General Thoracic

DENVER – Do you need a stethoscope, a blood pressure monitor, or a tool to assess cardiac rhythms? There are apps for that. In fact, by recent count there are more than 200,000 applications of technology – or "apps" – available for smartphones or tablet devices, and they’re being used more and more for medical purposes.

Need a convenient way to look up drug interactions, pediatric dosing, or clinical decision rules from guidelines? Or how about a translator, a light to examine a finicky infant’s throat, or a "white board" to draw a picture for your patient? Yup – they’re all in apps, and chances are you already may be using some of these.

Dr. Joshua S. Broder expects an exponential increase in the use of apps in medicine as smartphones and tablets continue to proliferate, but their accuracy needs to be verified and potential problems need to be addressed, he said at the annual meeting of the American College of Emergency Physicians.

Apps will be used increasingly for bedside diagnosis and measurement of hemoglobin or other physiologic parameters. "Some of these tests may be taken over by smartphones in the near future," according to Dr. Broder of Duke University, Durham, N.C.

On the other hand, he cautioned, how do you sterilize a smartphone as you move from one hospital room or patient to another, so that you avoid transmitting infection? There are few independent studies so far testing the accuracy and reliability of medical apps, most of which were designed for lay consumers, not physicians.

The Food and Drug Administration is "very interested" in regulating any apps that might substitute for proven technologies such as stethoscopes or that physicians use as accessories to medical devices that already are regulated, he said. The FDA described its approach to deciding which mobile technology to regulate in a draft report in July 2012.

Even the basic functions of smartphones can be convenient in clinical practice, such as taking photos or videos and transmitting information by text or e-mail, but make sure you protect patient privacy and autonomy in ways that maintain trust and comply with HIPAA, Dr. Broder said.

The Duke University Health System has resolved any issues with HIPAA so that it’s safe for physicians to transmit images and video as long as they’re not sent outside the system. Talk to the HIPAA compliance officer at your medical center to establish the ground rules, he said. You can refresh your memory about which parts of data are considered by HIPAA to be protected information via a University of Miami site.

Dr. Broder reviewed some smartphone functions and apps that may be helpful and others that are not yet ready for medical prime time. Many are available for no cost or for as nominal fee. One study of health and fitness apps suggests that apps costing $0.99 or more tend to be higher quality and more trustworthy than less-expensive ones, he noted (J. Med. Internet Res. 2012;14:e72).

• Sleep: One of his residents swears by "smart alarm clock" apps that claim to use a smartphone’s accelerometer to assess where you are in your sleep cycle (based on your movements in bed) to wake you at a time that will leave you feeling less fatigued. You may set for 6 a.m., but the alarm may wake you at 5:45 a.m. Apps like Sleep Cycle ($0.99) and Sleep as Android have some underlying sleep science behind them, but no independent studies have verified their claims.

• CPR: The accelerometer also is used in the free app PocketCPR to give real-time feedback during CPR on the rate and depth of compression. Its has not been cleared by the FDA for use in humans, however, so the app warns that it’s meant for practice only. One prospective, randomized trial in 1,586 cardiac arrests that happened outside of hospitals found that use by emergency services personnel did not significantly change the likelihood of return of spontaneous circulation or other outcomes (BMJ 2011;342:d512).

• Chest: If you’re trying to teach students and residents about heart and lung sounds, or if you still get confused between mitral regurgitation and aortic stenosis, you might want to have a digital stethoscope app handy. These apps interpret heart and lung sounds heard typically through your smartphone’s microphone, which may not be good enough for clinical use. The Thinklabs Stethoscope app at $70 is pricey, compared with others, but it records sounds directly via the smartphone or through an attached electronic stethoscope.

A case that turns an iPhone into an ECG device has been submitted to the FDA for approval. The AliveCor iPhone ECG is expected to sell for between $100 and $200, compared with the usual price tag of thousands of dollars for conventional ECG machines, according to PC Magazine.

One small prospective study of experimental software that programs an iPhone to detect atrial fibrillation by placing a patient’s finger over the camera lens showed it was 98% sensitive and nearly 100% specific in detecting atrial fibrillation (IEEE Trans. Biomed. Eng. 2012 [doi:10.1109/TBME.2012.2208112]).

• Translation: When your hospital’s interpreter isn’t available, a free app like Google Translate can help. You can write or speak in one language and your device will write and say the message in a wide selection of language. You’ll need a wireless Internet connection for some translation apps.

• Eye chart: Your office has an eye chart, but you can’t find it. Pull up an app like the free EyeChart on your smartphone or tablet.

• Light: You want to inspect a patient’s sore throat, but the light in the exam room is broken. Use the flash on your smartphone camera, or use one of many free "flashlight" apps that turn the smartphone screen into a light source. Be sure to turn it off when you’re done, though, or your battery will run down quickly.

• Ultrasound: The miniaturization of ultrasound devices continues, with systems like the Mobisante MoblUS that attaches a probe to show images on your smartphone screen.

• Skin: For better evaluation of skin lesions, turn your iPhone into a dermatoscope by using the DermScope app ($4.99) and attaching the phone to the DermScope hardware (sold separately).

• Decision support: The PediStat app ($2.99 and up) makes it easy to determine the right pediatric drug dosing, among other features. The free Calculate (Medical Calculator) by QxMD app provides quick intuitive guides to common decision rules and can be customized by medical specialty.

• Drugs: Look up drug dosing, side effects, interactions and other information on free apps from Micromedex and others.

• Photos/videos: These apps are handy for documenting and sharing the appearance of a wound, a patient’s range of motion, or performance on a neurologic exam. Anyone who thinks they see uvula deviation in the throat of a struggling 3-year-old can snap a photo or video for review with other health care providers, medical students, or parents and avoid having to repeat the exam. Images of a wound problem after surgery can be sent to the surgeon when he or she is out of town.

Dr. Broder particularly finds the video useful for children having "pseudoseizures" whose parents demand a neurologic consult, even though the seizure event probably won’t be happening when the neurologist arrives. A video shows the neurologist exactly what Dr. Broder saw. (See the Dos and Don’ts for using photos and videos below.)

Once you’ve got an image or data you want to transmit, avoid texting as first-line means of communication because texts typically are not encrypted. Be careful when e-mailing to make sure it’s going to the correct address and only that address. Use e-mail options such as "confirm delivery" or "request read receipt," and add a sentence to the e-mail saying, "Please delete once no longer necessary for patient care," he advised.

Always document in the patient’s chart that you obtained patient consent and describe what was sent and who received it. Describe any images you send.

Don’t leave images on your portable devices. They’re easily lost, and most have inadequate encryption. Make images part of the medical record by uploading to the patient’s record, printing and scanning, or describing them clearly in the medical record. Then delete them from your device.

Store images and data in "cloud" computing sites with caution, Dr. Broder said. Services such as Google Drive or Dropbox allow sharing of very large files but provide no assurances about the quality of encryption or security. Cloud sites may be best used for giving patients access to instructions, instructional videos, reference papers, anatomic diagrams, etc.

The FDA approved the free Centricity Radiology Mobile Access app, which lets you view CT and MRI images on your iPhone if the images are stored in a GE Centricity PACS (picture archiving and communication system) platform – which may include 20% of U.S. radiology images, according to the company.

Sherry Boschert/IMNG Medical Media A screen shot shows the Centricity Radiology Mobile Access app.

The free CloudOn app lets you use MS Office software (including Word, Excel, and Powerpoint) on an iPad.

Various screen replicators that allow you to remotely access your computer desktop from your mobile device (such as ones by Citrix, or Splashtop Remote Desktop) all have the same problem, Dr. Broder said – they’re too clunky and not "touchscreen friendly."

And one final word on an underappreciated perk of medical apps on smartphones: When your medical director stops by, wanting to talk about your productivity, pull out your smartphone to show the data you’ve entered about patient encounters in your free iRVU app, which calculates total RVUs, charges, and average charge per encounter, among other features.

This list only begins to scratch the surface of app use in medicine. Other apps are available for immunization schedules, dictation, infectious disease guides, and teaching aids. Journals provide content to portable devices through apps, and some medical societies offer multifaceted apps such as ACEP Mobile.

Apps on smartphones and tablets will become part of daily medical practice, Dr. Broder predicted, but physicians need to be conscious about their limitations and potential problems as well as their assets.

Click here to view a video interview with Dr. Broder.

Dos and Don’ts for Medical Images on Smartphones

Do:

Obtain consent to acquire images or transmit them for the patient’s medical benefit.

Explain to the patient and get consent for any other intended use, such as education or publication.

Tell the patient what you will do with images when their use is completed – delete them or upload them to the medical record.

Confirm receipt if you send to other health care providers.

Specify in your message what that provider should do with the image.

Document in the patient’s chart that consent was obtained, what was sent, who received it, and content of the images.

Don’t:

Obtain images covertly.

Send to any unnecessary recipients.

Show images to anyone for fun.

Post to social media sites.

Blog about "funny" patient encounters.

Dr. Broder owns stock in Apple.

DENVER – Do you need a stethoscope, a blood pressure monitor, or a tool to assess cardiac rhythms? There are apps for that. In fact, by recent count there are more than 200,000 applications of technology – or "apps" – available for smartphones or tablet devices, and they’re being used more and more for medical purposes.

Need a convenient way to look up drug interactions, pediatric dosing, or clinical decision rules from guidelines? Or how about a translator, a light to examine a finicky infant’s throat, or a "white board" to draw a picture for your patient? Yup – they’re all in apps, and chances are you already may be using some of these.

Dr. Joshua S. Broder expects an exponential increase in the use of apps in medicine as smartphones and tablets continue to proliferate, but their accuracy needs to be verified and potential problems need to be addressed, he said at the annual meeting of the American College of Emergency Physicians.

Apps will be used increasingly for bedside diagnosis and measurement of hemoglobin or other physiologic parameters. "Some of these tests may be taken over by smartphones in the near future," according to Dr. Broder of Duke University, Durham, N.C.

On the other hand, he cautioned, how do you sterilize a smartphone as you move from one hospital room or patient to another, so that you avoid transmitting infection? There are few independent studies so far testing the accuracy and reliability of medical apps, most of which were designed for lay consumers, not physicians.

The Food and Drug Administration is "very interested" in regulating any apps that might substitute for proven technologies such as stethoscopes or that physicians use as accessories to medical devices that already are regulated, he said. The FDA described its approach to deciding which mobile technology to regulate in a draft report in July 2012.

Even the basic functions of smartphones can be convenient in clinical practice, such as taking photos or videos and transmitting information by text or e-mail, but make sure you protect patient privacy and autonomy in ways that maintain trust and comply with HIPAA, Dr. Broder said.

The Duke University Health System has resolved any issues with HIPAA so that it’s safe for physicians to transmit images and video as long as they’re not sent outside the system. Talk to the HIPAA compliance officer at your medical center to establish the ground rules, he said. You can refresh your memory about which parts of data are considered by HIPAA to be protected information via a University of Miami site.

Dr. Broder reviewed some smartphone functions and apps that may be helpful and others that are not yet ready for medical prime time. Many are available for no cost or for as nominal fee. One study of health and fitness apps suggests that apps costing $0.99 or more tend to be higher quality and more trustworthy than less-expensive ones, he noted (J. Med. Internet Res. 2012;14:e72).

• Sleep: One of his residents swears by "smart alarm clock" apps that claim to use a smartphone’s accelerometer to assess where you are in your sleep cycle (based on your movements in bed) to wake you at a time that will leave you feeling less fatigued. You may set for 6 a.m., but the alarm may wake you at 5:45 a.m. Apps like Sleep Cycle ($0.99) and Sleep as Android have some underlying sleep science behind them, but no independent studies have verified their claims.

• CPR: The accelerometer also is used in the free app PocketCPR to give real-time feedback during CPR on the rate and depth of compression. Its has not been cleared by the FDA for use in humans, however, so the app warns that it’s meant for practice only. One prospective, randomized trial in 1,586 cardiac arrests that happened outside of hospitals found that use by emergency services personnel did not significantly change the likelihood of return of spontaneous circulation or other outcomes (BMJ 2011;342:d512).

• Chest: If you’re trying to teach students and residents about heart and lung sounds, or if you still get confused between mitral regurgitation and aortic stenosis, you might want to have a digital stethoscope app handy. These apps interpret heart and lung sounds heard typically through your smartphone’s microphone, which may not be good enough for clinical use. The Thinklabs Stethoscope app at $70 is pricey, compared with others, but it records sounds directly via the smartphone or through an attached electronic stethoscope.

A case that turns an iPhone into an ECG device has been submitted to the FDA for approval. The AliveCor iPhone ECG is expected to sell for between $100 and $200, compared with the usual price tag of thousands of dollars for conventional ECG machines, according to PC Magazine.

One small prospective study of experimental software that programs an iPhone to detect atrial fibrillation by placing a patient’s finger over the camera lens showed it was 98% sensitive and nearly 100% specific in detecting atrial fibrillation (IEEE Trans. Biomed. Eng. 2012 [doi:10.1109/TBME.2012.2208112]).

• Translation: When your hospital’s interpreter isn’t available, a free app like Google Translate can help. You can write or speak in one language and your device will write and say the message in a wide selection of language. You’ll need a wireless Internet connection for some translation apps.

• Eye chart: Your office has an eye chart, but you can’t find it. Pull up an app like the free EyeChart on your smartphone or tablet.

• Light: You want to inspect a patient’s sore throat, but the light in the exam room is broken. Use the flash on your smartphone camera, or use one of many free "flashlight" apps that turn the smartphone screen into a light source. Be sure to turn it off when you’re done, though, or your battery will run down quickly.

• Ultrasound: The miniaturization of ultrasound devices continues, with systems like the Mobisante MoblUS that attaches a probe to show images on your smartphone screen.

• Skin: For better evaluation of skin lesions, turn your iPhone into a dermatoscope by using the DermScope app ($4.99) and attaching the phone to the DermScope hardware (sold separately).

• Decision support: The PediStat app ($2.99 and up) makes it easy to determine the right pediatric drug dosing, among other features. The free Calculate (Medical Calculator) by QxMD app provides quick intuitive guides to common decision rules and can be customized by medical specialty.

• Drugs: Look up drug dosing, side effects, interactions and other information on free apps from Micromedex and others.

• Photos/videos: These apps are handy for documenting and sharing the appearance of a wound, a patient’s range of motion, or performance on a neurologic exam. Anyone who thinks they see uvula deviation in the throat of a struggling 3-year-old can snap a photo or video for review with other health care providers, medical students, or parents and avoid having to repeat the exam. Images of a wound problem after surgery can be sent to the surgeon when he or she is out of town.

Dr. Broder particularly finds the video useful for children having "pseudoseizures" whose parents demand a neurologic consult, even though the seizure event probably won’t be happening when the neurologist arrives. A video shows the neurologist exactly what Dr. Broder saw. (See the Dos and Don’ts for using photos and videos below.)

Once you’ve got an image or data you want to transmit, avoid texting as first-line means of communication because texts typically are not encrypted. Be careful when e-mailing to make sure it’s going to the correct address and only that address. Use e-mail options such as "confirm delivery" or "request read receipt," and add a sentence to the e-mail saying, "Please delete once no longer necessary for patient care," he advised.

Always document in the patient’s chart that you obtained patient consent and describe what was sent and who received it. Describe any images you send.

Don’t leave images on your portable devices. They’re easily lost, and most have inadequate encryption. Make images part of the medical record by uploading to the patient’s record, printing and scanning, or describing them clearly in the medical record. Then delete them from your device.

Store images and data in "cloud" computing sites with caution, Dr. Broder said. Services such as Google Drive or Dropbox allow sharing of very large files but provide no assurances about the quality of encryption or security. Cloud sites may be best used for giving patients access to instructions, instructional videos, reference papers, anatomic diagrams, etc.

The FDA approved the free Centricity Radiology Mobile Access app, which lets you view CT and MRI images on your iPhone if the images are stored in a GE Centricity PACS (picture archiving and communication system) platform – which may include 20% of U.S. radiology images, according to the company.

Sherry Boschert/IMNG Medical Media A screen shot shows the Centricity Radiology Mobile Access app.

The free CloudOn app lets you use MS Office software (including Word, Excel, and Powerpoint) on an iPad.

Various screen replicators that allow you to remotely access your computer desktop from your mobile device (such as ones by Citrix, or Splashtop Remote Desktop) all have the same problem, Dr. Broder said – they’re too clunky and not "touchscreen friendly."

And one final word on an underappreciated perk of medical apps on smartphones: When your medical director stops by, wanting to talk about your productivity, pull out your smartphone to show the data you’ve entered about patient encounters in your free iRVU app, which calculates total RVUs, charges, and average charge per encounter, among other features.

This list only begins to scratch the surface of app use in medicine. Other apps are available for immunization schedules, dictation, infectious disease guides, and teaching aids. Journals provide content to portable devices through apps, and some medical societies offer multifaceted apps such as ACEP Mobile.

Apps on smartphones and tablets will become part of daily medical practice, Dr. Broder predicted, but physicians need to be conscious about their limitations and potential problems as well as their assets.

Click here to view a video interview with Dr. Broder.

Dos and Don’ts for Medical Images on Smartphones

Do:

Obtain consent to acquire images or transmit them for the patient’s medical benefit.

Explain to the patient and get consent for any other intended use, such as education or publication.

Tell the patient what you will do with images when their use is completed – delete them or upload them to the medical record.

Confirm receipt if you send to other health care providers.

Specify in your message what that provider should do with the image.

Document in the patient’s chart that consent was obtained, what was sent, who received it, and content of the images.

Don’t:

Obtain images covertly.

Send to any unnecessary recipients.

Show images to anyone for fun.

Post to social media sites.

Blog about "funny" patient encounters.

Dr. Broder owns stock in Apple.

DENVER – Do you need a stethoscope, a blood pressure monitor, or a tool to assess cardiac rhythms? There are apps for that. In fact, by recent count there are more than 200,000 applications of technology – or "apps" – available for smartphones or tablet devices, and they’re being used more and more for medical purposes.

Need a convenient way to look up drug interactions, pediatric dosing, or clinical decision rules from guidelines? Or how about a translator, a light to examine a finicky infant’s throat, or a "white board" to draw a picture for your patient? Yup – they’re all in apps, and chances are you already may be using some of these.

Dr. Joshua S. Broder expects an exponential increase in the use of apps in medicine as smartphones and tablets continue to proliferate, but their accuracy needs to be verified and potential problems need to be addressed, he said at the annual meeting of the American College of Emergency Physicians.

Apps will be used increasingly for bedside diagnosis and measurement of hemoglobin or other physiologic parameters. "Some of these tests may be taken over by smartphones in the near future," according to Dr. Broder of Duke University, Durham, N.C.

On the other hand, he cautioned, how do you sterilize a smartphone as you move from one hospital room or patient to another, so that you avoid transmitting infection? There are few independent studies so far testing the accuracy and reliability of medical apps, most of which were designed for lay consumers, not physicians.

The Food and Drug Administration is "very interested" in regulating any apps that might substitute for proven technologies such as stethoscopes or that physicians use as accessories to medical devices that already are regulated, he said. The FDA described its approach to deciding which mobile technology to regulate in a draft report in July 2012.

Even the basic functions of smartphones can be convenient in clinical practice, such as taking photos or videos and transmitting information by text or e-mail, but make sure you protect patient privacy and autonomy in ways that maintain trust and comply with HIPAA, Dr. Broder said.

The Duke University Health System has resolved any issues with HIPAA so that it’s safe for physicians to transmit images and video as long as they’re not sent outside the system. Talk to the HIPAA compliance officer at your medical center to establish the ground rules, he said. You can refresh your memory about which parts of data are considered by HIPAA to be protected information via a University of Miami site.

Dr. Broder reviewed some smartphone functions and apps that may be helpful and others that are not yet ready for medical prime time. Many are available for no cost or for as nominal fee. One study of health and fitness apps suggests that apps costing $0.99 or more tend to be higher quality and more trustworthy than less-expensive ones, he noted (J. Med. Internet Res. 2012;14:e72).

• Sleep: One of his residents swears by "smart alarm clock" apps that claim to use a smartphone’s accelerometer to assess where you are in your sleep cycle (based on your movements in bed) to wake you at a time that will leave you feeling less fatigued. You may set for 6 a.m., but the alarm may wake you at 5:45 a.m. Apps like Sleep Cycle ($0.99) and Sleep as Android have some underlying sleep science behind them, but no independent studies have verified their claims.

• CPR: The accelerometer also is used in the free app PocketCPR to give real-time feedback during CPR on the rate and depth of compression. Its has not been cleared by the FDA for use in humans, however, so the app warns that it’s meant for practice only. One prospective, randomized trial in 1,586 cardiac arrests that happened outside of hospitals found that use by emergency services personnel did not significantly change the likelihood of return of spontaneous circulation or other outcomes (BMJ 2011;342:d512).

• Chest: If you’re trying to teach students and residents about heart and lung sounds, or if you still get confused between mitral regurgitation and aortic stenosis, you might want to have a digital stethoscope app handy. These apps interpret heart and lung sounds heard typically through your smartphone’s microphone, which may not be good enough for clinical use. The Thinklabs Stethoscope app at $70 is pricey, compared with others, but it records sounds directly via the smartphone or through an attached electronic stethoscope.

A case that turns an iPhone into an ECG device has been submitted to the FDA for approval. The AliveCor iPhone ECG is expected to sell for between $100 and $200, compared with the usual price tag of thousands of dollars for conventional ECG machines, according to PC Magazine.

One small prospective study of experimental software that programs an iPhone to detect atrial fibrillation by placing a patient’s finger over the camera lens showed it was 98% sensitive and nearly 100% specific in detecting atrial fibrillation (IEEE Trans. Biomed. Eng. 2012 [doi:10.1109/TBME.2012.2208112]).

• Translation: When your hospital’s interpreter isn’t available, a free app like Google Translate can help. You can write or speak in one language and your device will write and say the message in a wide selection of language. You’ll need a wireless Internet connection for some translation apps.

• Eye chart: Your office has an eye chart, but you can’t find it. Pull up an app like the free EyeChart on your smartphone or tablet.

• Light: You want to inspect a patient’s sore throat, but the light in the exam room is broken. Use the flash on your smartphone camera, or use one of many free "flashlight" apps that turn the smartphone screen into a light source. Be sure to turn it off when you’re done, though, or your battery will run down quickly.

• Ultrasound: The miniaturization of ultrasound devices continues, with systems like the Mobisante MoblUS that attaches a probe to show images on your smartphone screen.

• Skin: For better evaluation of skin lesions, turn your iPhone into a dermatoscope by using the DermScope app ($4.99) and attaching the phone to the DermScope hardware (sold separately).

• Decision support: The PediStat app ($2.99 and up) makes it easy to determine the right pediatric drug dosing, among other features. The free Calculate (Medical Calculator) by QxMD app provides quick intuitive guides to common decision rules and can be customized by medical specialty.

• Drugs: Look up drug dosing, side effects, interactions and other information on free apps from Micromedex and others.

• Photos/videos: These apps are handy for documenting and sharing the appearance of a wound, a patient’s range of motion, or performance on a neurologic exam. Anyone who thinks they see uvula deviation in the throat of a struggling 3-year-old can snap a photo or video for review with other health care providers, medical students, or parents and avoid having to repeat the exam. Images of a wound problem after surgery can be sent to the surgeon when he or she is out of town.

Dr. Broder particularly finds the video useful for children having "pseudoseizures" whose parents demand a neurologic consult, even though the seizure event probably won’t be happening when the neurologist arrives. A video shows the neurologist exactly what Dr. Broder saw. (See the Dos and Don’ts for using photos and videos below.)

Once you’ve got an image or data you want to transmit, avoid texting as first-line means of communication because texts typically are not encrypted. Be careful when e-mailing to make sure it’s going to the correct address and only that address. Use e-mail options such as "confirm delivery" or "request read receipt," and add a sentence to the e-mail saying, "Please delete once no longer necessary for patient care," he advised.

Always document in the patient’s chart that you obtained patient consent and describe what was sent and who received it. Describe any images you send.

Don’t leave images on your portable devices. They’re easily lost, and most have inadequate encryption. Make images part of the medical record by uploading to the patient’s record, printing and scanning, or describing them clearly in the medical record. Then delete them from your device.

Store images and data in "cloud" computing sites with caution, Dr. Broder said. Services such as Google Drive or Dropbox allow sharing of very large files but provide no assurances about the quality of encryption or security. Cloud sites may be best used for giving patients access to instructions, instructional videos, reference papers, anatomic diagrams, etc.

The FDA approved the free Centricity Radiology Mobile Access app, which lets you view CT and MRI images on your iPhone if the images are stored in a GE Centricity PACS (picture archiving and communication system) platform – which may include 20% of U.S. radiology images, according to the company.

Sherry Boschert/IMNG Medical Media A screen shot shows the Centricity Radiology Mobile Access app.

The free CloudOn app lets you use MS Office software (including Word, Excel, and Powerpoint) on an iPad.

Various screen replicators that allow you to remotely access your computer desktop from your mobile device (such as ones by Citrix, or Splashtop Remote Desktop) all have the same problem, Dr. Broder said – they’re too clunky and not "touchscreen friendly."

And one final word on an underappreciated perk of medical apps on smartphones: When your medical director stops by, wanting to talk about your productivity, pull out your smartphone to show the data you’ve entered about patient encounters in your free iRVU app, which calculates total RVUs, charges, and average charge per encounter, among other features.

This list only begins to scratch the surface of app use in medicine. Other apps are available for immunization schedules, dictation, infectious disease guides, and teaching aids. Journals provide content to portable devices through apps, and some medical societies offer multifaceted apps such as ACEP Mobile.

Apps on smartphones and tablets will become part of daily medical practice, Dr. Broder predicted, but physicians need to be conscious about their limitations and potential problems as well as their assets.

Click here to view a video interview with Dr. Broder.

Dos and Don’ts for Medical Images on Smartphones

Do:

Obtain consent to acquire images or transmit them for the patient’s medical benefit.

Explain to the patient and get consent for any other intended use, such as education or publication.

Tell the patient what you will do with images when their use is completed – delete them or upload them to the medical record.

Confirm receipt if you send to other health care providers.

Specify in your message what that provider should do with the image.

Document in the patient’s chart that consent was obtained, what was sent, who received it, and content of the images.

Don’t:

Obtain images covertly.

Send to any unnecessary recipients.

Show images to anyone for fun.

Post to social media sites.

Blog about "funny" patient encounters.

Dr. Broder owns stock in Apple.

Advances in technology from new forms of operative procedures, medical treatment, and imaging to electronic health record systems are rapidly changing thoracic surgery practice and cost structure. In addition, new government and insurance initiatives are changing the playing field at the same time as a crisis in recruitment and an aging population threaten to create a shortage of thoracic surgeons. In the face of these changes, the need for strong and polished leadership at all levels becomes a necessity.

To address these new leadership demands, specific training has become an imperative, and the American Association for Thoracic Surgery (AATS) has taken the initiative in this area by sponsoring new courses to further empower the current and upcoming generation of leaders.

Courtesy of Heratch Photography

The Brandeis University Advanced Leadership Program held September 20-23 was sponsored by the AATS and was supported in part by an unrestricted educational grant from Covidien. It was provided through the Brandeis' Heller School?s Executive Education Program, which creates courses in conjunction with client input to provide leaders and upcoming leaders "with concepts and tools needed to impact policy and improve performance," according to the program website. The courses are designed to allow participants to "measure, assess, and benchmark performance, and build commitment to operational excellence. The interactive sessions build on existing expertise and experience, and spark new ideas and skills in a collegial environment with peers."

The program website also notes that "the current environment demands that physician leaders develop a balance of policy and management skills in order to be effective." This environment requires building knowledge and skills that will improve the performance of their teams and organization and increase their personal and professional satisfaction-and impact, according to Dr. Jon Chilingerian, Ph.D., director of the Heller School program.

Dr. John S. Ikonomidis, who is chief of the division of cardiothoracic surgery at the Medical University of South Carolina, Charleston, summarized his experience of the course: "Dr. Chilingerian oversaw a very fast-paced and concentrated learning experience. Numerous subjects such as collective intelligence and strategic thinking in health care, effective leadership styles, the care and process of patient flow, leading change, and conflict negotiation were covered in great detail." Formal presentations were supplemented with group breakout sessions and computer simulations and several guest lecturers also provided valuable and diverse perspectives, according to Dr. Ikonomidis.

"For me, the highlight of the course was the highly entertaining and informative lecture given by Stuart Altman on the history, current status, and future directions of federal health care management. This was truly a fantastic course that I would recommend to anyone interested in the science and practice of health care leadership," he added.

Dr. Michael J. Liptay, another course participant, stated that "With the changing landscape of health care and a perceived dearth of physician leaders, surgeons should be well positioned with our natural leadership ability. This course provided thoughtful advice in adapting from an autocratic style most familiar in the operating room to one of effective engaging leadership. The most important lesson for me was that the successful leader doesn?t spend time persuading everyone to buy into his vision; but rather frames and asks powerful questions en route to creating a respectful dialogue. Through this process emerges a consensus and commitment to strategic goals." Dr. Liptay is chief of the division of thoracic surgery and program director, Thoracic Surgery Residency, Rush University Medical Center, Chicago, and an associate medical editor for Thoracic Surgery News.

According to course participant Dr. Jean-Francois Legare, associate professor of surgery, Dalhousie University, Halifax, N.S.: "I wish I would have taken this type of course much earlier in my career. I see now many occasions where I made mistakes I could have avoided. I speak as a Canadian entering my mid-career and realizing that health administration is an essential part of my daily work. I now feel better equipped to handle and advocate for myself and my colleagues and defend our interests and the interests of our patients. I am very grateful of the opportunity that was offered to me to attend that course."

Dr. Kirk Kanter, chief of pediatric cardiac surgery, Emory University, Atlanta, who also participated, added: "I found the AATS leadership course to be extremely valuable and provocative. The ability to interact in the classroom with the faculty and with other cardiothoracic surgeons immensely enhanced the entire training program. It was an extremely valuable investment in time, and I hope that in the future I will be able to participate in similar courses. I recommend it highly to any cardiothoracic surgeon who is interested in not only the interaction with his colleagues (both surgeons and administrators) in the hospital, [but also] getting an insight into the health care system as a whole."

Dr. Kevin Lobdell of Levine Children?s Hospital of North Carolina, Charlotte, summarized the course: "Based on my experience and conversations with the international cadre of distinguished colleagues, it was highly regarded and an unmitigated success. It was valuable to leaders at various levels, fostering expansion of their education and professional horizons through the intimate and interactive process."

This AATS-sponsored course is in addition to the highly-rated AATS academy program held immediately prior to the AATS annual meeting each year. The academy, inaugurated in 2009, provides a didactic and interactive program for new and upcoming CT-surgeon leaders, including networking opportunities with the goal of building professional relationships and future mentoring possibilities with faculty members who have been selected based upon their expertise, according to the AATS.

None of the participant doctors quoted had a financial interest in the course.

Advances in technology from new forms of operative procedures, medical treatment, and imaging to electronic health record systems are rapidly changing thoracic surgery practice and cost structure. In addition, new government and insurance initiatives are changing the playing field at the same time as a crisis in recruitment and an aging population threaten to create a shortage of thoracic surgeons. In the face of these changes, the need for strong and polished leadership at all levels becomes a necessity.

To address these new leadership demands, specific training has become an imperative, and the American Association for Thoracic Surgery (AATS) has taken the initiative in this area by sponsoring new courses to further empower the current and upcoming generation of leaders.

Courtesy of Heratch Photography

The Brandeis University Advanced Leadership Program held September 20-23 was sponsored by the AATS and was supported in part by an unrestricted educational grant from Covidien. It was provided through the Brandeis' Heller School?s Executive Education Program, which creates courses in conjunction with client input to provide leaders and upcoming leaders "with concepts and tools needed to impact policy and improve performance," according to the program website. The courses are designed to allow participants to "measure, assess, and benchmark performance, and build commitment to operational excellence. The interactive sessions build on existing expertise and experience, and spark new ideas and skills in a collegial environment with peers."

The program website also notes that "the current environment demands that physician leaders develop a balance of policy and management skills in order to be effective." This environment requires building knowledge and skills that will improve the performance of their teams and organization and increase their personal and professional satisfaction-and impact, according to Dr. Jon Chilingerian, Ph.D., director of the Heller School program.

Dr. John S. Ikonomidis, who is chief of the division of cardiothoracic surgery at the Medical University of South Carolina, Charleston, summarized his experience of the course: "Dr. Chilingerian oversaw a very fast-paced and concentrated learning experience. Numerous subjects such as collective intelligence and strategic thinking in health care, effective leadership styles, the care and process of patient flow, leading change, and conflict negotiation were covered in great detail." Formal presentations were supplemented with group breakout sessions and computer simulations and several guest lecturers also provided valuable and diverse perspectives, according to Dr. Ikonomidis.

"For me, the highlight of the course was the highly entertaining and informative lecture given by Stuart Altman on the history, current status, and future directions of federal health care management. This was truly a fantastic course that I would recommend to anyone interested in the science and practice of health care leadership," he added.

Dr. Michael J. Liptay, another course participant, stated that "With the changing landscape of health care and a perceived dearth of physician leaders, surgeons should be well positioned with our natural leadership ability. This course provided thoughtful advice in adapting from an autocratic style most familiar in the operating room to one of effective engaging leadership. The most important lesson for me was that the successful leader doesn?t spend time persuading everyone to buy into his vision; but rather frames and asks powerful questions en route to creating a respectful dialogue. Through this process emerges a consensus and commitment to strategic goals." Dr. Liptay is chief of the division of thoracic surgery and program director, Thoracic Surgery Residency, Rush University Medical Center, Chicago, and an associate medical editor for Thoracic Surgery News.

According to course participant Dr. Jean-Francois Legare, associate professor of surgery, Dalhousie University, Halifax, N.S.: "I wish I would have taken this type of course much earlier in my career. I see now many occasions where I made mistakes I could have avoided. I speak as a Canadian entering my mid-career and realizing that health administration is an essential part of my daily work. I now feel better equipped to handle and advocate for myself and my colleagues and defend our interests and the interests of our patients. I am very grateful of the opportunity that was offered to me to attend that course."

Dr. Kirk Kanter, chief of pediatric cardiac surgery, Emory University, Atlanta, who also participated, added: "I found the AATS leadership course to be extremely valuable and provocative. The ability to interact in the classroom with the faculty and with other cardiothoracic surgeons immensely enhanced the entire training program. It was an extremely valuable investment in time, and I hope that in the future I will be able to participate in similar courses. I recommend it highly to any cardiothoracic surgeon who is interested in not only the interaction with his colleagues (both surgeons and administrators) in the hospital, [but also] getting an insight into the health care system as a whole."

Dr. Kevin Lobdell of Levine Children?s Hospital of North Carolina, Charlotte, summarized the course: "Based on my experience and conversations with the international cadre of distinguished colleagues, it was highly regarded and an unmitigated success. It was valuable to leaders at various levels, fostering expansion of their education and professional horizons through the intimate and interactive process."

This AATS-sponsored course is in addition to the highly-rated AATS academy program held immediately prior to the AATS annual meeting each year. The academy, inaugurated in 2009, provides a didactic and interactive program for new and upcoming CT-surgeon leaders, including networking opportunities with the goal of building professional relationships and future mentoring possibilities with faculty members who have been selected based upon their expertise, according to the AATS.

None of the participant doctors quoted had a financial interest in the course.

Advances in technology from new forms of operative procedures, medical treatment, and imaging to electronic health record systems are rapidly changing thoracic surgery practice and cost structure. In addition, new government and insurance initiatives are changing the playing field at the same time as a crisis in recruitment and an aging population threaten to create a shortage of thoracic surgeons. In the face of these changes, the need for strong and polished leadership at all levels becomes a necessity.

To address these new leadership demands, specific training has become an imperative, and the American Association for Thoracic Surgery (AATS) has taken the initiative in this area by sponsoring new courses to further empower the current and upcoming generation of leaders.

Courtesy of Heratch Photography

The Brandeis University Advanced Leadership Program held September 20-23 was sponsored by the AATS and was supported in part by an unrestricted educational grant from Covidien. It was provided through the Brandeis' Heller School?s Executive Education Program, which creates courses in conjunction with client input to provide leaders and upcoming leaders "with concepts and tools needed to impact policy and improve performance," according to the program website. The courses are designed to allow participants to "measure, assess, and benchmark performance, and build commitment to operational excellence. The interactive sessions build on existing expertise and experience, and spark new ideas and skills in a collegial environment with peers."

The program website also notes that "the current environment demands that physician leaders develop a balance of policy and management skills in order to be effective." This environment requires building knowledge and skills that will improve the performance of their teams and organization and increase their personal and professional satisfaction-and impact, according to Dr. Jon Chilingerian, Ph.D., director of the Heller School program.

Dr. John S. Ikonomidis, who is chief of the division of cardiothoracic surgery at the Medical University of South Carolina, Charleston, summarized his experience of the course: "Dr. Chilingerian oversaw a very fast-paced and concentrated learning experience. Numerous subjects such as collective intelligence and strategic thinking in health care, effective leadership styles, the care and process of patient flow, leading change, and conflict negotiation were covered in great detail." Formal presentations were supplemented with group breakout sessions and computer simulations and several guest lecturers also provided valuable and diverse perspectives, according to Dr. Ikonomidis.

"For me, the highlight of the course was the highly entertaining and informative lecture given by Stuart Altman on the history, current status, and future directions of federal health care management. This was truly a fantastic course that I would recommend to anyone interested in the science and practice of health care leadership," he added.

Dr. Michael J. Liptay, another course participant, stated that "With the changing landscape of health care and a perceived dearth of physician leaders, surgeons should be well positioned with our natural leadership ability. This course provided thoughtful advice in adapting from an autocratic style most familiar in the operating room to one of effective engaging leadership. The most important lesson for me was that the successful leader doesn?t spend time persuading everyone to buy into his vision; but rather frames and asks powerful questions en route to creating a respectful dialogue. Through this process emerges a consensus and commitment to strategic goals." Dr. Liptay is chief of the division of thoracic surgery and program director, Thoracic Surgery Residency, Rush University Medical Center, Chicago, and an associate medical editor for Thoracic Surgery News.

According to course participant Dr. Jean-Francois Legare, associate professor of surgery, Dalhousie University, Halifax, N.S.: "I wish I would have taken this type of course much earlier in my career. I see now many occasions where I made mistakes I could have avoided. I speak as a Canadian entering my mid-career and realizing that health administration is an essential part of my daily work. I now feel better equipped to handle and advocate for myself and my colleagues and defend our interests and the interests of our patients. I am very grateful of the opportunity that was offered to me to attend that course."

Dr. Kirk Kanter, chief of pediatric cardiac surgery, Emory University, Atlanta, who also participated, added: "I found the AATS leadership course to be extremely valuable and provocative. The ability to interact in the classroom with the faculty and with other cardiothoracic surgeons immensely enhanced the entire training program. It was an extremely valuable investment in time, and I hope that in the future I will be able to participate in similar courses. I recommend it highly to any cardiothoracic surgeon who is interested in not only the interaction with his colleagues (both surgeons and administrators) in the hospital, [but also] getting an insight into the health care system as a whole."

Dr. Kevin Lobdell of Levine Children?s Hospital of North Carolina, Charlotte, summarized the course: "Based on my experience and conversations with the international cadre of distinguished colleagues, it was highly regarded and an unmitigated success. It was valuable to leaders at various levels, fostering expansion of their education and professional horizons through the intimate and interactive process."

This AATS-sponsored course is in addition to the highly-rated AATS academy program held immediately prior to the AATS annual meeting each year. The academy, inaugurated in 2009, provides a didactic and interactive program for new and upcoming CT-surgeon leaders, including networking opportunities with the goal of building professional relationships and future mentoring possibilities with faculty members who have been selected based upon their expertise, according to the AATS.

None of the participant doctors quoted had a financial interest in the course.

Advances in technology from new forms of operative procedures, medical treatment, and imaging to electronic health record systems are rapidly changing thoracic surgery practice and cost structure. In addition, new government and insurance initiatives are changing the playing field at the same time as a crisis in recruitment and an aging population threaten to create a shortage of thoracic surgeons. In the face of these changes, the need for strong and polished leadership at all levels becomes a necessity.

To address these new leadership demands, specific training has become an imperative, and the American Association for Thoracic Surgery (AATS) has taken the initiative in this area by sponsoring new courses to further empower the current and upcoming generation of leaders.

Courtesy of Heratch Photography

The Brandeis University Advanced Leadership Program held September 20-23 was sponsored by the AATS and was supported in part by an unrestricted educational grant from Covidien. It was provided through the Brandeis' Heller School?s Executive Education Program, which creates courses in conjunction with client input to provide leaders and upcoming leaders "with concepts and tools needed to impact policy and improve performance," according to the program website. The courses are designed to allow participants to "measure, assess, and benchmark performance, and build commitment to operational excellence. The interactive sessions build on existing expertise and experience, and spark new ideas and skills in a collegial environment with peers."

The program website also notes that "the current environment demands that physician leaders develop a balance of policy and management skills in order to be effective." This environment requires building knowledge and skills that will improve the performance of their teams and organization and increase their personal and professional satisfaction-and impact, according to Dr. Jon Chilingerian, Ph.D., director of the Heller School program.

Dr. John S. Ikonomidis, who is chief of the division of cardiothoracic surgery at the Medical University of South Carolina, Charleston, summarized his experience of the course: "Dr. Chilingerian oversaw a very fast-paced and concentrated learning experience. Numerous subjects such as collective intelligence and strategic thinking in health care, effective leadership styles, the care and process of patient flow, leading change, and conflict negotiation were covered in great detail." Formal presentations were supplemented with group breakout sessions and computer simulations and several guest lecturers also provided valuable and diverse perspectives, according to Dr. Ikonomidis.

"For me, the highlight of the course was the highly entertaining and informative lecture given by Stuart Altman on the history, current status, and future directions of federal health care management. This was truly a fantastic course that I would recommend to anyone interested in the science and practice of health care leadership," he added.

Dr. Michael J. Liptay, another course participant, stated that "With the changing landscape of health care and a perceived dearth of physician leaders, surgeons should be well positioned with our natural leadership ability. This course provided thoughtful advice in adapting from an autocratic style most familiar in the operating room to one of effective engaging leadership. The most important lesson for me was that the successful leader doesn?t spend time persuading everyone to buy into his vision; but rather frames and asks powerful questions en route to creating a respectful dialogue. Through this process emerges a consensus and commitment to strategic goals." Dr. Liptay is chief of the division of thoracic surgery and program director, Thoracic Surgery Residency, Rush University Medical Center, Chicago, and an associate medical editor for Thoracic Surgery News.

According to course participant Dr. Jean-Francois Legare, associate professor of surgery, Dalhousie University, Halifax, N.S.: "I wish I would have taken this type of course much earlier in my career. I see now many occasions where I made mistakes I could have avoided. I speak as a Canadian entering my mid-career and realizing that health administration is an essential part of my daily work. I now feel better equipped to handle and advocate for myself and my colleagues and defend our interests and the interests of our patients. I am very grateful of the opportunity that was offered to me to attend that course."

Dr. Kirk Kanter, chief of pediatric cardiac surgery, Emory University, Atlanta, who also participated, added: "I found the AATS leadership course to be extremely valuable and provocative. The ability to interact in the classroom with the faculty and with other cardiothoracic surgeons immensely enhanced the entire training program. It was an extremely valuable investment in time, and I hope that in the future I will be able to participate in similar courses. I recommend it highly to any cardiothoracic surgeon who is interested in not only the interaction with his colleagues (both surgeons and administrators) in the hospital, [but also] getting an insight into the health care system as a whole."

Dr. Kevin Lobdell of Levine Children?s Hospital of North Carolina, Charlotte, summarized the course: "Based on my experience and conversations with the international cadre of distinguished colleagues, it was highly regarded and an unmitigated success. It was valuable to leaders at various levels, fostering expansion of their education and professional horizons through the intimate and interactive process."

This AATS-sponsored course is in addition to the highly-rated AATS academy program held immediately prior to the AATS annual meeting each year. The academy, inaugurated in 2009, provides a didactic and interactive program for new and upcoming CT-surgeon leaders, including networking opportunities with the goal of building professional relationships and future mentoring possibilities with faculty members who have been selected based upon their expertise, according to the AATS.

None of the participant doctors quoted had a financial interest in the course.

Advances in technology from new forms of operative procedures, medical treatment, and imaging to electronic health record systems are rapidly changing thoracic surgery practice and cost structure. In addition, new government and insurance initiatives are changing the playing field at the same time as a crisis in recruitment and an aging population threaten to create a shortage of thoracic surgeons. In the face of these changes, the need for strong and polished leadership at all levels becomes a necessity.

To address these new leadership demands, specific training has become an imperative, and the American Association for Thoracic Surgery (AATS) has taken the initiative in this area by sponsoring new courses to further empower the current and upcoming generation of leaders.

Courtesy of Heratch Photography

The Brandeis University Advanced Leadership Program held September 20-23 was sponsored by the AATS and was supported in part by an unrestricted educational grant from Covidien. It was provided through the Brandeis' Heller School?s Executive Education Program, which creates courses in conjunction with client input to provide leaders and upcoming leaders "with concepts and tools needed to impact policy and improve performance," according to the program website. The courses are designed to allow participants to "measure, assess, and benchmark performance, and build commitment to operational excellence. The interactive sessions build on existing expertise and experience, and spark new ideas and skills in a collegial environment with peers."

The program website also notes that "the current environment demands that physician leaders develop a balance of policy and management skills in order to be effective." This environment requires building knowledge and skills that will improve the performance of their teams and organization and increase their personal and professional satisfaction-and impact, according to Dr. Jon Chilingerian, Ph.D., director of the Heller School program.

Dr. John S. Ikonomidis, who is chief of the division of cardiothoracic surgery at the Medical University of South Carolina, Charleston, summarized his experience of the course: "Dr. Chilingerian oversaw a very fast-paced and concentrated learning experience. Numerous subjects such as collective intelligence and strategic thinking in health care, effective leadership styles, the care and process of patient flow, leading change, and conflict negotiation were covered in great detail." Formal presentations were supplemented with group breakout sessions and computer simulations and several guest lecturers also provided valuable and diverse perspectives, according to Dr. Ikonomidis.

"For me, the highlight of the course was the highly entertaining and informative lecture given by Stuart Altman on the history, current status, and future directions of federal health care management. This was truly a fantastic course that I would recommend to anyone interested in the science and practice of health care leadership," he added.

Dr. Michael J. Liptay, another course participant, stated that "With the changing landscape of health care and a perceived dearth of physician leaders, surgeons should be well positioned with our natural leadership ability. This course provided thoughtful advice in adapting from an autocratic style most familiar in the operating room to one of effective engaging leadership. The most important lesson for me was that the successful leader doesn?t spend time persuading everyone to buy into his vision; but rather frames and asks powerful questions en route to creating a respectful dialogue. Through this process emerges a consensus and commitment to strategic goals." Dr. Liptay is chief of the division of thoracic surgery and program director, Thoracic Surgery Residency, Rush University Medical Center, Chicago, and an associate medical editor for Thoracic Surgery News.

According to course participant Dr. Jean-Francois Legare, associate professor of surgery, Dalhousie University, Halifax, N.S.: "I wish I would have taken this type of course much earlier in my career. I see now many occasions where I made mistakes I could have avoided. I speak as a Canadian entering my mid-career and realizing that health administration is an essential part of my daily work. I now feel better equipped to handle and advocate for myself and my colleagues and defend our interests and the interests of our patients. I am very grateful of the opportunity that was offered to me to attend that course."

Dr. Kirk Kanter, chief of pediatric cardiac surgery, Emory University, Atlanta, who also participated, added: "I found the AATS leadership course to be extremely valuable and provocative. The ability to interact in the classroom with the faculty and with other cardiothoracic surgeons immensely enhanced the entire training program. It was an extremely valuable investment in time, and I hope that in the future I will be able to participate in similar courses. I recommend it highly to any cardiothoracic surgeon who is interested in not only the interaction with his colleagues (both surgeons and administrators) in the hospital, [but also] getting an insight into the health care system as a whole."

Dr. Kevin Lobdell of Levine Children?s Hospital of North Carolina, Charlotte, summarized the course: "Based on my experience and conversations with the international cadre of distinguished colleagues, it was highly regarded and an unmitigated success. It was valuable to leaders at various levels, fostering expansion of their education and professional horizons through the intimate and interactive process."

This AATS-sponsored course is in addition to the highly-rated AATS academy program held immediately prior to the AATS annual meeting each year. The academy, inaugurated in 2009, provides a didactic and interactive program for new and upcoming CT-surgeon leaders, including networking opportunities with the goal of building professional relationships and future mentoring possibilities with faculty members who have been selected based upon their expertise, according to the AATS.

None of the participant doctors quoted had a financial interest in the course.

Advances in technology from new forms of operative procedures, medical treatment, and imaging to electronic health record systems are rapidly changing thoracic surgery practice and cost structure. In addition, new government and insurance initiatives are changing the playing field at the same time as a crisis in recruitment and an aging population threaten to create a shortage of thoracic surgeons. In the face of these changes, the need for strong and polished leadership at all levels becomes a necessity.

To address these new leadership demands, specific training has become an imperative, and the American Association for Thoracic Surgery (AATS) has taken the initiative in this area by sponsoring new courses to further empower the current and upcoming generation of leaders.

Courtesy of Heratch Photography

The Brandeis University Advanced Leadership Program held September 20-23 was sponsored by the AATS and was supported in part by an unrestricted educational grant from Covidien. It was provided through the Brandeis' Heller School?s Executive Education Program, which creates courses in conjunction with client input to provide leaders and upcoming leaders "with concepts and tools needed to impact policy and improve performance," according to the program website. The courses are designed to allow participants to "measure, assess, and benchmark performance, and build commitment to operational excellence. The interactive sessions build on existing expertise and experience, and spark new ideas and skills in a collegial environment with peers."

The program website also notes that "the current environment demands that physician leaders develop a balance of policy and management skills in order to be effective." This environment requires building knowledge and skills that will improve the performance of their teams and organization and increase their personal and professional satisfaction-and impact, according to Dr. Jon Chilingerian, Ph.D., director of the Heller School program.

Dr. John S. Ikonomidis, who is chief of the division of cardiothoracic surgery at the Medical University of South Carolina, Charleston, summarized his experience of the course: "Dr. Chilingerian oversaw a very fast-paced and concentrated learning experience. Numerous subjects such as collective intelligence and strategic thinking in health care, effective leadership styles, the care and process of patient flow, leading change, and conflict negotiation were covered in great detail." Formal presentations were supplemented with group breakout sessions and computer simulations and several guest lecturers also provided valuable and diverse perspectives, according to Dr. Ikonomidis.

"For me, the highlight of the course was the highly entertaining and informative lecture given by Stuart Altman on the history, current status, and future directions of federal health care management. This was truly a fantastic course that I would recommend to anyone interested in the science and practice of health care leadership," he added.

Dr. Michael J. Liptay, another course participant, stated that "With the changing landscape of health care and a perceived dearth of physician leaders, surgeons should be well positioned with our natural leadership ability. This course provided thoughtful advice in adapting from an autocratic style most familiar in the operating room to one of effective engaging leadership. The most important lesson for me was that the successful leader doesn?t spend time persuading everyone to buy into his vision; but rather frames and asks powerful questions en route to creating a respectful dialogue. Through this process emerges a consensus and commitment to strategic goals." Dr. Liptay is chief of the division of thoracic surgery and program director, Thoracic Surgery Residency, Rush University Medical Center, Chicago, and an associate medical editor for Thoracic Surgery News.

According to course participant Dr. Jean-Francois Legare, associate professor of surgery, Dalhousie University, Halifax, N.S.: "I wish I would have taken this type of course much earlier in my career. I see now many occasions where I made mistakes I could have avoided. I speak as a Canadian entering my mid-career and realizing that health administration is an essential part of my daily work. I now feel better equipped to handle and advocate for myself and my colleagues and defend our interests and the interests of our patients. I am very grateful of the opportunity that was offered to me to attend that course."

Dr. Kirk Kanter, chief of pediatric cardiac surgery, Emory University, Atlanta, who also participated, added: "I found the AATS leadership course to be extremely valuable and provocative. The ability to interact in the classroom with the faculty and with other cardiothoracic surgeons immensely enhanced the entire training program. It was an extremely valuable investment in time, and I hope that in the future I will be able to participate in similar courses. I recommend it highly to any cardiothoracic surgeon who is interested in not only the interaction with his colleagues (both surgeons and administrators) in the hospital, [but also] getting an insight into the health care system as a whole."

Dr. Kevin Lobdell of Levine Children?s Hospital of North Carolina, Charlotte, summarized the course: "Based on my experience and conversations with the international cadre of distinguished colleagues, it was highly regarded and an unmitigated success. It was valuable to leaders at various levels, fostering expansion of their education and professional horizons through the intimate and interactive process."

This AATS-sponsored course is in addition to the highly-rated AATS academy program held immediately prior to the AATS annual meeting each year. The academy, inaugurated in 2009, provides a didactic and interactive program for new and upcoming CT-surgeon leaders, including networking opportunities with the goal of building professional relationships and future mentoring possibilities with faculty members who have been selected based upon their expertise, according to the AATS.

None of the participant doctors quoted had a financial interest in the course.

The 2008 Medicare policy to withhold payment for treating certain hospital-acquired infections failed to decrease infection rates in U.S. hospitals, according to a report published online in the New England Journal of Medicine.

In a study involving a total of 398 hospitals or medical systems across the country, implementing a Centers for Medicare and Medicaid Services policy of nonpayment for the treatment of preventable catheter-associated bloodstream infections and catheter-associated urinary tract infections appeared to have no impact at all on the acquisition of those infections, according to Dr. Ashish K. Jha of the department of health policy and management, Harvard School of Public Health, Boston, and his associates.

"As CMS continues to expand this policy to cover Medicaid through the Affordable Care Act, require public reporting of National Healthcare Safety Network [NHSN] data through the Hospital Compare website, and impose greater financial penalties on hospitals that perform poorly on these measures, careful evaluation is needed to determine when these programs work, when they have unintended consequences, and what might be done to improve patient outcomes," Dr. Jha noted.

Dr. Jha and his colleagues assessed data from the NHSN, a public health surveillance program for monitoring health care-associated infections across the country. A total of 1,166 nonfederal acute-care hospitals report their infection rates to this Centers for Disease Control and Prevention's sponsored network every month.

Dr. Jha and his colleagues assessed NHSN data on three different types of infection at 398 of those hospitals in 41 states. They examined central catheter-associated bloodstream and catheter-associated urinary tract infections because these are the two hospital-acquired infections for which CMS currently does not pay. They also looked at ventilator-associated pneumonia, which is not targeted by the CMS policy, as a control.

Rates of central catheter-associated bloodstream infections were already decreasing at the time the CMS policy was implemented, likely because the federal government, national organizations, and accrediting agencies had already focused attention on preventing these nosocomial infections. The rate of these infections was 4.8% per quarter before the policy was implemented and 4.7% afterward, a nonsignificant difference, the investigators said (N. Engl. J. Med. 2012 [doi:10.1056/NEJMsa1202419]).

This pattern also was seen with catheter-associated UTIs, in which there was a small, nonsignificant increase in the infection rate after implementation of the CMS policy. For the control condition of ventilator-associated pneumonia, the infection rate was 7.3% before implementation and 8.2% after implementation of the policy, also showing no significant impact on infection rates.

These findings were consistent across all hospital types, regardless of size, regional location, type of ownership, or teaching status.

To assess whether any benefit of the nonpayment policy may have been offset by strategies to lower infection rates, such as mandatory reporting, the researchers performed a separate analysis involving only the hospital units located in states that didn't have mandatory reporting. Again, no demonstrable effect on infection rates was seen.

To allow more time for hospitals to adapt to the policy change, the investigators performed a sensitivity analysis comparing infection rates 2 years after implementation with those before implementation. Again, they found no further decreases in the rates of any infections.

A possible explanation for these findings is that the amount of this financial disincentive was quite small. "Reductions in payment may have been equivalent to as little as 0.6% of Medicare revenue for the average hospital," Dr. Jha and his associates said.

"Greater financial penalties might induce a greater change in hospital responsiveness to the CMS policy."

The study results are particularly important given the increasing use of financial disincentives to improve the quality of health care. There is very little evidence that this strategy, or other pay-for-performance strategies, actually improves patient outcomes, the authors noted.

This study was supported by the Agency for Healthcare Research and Quality.

None of the authors reported having any financial conflicts of interest regarding this study.

The 2008 Medicare policy to withhold payment for treating certain hospital-acquired infections failed to decrease infection rates in U.S. hospitals, according to a report published online in the New England Journal of Medicine.

In a study involving a total of 398 hospitals or medical systems across the country, implementing a Centers for Medicare and Medicaid Services policy of nonpayment for the treatment of preventable catheter-associated bloodstream infections and catheter-associated urinary tract infections appeared to have no impact at all on the acquisition of those infections, according to Dr. Ashish K. Jha of the department of health policy and management, Harvard School of Public Health, Boston, and his associates.

"As CMS continues to expand this policy to cover Medicaid through the Affordable Care Act, require public reporting of National Healthcare Safety Network [NHSN] data through the Hospital Compare website, and impose greater financial penalties on hospitals that perform poorly on these measures, careful evaluation is needed to determine when these programs work, when they have unintended consequences, and what might be done to improve patient outcomes," Dr. Jha noted.

Dr. Jha and his colleagues assessed data from the NHSN, a public health surveillance program for monitoring health care-associated infections across the country. A total of 1,166 nonfederal acute-care hospitals report their infection rates to this Centers for Disease Control and Prevention's sponsored network every month.

Dr. Jha and his colleagues assessed NHSN data on three different types of infection at 398 of those hospitals in 41 states. They examined central catheter-associated bloodstream and catheter-associated urinary tract infections because these are the two hospital-acquired infections for which CMS currently does not pay. They also looked at ventilator-associated pneumonia, which is not targeted by the CMS policy, as a control.

Rates of central catheter-associated bloodstream infections were already decreasing at the time the CMS policy was implemented, likely because the federal government, national organizations, and accrediting agencies had already focused attention on preventing these nosocomial infections. The rate of these infections was 4.8% per quarter before the policy was implemented and 4.7% afterward, a nonsignificant difference, the investigators said (N. Engl. J. Med. 2012 [doi:10.1056/NEJMsa1202419]).

This pattern also was seen with catheter-associated UTIs, in which there was a small, nonsignificant increase in the infection rate after implementation of the CMS policy. For the control condition of ventilator-associated pneumonia, the infection rate was 7.3% before implementation and 8.2% after implementation of the policy, also showing no significant impact on infection rates.

These findings were consistent across all hospital types, regardless of size, regional location, type of ownership, or teaching status.

To assess whether any benefit of the nonpayment policy may have been offset by strategies to lower infection rates, such as mandatory reporting, the researchers performed a separate analysis involving only the hospital units located in states that didn't have mandatory reporting. Again, no demonstrable effect on infection rates was seen.

To allow more time for hospitals to adapt to the policy change, the investigators performed a sensitivity analysis comparing infection rates 2 years after implementation with those before implementation. Again, they found no further decreases in the rates of any infections.

A possible explanation for these findings is that the amount of this financial disincentive was quite small. "Reductions in payment may have been equivalent to as little as 0.6% of Medicare revenue for the average hospital," Dr. Jha and his associates said.

"Greater financial penalties might induce a greater change in hospital responsiveness to the CMS policy."

The study results are particularly important given the increasing use of financial disincentives to improve the quality of health care. There is very little evidence that this strategy, or other pay-for-performance strategies, actually improves patient outcomes, the authors noted.

This study was supported by the Agency for Healthcare Research and Quality.

None of the authors reported having any financial conflicts of interest regarding this study.

The 2008 Medicare policy to withhold payment for treating certain hospital-acquired infections failed to decrease infection rates in U.S. hospitals, according to a report published online in the New England Journal of Medicine.

In a study involving a total of 398 hospitals or medical systems across the country, implementing a Centers for Medicare and Medicaid Services policy of nonpayment for the treatment of preventable catheter-associated bloodstream infections and catheter-associated urinary tract infections appeared to have no impact at all on the acquisition of those infections, according to Dr. Ashish K. Jha of the department of health policy and management, Harvard School of Public Health, Boston, and his associates.

"As CMS continues to expand this policy to cover Medicaid through the Affordable Care Act, require public reporting of National Healthcare Safety Network [NHSN] data through the Hospital Compare website, and impose greater financial penalties on hospitals that perform poorly on these measures, careful evaluation is needed to determine when these programs work, when they have unintended consequences, and what might be done to improve patient outcomes," Dr. Jha noted.

Dr. Jha and his colleagues assessed data from the NHSN, a public health surveillance program for monitoring health care-associated infections across the country. A total of 1,166 nonfederal acute-care hospitals report their infection rates to this Centers for Disease Control and Prevention's sponsored network every month.

Dr. Jha and his colleagues assessed NHSN data on three different types of infection at 398 of those hospitals in 41 states. They examined central catheter-associated bloodstream and catheter-associated urinary tract infections because these are the two hospital-acquired infections for which CMS currently does not pay. They also looked at ventilator-associated pneumonia, which is not targeted by the CMS policy, as a control.

Rates of central catheter-associated bloodstream infections were already decreasing at the time the CMS policy was implemented, likely because the federal government, national organizations, and accrediting agencies had already focused attention on preventing these nosocomial infections. The rate of these infections was 4.8% per quarter before the policy was implemented and 4.7% afterward, a nonsignificant difference, the investigators said (N. Engl. J. Med. 2012 [doi:10.1056/NEJMsa1202419]).

This pattern also was seen with catheter-associated UTIs, in which there was a small, nonsignificant increase in the infection rate after implementation of the CMS policy. For the control condition of ventilator-associated pneumonia, the infection rate was 7.3% before implementation and 8.2% after implementation of the policy, also showing no significant impact on infection rates.

These findings were consistent across all hospital types, regardless of size, regional location, type of ownership, or teaching status.

To assess whether any benefit of the nonpayment policy may have been offset by strategies to lower infection rates, such as mandatory reporting, the researchers performed a separate analysis involving only the hospital units located in states that didn't have mandatory reporting. Again, no demonstrable effect on infection rates was seen.

To allow more time for hospitals to adapt to the policy change, the investigators performed a sensitivity analysis comparing infection rates 2 years after implementation with those before implementation. Again, they found no further decreases in the rates of any infections.

A possible explanation for these findings is that the amount of this financial disincentive was quite small. "Reductions in payment may have been equivalent to as little as 0.6% of Medicare revenue for the average hospital," Dr. Jha and his associates said.

"Greater financial penalties might induce a greater change in hospital responsiveness to the CMS policy."

The study results are particularly important given the increasing use of financial disincentives to improve the quality of health care. There is very little evidence that this strategy, or other pay-for-performance strategies, actually improves patient outcomes, the authors noted.

This study was supported by the Agency for Healthcare Research and Quality.

None of the authors reported having any financial conflicts of interest regarding this study.

SAN FRANCISCO – Successful outcomes in 74 of 79 patients who underwent robotic-assisted thymectomy suggest that the technology is safe and feasible, results of a multicenter European study demonstrate.

Dr. Franca Melfi, of the University of Pisa in Italy, reported on 79 patients with early thymoma who were surgically treated at multiple centers in Europe between 2002 and 2011. More than half, 45 patients, had myasthenia gravis. At last follow-up, 74 patients were still alive and free from recurrence. One patient died of a diffuse intrathoracic recurrence and the others died of unrealted causes, she said at the annual meeting of the American Association for Thoracic Surgery.

Improved depth perception and precise movements facilitated by articulated instruments are among the benefits of the robotic approach. The robot facilitates safe access to the thymus in the upper mediastinal area where the space is small and there are numerous vessels. This approach also allows a prolonged thymectomy when removal of all the fat is required, she explained.

The 608 reported robotic-assisted thymectomies worldwide come from 43 papers published since 2003, but most feature a small number of patients and/or a short follow-up, Dr. Melfi said. One of the few larger studies of robotic-assisted thymectomy included 106 patients with myasthenia gravis (Ann. N.Y. Acad. Sci. 2008;1132:329-35). Researchers in this prospective study reported a mean operative time of 186 minutes, a 1% conversion rate, and a 30-day mortality of 0%. They had a low overall postoperative morbidity rate (2 of 95 patients): one instance of bleeding and one nerve injury.

A greater than 40% complete and stable remission rate for myasthenia gravis was "a real interesting result," Dr. Melfi said, noting that mean follow-up was 20 months. Most participants reported improved quality of life, she added.

Additional clinical experience and refinements are warranted, Dr. Melfi said, acknowledging the need for prospective, randomized trials.

Dr. Melfi reported no conflicts.☐

SAN FRANCISCO – Successful outcomes in 74 of 79 patients who underwent robotic-assisted thymectomy suggest that the technology is safe and feasible, results of a multicenter European study demonstrate.

Dr. Franca Melfi, of the University of Pisa in Italy, reported on 79 patients with early thymoma who were surgically treated at multiple centers in Europe between 2002 and 2011. More than half, 45 patients, had myasthenia gravis. At last follow-up, 74 patients were still alive and free from recurrence. One patient died of a diffuse intrathoracic recurrence and the others died of unrealted causes, she said at the annual meeting of the American Association for Thoracic Surgery.

Improved depth perception and precise movements facilitated by articulated instruments are among the benefits of the robotic approach. The robot facilitates safe access to the thymus in the upper mediastinal area where the space is small and there are numerous vessels. This approach also allows a prolonged thymectomy when removal of all the fat is required, she explained.

The 608 reported robotic-assisted thymectomies worldwide come from 43 papers published since 2003, but most feature a small number of patients and/or a short follow-up, Dr. Melfi said. One of the few larger studies of robotic-assisted thymectomy included 106 patients with myasthenia gravis (Ann. N.Y. Acad. Sci. 2008;1132:329-35). Researchers in this prospective study reported a mean operative time of 186 minutes, a 1% conversion rate, and a 30-day mortality of 0%. They had a low overall postoperative morbidity rate (2 of 95 patients): one instance of bleeding and one nerve injury.

A greater than 40% complete and stable remission rate for myasthenia gravis was "a real interesting result," Dr. Melfi said, noting that mean follow-up was 20 months. Most participants reported improved quality of life, she added.

Additional clinical experience and refinements are warranted, Dr. Melfi said, acknowledging the need for prospective, randomized trials.

Dr. Melfi reported no conflicts.☐

SAN FRANCISCO – Successful outcomes in 74 of 79 patients who underwent robotic-assisted thymectomy suggest that the technology is safe and feasible, results of a multicenter European study demonstrate.

Dr. Franca Melfi, of the University of Pisa in Italy, reported on 79 patients with early thymoma who were surgically treated at multiple centers in Europe between 2002 and 2011. More than half, 45 patients, had myasthenia gravis. At last follow-up, 74 patients were still alive and free from recurrence. One patient died of a diffuse intrathoracic recurrence and the others died of unrealted causes, she said at the annual meeting of the American Association for Thoracic Surgery.

Improved depth perception and precise movements facilitated by articulated instruments are among the benefits of the robotic approach. The robot facilitates safe access to the thymus in the upper mediastinal area where the space is small and there are numerous vessels. This approach also allows a prolonged thymectomy when removal of all the fat is required, she explained.

The 608 reported robotic-assisted thymectomies worldwide come from 43 papers published since 2003, but most feature a small number of patients and/or a short follow-up, Dr. Melfi said. One of the few larger studies of robotic-assisted thymectomy included 106 patients with myasthenia gravis (Ann. N.Y. Acad. Sci. 2008;1132:329-35). Researchers in this prospective study reported a mean operative time of 186 minutes, a 1% conversion rate, and a 30-day mortality of 0%. They had a low overall postoperative morbidity rate (2 of 95 patients): one instance of bleeding and one nerve injury.

A greater than 40% complete and stable remission rate for myasthenia gravis was "a real interesting result," Dr. Melfi said, noting that mean follow-up was 20 months. Most participants reported improved quality of life, she added.

Additional clinical experience and refinements are warranted, Dr. Melfi said, acknowledging the need for prospective, randomized trials.

Dr. Melfi reported no conflicts.☐

SAN FRANCISCO – Successful outcomes in 74 of 79 patients who underwent robotic-assisted thymectomy suggest that the technology is safe and feasible, results of a multicenter European study demonstrate.

Dr. Franca Melfi, of the University of Pisa in Italy, reported on 79 patients with early thymoma who were surgically treated at multiple centers in Europe between 2002 and 2011. More than half, 45 patients, had myasthenia gravis. At last follow-up, 74 patients were still alive and free from recurrence. One patient died of a diffuse intrathoracic recurrence and the others died of unrealted causes, she said at the annual meeting of the American Association for Thoracic Surgery.

Improved depth perception and precise movements facilitated by articulated instruments are among the benefits of the robotic approach. The robot facilitates safe access to the thymus in the upper mediastinal area where the space is small and there are numerous vessels. This approach also allows a prolonged thymectomy when removal of all the fat is required, she explained.

The 608 reported robotic-assisted thymectomies worldwide come from 43 papers published since 2003, but most feature a small number of patients and/or a short follow-up, Dr. Melfi said. One of the few larger studies of robotic-assisted thymectomy included 106 patients with myasthenia gravis (Ann. N.Y. Acad. Sci. 2008;1132:329-35). Researchers in this prospective study reported a mean operative time of 186 minutes, a 1% conversion rate, and a 30-day mortality of 0%. They had a low overall postoperative morbidity rate (2 of 95 patients): one instance of bleeding and one nerve injury.

A greater than 40% complete and stable remission rate for myasthenia gravis was "a real interesting result," Dr. Melfi said, noting that mean follow-up was 20 months. Most participants reported improved quality of life, she added.

Additional clinical experience and refinements are warranted, Dr. Melfi said, acknowledging the need for prospective, randomized trials.

Dr. Melfi reported no conflicts.☐

SAN FRANCISCO – Successful outcomes in 74 of 79 patients who underwent robotic-assisted thymectomy suggest that the technology is safe and feasible, results of a multicenter European study demonstrate.

Dr. Franca Melfi, of the University of Pisa in Italy, reported on 79 patients with early thymoma who were surgically treated at multiple centers in Europe between 2002 and 2011. More than half, 45 patients, had myasthenia gravis. At last follow-up, 74 patients were still alive and free from recurrence. One patient died of a diffuse intrathoracic recurrence and the others died of unrealted causes, she said at the annual meeting of the American Association for Thoracic Surgery.

Improved depth perception and precise movements facilitated by articulated instruments are among the benefits of the robotic approach. The robot facilitates safe access to the thymus in the upper mediastinal area where the space is small and there are numerous vessels. This approach also allows a prolonged thymectomy when removal of all the fat is required, she explained.

The 608 reported robotic-assisted thymectomies worldwide come from 43 papers published since 2003, but most feature a small number of patients and/or a short follow-up, Dr. Melfi said. One of the few larger studies of robotic-assisted thymectomy included 106 patients with myasthenia gravis (Ann. N.Y. Acad. Sci. 2008;1132:329-35). Researchers in this prospective study reported a mean operative time of 186 minutes, a 1% conversion rate, and a 30-day mortality of 0%. They had a low overall postoperative morbidity rate (2 of 95 patients): one instance of bleeding and one nerve injury.

A greater than 40% complete and stable remission rate for myasthenia gravis was "a real interesting result," Dr. Melfi said, noting that mean follow-up was 20 months. Most participants reported improved quality of life, she added.

Additional clinical experience and refinements are warranted, Dr. Melfi said, acknowledging the need for prospective, randomized trials.

Dr. Melfi reported no conflicts.☐

SAN FRANCISCO – Successful outcomes in 74 of 79 patients who underwent robotic-assisted thymectomy suggest that the technology is safe and feasible, results of a multicenter European study demonstrate.

Dr. Franca Melfi, of the University of Pisa in Italy, reported on 79 patients with early thymoma who were surgically treated at multiple centers in Europe between 2002 and 2011. More than half, 45 patients, had myasthenia gravis. At last follow-up, 74 patients were still alive and free from recurrence. One patient died of a diffuse intrathoracic recurrence and the others died of unrealted causes, she said at the annual meeting of the American Association for Thoracic Surgery.

Improved depth perception and precise movements facilitated by articulated instruments are among the benefits of the robotic approach. The robot facilitates safe access to the thymus in the upper mediastinal area where the space is small and there are numerous vessels. This approach also allows a prolonged thymectomy when removal of all the fat is required, she explained.

The 608 reported robotic-assisted thymectomies worldwide come from 43 papers published since 2003, but most feature a small number of patients and/or a short follow-up, Dr. Melfi said. One of the few larger studies of robotic-assisted thymectomy included 106 patients with myasthenia gravis (Ann. N.Y. Acad. Sci. 2008;1132:329-35). Researchers in this prospective study reported a mean operative time of 186 minutes, a 1% conversion rate, and a 30-day mortality of 0%. They had a low overall postoperative morbidity rate (2 of 95 patients): one instance of bleeding and one nerve injury.

A greater than 40% complete and stable remission rate for myasthenia gravis was "a real interesting result," Dr. Melfi said, noting that mean follow-up was 20 months. Most participants reported improved quality of life, she added.

Additional clinical experience and refinements are warranted, Dr. Melfi said, acknowledging the need for prospective, randomized trials.

Dr. Melfi reported no conflicts.☐

CHICAGO – The diagnostic accuracy of FDG-PET in lung cancer performed below levels described in previous reports and varied widely among U.S. centers in a secondary analysis of a large phase III clinical trial.

"FDG-PET performed poorly for diagnosing non–small cell lung cancer in a national sample of clinical stage 1 patients," Dr. Eric L. Grogan said at the annnual meeting of the of the American Society of Clinical Oncology.

The current National Comprehensive Cancer Network guidelines recommend the use of fluorodeoxyglucose positron emission tomography (FDG-PET) for the diagnosis of NSCLC based on studies showing a high degree of accuracy for this diagnostic tool, notably a sensitivity of 94% and a median specificity of 83% in a meta-analysis of 40 studies (JAMA 2001;285:914-24).

Others have reported, however, that FDG-PET performs poorly at single institutions in regions of endemic fungal lung diseases (Ann. Thor. Surg. 2011;92:428-32 and Lung Cancer 2002;36:297-301), observed Dr. Grogan, of Vanderbilt-Ingram Cancer Center in Nashville, Tenn.

Among 682 patients in the American College of Surgeons Oncology Group (ACOSOG) Z4031 trial, the overall accuracy of FDG-PET was 73%, the sensitivity 82%, and the specificity only 31%.

The series is the largest to date evaluating the accuracy of FDG-PET in patients with known or suspected clinical stage 1 NSCLC. In addition, it is generalizable to clinical practice because multiple FDG-PET scanners were used and the scans were performed in community and academic centers and interpreted by multiple radiologists, Dr. Grogan said.

"Results of PET scans in this population should be interpreted cautiously, and reasons for the poor test performance should be explored in other studies," he said.

Discussant Dr. Tetsuya Mitsudomi, who is the chief of thoracic surgery at Aichi Cancer Center Hospital in Nagoya, Japan, said FDG-PET shows reasonable sensitivity, but very low specificity compared with previous studies.

"I think this reflects the real world," he said. "So, the lung cancer diagnosis cannot be made on the basis of PET positivity alone."

Investigators at 51 sites in 39 cities enrolled 969 patients with known or clinically suspicious stage 1 lesions between 2004 and 2006 to evaluate the value of proteomic analysis in diagnosing NSCLC (the results were presented at ASCO 2010). FDG-PET scans were available for 682 patients. All underwent surgical resection. Analyses were performed for all patients and for sites with more than 25 patients.

PET avidity was determined by the radiologist’s description of lesion activity or by the reported maximum standard uptake value (SUV). Avidity was classified in four categories: category 1 was no avidity/not cancer (SUV = 0), category 2 was low avidity/not likely cancer (SUV 0 to less than 2.5), category 3 was avidity/possibly cancer (SUV 2.5 to less than 5.0), and category 4 was high avidity/likely cancer (SUV 5.0 or more).

Among the 682 patients, there were 566 cancers and 116 benign cases. In all, 82% of the cancerous lesions were PET avid, and "surprisingly, 69% of the benign lesions were avid," Dr. Grogan said.

Patients with cancer were significantly older (67 vs. 61 years; P less than .001) and had larger lesions (26 mm vs. 20 mm; P less than .001).

The positive predictive value of FDG-PET was 85% and negative predictive value 26%. This translates into 80 false positives and 101 false negatives. The majority of false positives were found to be granulomas (69%), he observed. Eleven of the false negatives were 10 mm or less.

Not surprising, FDG-PET accuracy improved with lesion size, Dr. Grogan said. The accuracy was less than 50% for lesions less than 20 mm, but greater than 80% for lesions larger than 30 mm. "Above 30 mm, the accuracy did not seem to improve," he observed.

In the eight cities that had more than 25 patients, the sensitivity varied significantly, from a low of 67% in Los Angeles to a high of 91% in Durham, N.C. (P = .03), Dr. Grogan said, without explanation. Specificity ranged from 15% in Birmingham, Ala., to 46% in Philadelphia, but this did not reach statistical significance because of the small number of benign cases at each institution (P = .72).

Dr. Mitsudomi said he could not explain the reason for the heterogeneity, especially in terms of the specificity, between centers.

"It’s not possible to remove all the false positives if you use FDG, but newer tracers are being developed and they may increase the specificity rate," he added.

Dr. Grogan reported no disclosures. Dr. Mitsudomi reported having a consulting/advisory role with Boehringer Ingelheim, Kyowa Hakko Kirin, Lilly, and Pfizer, and receiving honoraria from AstraZeneca, Chugai Pharma, Lilly, and Roche.☐

CHICAGO – The diagnostic accuracy of FDG-PET in lung cancer performed below levels described in previous reports and varied widely among U.S. centers in a secondary analysis of a large phase III clinical trial.

"FDG-PET performed poorly for diagnosing non–small cell lung cancer in a national sample of clinical stage 1 patients," Dr. Eric L. Grogan said at the annnual meeting of the of the American Society of Clinical Oncology.

The current National Comprehensive Cancer Network guidelines recommend the use of fluorodeoxyglucose positron emission tomography (FDG-PET) for the diagnosis of NSCLC based on studies showing a high degree of accuracy for this diagnostic tool, notably a sensitivity of 94% and a median specificity of 83% in a meta-analysis of 40 studies (JAMA 2001;285:914-24).

Others have reported, however, that FDG-PET performs poorly at single institutions in regions of endemic fungal lung diseases (Ann. Thor. Surg. 2011;92:428-32 and Lung Cancer 2002;36:297-301), observed Dr. Grogan, of Vanderbilt-Ingram Cancer Center in Nashville, Tenn.

Among 682 patients in the American College of Surgeons Oncology Group (ACOSOG) Z4031 trial, the overall accuracy of FDG-PET was 73%, the sensitivity 82%, and the specificity only 31%.

The series is the largest to date evaluating the accuracy of FDG-PET in patients with known or suspected clinical stage 1 NSCLC. In addition, it is generalizable to clinical practice because multiple FDG-PET scanners were used and the scans were performed in community and academic centers and interpreted by multiple radiologists, Dr. Grogan said.

"Results of PET scans in this population should be interpreted cautiously, and reasons for the poor test performance should be explored in other studies," he said.

Discussant Dr. Tetsuya Mitsudomi, who is the chief of thoracic surgery at Aichi Cancer Center Hospital in Nagoya, Japan, said FDG-PET shows reasonable sensitivity, but very low specificity compared with previous studies.

"I think this reflects the real world," he said. "So, the lung cancer diagnosis cannot be made on the basis of PET positivity alone."

Investigators at 51 sites in 39 cities enrolled 969 patients with known or clinically suspicious stage 1 lesions between 2004 and 2006 to evaluate the value of proteomic analysis in diagnosing NSCLC (the results were presented at ASCO 2010). FDG-PET scans were available for 682 patients. All underwent surgical resection. Analyses were performed for all patients and for sites with more than 25 patients.

PET avidity was determined by the radiologist’s description of lesion activity or by the reported maximum standard uptake value (SUV). Avidity was classified in four categories: category 1 was no avidity/not cancer (SUV = 0), category 2 was low avidity/not likely cancer (SUV 0 to less than 2.5), category 3 was avidity/possibly cancer (SUV 2.5 to less than 5.0), and category 4 was high avidity/likely cancer (SUV 5.0 or more).

Among the 682 patients, there were 566 cancers and 116 benign cases. In all, 82% of the cancerous lesions were PET avid, and "surprisingly, 69% of the benign lesions were avid," Dr. Grogan said.

Patients with cancer were significantly older (67 vs. 61 years; P less than .001) and had larger lesions (26 mm vs. 20 mm; P less than .001).

The positive predictive value of FDG-PET was 85% and negative predictive value 26%. This translates into 80 false positives and 101 false negatives. The majority of false positives were found to be granulomas (69%), he observed. Eleven of the false negatives were 10 mm or less.

Not surprising, FDG-PET accuracy improved with lesion size, Dr. Grogan said. The accuracy was less than 50% for lesions less than 20 mm, but greater than 80% for lesions larger than 30 mm. "Above 30 mm, the accuracy did not seem to improve," he observed.

In the eight cities that had more than 25 patients, the sensitivity varied significantly, from a low of 67% in Los Angeles to a high of 91% in Durham, N.C. (P = .03), Dr. Grogan said, without explanation. Specificity ranged from 15% in Birmingham, Ala., to 46% in Philadelphia, but this did not reach statistical significance because of the small number of benign cases at each institution (P = .72).

Dr. Mitsudomi said he could not explain the reason for the heterogeneity, especially in terms of the specificity, between centers.

"It’s not possible to remove all the false positives if you use FDG, but newer tracers are being developed and they may increase the specificity rate," he added.

Dr. Grogan reported no disclosures. Dr. Mitsudomi reported having a consulting/advisory role with Boehringer Ingelheim, Kyowa Hakko Kirin, Lilly, and Pfizer, and receiving honoraria from AstraZeneca, Chugai Pharma, Lilly, and Roche.☐

CHICAGO – The diagnostic accuracy of FDG-PET in lung cancer performed below levels described in previous reports and varied widely among U.S. centers in a secondary analysis of a large phase III clinical trial.

"FDG-PET performed poorly for diagnosing non–small cell lung cancer in a national sample of clinical stage 1 patients," Dr. Eric L. Grogan said at the annnual meeting of the of the American Society of Clinical Oncology.

The current National Comprehensive Cancer Network guidelines recommend the use of fluorodeoxyglucose positron emission tomography (FDG-PET) for the diagnosis of NSCLC based on studies showing a high degree of accuracy for this diagnostic tool, notably a sensitivity of 94% and a median specificity of 83% in a meta-analysis of 40 studies (JAMA 2001;285:914-24).

Others have reported, however, that FDG-PET performs poorly at single institutions in regions of endemic fungal lung diseases (Ann. Thor. Surg. 2011;92:428-32 and Lung Cancer 2002;36:297-301), observed Dr. Grogan, of Vanderbilt-Ingram Cancer Center in Nashville, Tenn.

Among 682 patients in the American College of Surgeons Oncology Group (ACOSOG) Z4031 trial, the overall accuracy of FDG-PET was 73%, the sensitivity 82%, and the specificity only 31%.

The series is the largest to date evaluating the accuracy of FDG-PET in patients with known or suspected clinical stage 1 NSCLC. In addition, it is generalizable to clinical practice because multiple FDG-PET scanners were used and the scans were performed in community and academic centers and interpreted by multiple radiologists, Dr. Grogan said.

"Results of PET scans in this population should be interpreted cautiously, and reasons for the poor test performance should be explored in other studies," he said.

Discussant Dr. Tetsuya Mitsudomi, who is the chief of thoracic surgery at Aichi Cancer Center Hospital in Nagoya, Japan, said FDG-PET shows reasonable sensitivity, but very low specificity compared with previous studies.

"I think this reflects the real world," he said. "So, the lung cancer diagnosis cannot be made on the basis of PET positivity alone."

Investigators at 51 sites in 39 cities enrolled 969 patients with known or clinically suspicious stage 1 lesions between 2004 and 2006 to evaluate the value of proteomic analysis in diagnosing NSCLC (the results were presented at ASCO 2010). FDG-PET scans were available for 682 patients. All underwent surgical resection. Analyses were performed for all patients and for sites with more than 25 patients.

PET avidity was determined by the radiologist’s description of lesion activity or by the reported maximum standard uptake value (SUV). Avidity was classified in four categories: category 1 was no avidity/not cancer (SUV = 0), category 2 was low avidity/not likely cancer (SUV 0 to less than 2.5), category 3 was avidity/possibly cancer (SUV 2.5 to less than 5.0), and category 4 was high avidity/likely cancer (SUV 5.0 or more).

Among the 682 patients, there were 566 cancers and 116 benign cases. In all, 82% of the cancerous lesions were PET avid, and "surprisingly, 69% of the benign lesions were avid," Dr. Grogan said.

Patients with cancer were significantly older (67 vs. 61 years; P less than .001) and had larger lesions (26 mm vs. 20 mm; P less than .001).

The positive predictive value of FDG-PET was 85% and negative predictive value 26%. This translates into 80 false positives and 101 false negatives. The majority of false positives were found to be granulomas (69%), he observed. Eleven of the false negatives were 10 mm or less.

Not surprising, FDG-PET accuracy improved with lesion size, Dr. Grogan said. The accuracy was less than 50% for lesions less than 20 mm, but greater than 80% for lesions larger than 30 mm. "Above 30 mm, the accuracy did not seem to improve," he observed.

In the eight cities that had more than 25 patients, the sensitivity varied significantly, from a low of 67% in Los Angeles to a high of 91% in Durham, N.C. (P = .03), Dr. Grogan said, without explanation. Specificity ranged from 15% in Birmingham, Ala., to 46% in Philadelphia, but this did not reach statistical significance because of the small number of benign cases at each institution (P = .72).

Dr. Mitsudomi said he could not explain the reason for the heterogeneity, especially in terms of the specificity, between centers.

"It’s not possible to remove all the false positives if you use FDG, but newer tracers are being developed and they may increase the specificity rate," he added.

Dr. Grogan reported no disclosures. Dr. Mitsudomi reported having a consulting/advisory role with Boehringer Ingelheim, Kyowa Hakko Kirin, Lilly, and Pfizer, and receiving honoraria from AstraZeneca, Chugai Pharma, Lilly, and Roche.☐

SAN FRANCISCO – Thoracic surgeons should not shy away from segmentectomy in select patients with NSCLC, an expert advises, because the technique confers specific advantages.

In addition, it is as feasible as lobectomy. "If you can do a lobectomy, you can do a segmentectomy. There is no doubt about it," Dr. Matthew J. Schuchert said at the annual meeting of the American Association for Thoracic Surgery.

He shared patient selection criteria and technique tips based on experience with the more than 800 segmentectomies performed at the University of Pittsburgh Medical Center/UPMC Cancer Institute, where he is a general and thoracic surgeon.

Anatomic segmentectomy accomplishes the fundamental surgical tenets achieved by lobectomy, including R0 resection, adequate margins, and an opportunity for systematic nodal staging in early lung cancer, Dr. Schuchert said.

Lung preservation is another potential benefit of segmentectomy and the procedure is particularly useful for tumors with low malignancy potential where you may not have to take out an entire lobe to gain oncologic control, he said.

Equivalent survival to lobectomy has been demonstrated for stage 1A disease, especially for lesions smaller than 2 cm. In addition, "there may be decreased morbidity and mortality risk, especially among the elderly, a population we are going to be seeing more and more of."

Patient selection is paramount. In addition to the elderly, segmentectomy is particularly suitable for patients with marginal pulmonary function; those with "ground glass opacity" that may have low nodal positivity rates; and those who had prior lobectomy seeking parenchymal preservation.

"If you are contemplating the use of segmentectomy, it all really comes down to evaluation of the case," he said. Preoperative imaging ideally reveals a small tumor (less than 2 cm) in the outer one third of the lung. In addition, tumors should be confined to a discrete segmental boundary. "That’s critical. That’s the ticket for success," he said.

Surgeons can use the same anatomic approach they employ for lobectomy, only direct it at one segment. It is important to know segmental vascular and segmental bronchial anatomy, Dr. Schuchert noted.

"All of the same anatomic concerns, exposure concerns, and dissection concerns and techniques really apply." Segmentectomy can be performed through video-assisted thoracic surgery (VATS) or an open approach; the majority of cases at the University of Pittsburgh are VATS.

"We typically position the camera at about the seventh interspace in the mid-axillary line. Along the same interspace, a little more posteriorly, we will utilize a 10-mm incision for retraction and stapling. The access incision is pretty much the same as it is for a VATS lobectomy, usually somewhere along the line of the inframammary crease, and we place it right over the anterior hilum." This incision is usually around the level of the minor fissure on the right and slightly above the major fissure on the left, he added. Next, a 5-mm incision is made for retraction; it can also be particularly useful during node dissection, Dr. Schuchert said.

Preservation of the remaining lung is always a goal. "If you devitalize the remaining lung or impinge upon the bronchial supply, that patient is going to be doomed to have some perioperative issues." Remember that segmentectomy is a functional operation as well, he pointed out. "We are not just taking things out; what we leave behind still has to work."

Dissection assisted by an energy device is a more recent development in their hands. "We have now utilized energy in well over 100 patients undergoing both segmentectomy and lobectomy," he said.

Another essential goal of segmentectomy is to achieve a margin-to-tumor ratio greater than the size of the tumor itself, he said. As an example, he cited the case of a 71-year-old man with a history of diverticulitis with a pulmonary nodule picked up on an abdominal CT scan. The nodule was 1.7 cm, well confined in the outer third of the lung, and well centered within the basilar segment. Fine-needle aspiration of the nodule revealed adenocarcinoma. "He was considered to be an excellent candidate for segmentectomy. In this case, the margin was about 5 cm for a 1.7-cm tumor."

He and his colleagues published additional details of the segmentectomies they performed between 2002 and 2010 at UPMC in a retrospective study (Ann. Thorac. Surg. 2012:93:1780-7).

He said that he had no disclosures.

SAN FRANCISCO – Thoracic surgeons should not shy away from segmentectomy in select patients with NSCLC, an expert advises, because the technique confers specific advantages.

In addition, it is as feasible as lobectomy. "If you can do a lobectomy, you can do a segmentectomy. There is no doubt about it," Dr. Matthew J. Schuchert said at the annual meeting of the American Association for Thoracic Surgery.

He shared patient selection criteria and technique tips based on experience with the more than 800 segmentectomies performed at the University of Pittsburgh Medical Center/UPMC Cancer Institute, where he is a general and thoracic surgeon.

Anatomic segmentectomy accomplishes the fundamental surgical tenets achieved by lobectomy, including R0 resection, adequate margins, and an opportunity for systematic nodal staging in early lung cancer, Dr. Schuchert said.

Lung preservation is another potential benefit of segmentectomy and the procedure is particularly useful for tumors with low malignancy potential where you may not have to take out an entire lobe to gain oncologic control, he said.

Equivalent survival to lobectomy has been demonstrated for stage 1A disease, especially for lesions smaller than 2 cm. In addition, "there may be decreased morbidity and mortality risk, especially among the elderly, a population we are going to be seeing more and more of."

Patient selection is paramount. In addition to the elderly, segmentectomy is particularly suitable for patients with marginal pulmonary function; those with "ground glass opacity" that may have low nodal positivity rates; and those who had prior lobectomy seeking parenchymal preservation.

"If you are contemplating the use of segmentectomy, it all really comes down to evaluation of the case," he said. Preoperative imaging ideally reveals a small tumor (less than 2 cm) in the outer one third of the lung. In addition, tumors should be confined to a discrete segmental boundary. "That’s critical. That’s the ticket for success," he said.

Surgeons can use the same anatomic approach they employ for lobectomy, only direct it at one segment. It is important to know segmental vascular and segmental bronchial anatomy, Dr. Schuchert noted.

"All of the same anatomic concerns, exposure concerns, and dissection concerns and techniques really apply." Segmentectomy can be performed through video-assisted thoracic surgery (VATS) or an open approach; the majority of cases at the University of Pittsburgh are VATS.

"We typically position the camera at about the seventh interspace in the mid-axillary line. Along the same interspace, a little more posteriorly, we will utilize a 10-mm incision for retraction and stapling. The access incision is pretty much the same as it is for a VATS lobectomy, usually somewhere along the line of the inframammary crease, and we place it right over the anterior hilum." This incision is usually around the level of the minor fissure on the right and slightly above the major fissure on the left, he added. Next, a 5-mm incision is made for retraction; it can also be particularly useful during node dissection, Dr. Schuchert said.

Preservation of the remaining lung is always a goal. "If you devitalize the remaining lung or impinge upon the bronchial supply, that patient is going to be doomed to have some perioperative issues." Remember that segmentectomy is a functional operation as well, he pointed out. "We are not just taking things out; what we leave behind still has to work."

Dissection assisted by an energy device is a more recent development in their hands. "We have now utilized energy in well over 100 patients undergoing both segmentectomy and lobectomy," he said.

Another essential goal of segmentectomy is to achieve a margin-to-tumor ratio greater than the size of the tumor itself, he said. As an example, he cited the case of a 71-year-old man with a history of diverticulitis with a pulmonary nodule picked up on an abdominal CT scan. The nodule was 1.7 cm, well confined in the outer third of the lung, and well centered within the basilar segment. Fine-needle aspiration of the nodule revealed adenocarcinoma. "He was considered to be an excellent candidate for segmentectomy. In this case, the margin was about 5 cm for a 1.7-cm tumor."

He and his colleagues published additional details of the segmentectomies they performed between 2002 and 2010 at UPMC in a retrospective study (Ann. Thorac. Surg. 2012:93:1780-7).

He said that he had no disclosures.

SAN FRANCISCO – Thoracic surgeons should not shy away from segmentectomy in select patients with NSCLC, an expert advises, because the technique confers specific advantages.

In addition, it is as feasible as lobectomy. "If you can do a lobectomy, you can do a segmentectomy. There is no doubt about it," Dr. Matthew J. Schuchert said at the annual meeting of the American Association for Thoracic Surgery.

He shared patient selection criteria and technique tips based on experience with the more than 800 segmentectomies performed at the University of Pittsburgh Medical Center/UPMC Cancer Institute, where he is a general and thoracic surgeon.

Anatomic segmentectomy accomplishes the fundamental surgical tenets achieved by lobectomy, including R0 resection, adequate margins, and an opportunity for systematic nodal staging in early lung cancer, Dr. Schuchert said.

Lung preservation is another potential benefit of segmentectomy and the procedure is particularly useful for tumors with low malignancy potential where you may not have to take out an entire lobe to gain oncologic control, he said.

Equivalent survival to lobectomy has been demonstrated for stage 1A disease, especially for lesions smaller than 2 cm. In addition, "there may be decreased morbidity and mortality risk, especially among the elderly, a population we are going to be seeing more and more of."

Patient selection is paramount. In addition to the elderly, segmentectomy is particularly suitable for patients with marginal pulmonary function; those with "ground glass opacity" that may have low nodal positivity rates; and those who had prior lobectomy seeking parenchymal preservation.

"If you are contemplating the use of segmentectomy, it all really comes down to evaluation of the case," he said. Preoperative imaging ideally reveals a small tumor (less than 2 cm) in the outer one third of the lung. In addition, tumors should be confined to a discrete segmental boundary. "That’s critical. That’s the ticket for success," he said.

Surgeons can use the same anatomic approach they employ for lobectomy, only direct it at one segment. It is important to know segmental vascular and segmental bronchial anatomy, Dr. Schuchert noted.

"All of the same anatomic concerns, exposure concerns, and dissection concerns and techniques really apply." Segmentectomy can be performed through video-assisted thoracic surgery (VATS) or an open approach; the majority of cases at the University of Pittsburgh are VATS.

"We typically position the camera at about the seventh interspace in the mid-axillary line. Along the same interspace, a little more posteriorly, we will utilize a 10-mm incision for retraction and stapling. The access incision is pretty much the same as it is for a VATS lobectomy, usually somewhere along the line of the inframammary crease, and we place it right over the anterior hilum." This incision is usually around the level of the minor fissure on the right and slightly above the major fissure on the left, he added. Next, a 5-mm incision is made for retraction; it can also be particularly useful during node dissection, Dr. Schuchert said.

Preservation of the remaining lung is always a goal. "If you devitalize the remaining lung or impinge upon the bronchial supply, that patient is going to be doomed to have some perioperative issues." Remember that segmentectomy is a functional operation as well, he pointed out. "We are not just taking things out; what we leave behind still has to work."

Dissection assisted by an energy device is a more recent development in their hands. "We have now utilized energy in well over 100 patients undergoing both segmentectomy and lobectomy," he said.

Another essential goal of segmentectomy is to achieve a margin-to-tumor ratio greater than the size of the tumor itself, he said. As an example, he cited the case of a 71-year-old man with a history of diverticulitis with a pulmonary nodule picked up on an abdominal CT scan. The nodule was 1.7 cm, well confined in the outer third of the lung, and well centered within the basilar segment. Fine-needle aspiration of the nodule revealed adenocarcinoma. "He was considered to be an excellent candidate for segmentectomy. In this case, the margin was about 5 cm for a 1.7-cm tumor."

He and his colleagues published additional details of the segmentectomies they performed between 2002 and 2010 at UPMC in a retrospective study (Ann. Thorac. Surg. 2012:93:1780-7).

He said that he had no disclosures.

CHICAGO – The diagnostic accuracy of FDG-PET in lung cancer performed below levels described in previous reports and varied widely among U.S. centers in a secondary analysis of a large phase III clinical trial.

"FDG-PET performed poorly for diagnosing non–small cell lung cancer in a national sample of clinical stage 1 patients," Dr. Eric L. Grogan said at the annnual meeting of the of the American Society of Clinical Oncology.

The current National Comprehensive Cancer Network guidelines recommend the use of fluorodeoxyglucose positron emission tomography (FDG-PET) for the diagnosis of NSCLC based on studies showing a high degree of accuracy for this diagnostic tool, notably a sensitivity of 94% and a median specificity of 83% in a meta-analysis of 40 studies (JAMA 2001;285:914-24).

Others have reported, however, that FDG-PET performs poorly at single institutions in regions of endemic fungal lung diseases (Ann. Thor. Surg. 2011;92:428-32 and Lung Cancer 2002;36:297-301), observed Dr. Grogan, of Vanderbilt-Ingram Cancer Center in Nashville, Tenn.

Among 682 patients in the American College of Surgeons Oncology Group (ACOSOG) Z4031 trial, the overall accuracy of FDG-PET was 73%, the sensitivity 82%, and the specificity only 31%.

The series is the largest to date evaluating the accuracy of FDG-PET in patients with known or suspected clinical stage 1 NSCLC. In addition, it is generalizable to clinical practice because multiple FDG-PET scanners were used and the scans were performed in community and academic centers and interpreted by multiple radiologists, Dr. Grogan said.

"Results of PET scans in this population should be interpreted cautiously, and reasons for the poor test performance should be explored in other studies," he said.

Discussant Dr. Tetsuya Mitsudomi, who is the chief of thoracic surgery at Aichi Cancer Center Hospital in Nagoya, Japan, said FDG-PET shows reasonable sensitivity, but very low specificity compared with previous studies.

"I think this reflects the real world," he said. "So, the lung cancer diagnosis cannot be made on the basis of PET positivity alone."

Investigators at 51 sites in 39 cities enrolled 969 patients with known or clinically suspicious stage 1 lesions between 2004 and 2006 to evaluate the value of proteomic analysis in diagnosing NSCLC (the results were presented at ASCO 2010). FDG-PET scans were available for 682 patients. All underwent surgical resection. Analyses were performed for all patients and for sites with more than 25 patients.

PET avidity was determined by the radiologist’s description of lesion activity or by the reported maximum standard uptake value (SUV). Avidity was classified in four categories: category 1 was no avidity/not cancer (SUV = 0), category 2 was low avidity/not likely cancer (SUV 0 to less than 2.5), category 3 was avidity/possibly cancer (SUV 2.5 to less than 5.0), and category 4 was high avidity/likely cancer (SUV 5.0 or more).

Among the 682 patients, there were 566 cancers and 116 benign cases. In all, 82% of the cancerous lesions were PET avid, and "surprisingly, 69% of the benign lesions were avid," Dr. Grogan said.

Patients with cancer were significantly older (67 vs. 61 years; P less than .001) and had larger lesions (26 mm vs. 20 mm; P less than .001).

The positive predictive value of FDG-PET was 85% and negative predictive value 26%. This translates into 80 false positives and 101 false negatives. The majority of false positives were found to be granulomas (69%), he observed. Eleven of the false negatives were 10 mm or less.

Not surprising, FDG-PET accuracy improved with lesion size, Dr. Grogan said. The accuracy was less than 50% for lesions less than 20 mm, but greater than 80% for lesions larger than 30 mm. "Above 30 mm, the accuracy did not seem to improve," he observed.

In the eight cities that had more than 25 patients, the sensitivity varied significantly, from a low of 67% in Los Angeles to a high of 91% in Durham, N.C. (P = .03), Dr. Grogan said, without explanation. Specificity ranged from 15% in Birmingham, Ala., to 46% in Philadelphia, but this did not reach statistical significance because of the small number of benign cases at each institution (P = .72).

Dr. Mitsudomi said he could not explain the reason for the heterogeneity, especially in terms of the specificity, between centers.

"It’s not possible to remove all the false positives if you use FDG, but newer tracers are being developed and they may increase the specificity rate," he added.

Dr. Grogan reported no disclosures. Dr. Mitsudomi reported having a consulting/advisory role with Boehringer Ingelheim, Kyowa Hakko Kirin, Lilly, and Pfizer, and receiving honoraria from AstraZeneca, Chugai Pharma, Lilly, and Roche.☐

CHICAGO – The diagnostic accuracy of FDG-PET in lung cancer performed below levels described in previous reports and varied widely among U.S. centers in a secondary analysis of a large phase III clinical trial.

"FDG-PET performed poorly for diagnosing non–small cell lung cancer in a national sample of clinical stage 1 patients," Dr. Eric L. Grogan said at the annnual meeting of the of the American Society of Clinical Oncology.

The current National Comprehensive Cancer Network guidelines recommend the use of fluorodeoxyglucose positron emission tomography (FDG-PET) for the diagnosis of NSCLC based on studies showing a high degree of accuracy for this diagnostic tool, notably a sensitivity of 94% and a median specificity of 83% in a meta-analysis of 40 studies (JAMA 2001;285:914-24).

Others have reported, however, that FDG-PET performs poorly at single institutions in regions of endemic fungal lung diseases (Ann. Thor. Surg. 2011;92:428-32 and Lung Cancer 2002;36:297-301), observed Dr. Grogan, of Vanderbilt-Ingram Cancer Center in Nashville, Tenn.

Among 682 patients in the American College of Surgeons Oncology Group (ACOSOG) Z4031 trial, the overall accuracy of FDG-PET was 73%, the sensitivity 82%, and the specificity only 31%.

The series is the largest to date evaluating the accuracy of FDG-PET in patients with known or suspected clinical stage 1 NSCLC. In addition, it is generalizable to clinical practice because multiple FDG-PET scanners were used and the scans were performed in community and academic centers and interpreted by multiple radiologists, Dr. Grogan said.

"Results of PET scans in this population should be interpreted cautiously, and reasons for the poor test performance should be explored in other studies," he said.

Discussant Dr. Tetsuya Mitsudomi, who is the chief of thoracic surgery at Aichi Cancer Center Hospital in Nagoya, Japan, said FDG-PET shows reasonable sensitivity, but very low specificity compared with previous studies.

"I think this reflects the real world," he said. "So, the lung cancer diagnosis cannot be made on the basis of PET positivity alone."

Investigators at 51 sites in 39 cities enrolled 969 patients with known or clinically suspicious stage 1 lesions between 2004 and 2006 to evaluate the value of proteomic analysis in diagnosing NSCLC (the results were presented at ASCO 2010). FDG-PET scans were available for 682 patients. All underwent surgical resection. Analyses were performed for all patients and for sites with more than 25 patients.

PET avidity was determined by the radiologist’s description of lesion activity or by the reported maximum standard uptake value (SUV). Avidity was classified in four categories: category 1 was no avidity/not cancer (SUV = 0), category 2 was low avidity/not likely cancer (SUV 0 to less than 2.5), category 3 was avidity/possibly cancer (SUV 2.5 to less than 5.0), and category 4 was high avidity/likely cancer (SUV 5.0 or more).

Among the 682 patients, there were 566 cancers and 116 benign cases. In all, 82% of the cancerous lesions were PET avid, and "surprisingly, 69% of the benign lesions were avid," Dr. Grogan said.

Patients with cancer were significantly older (67 vs. 61 years; P less than .001) and had larger lesions (26 mm vs. 20 mm; P less than .001).

The positive predictive value of FDG-PET was 85% and negative predictive value 26%. This translates into 80 false positives and 101 false negatives. The majority of false positives were found to be granulomas (69%), he observed. Eleven of the false negatives were 10 mm or less.

Not surprising, FDG-PET accuracy improved with lesion size, Dr. Grogan said. The accuracy was less than 50% for lesions less than 20 mm, but greater than 80% for lesions larger than 30 mm. "Above 30 mm, the accuracy did not seem to improve," he observed.

In the eight cities that had more than 25 patients, the sensitivity varied significantly, from a low of 67% in Los Angeles to a high of 91% in Durham, N.C. (P = .03), Dr. Grogan said, without explanation. Specificity ranged from 15% in Birmingham, Ala., to 46% in Philadelphia, but this did not reach statistical significance because of the small number of benign cases at each institution (P = .72).

Dr. Mitsudomi said he could not explain the reason for the heterogeneity, especially in terms of the specificity, between centers.

"It’s not possible to remove all the false positives if you use FDG, but newer tracers are being developed and they may increase the specificity rate," he added.

Dr. Grogan reported no disclosures. Dr. Mitsudomi reported having a consulting/advisory role with Boehringer Ingelheim, Kyowa Hakko Kirin, Lilly, and Pfizer, and receiving honoraria from AstraZeneca, Chugai Pharma, Lilly, and Roche.☐

CHICAGO – The diagnostic accuracy of FDG-PET in lung cancer performed below levels described in previous reports and varied widely among U.S. centers in a secondary analysis of a large phase III clinical trial.

"FDG-PET performed poorly for diagnosing non–small cell lung cancer in a national sample of clinical stage 1 patients," Dr. Eric L. Grogan said at the annnual meeting of the of the American Society of Clinical Oncology.

The current National Comprehensive Cancer Network guidelines recommend the use of fluorodeoxyglucose positron emission tomography (FDG-PET) for the diagnosis of NSCLC based on studies showing a high degree of accuracy for this diagnostic tool, notably a sensitivity of 94% and a median specificity of 83% in a meta-analysis of 40 studies (JAMA 2001;285:914-24).

Others have reported, however, that FDG-PET performs poorly at single institutions in regions of endemic fungal lung diseases (Ann. Thor. Surg. 2011;92:428-32 and Lung Cancer 2002;36:297-301), observed Dr. Grogan, of Vanderbilt-Ingram Cancer Center in Nashville, Tenn.

Among 682 patients in the American College of Surgeons Oncology Group (ACOSOG) Z4031 trial, the overall accuracy of FDG-PET was 73%, the sensitivity 82%, and the specificity only 31%.

The series is the largest to date evaluating the accuracy of FDG-PET in patients with known or suspected clinical stage 1 NSCLC. In addition, it is generalizable to clinical practice because multiple FDG-PET scanners were used and the scans were performed in community and academic centers and interpreted by multiple radiologists, Dr. Grogan said.

"Results of PET scans in this population should be interpreted cautiously, and reasons for the poor test performance should be explored in other studies," he said.

Discussant Dr. Tetsuya Mitsudomi, who is the chief of thoracic surgery at Aichi Cancer Center Hospital in Nagoya, Japan, said FDG-PET shows reasonable sensitivity, but very low specificity compared with previous studies.

"I think this reflects the real world," he said. "So, the lung cancer diagnosis cannot be made on the basis of PET positivity alone."

Investigators at 51 sites in 39 cities enrolled 969 patients with known or clinically suspicious stage 1 lesions between 2004 and 2006 to evaluate the value of proteomic analysis in diagnosing NSCLC (the results were presented at ASCO 2010). FDG-PET scans were available for 682 patients. All underwent surgical resection. Analyses were performed for all patients and for sites with more than 25 patients.

PET avidity was determined by the radiologist’s description of lesion activity or by the reported maximum standard uptake value (SUV). Avidity was classified in four categories: category 1 was no avidity/not cancer (SUV = 0), category 2 was low avidity/not likely cancer (SUV 0 to less than 2.5), category 3 was avidity/possibly cancer (SUV 2.5 to less than 5.0), and category 4 was high avidity/likely cancer (SUV 5.0 or more).

Among the 682 patients, there were 566 cancers and 116 benign cases. In all, 82% of the cancerous lesions were PET avid, and "surprisingly, 69% of the benign lesions were avid," Dr. Grogan said.

Patients with cancer were significantly older (67 vs. 61 years; P less than .001) and had larger lesions (26 mm vs. 20 mm; P less than .001).

The positive predictive value of FDG-PET was 85% and negative predictive value 26%. This translates into 80 false positives and 101 false negatives. The majority of false positives were found to be granulomas (69%), he observed. Eleven of the false negatives were 10 mm or less.

Not surprising, FDG-PET accuracy improved with lesion size, Dr. Grogan said. The accuracy was less than 50% for lesions less than 20 mm, but greater than 80% for lesions larger than 30 mm. "Above 30 mm, the accuracy did not seem to improve," he observed.

In the eight cities that had more than 25 patients, the sensitivity varied significantly, from a low of 67% in Los Angeles to a high of 91% in Durham, N.C. (P = .03), Dr. Grogan said, without explanation. Specificity ranged from 15% in Birmingham, Ala., to 46% in Philadelphia, but this did not reach statistical significance because of the small number of benign cases at each institution (P = .72).

Dr. Mitsudomi said he could not explain the reason for the heterogeneity, especially in terms of the specificity, between centers.

"It’s not possible to remove all the false positives if you use FDG, but newer tracers are being developed and they may increase the specificity rate," he added.

Dr. Grogan reported no disclosures. Dr. Mitsudomi reported having a consulting/advisory role with Boehringer Ingelheim, Kyowa Hakko Kirin, Lilly, and Pfizer, and receiving honoraria from AstraZeneca, Chugai Pharma, Lilly, and Roche.☐

SAN FRANCISCO – Thoracic surgeons should not shy away from segmentectomy in select patients with NSCLC, an expert advises, because the technique confers specific advantages.

In addition, it is as feasible as lobectomy. "If you can do a lobectomy, you can do a segmentectomy. There is no doubt about it," Dr. Matthew J. Schuchert said at the annual meeting of the American Association for Thoracic Surgery.

He shared patient selection criteria and technique tips based on experience with the more than 800 segmentectomies performed at the University of Pittsburgh Medical Center/UPMC Cancer Institute, where he is a general and thoracic surgeon.

Anatomic segmentectomy accomplishes the fundamental surgical tenets achieved by lobectomy, including R0 resection, adequate margins, and an opportunity for systematic nodal staging in early lung cancer, Dr. Schuchert said.

Lung preservation is another potential benefit of segmentectomy and the procedure is particularly useful for tumors with low malignancy potential where you may not have to take out an entire lobe to gain oncologic control, he said.

Equivalent survival to lobectomy has been demonstrated for stage 1A disease, especially for lesions smaller than 2 cm. In addition, "there may be decreased morbidity and mortality risk, especially among the elderly, a population we are going to be seeing more and more of."

Patient selection is paramount. In addition to the elderly, segmentectomy is particularly suitable for patients with marginal pulmonary function; those with "ground glass opacity" that may have low nodal positivity rates; and those who had prior lobectomy seeking parenchymal preservation.

"If you are contemplating the use of segmentectomy, it all really comes down to evaluation of the case," he said. Preoperative imaging ideally reveals a small tumor (less than 2 cm) in the outer one third of the lung. In addition, tumors should be confined to a discrete segmental boundary. "That’s critical. That’s the ticket for success," he said.

Surgeons can use the same anatomic approach they employ for lobectomy, only direct it at one segment. It is important to know segmental vascular and segmental bronchial anatomy, Dr. Schuchert noted.

"All of the same anatomic concerns, exposure concerns, and dissection concerns and techniques really apply." Segmentectomy can be performed through video-assisted thoracic surgery (VATS) or an open approach; the majority of cases at the University of Pittsburgh are VATS.

"We typically position the camera at about the seventh interspace in the mid-axillary line. Along the same interspace, a little more posteriorly, we will utilize a 10-mm incision for retraction and stapling. The access incision is pretty much the same as it is for a VATS lobectomy, usually somewhere along the line of the inframammary crease, and we place it right over the anterior hilum." This incision is usually around the level of the minor fissure on the right and slightly above the major fissure on the left, he added. Next, a 5-mm incision is made for retraction; it can also be particularly useful during node dissection, Dr. Schuchert said.

Preservation of the remaining lung is always a goal. "If you devitalize the remaining lung or impinge upon the bronchial supply, that patient is going to be doomed to have some perioperative issues." Remember that segmentectomy is a functional operation as well, he pointed out. "We are not just taking things out; what we leave behind still has to work."

Dissection assisted by an energy device is a more recent development in their hands. "We have now utilized energy in well over 100 patients undergoing both segmentectomy and lobectomy," he said.

Another essential goal of segmentectomy is to achieve a margin-to-tumor ratio greater than the size of the tumor itself, he said. As an example, he cited the case of a 71-year-old man with a history of diverticulitis with a pulmonary nodule picked up on an abdominal CT scan. The nodule was 1.7 cm, well confined in the outer third of the lung, and well centered within the basilar segment. Fine-needle aspiration of the nodule revealed adenocarcinoma. "He was considered to be an excellent candidate for segmentectomy. In this case, the margin was about 5 cm for a 1.7-cm tumor."

He and his colleagues published additional details of the segmentectomies they performed between 2002 and 2010 at UPMC in a retrospective study (Ann. Thorac. Surg. 2012:93:1780-7).

He said that he had no disclosures.

SAN FRANCISCO – Thoracic surgeons should not shy away from segmentectomy in select patients with NSCLC, an expert advises, because the technique confers specific advantages.

In addition, it is as feasible as lobectomy. "If you can do a lobectomy, you can do a segmentectomy. There is no doubt about it," Dr. Matthew J. Schuchert said at the annual meeting of the American Association for Thoracic Surgery.

He shared patient selection criteria and technique tips based on experience with the more than 800 segmentectomies performed at the University of Pittsburgh Medical Center/UPMC Cancer Institute, where he is a general and thoracic surgeon.

Anatomic segmentectomy accomplishes the fundamental surgical tenets achieved by lobectomy, including R0 resection, adequate margins, and an opportunity for systematic nodal staging in early lung cancer, Dr. Schuchert said.

Lung preservation is another potential benefit of segmentectomy and the procedure is particularly useful for tumors with low malignancy potential where you may not have to take out an entire lobe to gain oncologic control, he said.

Equivalent survival to lobectomy has been demonstrated for stage 1A disease, especially for lesions smaller than 2 cm. In addition, "there may be decreased morbidity and mortality risk, especially among the elderly, a population we are going to be seeing more and more of."

Patient selection is paramount. In addition to the elderly, segmentectomy is particularly suitable for patients with marginal pulmonary function; those with "ground glass opacity" that may have low nodal positivity rates; and those who had prior lobectomy seeking parenchymal preservation.

"If you are contemplating the use of segmentectomy, it all really comes down to evaluation of the case," he said. Preoperative imaging ideally reveals a small tumor (less than 2 cm) in the outer one third of the lung. In addition, tumors should be confined to a discrete segmental boundary. "That’s critical. That’s the ticket for success," he said.

Surgeons can use the same anatomic approach they employ for lobectomy, only direct it at one segment. It is important to know segmental vascular and segmental bronchial anatomy, Dr. Schuchert noted.

"All of the same anatomic concerns, exposure concerns, and dissection concerns and techniques really apply." Segmentectomy can be performed through video-assisted thoracic surgery (VATS) or an open approach; the majority of cases at the University of Pittsburgh are VATS.

"We typically position the camera at about the seventh interspace in the mid-axillary line. Along the same interspace, a little more posteriorly, we will utilize a 10-mm incision for retraction and stapling. The access incision is pretty much the same as it is for a VATS lobectomy, usually somewhere along the line of the inframammary crease, and we place it right over the anterior hilum." This incision is usually around the level of the minor fissure on the right and slightly above the major fissure on the left, he added. Next, a 5-mm incision is made for retraction; it can also be particularly useful during node dissection, Dr. Schuchert said.

Preservation of the remaining lung is always a goal. "If you devitalize the remaining lung or impinge upon the bronchial supply, that patient is going to be doomed to have some perioperative issues." Remember that segmentectomy is a functional operation as well, he pointed out. "We are not just taking things out; what we leave behind still has to work."

Dissection assisted by an energy device is a more recent development in their hands. "We have now utilized energy in well over 100 patients undergoing both segmentectomy and lobectomy," he said.

Another essential goal of segmentectomy is to achieve a margin-to-tumor ratio greater than the size of the tumor itself, he said. As an example, he cited the case of a 71-year-old man with a history of diverticulitis with a pulmonary nodule picked up on an abdominal CT scan. The nodule was 1.7 cm, well confined in the outer third of the lung, and well centered within the basilar segment. Fine-needle aspiration of the nodule revealed adenocarcinoma. "He was considered to be an excellent candidate for segmentectomy. In this case, the margin was about 5 cm for a 1.7-cm tumor."

He and his colleagues published additional details of the segmentectomies they performed between 2002 and 2010 at UPMC in a retrospective study (Ann. Thorac. Surg. 2012:93:1780-7).

He said that he had no disclosures.

SAN FRANCISCO – Thoracic surgeons should not shy away from segmentectomy in select patients with NSCLC, an expert advises, because the technique confers specific advantages.

In addition, it is as feasible as lobectomy. "If you can do a lobectomy, you can do a segmentectomy. There is no doubt about it," Dr. Matthew J. Schuchert said at the annual meeting of the American Association for Thoracic Surgery.

He shared patient selection criteria and technique tips based on experience with the more than 800 segmentectomies performed at the University of Pittsburgh Medical Center/UPMC Cancer Institute, where he is a general and thoracic surgeon.

Anatomic segmentectomy accomplishes the fundamental surgical tenets achieved by lobectomy, including R0 resection, adequate margins, and an opportunity for systematic nodal staging in early lung cancer, Dr. Schuchert said.

Lung preservation is another potential benefit of segmentectomy and the procedure is particularly useful for tumors with low malignancy potential where you may not have to take out an entire lobe to gain oncologic control, he said.

Equivalent survival to lobectomy has been demonstrated for stage 1A disease, especially for lesions smaller than 2 cm. In addition, "there may be decreased morbidity and mortality risk, especially among the elderly, a population we are going to be seeing more and more of."

Patient selection is paramount. In addition to the elderly, segmentectomy is particularly suitable for patients with marginal pulmonary function; those with "ground glass opacity" that may have low nodal positivity rates; and those who had prior lobectomy seeking parenchymal preservation.

"If you are contemplating the use of segmentectomy, it all really comes down to evaluation of the case," he said. Preoperative imaging ideally reveals a small tumor (less than 2 cm) in the outer one third of the lung. In addition, tumors should be confined to a discrete segmental boundary. "That’s critical. That’s the ticket for success," he said.

Surgeons can use the same anatomic approach they employ for lobectomy, only direct it at one segment. It is important to know segmental vascular and segmental bronchial anatomy, Dr. Schuchert noted.

"All of the same anatomic concerns, exposure concerns, and dissection concerns and techniques really apply." Segmentectomy can be performed through video-assisted thoracic surgery (VATS) or an open approach; the majority of cases at the University of Pittsburgh are VATS.

"We typically position the camera at about the seventh interspace in the mid-axillary line. Along the same interspace, a little more posteriorly, we will utilize a 10-mm incision for retraction and stapling. The access incision is pretty much the same as it is for a VATS lobectomy, usually somewhere along the line of the inframammary crease, and we place it right over the anterior hilum." This incision is usually around the level of the minor fissure on the right and slightly above the major fissure on the left, he added. Next, a 5-mm incision is made for retraction; it can also be particularly useful during node dissection, Dr. Schuchert said.

Preservation of the remaining lung is always a goal. "If you devitalize the remaining lung or impinge upon the bronchial supply, that patient is going to be doomed to have some perioperative issues." Remember that segmentectomy is a functional operation as well, he pointed out. "We are not just taking things out; what we leave behind still has to work."

Dissection assisted by an energy device is a more recent development in their hands. "We have now utilized energy in well over 100 patients undergoing both segmentectomy and lobectomy," he said.

Another essential goal of segmentectomy is to achieve a margin-to-tumor ratio greater than the size of the tumor itself, he said. As an example, he cited the case of a 71-year-old man with a history of diverticulitis with a pulmonary nodule picked up on an abdominal CT scan. The nodule was 1.7 cm, well confined in the outer third of the lung, and well centered within the basilar segment. Fine-needle aspiration of the nodule revealed adenocarcinoma. "He was considered to be an excellent candidate for segmentectomy. In this case, the margin was about 5 cm for a 1.7-cm tumor."

He and his colleagues published additional details of the segmentectomies they performed between 2002 and 2010 at UPMC in a retrospective study (Ann. Thorac. Surg. 2012:93:1780-7).

He said that he had no disclosures.