;131(2):383-388.

Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013; 143(5 suppl):e93S.

Gould MK, Tang T, Liu IL, et al. Recent trends in the identification of incidental pulmonary nodules. Am J Respir Crit Care Med. 2015; 192(10):1208-1214.

Lung-RADS Version 1.0 Assessment Categories Release date: April 28,2014. http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/LungRADS/AssessmentCategories.pdf. Accessed Oct 31, 2014.

MacMahon H, Austin JH, Gamsu G, et al. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology. 2005;237(2):395-400.

McWilliams A, Tammemagi MC, Mayo JR, et al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med. 2013;369(10):910-919.

Naidich DP, Bankier AA, MacMahon H, et al. Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society. Radiology. 2013;266(1):304-317.

Swensen SJ, Silverstein MD, Edell ES, et al. Solitary pulmonary nodules: clinical prediction model versus physicians. Mayo Clin Proc. 1999;74(4):319-329.

Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES. The probability of malignancy in solitary pulmonary nodules: Application to small radiologically indeterminate nodules. Arch Intern Med. 1997;157(8): 849-855.

Clinical utility of the acute bronchodilator response

Recently, numerous articles evaluating the acute bronchodilator (BD) response in various disease states have appeared in the literature (Chest. 2015;148[6]:1489; J Thorac Dis. 2016;8[1]:14; Int J Chron Obstruct Pulmon Dis. 2016;11:93; Respir Med. 2016;112:45). New algorithms have been proposed to improve quality control in BD (Eur Clin Respir J. 2015;30;2).

In our lab, requests for pre- and post-BD spirometry continue unabated. Undoubtedly, many labs comply with these requests without regard for pre-BD values. The number of these requests far exceeds the number needed to confirm asthma diagnosis, or to assure that post-BD FEV1/FVC ratio remains below 0.7 for COPD diagnosis, which are the only universally accepted indications for BD testing.

Acute BD testing technique, interpretation, and clinical application involve important issues that remain unresolved, even in COPD where this test has been studied more than any other disease state except asthma (Chest. 2011;140[4]:1055; Int J Chron Obstruct Pulmon Dis. 2015;10:407). There remains no clear consensus for a clinically relevant BD response. The ACCP definition proposed in 1974 (FEV1 improvement by greater than 15%) has not been updated, and the widely used ATS/ERS definition (FEV1 and/or FVC improvement by greater than 12% and 200 mL) is felt to be arbitrary and based more on expert opinion than scientific evidence (Respir Care. 2012;57[10]:1564). Literature review (excluding asthma) reveals no well-done, reproducible studies that demonstrate meaningful or widely applicable uses for the acute BD response.

Overcoming the many factors influencing acute bronchodilator testing, developing a unified definition for a positive test, and then showing a predictive significance to the acute-BD response is an extremely difficult task. Until this test is further studied in a rigorous manner, any meaning attached to a positive response outside of asthma is purely arbitrary.

Dr. Oleh Hnatiuk, FCCP

Steering Committee Member

Gun violence in the hospital

Thirty-one thousand fatal gunshot wounds (GSW) occur in the United States each year and are increasing; 55% are self-inflicted, mostly isolated incidents. However, mass shooting events (MSE = more than 3 victims) are rising with 355 events in 2015 (462 deaths and 1,314 injuries). The mortality of GSW has risen due to the use of high caliber automatic handguns. Health-care providers, facilities, and systems need to include preparation for primary prevention and secondary mitigation for violent acts of this nature.

MSE attacker demographics reveal a male predominance (90%) with ethnicity mirroring the US population (65% Caucasian, 16% black, and 9% Asian) and mainly occurring in urban settings. The psychosocial basis of these changes is complex and multifactorial. Two-thirds of mass shooters have a history of mental illness with paranoid schizophrenia predominating. Motives are shifting from self-destruction to grievance-related events. Targets and victims of GSW violence also seem to be changing, and health-care workers are potential targets for GSW violence.

A 12-year review of hospital shooting events (HSE) found 154 events with 235 victims. There is a rise in this type of violent act. Grievance motives are dominant in these events. Most HSE occur in the ED or at the entrance to the hospital or parking lot (77%). The case fatality rate in HSE averages 50%. The perpetrators are injured in 85% of cases. Nurses are the most common victims of HSE.

Prevention strategies such as metal detectors, camera surveillance, strengthened security staff, and emergency protocols are vital. However, in many hospitals, these strategies are inadequate or not considered. Secondary mitigation requires special education and training and some material preparation to be successful. Providers must consider themselves potential gun violence victims. We encourage all medical providers to engage in planning and preparation for HSE, as well as advocate for gun safety laws

Dr. Dennis Amundson, FCCP

NetWork Member

Critical violent injury in the United States: A review and call to action. Crit Care Med. 2015;43(11):2460-2466.

Hospital-based shooting in the United States: 2000-2011. Ann Emerg Med. 2012;60(6):790-798.

The epidemiology of trauma-related mortality in the United States From 2002-2012. J Trauma Acute Care Surg. 2014;76(4):913-920.

Balloon pulmonary angioplasty for CTEPH

The gold-standard treatment for chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary thromboendarterectomy (PTE). However, not every patient is a surgical candidate, including those who are deemed technically inoperable (after review by a multidisciplinary, experienced CTEPH team) or those whose goals of care are more palliative.

Such factors created an opportunity for an alternative procedure to manage CTEPH: catheter-based balloon pulmonary angioplasty (BPA). Despite the limited success with early BPA experience, with initial set-backs including high reperfusion edema rates and other procedure complications, BPA has become more refined over time. Initially led by the efforts of several groups based in Japan, modifications included greater precision in “right-sizing” balloons, staging the procedure (average two to five sessions/patient), and better vascular imaging techniques with advancing technical capabilities.

BPA has received attention due to the favorable hemodynamic and functional outcomes reported in select patients. Despite a lack of consensus regarding who might benefit most, these preliminary results have stimulated considerable interest for acquiring this technique worldwide.

Caution should be exercised when BPA is considered for CTEPH treatment. Critical to success is the selection of patients who might benefit, and adequate training and technical expertise is essential for BPA performance. For those with operable CTEPH who are otherwise surgical candidates, data do not yet exist to suggest BPA as a comparable alternative to PTE. Furthermore, the absence of head-to-head comparison between medical therapy and BPA for inoperable CTEPH further blurs the role BPA will have in this unique patient population. But, it holds promise, awaiting further trials data.

Dr. Wassim H. Fares, FCCP, NetWork Member

Dr. William R. Auger, FCCP, Steering Committee Member

Pulmonary nodules: Are you seeing spots?

Pulmonary nodules are increasingly being identified in clinical practice. A recent study estimated that 1.5 million nodules are identified annually in the United States (Gould et al. 2015; Am J Respir Crit Care Med. 192[10], 1208). This 10-fold increase in number over prior estimates reflects the steep escalation in utilization of CT scanning over the past several decades, and is likely to rise further as lung cancer screening is implemented. While the majority of nodules are benign, evaluation necessarily includes an assessment of the probability of malignancy, since this is a major driver of the decision as to whether no further intervention is required, or whether watchful surveillance or further noninvasive or invasive evaluation is appropriate (Gould et al., 2013). It is reassuring that experienced chest physicians perform well in the assessment of the probability of malignancy (Gould et al., 2013; Swensen et al., 1999), but also important to recognize that evidence-based guidelines for nodule evaluation as well as validated tools for assessing the likelihood of malignancy are readily available (Gould, Ananth, Barnett, & Veterans Affairs, 2007; Gould et al., 2013; McWilliams et al., 2013; Swensen, Silverstein, Ilstrup, Schleck, & Edell, 1997). It is important to engage our radiology colleagues in this discussion; guidelines from the Fleischner Society and the American College of Radiology for reporting on incidentally identified small solid nodules, incidentally identified subsolid nodules, and screening-detected nodules are individually distinct in definitions of abnormality as well as recommendations for follow up, and should be applied appropriately in the context of the individual patient as well as the situation for which the CT was performed (“Lung-RADS Version 1.0 Assessment Categories Release date: April 28, 2014,” 2014; MacMahon et al., 2005; Naidich et al., 2013). All of these potential sources of variation highlight the value of standardizing the approach to nodule evaluation, to ensure that appropriate evaluation will be done to maximize the likelihood of identifying nodules that are actually cancer, and minimize harm potentially incurred by unnecessary invasive and noninvasive testing of nodules that are actually benign.

Dr. Lynn Tanoue, FCCP

NetWork Chair

Gould MK, Ananth L, Barnett PG, and Veterans Affairs, S. C. S. G. A clinical model to estimate the pretest probability of lung cancer in patients with solitary pulmonary nodules. Chest. 2007;131(2):383-388.

Gould MK, Donington J, Lynch WR, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013; 143(5 suppl):e93S.

Gould MK, Tang T, Liu IL, et al. Recent trends in the identification of incidental pulmonary nodules. Am J Respir Crit Care Med. 2015; 192(10):1208-1214.

Lung-RADS Version 1.0 Assessment Categories Release date: April 28,2014. http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/LungRADS/AssessmentCategories.pdf. Accessed Oct 31, 2014.

MacMahon H, Austin JH, Gamsu G, et al. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology. 2005;237(2):395-400.

McWilliams A, Tammemagi MC, Mayo JR, et al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med. 2013;369(10):910-919.

Naidich DP, Bankier AA, MacMahon H, et al. Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society. Radiology. 2013;266(1):304-317.

Swensen SJ, Silverstein MD, Edell ES, et al. Solitary pulmonary nodules: clinical prediction model versus physicians. Mayo Clin Proc. 1999;74(4):319-329.

Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES. The probability of malignancy in solitary pulmonary nodules: Application to small radiologically indeterminate nodules. Arch Intern Med. 1997;157(8): 849-855.

Editorial

New Sepsis Criteria: A Change We Should Not Make.By Dr. S. Q. Simpson.

Giants in Chest Medicine

Arthur P. Wheeler, MD, FCCP. By Dr. G. R. Bernard.

Topics In Practice Management

Update on Exhaled Nitric Oxide in Clinical Practice.By Dr. S.R. Mummadi and Dr. P.Y. Hahn.

Original Research

Airway Surfactant Protein D Deficiency in Adults With Severe Asthma.By Dr. R.A. Mackay et al.

Outcomes of Nurse Practitioner–Delivered Critical Care: A Prospective Cohort Study.By Dr. J.S. Landsperger et al.

Editorial

New Sepsis Criteria: A Change We Should Not Make.By Dr. S. Q. Simpson.

Giants in Chest Medicine

Arthur P. Wheeler, MD, FCCP. By Dr. G. R. Bernard.

Topics In Practice Management

Update on Exhaled Nitric Oxide in Clinical Practice.By Dr. S.R. Mummadi and Dr. P.Y. Hahn.

Original Research

Airway Surfactant Protein D Deficiency in Adults With Severe Asthma.By Dr. R.A. Mackay et al.

Outcomes of Nurse Practitioner–Delivered Critical Care: A Prospective Cohort Study.By Dr. J.S. Landsperger et al.

Editorial

New Sepsis Criteria: A Change We Should Not Make.By Dr. S. Q. Simpson.

Giants in Chest Medicine

Arthur P. Wheeler, MD, FCCP. By Dr. G. R. Bernard.

Topics In Practice Management

Update on Exhaled Nitric Oxide in Clinical Practice.By Dr. S.R. Mummadi and Dr. P.Y. Hahn.

Original Research

Airway Surfactant Protein D Deficiency in Adults With Severe Asthma.By Dr. R.A. Mackay et al.

Outcomes of Nurse Practitioner–Delivered Critical Care: A Prospective Cohort Study.By Dr. J.S. Landsperger et al.

In March, the foundation kicked off the 2016 NetWorks Challenge, and we’re delighted to see a very enthusiastic response from our NetWorks Steering Committee members. In fact, we are thrilled to announce that the first NetWorks Steering Committee to achieve 100% participation is the Women’s Health NetWork. Every member on the steering committee made a donation to the CHEST Foundation last month.

“Physicians are competitive by nature and always welcome a challenge; the CHEST Foundation challenge is no exception,” stated Ghada Bourjeily, MD, FCCP, and Chair of the Women’s Health NetWork. “The Women’s Health NetWork Steering Committee members jumped on the opportunity to donate as soon as they heard about this great opportunity and donated to the CHEST Foundation.”

This year, the prizes for winning the NetWorks Challenge are more enticing than ever before. In the first round, the highest percentage of participation by a NetWork Steering Committee will receive additional time for the NetWorks Featured Lecture at CHEST 2016. And, for the very first time, the CHEST Foundation is offering up to two travel grants to CHEST 2016. In the second round, the top two NetWorks Steering Committees that are able to contribute the highest total amount will receive a seat on the CHEST Foundation’s Awards Committee and a potential clinical research grant. Up to two travel grants to CHEST 2017 will also be awarded in the final round to the NetWork that has the highest percentage of participation among their membership.

David Schulman, MD, MPH, FCCP, Chair of the Council of NetWorks, recently commented on why it is critical to take part in the NetWorks Challenge. “Participating in the NetWorks Challenge will serve many great purposes. First, it’s an opportunity to give to a great organization that does fantastic work. Second, if you’re a member of a NetWork and you participate, it allows your NetWork to achieve greatness. How? Because you get extra time at the annual meeting to show off your wares to your members by letting your national leaders speak to your members. Third, you can get travel grants for your colleagues, which allow them to attend the annual Meeting at no cost. Fourth, you can participate in awarding grants to next year’s foundation awardees as a public member of the CHEST Foundation Awards Committee. In short, there is no reason not to give to the foundation as part of the NetWorks Challenge.”

In March, the foundation kicked off the 2016 NetWorks Challenge, and we’re delighted to see a very enthusiastic response from our NetWorks Steering Committee members. In fact, we are thrilled to announce that the first NetWorks Steering Committee to achieve 100% participation is the Women’s Health NetWork. Every member on the steering committee made a donation to the CHEST Foundation last month.

“Physicians are competitive by nature and always welcome a challenge; the CHEST Foundation challenge is no exception,” stated Ghada Bourjeily, MD, FCCP, and Chair of the Women’s Health NetWork. “The Women’s Health NetWork Steering Committee members jumped on the opportunity to donate as soon as they heard about this great opportunity and donated to the CHEST Foundation.”

This year, the prizes for winning the NetWorks Challenge are more enticing than ever before. In the first round, the highest percentage of participation by a NetWork Steering Committee will receive additional time for the NetWorks Featured Lecture at CHEST 2016. And, for the very first time, the CHEST Foundation is offering up to two travel grants to CHEST 2016. In the second round, the top two NetWorks Steering Committees that are able to contribute the highest total amount will receive a seat on the CHEST Foundation’s Awards Committee and a potential clinical research grant. Up to two travel grants to CHEST 2017 will also be awarded in the final round to the NetWork that has the highest percentage of participation among their membership.

David Schulman, MD, MPH, FCCP, Chair of the Council of NetWorks, recently commented on why it is critical to take part in the NetWorks Challenge. “Participating in the NetWorks Challenge will serve many great purposes. First, it’s an opportunity to give to a great organization that does fantastic work. Second, if you’re a member of a NetWork and you participate, it allows your NetWork to achieve greatness. How? Because you get extra time at the annual meeting to show off your wares to your members by letting your national leaders speak to your members. Third, you can get travel grants for your colleagues, which allow them to attend the annual Meeting at no cost. Fourth, you can participate in awarding grants to next year’s foundation awardees as a public member of the CHEST Foundation Awards Committee. In short, there is no reason not to give to the foundation as part of the NetWorks Challenge.”

In March, the foundation kicked off the 2016 NetWorks Challenge, and we’re delighted to see a very enthusiastic response from our NetWorks Steering Committee members. In fact, we are thrilled to announce that the first NetWorks Steering Committee to achieve 100% participation is the Women’s Health NetWork. Every member on the steering committee made a donation to the CHEST Foundation last month.

“Physicians are competitive by nature and always welcome a challenge; the CHEST Foundation challenge is no exception,” stated Ghada Bourjeily, MD, FCCP, and Chair of the Women’s Health NetWork. “The Women’s Health NetWork Steering Committee members jumped on the opportunity to donate as soon as they heard about this great opportunity and donated to the CHEST Foundation.”

This year, the prizes for winning the NetWorks Challenge are more enticing than ever before. In the first round, the highest percentage of participation by a NetWork Steering Committee will receive additional time for the NetWorks Featured Lecture at CHEST 2016. And, for the very first time, the CHEST Foundation is offering up to two travel grants to CHEST 2016. In the second round, the top two NetWorks Steering Committees that are able to contribute the highest total amount will receive a seat on the CHEST Foundation’s Awards Committee and a potential clinical research grant. Up to two travel grants to CHEST 2017 will also be awarded in the final round to the NetWork that has the highest percentage of participation among their membership.

David Schulman, MD, MPH, FCCP, Chair of the Council of NetWorks, recently commented on why it is critical to take part in the NetWorks Challenge. “Participating in the NetWorks Challenge will serve many great purposes. First, it’s an opportunity to give to a great organization that does fantastic work. Second, if you’re a member of a NetWork and you participate, it allows your NetWork to achieve greatness. How? Because you get extra time at the annual meeting to show off your wares to your members by letting your national leaders speak to your members. Third, you can get travel grants for your colleagues, which allow them to attend the annual Meeting at no cost. Fourth, you can participate in awarding grants to next year’s foundation awardees as a public member of the CHEST Foundation Awards Committee. In short, there is no reason not to give to the foundation as part of the NetWorks Challenge.”

On April 8, 2106, CHEST joined 29 other medical specialty societies at the American Board of Internal Medicine’s (ABIM’s) biannual Liaison Committee on Certification and Recertification (LCCR) meeting in Philadelphia. The meeting focused on the changing face of Maintenance of Certification (MOC) and the vision ABIM has for the future of MOC.

President Richard J. Baron, MD, responded to a letter signed by several medical specialty societies, asking for clarification on ABIM’s vision and philosophy for MOC and the future changes ABIM is considering for the MOC program. Dr. Baron articulated the desire for MOC to be relevant to physicians’ practices in collaboration with the ABIM and the medical specialty societies, to produce, “a credential that speaks to whether physicians are staying current in knowledge and practice over the course of their career in their specialty.”

Dr. Richard G. Battaglia, ABIM Chief Medical Officer, and Eric McKeeby, ABIM Director of Community Engagement, reported the results of a membership survey and focus group discussions regarding ABIM’s Assessment 2020 Report, published in September 2015. They highlighted the challenges, opportunities, and future plans for the MOC program, in light of diplomates’ input through these mechanisms. In the feedback received, the majority of diplomates favored a move away from the secure 10-year MOC recertification examination. Several options were presented, including smaller, more frequent exams, secure exams taken from home or office, and the ability to “test out” of the 10-year exam by successfully completing smaller assessments along the way. Ultimately, participants favored a move away from assessment and toward learning and improvement through a mechanism that is relevant to their real-world practices. Dr. Baron noted the ABIM survey results in which 76.3% of diplomates said they wanted the MOC credential to mean “I am staying current in the knowledge I need to practice,” and he reiterated the Board’s commitment to developing assessment approaches that would result in a meaningful credential based on performance. The ABIM Board of Directors met in April, with the exam format being a priority for them.

Regarding the future of MOC, while the practice assessment requirement is on hold through 2018, ABIM recognizes the work in this area many physicians are currently doing. By early 2017, ABIM is planning on extending the partnership with ACCME to recognize practice assessment activities, along with current medical knowledge activities, for both CME and MOC. This expansion would include blended activities that meet both medical knowledge and practice assessment requirements.

In addition to ABIM staff’s perspectives, three medical societies, including CHEST, reported on their MOC efforts. Heather Dethloff, CHEST Education and Accreditation Specialist, participated in a panel discussion, along with the Endocrine Society and the American Academy of Hospice and Palliative Medicine regarding the ongoing efforts to incorporate MOC into educational activities within their organizations. Successes and challenges encountered through the ABIM MOC certification process were the topics for discussion. During this presentation, CHEST announced its plan to incorporate ABIM MOC into the entire CHEST Annual Meeting 2016; details will be communicated to CHEST members and meeting registrants in coming months.

Throughout these changes to the MOC program, CHEST has been, and will continue to be, in communication with ABIM, advocating for our members. Any questions or concerns about this process can be directed to Heather Dethloff, Education and Accreditation Specialist, at [email protected].

More information

New ABIM Survey Indicates Physician Interest in Potential Changes to MOC Assessment: www.abim.org/news/new-abim-survey-indicates-physician-interest-in-potential-changes-to-moc-assessment.aspx

On April 8, 2106, CHEST joined 29 other medical specialty societies at the American Board of Internal Medicine’s (ABIM’s) biannual Liaison Committee on Certification and Recertification (LCCR) meeting in Philadelphia. The meeting focused on the changing face of Maintenance of Certification (MOC) and the vision ABIM has for the future of MOC.

President Richard J. Baron, MD, responded to a letter signed by several medical specialty societies, asking for clarification on ABIM’s vision and philosophy for MOC and the future changes ABIM is considering for the MOC program. Dr. Baron articulated the desire for MOC to be relevant to physicians’ practices in collaboration with the ABIM and the medical specialty societies, to produce, “a credential that speaks to whether physicians are staying current in knowledge and practice over the course of their career in their specialty.”

Dr. Richard G. Battaglia, ABIM Chief Medical Officer, and Eric McKeeby, ABIM Director of Community Engagement, reported the results of a membership survey and focus group discussions regarding ABIM’s Assessment 2020 Report, published in September 2015. They highlighted the challenges, opportunities, and future plans for the MOC program, in light of diplomates’ input through these mechanisms. In the feedback received, the majority of diplomates favored a move away from the secure 10-year MOC recertification examination. Several options were presented, including smaller, more frequent exams, secure exams taken from home or office, and the ability to “test out” of the 10-year exam by successfully completing smaller assessments along the way. Ultimately, participants favored a move away from assessment and toward learning and improvement through a mechanism that is relevant to their real-world practices. Dr. Baron noted the ABIM survey results in which 76.3% of diplomates said they wanted the MOC credential to mean “I am staying current in the knowledge I need to practice,” and he reiterated the Board’s commitment to developing assessment approaches that would result in a meaningful credential based on performance. The ABIM Board of Directors met in April, with the exam format being a priority for them.

Regarding the future of MOC, while the practice assessment requirement is on hold through 2018, ABIM recognizes the work in this area many physicians are currently doing. By early 2017, ABIM is planning on extending the partnership with ACCME to recognize practice assessment activities, along with current medical knowledge activities, for both CME and MOC. This expansion would include blended activities that meet both medical knowledge and practice assessment requirements.

In addition to ABIM staff’s perspectives, three medical societies, including CHEST, reported on their MOC efforts. Heather Dethloff, CHEST Education and Accreditation Specialist, participated in a panel discussion, along with the Endocrine Society and the American Academy of Hospice and Palliative Medicine regarding the ongoing efforts to incorporate MOC into educational activities within their organizations. Successes and challenges encountered through the ABIM MOC certification process were the topics for discussion. During this presentation, CHEST announced its plan to incorporate ABIM MOC into the entire CHEST Annual Meeting 2016; details will be communicated to CHEST members and meeting registrants in coming months.

Throughout these changes to the MOC program, CHEST has been, and will continue to be, in communication with ABIM, advocating for our members. Any questions or concerns about this process can be directed to Heather Dethloff, Education and Accreditation Specialist, at [email protected].

More information

New ABIM Survey Indicates Physician Interest in Potential Changes to MOC Assessment: www.abim.org/news/new-abim-survey-indicates-physician-interest-in-potential-changes-to-moc-assessment.aspx

On April 8, 2106, CHEST joined 29 other medical specialty societies at the American Board of Internal Medicine’s (ABIM’s) biannual Liaison Committee on Certification and Recertification (LCCR) meeting in Philadelphia. The meeting focused on the changing face of Maintenance of Certification (MOC) and the vision ABIM has for the future of MOC.

President Richard J. Baron, MD, responded to a letter signed by several medical specialty societies, asking for clarification on ABIM’s vision and philosophy for MOC and the future changes ABIM is considering for the MOC program. Dr. Baron articulated the desire for MOC to be relevant to physicians’ practices in collaboration with the ABIM and the medical specialty societies, to produce, “a credential that speaks to whether physicians are staying current in knowledge and practice over the course of their career in their specialty.”

Dr. Richard G. Battaglia, ABIM Chief Medical Officer, and Eric McKeeby, ABIM Director of Community Engagement, reported the results of a membership survey and focus group discussions regarding ABIM’s Assessment 2020 Report, published in September 2015. They highlighted the challenges, opportunities, and future plans for the MOC program, in light of diplomates’ input through these mechanisms. In the feedback received, the majority of diplomates favored a move away from the secure 10-year MOC recertification examination. Several options were presented, including smaller, more frequent exams, secure exams taken from home or office, and the ability to “test out” of the 10-year exam by successfully completing smaller assessments along the way. Ultimately, participants favored a move away from assessment and toward learning and improvement through a mechanism that is relevant to their real-world practices. Dr. Baron noted the ABIM survey results in which 76.3% of diplomates said they wanted the MOC credential to mean “I am staying current in the knowledge I need to practice,” and he reiterated the Board’s commitment to developing assessment approaches that would result in a meaningful credential based on performance. The ABIM Board of Directors met in April, with the exam format being a priority for them.

Regarding the future of MOC, while the practice assessment requirement is on hold through 2018, ABIM recognizes the work in this area many physicians are currently doing. By early 2017, ABIM is planning on extending the partnership with ACCME to recognize practice assessment activities, along with current medical knowledge activities, for both CME and MOC. This expansion would include blended activities that meet both medical knowledge and practice assessment requirements.

In addition to ABIM staff’s perspectives, three medical societies, including CHEST, reported on their MOC efforts. Heather Dethloff, CHEST Education and Accreditation Specialist, participated in a panel discussion, along with the Endocrine Society and the American Academy of Hospice and Palliative Medicine regarding the ongoing efforts to incorporate MOC into educational activities within their organizations. Successes and challenges encountered through the ABIM MOC certification process were the topics for discussion. During this presentation, CHEST announced its plan to incorporate ABIM MOC into the entire CHEST Annual Meeting 2016; details will be communicated to CHEST members and meeting registrants in coming months.

Throughout these changes to the MOC program, CHEST has been, and will continue to be, in communication with ABIM, advocating for our members. Any questions or concerns about this process can be directed to Heather Dethloff, Education and Accreditation Specialist, at [email protected].

More information

New ABIM Survey Indicates Physician Interest in Potential Changes to MOC Assessment: www.abim.org/news/new-abim-survey-indicates-physician-interest-in-potential-changes-to-moc-assessment.aspx

Where are they now? What have they been up to? CHEST’s Past Presidents each forged the way for the many successes of the American College of Chest Physicians (CHEST), leading to enhanced patient care around the globe. Their outstanding leadership and vision are evidenced today in many of CHEST’s current initiatives, and now it is time to check in with these past leaders to give us a look at what’s new in their lives.

Kalpalatha K. Guntupalli, MD, Master FCCP, MACP, FCCM

Frances K. Friedman and Oscar Friedman, MD ’36 Endowed Professor for Pulmonary Disorders; and Chief, Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Baylor College of Medicine.

President 2009-2010

November 1, 2009, is clearly etched into my memory. I was sworn in as the 73rd President, and 3rd woman President, of the American College of Chest Physicians during CHEST Annual Meeting 2009 in San Diego.

I consider the 2 years leading up to the presidency and the year following my term as the best years of my professional career. They were action packed, full of excitement that gave immense satisfaction. During my year, the longtime EVP/CEO, Al Lever, retired, and we welcomed the new EVP/CEO Mr. Paul Markowski.

To make the transition easier, I started the “4 Ps” call of the 4 Presidents (President-Designate, President-Elect, President, and the Past President), a weekly call to catch up and keep everyone in the loop. This has since become a tradition in the organization.

My theme for the year was “Act local, Think global.” We started many international initiatives, in the Middle East, India, China, and South America, that have since evolved into successful programs. In 2010, as members of the Federation of International Respiratory Societies (FIRS), we celebrated the “Year of the Lung.” We participated in the “world spirometry day” (102,487 spirometries were done globally) and did many other programs to increase awareness of lung disease. We held a long-term strategic retreat developing goals for the College. We implemented many other process-driven initiatives under the new CEO’s leadership.

Land was acquired where the new beautiful headquarters building now stands.

What is life like after CHEST Presidency?

I was very honored in 2012 to receive the “Pravasi Bharatiya Samman,” the highest award bestowed on a nonresident Indian by the President of India or distinguished members of the Indian Diaspora to “honor exceptional and meritorious contributions in their chosen field/profession and enhancing the image of India.” In 2013, I spent 4 months as a Fulbright Scholar forming an ARDS network in India, and in 2015, I was honored as a Master FCCP by our own organization.

As the Section Chief, I have been busy building a “Lung Institute” and ICU services along with many new initiatives in our very active Pulmonary/CC/Sleep section at Baylor College of Medicine.

Where are they now? What have they been up to? CHEST’s Past Presidents each forged the way for the many successes of the American College of Chest Physicians (CHEST), leading to enhanced patient care around the globe. Their outstanding leadership and vision are evidenced today in many of CHEST’s current initiatives, and now it is time to check in with these past leaders to give us a look at what’s new in their lives.

Kalpalatha K. Guntupalli, MD, Master FCCP, MACP, FCCM

Frances K. Friedman and Oscar Friedman, MD ’36 Endowed Professor for Pulmonary Disorders; and Chief, Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Baylor College of Medicine.

President 2009-2010

November 1, 2009, is clearly etched into my memory. I was sworn in as the 73rd President, and 3rd woman President, of the American College of Chest Physicians during CHEST Annual Meeting 2009 in San Diego.

I consider the 2 years leading up to the presidency and the year following my term as the best years of my professional career. They were action packed, full of excitement that gave immense satisfaction. During my year, the longtime EVP/CEO, Al Lever, retired, and we welcomed the new EVP/CEO Mr. Paul Markowski.

To make the transition easier, I started the “4 Ps” call of the 4 Presidents (President-Designate, President-Elect, President, and the Past President), a weekly call to catch up and keep everyone in the loop. This has since become a tradition in the organization.

My theme for the year was “Act local, Think global.” We started many international initiatives, in the Middle East, India, China, and South America, that have since evolved into successful programs. In 2010, as members of the Federation of International Respiratory Societies (FIRS), we celebrated the “Year of the Lung.” We participated in the “world spirometry day” (102,487 spirometries were done globally) and did many other programs to increase awareness of lung disease. We held a long-term strategic retreat developing goals for the College. We implemented many other process-driven initiatives under the new CEO’s leadership.

Land was acquired where the new beautiful headquarters building now stands.

What is life like after CHEST Presidency?

I was very honored in 2012 to receive the “Pravasi Bharatiya Samman,” the highest award bestowed on a nonresident Indian by the President of India or distinguished members of the Indian Diaspora to “honor exceptional and meritorious contributions in their chosen field/profession and enhancing the image of India.” In 2013, I spent 4 months as a Fulbright Scholar forming an ARDS network in India, and in 2015, I was honored as a Master FCCP by our own organization.

As the Section Chief, I have been busy building a “Lung Institute” and ICU services along with many new initiatives in our very active Pulmonary/CC/Sleep section at Baylor College of Medicine.

Where are they now? What have they been up to? CHEST’s Past Presidents each forged the way for the many successes of the American College of Chest Physicians (CHEST), leading to enhanced patient care around the globe. Their outstanding leadership and vision are evidenced today in many of CHEST’s current initiatives, and now it is time to check in with these past leaders to give us a look at what’s new in their lives.

Kalpalatha K. Guntupalli, MD, Master FCCP, MACP, FCCM

Frances K. Friedman and Oscar Friedman, MD ’36 Endowed Professor for Pulmonary Disorders; and Chief, Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Baylor College of Medicine.

President 2009-2010

November 1, 2009, is clearly etched into my memory. I was sworn in as the 73rd President, and 3rd woman President, of the American College of Chest Physicians during CHEST Annual Meeting 2009 in San Diego.

I consider the 2 years leading up to the presidency and the year following my term as the best years of my professional career. They were action packed, full of excitement that gave immense satisfaction. During my year, the longtime EVP/CEO, Al Lever, retired, and we welcomed the new EVP/CEO Mr. Paul Markowski.

To make the transition easier, I started the “4 Ps” call of the 4 Presidents (President-Designate, President-Elect, President, and the Past President), a weekly call to catch up and keep everyone in the loop. This has since become a tradition in the organization.

My theme for the year was “Act local, Think global.” We started many international initiatives, in the Middle East, India, China, and South America, that have since evolved into successful programs. In 2010, as members of the Federation of International Respiratory Societies (FIRS), we celebrated the “Year of the Lung.” We participated in the “world spirometry day” (102,487 spirometries were done globally) and did many other programs to increase awareness of lung disease. We held a long-term strategic retreat developing goals for the College. We implemented many other process-driven initiatives under the new CEO’s leadership.

Land was acquired where the new beautiful headquarters building now stands.

What is life like after CHEST Presidency?

I was very honored in 2012 to receive the “Pravasi Bharatiya Samman,” the highest award bestowed on a nonresident Indian by the President of India or distinguished members of the Indian Diaspora to “honor exceptional and meritorious contributions in their chosen field/profession and enhancing the image of India.” In 2013, I spent 4 months as a Fulbright Scholar forming an ARDS network in India, and in 2015, I was honored as a Master FCCP by our own organization.

As the Section Chief, I have been busy building a “Lung Institute” and ICU services along with many new initiatives in our very active Pulmonary/CC/Sleep section at Baylor College of Medicine.

When it comes to predictive demographic and clinical factors associated with abnormal patterns of lung growth and decline in those with persistent, mild-to-moderate asthma in childhood, male sex and childhood levels of lung function as assessed by the forced expiratory volume in 1 second (FEV1) make all the difference, according to the results of a study published in the New England Journal of Medicine.

“Determinants of abnormal patterns of FEV₁ growth and decline are multifactorial and complex, and identification of factors associated with the timing of a decline from the maximal level requires longitudinal data,” said author Michael McGeachie, Ph.D., of Brigham and Women’s Hospital, Boston, and his colleagues.

©Sergey Nivens/thinkstockphotos

To identify these determinants, particularly in those with asthma, Dr. McGeachie and colleagues analyzed longitudinal data from a subset of participants from the Childhood Asthma Management Program (CAMP) cohort who were followed from enrollment at the age of 5 to 12 years, into the third decade of life. The trajectory of lung growth and the decline from maximum growth in this large cohort of persons who had persistent, mild-to-moderate asthma in childhood were compared against those from persons without asthma who were participants in the third National Health and Nutrition Examination Survey. (N Engl J Med. 2016;374:1842-52).

Data from 684 participants from the CAMP cohort were assessed and 25% had normal lung-function growth without an early decline, 26% had normal growth and an early decline, 23% had reduced growth without an early decline, and 26% had reduced growth and an early decline. Results of the multinomial logistic-regression analysis of risk factors for abnormal patterns of lung growth and decline showed that the 26% of participants with reduced growth and an early decline had lower FEV₁ lung function at enrollment and were more likely to be male, compared with those who had normal growth.

Additional study results indicated that 18% of the participants who had reduced lung-function growth, with or without an early decline, met the case definition for chronic obstructive pulmonary disease (COPD) based on the postbronchodilator spirometric criteria at an age of less than 30 years.

Based on their data, Dr. McGeachie and his colleagues said that detection of an abnormal trajectory by means of early and ongoing serial FEV₁ monitoring may help identify children and young adults at risk for abnormal lung-function growth that could lead to chronic airflow obstruction in adulthood.

Funding for this project was provided by grants from the Parker B. Francis Foundation, the National Institutes of Health, the National Human Genome Research Institute, and the Human Frontier Science Program Organization. Dr. McGeachie reported grant support from one of the funding sources during the conduct of the study. Nineteen coauthors reported they had nothing to disclose and the remainder either reported grant support or ties to industry sources.

When it comes to predictive demographic and clinical factors associated with abnormal patterns of lung growth and decline in those with persistent, mild-to-moderate asthma in childhood, male sex and childhood levels of lung function as assessed by the forced expiratory volume in 1 second (FEV1) make all the difference, according to the results of a study published in the New England Journal of Medicine.

“Determinants of abnormal patterns of FEV₁ growth and decline are multifactorial and complex, and identification of factors associated with the timing of a decline from the maximal level requires longitudinal data,” said author Michael McGeachie, Ph.D., of Brigham and Women’s Hospital, Boston, and his colleagues.

©Sergey Nivens/thinkstockphotos

To identify these determinants, particularly in those with asthma, Dr. McGeachie and colleagues analyzed longitudinal data from a subset of participants from the Childhood Asthma Management Program (CAMP) cohort who were followed from enrollment at the age of 5 to 12 years, into the third decade of life. The trajectory of lung growth and the decline from maximum growth in this large cohort of persons who had persistent, mild-to-moderate asthma in childhood were compared against those from persons without asthma who were participants in the third National Health and Nutrition Examination Survey. (N Engl J Med. 2016;374:1842-52).

Data from 684 participants from the CAMP cohort were assessed and 25% had normal lung-function growth without an early decline, 26% had normal growth and an early decline, 23% had reduced growth without an early decline, and 26% had reduced growth and an early decline. Results of the multinomial logistic-regression analysis of risk factors for abnormal patterns of lung growth and decline showed that the 26% of participants with reduced growth and an early decline had lower FEV₁ lung function at enrollment and were more likely to be male, compared with those who had normal growth.

Additional study results indicated that 18% of the participants who had reduced lung-function growth, with or without an early decline, met the case definition for chronic obstructive pulmonary disease (COPD) based on the postbronchodilator spirometric criteria at an age of less than 30 years.

Based on their data, Dr. McGeachie and his colleagues said that detection of an abnormal trajectory by means of early and ongoing serial FEV₁ monitoring may help identify children and young adults at risk for abnormal lung-function growth that could lead to chronic airflow obstruction in adulthood.

Funding for this project was provided by grants from the Parker B. Francis Foundation, the National Institutes of Health, the National Human Genome Research Institute, and the Human Frontier Science Program Organization. Dr. McGeachie reported grant support from one of the funding sources during the conduct of the study. Nineteen coauthors reported they had nothing to disclose and the remainder either reported grant support or ties to industry sources.

When it comes to predictive demographic and clinical factors associated with abnormal patterns of lung growth and decline in those with persistent, mild-to-moderate asthma in childhood, male sex and childhood levels of lung function as assessed by the forced expiratory volume in 1 second (FEV1) make all the difference, according to the results of a study published in the New England Journal of Medicine.

“Determinants of abnormal patterns of FEV₁ growth and decline are multifactorial and complex, and identification of factors associated with the timing of a decline from the maximal level requires longitudinal data,” said author Michael McGeachie, Ph.D., of Brigham and Women’s Hospital, Boston, and his colleagues.

©Sergey Nivens/thinkstockphotos

To identify these determinants, particularly in those with asthma, Dr. McGeachie and colleagues analyzed longitudinal data from a subset of participants from the Childhood Asthma Management Program (CAMP) cohort who were followed from enrollment at the age of 5 to 12 years, into the third decade of life. The trajectory of lung growth and the decline from maximum growth in this large cohort of persons who had persistent, mild-to-moderate asthma in childhood were compared against those from persons without asthma who were participants in the third National Health and Nutrition Examination Survey. (N Engl J Med. 2016;374:1842-52).

Data from 684 participants from the CAMP cohort were assessed and 25% had normal lung-function growth without an early decline, 26% had normal growth and an early decline, 23% had reduced growth without an early decline, and 26% had reduced growth and an early decline. Results of the multinomial logistic-regression analysis of risk factors for abnormal patterns of lung growth and decline showed that the 26% of participants with reduced growth and an early decline had lower FEV₁ lung function at enrollment and were more likely to be male, compared with those who had normal growth.

Additional study results indicated that 18% of the participants who had reduced lung-function growth, with or without an early decline, met the case definition for chronic obstructive pulmonary disease (COPD) based on the postbronchodilator spirometric criteria at an age of less than 30 years.

Based on their data, Dr. McGeachie and his colleagues said that detection of an abnormal trajectory by means of early and ongoing serial FEV₁ monitoring may help identify children and young adults at risk for abnormal lung-function growth that could lead to chronic airflow obstruction in adulthood.

Funding for this project was provided by grants from the Parker B. Francis Foundation, the National Institutes of Health, the National Human Genome Research Institute, and the Human Frontier Science Program Organization. Dr. McGeachie reported grant support from one of the funding sources during the conduct of the study. Nineteen coauthors reported they had nothing to disclose and the remainder either reported grant support or ties to industry sources.

The digital May issue of ACS Surgery News is available online. Use the mobile app to download or view as a pdf.

The growing problem with reproducibility and sloppy use of statistical tools in biomedical research is the topic of this month’s feature. Even lab mice can be the sources of misleading research results. Dr. Peter Angelos reflects on what all this can mean for surgical research.

Don’t miss Dr. Tyler Hughes’s lighthearted look at a fictional surgeon of the future, Dr. ‘Bones’ McCoy, and how some of Dr. McCoy’s challenges are all too familiar to today’s surgeons.

This issue has news from on-site coverage of the annual meetings of the American Association of Endocrine Surgeons, the American Surgical Association, and the Central Surgical Association.

The digital May issue of ACS Surgery News is available online. Use the mobile app to download or view as a pdf.

The growing problem with reproducibility and sloppy use of statistical tools in biomedical research is the topic of this month’s feature. Even lab mice can be the sources of misleading research results. Dr. Peter Angelos reflects on what all this can mean for surgical research.

Don’t miss Dr. Tyler Hughes’s lighthearted look at a fictional surgeon of the future, Dr. ‘Bones’ McCoy, and how some of Dr. McCoy’s challenges are all too familiar to today’s surgeons.

This issue has news from on-site coverage of the annual meetings of the American Association of Endocrine Surgeons, the American Surgical Association, and the Central Surgical Association.

The digital May issue of ACS Surgery News is available online. Use the mobile app to download or view as a pdf.

The growing problem with reproducibility and sloppy use of statistical tools in biomedical research is the topic of this month’s feature. Even lab mice can be the sources of misleading research results. Dr. Peter Angelos reflects on what all this can mean for surgical research.

Don’t miss Dr. Tyler Hughes’s lighthearted look at a fictional surgeon of the future, Dr. ‘Bones’ McCoy, and how some of Dr. McCoy’s challenges are all too familiar to today’s surgeons.

This issue has news from on-site coverage of the annual meetings of the American Association of Endocrine Surgeons, the American Surgical Association, and the Central Surgical Association.

CHICAGO – Atrial fibrillation with good heart rate control in patients who have heart failure with preserved ejection fraction is independently associated with exercise intolerance, impaired contractile reserve, and a sharply higher mortality rate than in matched HFpEF patients without the arrhythmia, a retrospective analysis showed.

“Our study, the largest of its kind, provides mechanistic evidence from cardiopulmonary testing that a rhythm control strategy may potentially improve peak exercise capacity and survival in this patient population, a finding that of course requires future prospective appraisal in randomized trials comparing rate and rhythm control of atrial fibrillation in HFpEF,” Dr. Mohamed Badreldin Elshazly reported at the annual meeting of the American College of Cardiology.

Bruce Jancin/Frontline Medical News

In the meantime, his study also shows the useful role cardiopulmonary stress testing can play in the setting of atrial fibrillation (AF) in HFpEF, he added.

“Cardiopulmonary stress tests are cheap and easy to do. They’re a big asset for personalized medicine. Using an objective measure like cardiopulmonary stress testing to define the physiologic and hemodynamic consequences of atrial fibrillation in individual patients may help identify those in whom rhythm control may improve exercise tolerance and quality of life, and those who may be okay with rate control,” according to Dr. Elshazly of the Cleveland Clinic.

He noted that while it’s well established that atrial fibrillation is associated with exercise intolerance in patients with heart failure with reduced ejection fraction (HFrEF) and that restoration of sinus rhythm in such patients has a positive impact on exercise hemodynamics, symptom severity, and quality of life, the situation is murkier regarding AF in patients with HFpEF. Prior studies were generally small and unable to establish whether AF was independently associated with exercise intolerance or if HFpEF patients who developed AF were sicker and higher risk.

He presented a retrospective, case-control study in a cohort of 1,825 patients with HFpEF referred for maximal, symptom-limited cardiopulmonary stress testing at the Cleveland Clinic. Among these were 242 patients with AF. They were extensively propensity matched – including on the basis of heart failure etiology – to 484 HFpEF patients without AF.

“That’s what makes our study strong. We were the first to be able to do propensity matching and therefore account for other risk factors in our analysis,” Dr. Elshazly explained.

The investigators measured peak oxygen uptake (VO₂), the minute ventilation–carbon dioxide production relationship (V_E/V_CO2) as an indicator of ventilatory efficiency, metabolic equivalents (METS), ventilatory anaerobic threshold, circulatory power as a proxy for cardiac power, peak oxygen pulse as a surrogate for stroke volume, and resting and peak heart rate and systolic blood pressure. The patients with AF were in fibrillation at the time of their cardiopulmonary stress testing.

The HFpEF patients with AF had a mean resting heart rate of 70 beats per minute and a peak rate of 130 bpm. This group showed evidence of impaired peak exercise tolerance as reflected in lower peak VO₂, oxygen pulse, and circulatory power at peak exercise. Their V_E/V_CO2 was higher, indicating impaired ventilatory efficiency. Notably, however, their submaximal exercise capacity was similar to the non-AF controls.

“Atrial fibrillation in these patients is really more of a disease that shows itself in patients when you take them to their peak exercise capacity,” he observed.

All-cause mortality was significantly higher in the AF as compared with no-AF patients with HFpEF. The mortality curves separated early and the divergence grew larger over the course of 8 years of follow-up.

One audience member pointed out that the large mortality difference between the two groups seems disproportionate to the rather modest differences in exercise capacity.

“It brings up an interesting point,” Dr. Elshazly replied. “Maybe the increase in total mortality that we see is being driven by other things besides cardiovascular mortality. Our data doesn’t capture the specific cause of death, be it cancer, for example, but it does raise the idea that this mortality difference is not all driven by cardiovascular mortality, but by atrial fibrillation.”

Dr. Elshazly reported having no financial conflicts of interest regarding his institutionally supported study.

[email protected]

CHICAGO – Atrial fibrillation with good heart rate control in patients who have heart failure with preserved ejection fraction is independently associated with exercise intolerance, impaired contractile reserve, and a sharply higher mortality rate than in matched HFpEF patients without the arrhythmia, a retrospective analysis showed.

“Our study, the largest of its kind, provides mechanistic evidence from cardiopulmonary testing that a rhythm control strategy may potentially improve peak exercise capacity and survival in this patient population, a finding that of course requires future prospective appraisal in randomized trials comparing rate and rhythm control of atrial fibrillation in HFpEF,” Dr. Mohamed Badreldin Elshazly reported at the annual meeting of the American College of Cardiology.

Bruce Jancin/Frontline Medical News

In the meantime, his study also shows the useful role cardiopulmonary stress testing can play in the setting of atrial fibrillation (AF) in HFpEF, he added.

“Cardiopulmonary stress tests are cheap and easy to do. They’re a big asset for personalized medicine. Using an objective measure like cardiopulmonary stress testing to define the physiologic and hemodynamic consequences of atrial fibrillation in individual patients may help identify those in whom rhythm control may improve exercise tolerance and quality of life, and those who may be okay with rate control,” according to Dr. Elshazly of the Cleveland Clinic.

He noted that while it’s well established that atrial fibrillation is associated with exercise intolerance in patients with heart failure with reduced ejection fraction (HFrEF) and that restoration of sinus rhythm in such patients has a positive impact on exercise hemodynamics, symptom severity, and quality of life, the situation is murkier regarding AF in patients with HFpEF. Prior studies were generally small and unable to establish whether AF was independently associated with exercise intolerance or if HFpEF patients who developed AF were sicker and higher risk.

He presented a retrospective, case-control study in a cohort of 1,825 patients with HFpEF referred for maximal, symptom-limited cardiopulmonary stress testing at the Cleveland Clinic. Among these were 242 patients with AF. They were extensively propensity matched – including on the basis of heart failure etiology – to 484 HFpEF patients without AF.

“That’s what makes our study strong. We were the first to be able to do propensity matching and therefore account for other risk factors in our analysis,” Dr. Elshazly explained.

The investigators measured peak oxygen uptake (VO₂), the minute ventilation–carbon dioxide production relationship (V_E/V_CO2) as an indicator of ventilatory efficiency, metabolic equivalents (METS), ventilatory anaerobic threshold, circulatory power as a proxy for cardiac power, peak oxygen pulse as a surrogate for stroke volume, and resting and peak heart rate and systolic blood pressure. The patients with AF were in fibrillation at the time of their cardiopulmonary stress testing.

The HFpEF patients with AF had a mean resting heart rate of 70 beats per minute and a peak rate of 130 bpm. This group showed evidence of impaired peak exercise tolerance as reflected in lower peak VO₂, oxygen pulse, and circulatory power at peak exercise. Their V_E/V_CO2 was higher, indicating impaired ventilatory efficiency. Notably, however, their submaximal exercise capacity was similar to the non-AF controls.

“Atrial fibrillation in these patients is really more of a disease that shows itself in patients when you take them to their peak exercise capacity,” he observed.

All-cause mortality was significantly higher in the AF as compared with no-AF patients with HFpEF. The mortality curves separated early and the divergence grew larger over the course of 8 years of follow-up.

One audience member pointed out that the large mortality difference between the two groups seems disproportionate to the rather modest differences in exercise capacity.

“It brings up an interesting point,” Dr. Elshazly replied. “Maybe the increase in total mortality that we see is being driven by other things besides cardiovascular mortality. Our data doesn’t capture the specific cause of death, be it cancer, for example, but it does raise the idea that this mortality difference is not all driven by cardiovascular mortality, but by atrial fibrillation.”

Dr. Elshazly reported having no financial conflicts of interest regarding his institutionally supported study.

[email protected]

CHICAGO – Atrial fibrillation with good heart rate control in patients who have heart failure with preserved ejection fraction is independently associated with exercise intolerance, impaired contractile reserve, and a sharply higher mortality rate than in matched HFpEF patients without the arrhythmia, a retrospective analysis showed.

“Our study, the largest of its kind, provides mechanistic evidence from cardiopulmonary testing that a rhythm control strategy may potentially improve peak exercise capacity and survival in this patient population, a finding that of course requires future prospective appraisal in randomized trials comparing rate and rhythm control of atrial fibrillation in HFpEF,” Dr. Mohamed Badreldin Elshazly reported at the annual meeting of the American College of Cardiology.

Bruce Jancin/Frontline Medical News

In the meantime, his study also shows the useful role cardiopulmonary stress testing can play in the setting of atrial fibrillation (AF) in HFpEF, he added.

“Cardiopulmonary stress tests are cheap and easy to do. They’re a big asset for personalized medicine. Using an objective measure like cardiopulmonary stress testing to define the physiologic and hemodynamic consequences of atrial fibrillation in individual patients may help identify those in whom rhythm control may improve exercise tolerance and quality of life, and those who may be okay with rate control,” according to Dr. Elshazly of the Cleveland Clinic.

He noted that while it’s well established that atrial fibrillation is associated with exercise intolerance in patients with heart failure with reduced ejection fraction (HFrEF) and that restoration of sinus rhythm in such patients has a positive impact on exercise hemodynamics, symptom severity, and quality of life, the situation is murkier regarding AF in patients with HFpEF. Prior studies were generally small and unable to establish whether AF was independently associated with exercise intolerance or if HFpEF patients who developed AF were sicker and higher risk.

He presented a retrospective, case-control study in a cohort of 1,825 patients with HFpEF referred for maximal, symptom-limited cardiopulmonary stress testing at the Cleveland Clinic. Among these were 242 patients with AF. They were extensively propensity matched – including on the basis of heart failure etiology – to 484 HFpEF patients without AF.

“That’s what makes our study strong. We were the first to be able to do propensity matching and therefore account for other risk factors in our analysis,” Dr. Elshazly explained.

The investigators measured peak oxygen uptake (VO₂), the minute ventilation–carbon dioxide production relationship (V_E/V_CO2) as an indicator of ventilatory efficiency, metabolic equivalents (METS), ventilatory anaerobic threshold, circulatory power as a proxy for cardiac power, peak oxygen pulse as a surrogate for stroke volume, and resting and peak heart rate and systolic blood pressure. The patients with AF were in fibrillation at the time of their cardiopulmonary stress testing.

The HFpEF patients with AF had a mean resting heart rate of 70 beats per minute and a peak rate of 130 bpm. This group showed evidence of impaired peak exercise tolerance as reflected in lower peak VO₂, oxygen pulse, and circulatory power at peak exercise. Their V_E/V_CO2 was higher, indicating impaired ventilatory efficiency. Notably, however, their submaximal exercise capacity was similar to the non-AF controls.

“Atrial fibrillation in these patients is really more of a disease that shows itself in patients when you take them to their peak exercise capacity,” he observed.

All-cause mortality was significantly higher in the AF as compared with no-AF patients with HFpEF. The mortality curves separated early and the divergence grew larger over the course of 8 years of follow-up.

One audience member pointed out that the large mortality difference between the two groups seems disproportionate to the rather modest differences in exercise capacity.

“It brings up an interesting point,” Dr. Elshazly replied. “Maybe the increase in total mortality that we see is being driven by other things besides cardiovascular mortality. Our data doesn’t capture the specific cause of death, be it cancer, for example, but it does raise the idea that this mortality difference is not all driven by cardiovascular mortality, but by atrial fibrillation.”

Dr. Elshazly reported having no financial conflicts of interest regarding his institutionally supported study.

[email protected]

SAN FRANCISCO – Lower doses and conservative applications eliminated phrenic nerve palsy with Medtronic’s Arctic Front Advance cryoballoon ablation catheter at the University of Florida, Gainesville.

Cardiologists there were accustomed to performing atrial fibrillation pulmonary vein isolation with the first-generation device – the Arctic Front – when they switched to the second-generation Advance catheter in 2012; they had 2 phrenic nerve palsies in the first 33 patients (6%), a doubling from the 2 cases in 74 patients (2.7%) with the first-generation device.

M. Alexander Otto/Frontline Medical News

The second-generation catheter is more powerful, with a cooling jet in the front of the balloon that delivers colder temperatures deeper into pulmonary veins. “We realized we needed to change the way we were using these catheters. You can use them safely, but you have to respect” their power, said lead investigator Dr. Robert Gibson.

“We reduced freezing times from 240 seconds to 180 seconds, and made that a hard rule. We limited the number of ablations” to two complete occlusions per vein, down from four to seven with the first-generation Arctic Front. “We also implemented a nadir cutoff to stop ablation when catheter temperatures fell below –55° C, and we tried to stay as proximal as possible to the pulmonary vein antra while still maintaining complete occlusion.” To help with that, cardiologists stopped using the 23-mm catheter, opting instead for the 28-mm catheter, Dr. Gibson said at the Heart Rhythm Society annual meeting.

Since making the changes, the team has performed 140 ablations, and there has not been a single phrenic nerve palsy. “We haven’t experienced a diaphragm paralysis” with the new approach. “We are very happy with these results. The changes make physiologic sense. You stay back; you use fewer freezes,” he said.

Phrenic nerve injury also decreased, from 3 cases in the first 33 second-generation patients (9%) to 9 in the 140 (6.4%) with the refined technique. Total phrenic nerve complications are now fewer in Gainesville than with the original, less powerful first-generation Arctic Front.

The team didn’t report ablation success with their new approach, but a 2015 review of Arctic Front Advance in more than 3,000 patients suggested long-term success with similar refinements (Heart Rhythm. 2015 Jul;12[7]:1658-66).

Patients in the University of Florida review were in their early 60s, on average, and about two-thirds were men. About 30% had prior ablations. Phrenic nerve injury was determined by continuous phrenic nerve stimulation and manual diaphragm palpation during cryoablation.

The investigators had no relevant financial disclosures. Medtronic helped with the statistical analysis.

[email protected]

SAN FRANCISCO – Lower doses and conservative applications eliminated phrenic nerve palsy with Medtronic’s Arctic Front Advance cryoballoon ablation catheter at the University of Florida, Gainesville.

Cardiologists there were accustomed to performing atrial fibrillation pulmonary vein isolation with the first-generation device – the Arctic Front – when they switched to the second-generation Advance catheter in 2012; they had 2 phrenic nerve palsies in the first 33 patients (6%), a doubling from the 2 cases in 74 patients (2.7%) with the first-generation device.

M. Alexander Otto/Frontline Medical News

The second-generation catheter is more powerful, with a cooling jet in the front of the balloon that delivers colder temperatures deeper into pulmonary veins. “We realized we needed to change the way we were using these catheters. You can use them safely, but you have to respect” their power, said lead investigator Dr. Robert Gibson.

“We reduced freezing times from 240 seconds to 180 seconds, and made that a hard rule. We limited the number of ablations” to two complete occlusions per vein, down from four to seven with the first-generation Arctic Front. “We also implemented a nadir cutoff to stop ablation when catheter temperatures fell below –55° C, and we tried to stay as proximal as possible to the pulmonary vein antra while still maintaining complete occlusion.” To help with that, cardiologists stopped using the 23-mm catheter, opting instead for the 28-mm catheter, Dr. Gibson said at the Heart Rhythm Society annual meeting.

Since making the changes, the team has performed 140 ablations, and there has not been a single phrenic nerve palsy. “We haven’t experienced a diaphragm paralysis” with the new approach. “We are very happy with these results. The changes make physiologic sense. You stay back; you use fewer freezes,” he said.

Phrenic nerve injury also decreased, from 3 cases in the first 33 second-generation patients (9%) to 9 in the 140 (6.4%) with the refined technique. Total phrenic nerve complications are now fewer in Gainesville than with the original, less powerful first-generation Arctic Front.

The team didn’t report ablation success with their new approach, but a 2015 review of Arctic Front Advance in more than 3,000 patients suggested long-term success with similar refinements (Heart Rhythm. 2015 Jul;12[7]:1658-66).

Patients in the University of Florida review were in their early 60s, on average, and about two-thirds were men. About 30% had prior ablations. Phrenic nerve injury was determined by continuous phrenic nerve stimulation and manual diaphragm palpation during cryoablation.

The investigators had no relevant financial disclosures. Medtronic helped with the statistical analysis.

[email protected]

SAN FRANCISCO – Lower doses and conservative applications eliminated phrenic nerve palsy with Medtronic’s Arctic Front Advance cryoballoon ablation catheter at the University of Florida, Gainesville.

Cardiologists there were accustomed to performing atrial fibrillation pulmonary vein isolation with the first-generation device – the Arctic Front – when they switched to the second-generation Advance catheter in 2012; they had 2 phrenic nerve palsies in the first 33 patients (6%), a doubling from the 2 cases in 74 patients (2.7%) with the first-generation device.

M. Alexander Otto/Frontline Medical News

The second-generation catheter is more powerful, with a cooling jet in the front of the balloon that delivers colder temperatures deeper into pulmonary veins. “We realized we needed to change the way we were using these catheters. You can use them safely, but you have to respect” their power, said lead investigator Dr. Robert Gibson.

“We reduced freezing times from 240 seconds to 180 seconds, and made that a hard rule. We limited the number of ablations” to two complete occlusions per vein, down from four to seven with the first-generation Arctic Front. “We also implemented a nadir cutoff to stop ablation when catheter temperatures fell below –55° C, and we tried to stay as proximal as possible to the pulmonary vein antra while still maintaining complete occlusion.” To help with that, cardiologists stopped using the 23-mm catheter, opting instead for the 28-mm catheter, Dr. Gibson said at the Heart Rhythm Society annual meeting.

Since making the changes, the team has performed 140 ablations, and there has not been a single phrenic nerve palsy. “We haven’t experienced a diaphragm paralysis” with the new approach. “We are very happy with these results. The changes make physiologic sense. You stay back; you use fewer freezes,” he said.

Phrenic nerve injury also decreased, from 3 cases in the first 33 second-generation patients (9%) to 9 in the 140 (6.4%) with the refined technique. Total phrenic nerve complications are now fewer in Gainesville than with the original, less powerful first-generation Arctic Front.

The team didn’t report ablation success with their new approach, but a 2015 review of Arctic Front Advance in more than 3,000 patients suggested long-term success with similar refinements (Heart Rhythm. 2015 Jul;12[7]:1658-66).

Patients in the University of Florida review were in their early 60s, on average, and about two-thirds were men. About 30% had prior ablations. Phrenic nerve injury was determined by continuous phrenic nerve stimulation and manual diaphragm palpation during cryoablation.

The investigators had no relevant financial disclosures. Medtronic helped with the statistical analysis.

[email protected]