Society News

Interventional Chest/Diagnostic Procedures

Review of The AMPLE Trial: is talc making a comeback?

A proposed advantage of indwelling pleural catheters (IPC) is their purported ability to reduce hospitalization time when compared with the more traditional talc pleurodesis procedure. The recently published AMPLE trial was a multicenter randomized trial comparing the impact of IPCs vs talc pleurodesis on hospitalization days in patients with malignant pleural effusions. One-hundred forty-six patients were randomized for pleurodesis to either IPC vs pleurodesis via talc slurry in nine centers in Australia, New Zealand, Singapore, and Hong Kong. Patients were followed for up to 12 months. Secondary outcomes included need for further pleural intervention, breathlessness, quality of life, and adverse events.

Patients randomized to IPC spent on average 2 days less in the hospital (10 vs 12 days), a difference that was statistically significant, though of questionable clinical relevance, and somewhat disappointing in light of a prior prospective study from the same group suggesting a benefit of 6 to 7 days (Fysh. Chest. 2012;142[2]:394. As in previous studies, additional pleural procedures were more common in the talc group, adverse events occurred more frequently with IPC, but breathlessness and quality of life were identical in both groups.

This study raises interesting questions. Clearly, IPCs have been favored over talc pleurodesis in the US in the last decade, primarily because of a perceived benefit in terms of hospitalization time. In the absence of clear advantage of IPC on time spent in the hospital, impact on breathlessness and quality of life, and considering the inconvenience of frequent drainage, co-pay incurred by patients, and increased adverse events with IPC, the pendulum may swing again toward talc pleurodesis.

Christine Argento, MD, FCCP

Fabien Maldonado, MD, FCCP

Steering Committee Members

Pediatric Chest Medicine

Early escalation of inhaled corticosteroids: does it help prevent asthma exacerbations?

Asthma is one of the most common chronic conditions in children. The importance of effective control of asthma to prevent exacerbations is well accepted. Inhaled corticosteroids (ICS) are a preferred component of treatment to improve asthma control in children with persistent asthma; however, exacerbations can still occur and result in significant morbidity. Most patients receive systemic corticosteroids during acute asthma exacerbations. The most recent Global Initiative for Asthma (GINA) guidelines recommend increasing ICS at the first signs of an asthma exacerbation in an effort to lessen the need for systemic corticosteroids (GINA. Global strategy for asthma management and prevention. 2017. http://www.ginasthma.org/).

In a recent issue of the New England Journal of Medicine, Jackson and colleagues at the National Heart, Lung, and Blood Institute AsthmaNet published the results of a randomized, double-blind 48-week trial, which included 254 children between ages 5 and 11 years with mild-moderate asthma. Their objectives were to compare exacerbation rates, time to first exacerbation, acute care visits, and bronchodilator use in children randomized to treatment with either high (5 x baseline ICS dose x 7 days) or low dose inhaled corticosteroids early in a drop to the “yellow zone” (Jackson, et al. N Engl J Med. 2018;378[10]:891).

Time to asthma exacerbations and exacerbations that required treatment with corticosteroids did not significantly differ between the low dose and high dose groups. Unexpectedly, the rate of exacerbations was higher with the high dose compared with the low dose group (0.48 vs 0.37). The children who were in the high dose group received 16% more ICS compared with the low dose group. Although not significant, there was a lower linear growth rate, ~0.23 cm per year seen in this high-dose group than in the low-dose group. Additionally, the use of bronchodilator, symptoms, and the rates of evaluation by a physician (ie, emergency department or urgent care visits) did not significantly differ between the two groups.

This study was specific to school-age children with mild-moderate persistent asthma treated with low dose ICS with a history of good adherence. Overall, this well-designed study helps address a question that many clinicians have regarding escalating ICS in the “yellow zone.” Escalating ICS did not reduce exacerbations at the cost of a lower linear growth rate. When it comes to escalating ICS for asthma exacerbation, more is not better.

In conclusion, in children with mild-to-moderate persistent asthma treated with daily inhaled glucocorticoids, quintupling the dose at the early signs of loss of asthma control did not reduce the rate of severe asthma exacerbations or improve other asthma outcomes and may be associated with diminished linear growth. (Funded by the National Heart, Lung, and Blood Institute; STICS ClinicalTrials.gov number, NCT02066129).

John Bishara, DO

Fellow-in-Training Member

Pulmonary Physiology, Function, and Rehabilitation

Understanding cardiopulmonary exercise testing

The cardiopulmonary exercise test (CPET) is an underutilized tool for evaluating patients with dyspnea of uncertain etiology. This is often due to the daunting task of trying to make sense of seemingly large amounts of interacting data, along with clinicians not having been taught a systematic approach for interpreting the results. Unlike other typical tests we order that point to a specific laboratory or anatomic radiographic abnormality, narrowing our differential to a few possibilities, one needs a different mindset when interpreting a CPET. This is a study to demonstrate the body’s normal or abnormal physiologic responses to increasing levels of physical stress. Because different conditions can give similar findings, the physiologic abnormalities must be interpreted in the context of the clinical presentation. If the results do not entirely fit the suspected diagnosis, they should be reported in a manner that may help guide the ordering physician down an alternate pathway. This CHEST NetWork has sought ways to reach out to members to promote a better understanding of the utilization of the basics of pulmonary physiology in the management of patients. We created an online two-part video demonstrating a basic systematic approach toward understanding the combinations of findings one often sees when performing a CPET. A comprehensive understanding cannot be shown in a 40-minute video series, but, hopefully, this will give a starting point to make this task easier and more enjoyable.

Zachary Morris, MD, FCCP

Steering Committee Member

Pulmonary Vascular Disease

BMPR2 mutation regulates singular millimetric fibrovascular lesions in bronchial circulation in PAH

Patients with PAH with BMPR2 mutation are younger with worse hemodynamics, ie, higher mean PAP with higher PVR and a lower cardiac index in comparison to the noncarriers. A systematic analysis of pulmonary imaging using CT angiography or magnetic resonance imaging in patients with PAH demonstrated increased bronchial arterial hypertrophy in BMPR2 mutation carriers compared with those without the mutation. Moreover, hemoptysis is more frequently encountered in patients with PAH with BMPR2 mutation and presumably related to bronchial artery remodeling and angiogenesis. French investigators described, in histopathology findings of explanted lungs of 44 patients with PAH (23 carriers of BMPR2 and 21 noncarriers), unusual singular millimetric fibrovascular lesions (SiMFi) in patients with BMPR2 mutations. The SiMFi is a structure of millimetric dimension with fibrovascular characteristics that are extremely rich in collagen and displayed more than one vascular channel. SiMFi did not show a classic glomeruloid pattern with predominant endothelial cell proliferation as seen in plexiform lesions but rather a large conglomerate of hypertrophic vessels. Performing an ink injection experiment in a freshly explanted lung highlighted a patent connection between bronchial/systemic vessels and pulmonary septal veins. SiMFis had an increased amount of bronchial microvessels and showed increased hypertrophy of larger bronchial arteries. SiMFi is directly related to hypertrophy and/or angiogenesis of vasa vasorum/bronchial arteries in the vicinity of the diseased artery. In patients with PAH with BMPR2 mutations, bronchial angiogenesis is more prevalent compared with patients with PAH lacking these mutations. This highlights the role of bronchial arteries in the spectrum of PAH.

Hector Cajigas, MD, FCCP

Sandeep Sahay, MD, FCCP

Steering Committee Members

References

1.Ghigna MR, et al. BMPR2 mutation status influences bronchial vascular changes in pulmonary arterial hypertension. Eur Respir J. 2016;48[6]:1668. Epub 2016 Nov 3.

2. Tio D, et al. Risk factors for hemoptysis in idiopathic and hereditary pulmonary arterial hypertension. PLoS One. 2013;8:e78132.

3. Elliott CG, et al. Relationship of BMPR2 mutations to vasoreactivity in pulmonary arterial hypertension. Circulation. 2006;113[21]:2509.

Thoracic Oncology

We have a lung cancer screening test but we could use it better

The American Lung Association recently demonstrated the majority of current and former smokers don’t know about lung cancer screening (LCS) with low-dose CT scanning.¹ Researchers estimate less than 5% of eligible persons received LCS.² Awareness campaigns targeting patients and health care providers at the local level can improve LCS uptake.^3,4 While any new clinical practice has an expected implementation delay, LCS has another implementation barrier: complex eligibility criteria (age 55 – 80 years PLUS 30+ pack-year smoking history PLUS quit time less than 15 years). Electronic health record (EHR) tools might accelerate the adoption curve to identify eligible persons.⁵ Moreover, assessing and recording a qualitative smoking history is challenging, at best. One center showed 96.2% discordance between EHR smoking history and that obtained during shared decision-making visit for LCS.⁶ Mostly, the EHR underreported quantitative pack-year history; meaning LCS-eligible patients might fail to be identified by EHR review alone. Another small pilot showed that some patients age 55 – 79 years will update their EHR smoking history using patient portal, but this will not be effective for all patients.⁷ For current smokers, age alone may be an effective identification strategy, given the average start time for most smokers.⁸

Even though current LCS guidelines leave out some individuals at high risk for lung cancer, we must continue efforts to offer this potentially life-saving service to patients now eligible. Using EHR tools may help proactively identify those who are eligible for lung cancer screening.

A bbie Begnaud, MD

NetWork Member

References

1. New Study from American Lung Association’s LUNG FORCE Reveals Low Awareness of Lifesaving Lung Cancer Screening Among Those at Greatest Risk. (2017). http://www.lung.org/about-us/media/press-releases/new-study-lung-cancer-screening.html. Accessed April 19, 2018.

2. Soneji S, et al. Underuse of Chest Radiography Versus Computed Tomography for Lung Cancer Screening. Am J Public Health. 2017;107(8):1248.

3. Cardarelli R, et al. Terminate lung cancer (TLC) study-A mixed-methods population approach to increase lung cancer screening awareness and low-dose computed tomography in Eastern Kentucky. Cancer Epidemiol. 2017;46:1.

4. Jessup, DL, et al. Implementation of digital awareness strategies to engage patients and providers in a lung cancer screening program: retrospective study. J Med Internet Res. 2018;20(2):e52.

5. Comparison of the Electronic Medical Record versus a Shared Decision Making Conversation. Ann Am Thorac Soc. 2018. In press.

6. Modin HE, et al. Pack-year cigarette smoking history for determination of lung cancer screening eligibility. Ann Am Thorac Soc. 2017 Aug;14(8):1320-1325.

7. Begnaud AL, et al. Randomized electronic promotion of lung cancer screening: a pilot. JCO Clinical Cancer Informatics(1), 1-6. doi:10.1200/cci.17.00033

8. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. (2014). Atlanta, GA.

Interventional Chest/Diagnostic Procedures

Review of The AMPLE Trial: is talc making a comeback?

A proposed advantage of indwelling pleural catheters (IPC) is their purported ability to reduce hospitalization time when compared with the more traditional talc pleurodesis procedure. The recently published AMPLE trial was a multicenter randomized trial comparing the impact of IPCs vs talc pleurodesis on hospitalization days in patients with malignant pleural effusions. One-hundred forty-six patients were randomized for pleurodesis to either IPC vs pleurodesis via talc slurry in nine centers in Australia, New Zealand, Singapore, and Hong Kong. Patients were followed for up to 12 months. Secondary outcomes included need for further pleural intervention, breathlessness, quality of life, and adverse events.

Patients randomized to IPC spent on average 2 days less in the hospital (10 vs 12 days), a difference that was statistically significant, though of questionable clinical relevance, and somewhat disappointing in light of a prior prospective study from the same group suggesting a benefit of 6 to 7 days (Fysh. Chest. 2012;142[2]:394. As in previous studies, additional pleural procedures were more common in the talc group, adverse events occurred more frequently with IPC, but breathlessness and quality of life were identical in both groups.

This study raises interesting questions. Clearly, IPCs have been favored over talc pleurodesis in the US in the last decade, primarily because of a perceived benefit in terms of hospitalization time. In the absence of clear advantage of IPC on time spent in the hospital, impact on breathlessness and quality of life, and considering the inconvenience of frequent drainage, co-pay incurred by patients, and increased adverse events with IPC, the pendulum may swing again toward talc pleurodesis.

Christine Argento, MD, FCCP

Fabien Maldonado, MD, FCCP

Steering Committee Members

Pediatric Chest Medicine

Early escalation of inhaled corticosteroids: does it help prevent asthma exacerbations?

Asthma is one of the most common chronic conditions in children. The importance of effective control of asthma to prevent exacerbations is well accepted. Inhaled corticosteroids (ICS) are a preferred component of treatment to improve asthma control in children with persistent asthma; however, exacerbations can still occur and result in significant morbidity. Most patients receive systemic corticosteroids during acute asthma exacerbations. The most recent Global Initiative for Asthma (GINA) guidelines recommend increasing ICS at the first signs of an asthma exacerbation in an effort to lessen the need for systemic corticosteroids (GINA. Global strategy for asthma management and prevention. 2017. http://www.ginasthma.org/).

In a recent issue of the New England Journal of Medicine, Jackson and colleagues at the National Heart, Lung, and Blood Institute AsthmaNet published the results of a randomized, double-blind 48-week trial, which included 254 children between ages 5 and 11 years with mild-moderate asthma. Their objectives were to compare exacerbation rates, time to first exacerbation, acute care visits, and bronchodilator use in children randomized to treatment with either high (5 x baseline ICS dose x 7 days) or low dose inhaled corticosteroids early in a drop to the “yellow zone” (Jackson, et al. N Engl J Med. 2018;378[10]:891).

Time to asthma exacerbations and exacerbations that required treatment with corticosteroids did not significantly differ between the low dose and high dose groups. Unexpectedly, the rate of exacerbations was higher with the high dose compared with the low dose group (0.48 vs 0.37). The children who were in the high dose group received 16% more ICS compared with the low dose group. Although not significant, there was a lower linear growth rate, ~0.23 cm per year seen in this high-dose group than in the low-dose group. Additionally, the use of bronchodilator, symptoms, and the rates of evaluation by a physician (ie, emergency department or urgent care visits) did not significantly differ between the two groups.

This study was specific to school-age children with mild-moderate persistent asthma treated with low dose ICS with a history of good adherence. Overall, this well-designed study helps address a question that many clinicians have regarding escalating ICS in the “yellow zone.” Escalating ICS did not reduce exacerbations at the cost of a lower linear growth rate. When it comes to escalating ICS for asthma exacerbation, more is not better.

In conclusion, in children with mild-to-moderate persistent asthma treated with daily inhaled glucocorticoids, quintupling the dose at the early signs of loss of asthma control did not reduce the rate of severe asthma exacerbations or improve other asthma outcomes and may be associated with diminished linear growth. (Funded by the National Heart, Lung, and Blood Institute; STICS ClinicalTrials.gov number, NCT02066129).

John Bishara, DO

Fellow-in-Training Member

Pulmonary Physiology, Function, and Rehabilitation

Understanding cardiopulmonary exercise testing

The cardiopulmonary exercise test (CPET) is an underutilized tool for evaluating patients with dyspnea of uncertain etiology. This is often due to the daunting task of trying to make sense of seemingly large amounts of interacting data, along with clinicians not having been taught a systematic approach for interpreting the results. Unlike other typical tests we order that point to a specific laboratory or anatomic radiographic abnormality, narrowing our differential to a few possibilities, one needs a different mindset when interpreting a CPET. This is a study to demonstrate the body’s normal or abnormal physiologic responses to increasing levels of physical stress. Because different conditions can give similar findings, the physiologic abnormalities must be interpreted in the context of the clinical presentation. If the results do not entirely fit the suspected diagnosis, they should be reported in a manner that may help guide the ordering physician down an alternate pathway. This CHEST NetWork has sought ways to reach out to members to promote a better understanding of the utilization of the basics of pulmonary physiology in the management of patients. We created an online two-part video demonstrating a basic systematic approach toward understanding the combinations of findings one often sees when performing a CPET. A comprehensive understanding cannot be shown in a 40-minute video series, but, hopefully, this will give a starting point to make this task easier and more enjoyable.

Zachary Morris, MD, FCCP

Steering Committee Member

Pulmonary Vascular Disease

BMPR2 mutation regulates singular millimetric fibrovascular lesions in bronchial circulation in PAH

Patients with PAH with BMPR2 mutation are younger with worse hemodynamics, ie, higher mean PAP with higher PVR and a lower cardiac index in comparison to the noncarriers. A systematic analysis of pulmonary imaging using CT angiography or magnetic resonance imaging in patients with PAH demonstrated increased bronchial arterial hypertrophy in BMPR2 mutation carriers compared with those without the mutation. Moreover, hemoptysis is more frequently encountered in patients with PAH with BMPR2 mutation and presumably related to bronchial artery remodeling and angiogenesis. French investigators described, in histopathology findings of explanted lungs of 44 patients with PAH (23 carriers of BMPR2 and 21 noncarriers), unusual singular millimetric fibrovascular lesions (SiMFi) in patients with BMPR2 mutations. The SiMFi is a structure of millimetric dimension with fibrovascular characteristics that are extremely rich in collagen and displayed more than one vascular channel. SiMFi did not show a classic glomeruloid pattern with predominant endothelial cell proliferation as seen in plexiform lesions but rather a large conglomerate of hypertrophic vessels. Performing an ink injection experiment in a freshly explanted lung highlighted a patent connection between bronchial/systemic vessels and pulmonary septal veins. SiMFis had an increased amount of bronchial microvessels and showed increased hypertrophy of larger bronchial arteries. SiMFi is directly related to hypertrophy and/or angiogenesis of vasa vasorum/bronchial arteries in the vicinity of the diseased artery. In patients with PAH with BMPR2 mutations, bronchial angiogenesis is more prevalent compared with patients with PAH lacking these mutations. This highlights the role of bronchial arteries in the spectrum of PAH.

Hector Cajigas, MD, FCCP

Sandeep Sahay, MD, FCCP

Steering Committee Members

References

1.Ghigna MR, et al. BMPR2 mutation status influences bronchial vascular changes in pulmonary arterial hypertension. Eur Respir J. 2016;48[6]:1668. Epub 2016 Nov 3.

2. Tio D, et al. Risk factors for hemoptysis in idiopathic and hereditary pulmonary arterial hypertension. PLoS One. 2013;8:e78132.

3. Elliott CG, et al. Relationship of BMPR2 mutations to vasoreactivity in pulmonary arterial hypertension. Circulation. 2006;113[21]:2509.

Thoracic Oncology

We have a lung cancer screening test but we could use it better

The American Lung Association recently demonstrated the majority of current and former smokers don’t know about lung cancer screening (LCS) with low-dose CT scanning.¹ Researchers estimate less than 5% of eligible persons received LCS.² Awareness campaigns targeting patients and health care providers at the local level can improve LCS uptake.^3,4 While any new clinical practice has an expected implementation delay, LCS has another implementation barrier: complex eligibility criteria (age 55 – 80 years PLUS 30+ pack-year smoking history PLUS quit time less than 15 years). Electronic health record (EHR) tools might accelerate the adoption curve to identify eligible persons.⁵ Moreover, assessing and recording a qualitative smoking history is challenging, at best. One center showed 96.2% discordance between EHR smoking history and that obtained during shared decision-making visit for LCS.⁶ Mostly, the EHR underreported quantitative pack-year history; meaning LCS-eligible patients might fail to be identified by EHR review alone. Another small pilot showed that some patients age 55 – 79 years will update their EHR smoking history using patient portal, but this will not be effective for all patients.⁷ For current smokers, age alone may be an effective identification strategy, given the average start time for most smokers.⁸

Even though current LCS guidelines leave out some individuals at high risk for lung cancer, we must continue efforts to offer this potentially life-saving service to patients now eligible. Using EHR tools may help proactively identify those who are eligible for lung cancer screening.

A bbie Begnaud, MD

NetWork Member

References

1. New Study from American Lung Association’s LUNG FORCE Reveals Low Awareness of Lifesaving Lung Cancer Screening Among Those at Greatest Risk. (2017). http://www.lung.org/about-us/media/press-releases/new-study-lung-cancer-screening.html. Accessed April 19, 2018.

2. Soneji S, et al. Underuse of Chest Radiography Versus Computed Tomography for Lung Cancer Screening. Am J Public Health. 2017;107(8):1248.

3. Cardarelli R, et al. Terminate lung cancer (TLC) study-A mixed-methods population approach to increase lung cancer screening awareness and low-dose computed tomography in Eastern Kentucky. Cancer Epidemiol. 2017;46:1.

4. Jessup, DL, et al. Implementation of digital awareness strategies to engage patients and providers in a lung cancer screening program: retrospective study. J Med Internet Res. 2018;20(2):e52.

5. Comparison of the Electronic Medical Record versus a Shared Decision Making Conversation. Ann Am Thorac Soc. 2018. In press.

6. Modin HE, et al. Pack-year cigarette smoking history for determination of lung cancer screening eligibility. Ann Am Thorac Soc. 2017 Aug;14(8):1320-1325.

7. Begnaud AL, et al. Randomized electronic promotion of lung cancer screening: a pilot. JCO Clinical Cancer Informatics(1), 1-6. doi:10.1200/cci.17.00033

8. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. (2014). Atlanta, GA.

Interventional Chest/Diagnostic Procedures

Review of The AMPLE Trial: is talc making a comeback?

A proposed advantage of indwelling pleural catheters (IPC) is their purported ability to reduce hospitalization time when compared with the more traditional talc pleurodesis procedure. The recently published AMPLE trial was a multicenter randomized trial comparing the impact of IPCs vs talc pleurodesis on hospitalization days in patients with malignant pleural effusions. One-hundred forty-six patients were randomized for pleurodesis to either IPC vs pleurodesis via talc slurry in nine centers in Australia, New Zealand, Singapore, and Hong Kong. Patients were followed for up to 12 months. Secondary outcomes included need for further pleural intervention, breathlessness, quality of life, and adverse events.

Patients randomized to IPC spent on average 2 days less in the hospital (10 vs 12 days), a difference that was statistically significant, though of questionable clinical relevance, and somewhat disappointing in light of a prior prospective study from the same group suggesting a benefit of 6 to 7 days (Fysh. Chest. 2012;142[2]:394. As in previous studies, additional pleural procedures were more common in the talc group, adverse events occurred more frequently with IPC, but breathlessness and quality of life were identical in both groups.

This study raises interesting questions. Clearly, IPCs have been favored over talc pleurodesis in the US in the last decade, primarily because of a perceived benefit in terms of hospitalization time. In the absence of clear advantage of IPC on time spent in the hospital, impact on breathlessness and quality of life, and considering the inconvenience of frequent drainage, co-pay incurred by patients, and increased adverse events with IPC, the pendulum may swing again toward talc pleurodesis.

Christine Argento, MD, FCCP

Fabien Maldonado, MD, FCCP

Steering Committee Members

Pediatric Chest Medicine

Early escalation of inhaled corticosteroids: does it help prevent asthma exacerbations?

Asthma is one of the most common chronic conditions in children. The importance of effective control of asthma to prevent exacerbations is well accepted. Inhaled corticosteroids (ICS) are a preferred component of treatment to improve asthma control in children with persistent asthma; however, exacerbations can still occur and result in significant morbidity. Most patients receive systemic corticosteroids during acute asthma exacerbations. The most recent Global Initiative for Asthma (GINA) guidelines recommend increasing ICS at the first signs of an asthma exacerbation in an effort to lessen the need for systemic corticosteroids (GINA. Global strategy for asthma management and prevention. 2017. http://www.ginasthma.org/).

In a recent issue of the New England Journal of Medicine, Jackson and colleagues at the National Heart, Lung, and Blood Institute AsthmaNet published the results of a randomized, double-blind 48-week trial, which included 254 children between ages 5 and 11 years with mild-moderate asthma. Their objectives were to compare exacerbation rates, time to first exacerbation, acute care visits, and bronchodilator use in children randomized to treatment with either high (5 x baseline ICS dose x 7 days) or low dose inhaled corticosteroids early in a drop to the “yellow zone” (Jackson, et al. N Engl J Med. 2018;378[10]:891).

Time to asthma exacerbations and exacerbations that required treatment with corticosteroids did not significantly differ between the low dose and high dose groups. Unexpectedly, the rate of exacerbations was higher with the high dose compared with the low dose group (0.48 vs 0.37). The children who were in the high dose group received 16% more ICS compared with the low dose group. Although not significant, there was a lower linear growth rate, ~0.23 cm per year seen in this high-dose group than in the low-dose group. Additionally, the use of bronchodilator, symptoms, and the rates of evaluation by a physician (ie, emergency department or urgent care visits) did not significantly differ between the two groups.

This study was specific to school-age children with mild-moderate persistent asthma treated with low dose ICS with a history of good adherence. Overall, this well-designed study helps address a question that many clinicians have regarding escalating ICS in the “yellow zone.” Escalating ICS did not reduce exacerbations at the cost of a lower linear growth rate. When it comes to escalating ICS for asthma exacerbation, more is not better.

In conclusion, in children with mild-to-moderate persistent asthma treated with daily inhaled glucocorticoids, quintupling the dose at the early signs of loss of asthma control did not reduce the rate of severe asthma exacerbations or improve other asthma outcomes and may be associated with diminished linear growth. (Funded by the National Heart, Lung, and Blood Institute; STICS ClinicalTrials.gov number, NCT02066129).

John Bishara, DO

Fellow-in-Training Member

Pulmonary Physiology, Function, and Rehabilitation

Understanding cardiopulmonary exercise testing

The cardiopulmonary exercise test (CPET) is an underutilized tool for evaluating patients with dyspnea of uncertain etiology. This is often due to the daunting task of trying to make sense of seemingly large amounts of interacting data, along with clinicians not having been taught a systematic approach for interpreting the results. Unlike other typical tests we order that point to a specific laboratory or anatomic radiographic abnormality, narrowing our differential to a few possibilities, one needs a different mindset when interpreting a CPET. This is a study to demonstrate the body’s normal or abnormal physiologic responses to increasing levels of physical stress. Because different conditions can give similar findings, the physiologic abnormalities must be interpreted in the context of the clinical presentation. If the results do not entirely fit the suspected diagnosis, they should be reported in a manner that may help guide the ordering physician down an alternate pathway. This CHEST NetWork has sought ways to reach out to members to promote a better understanding of the utilization of the basics of pulmonary physiology in the management of patients. We created an online two-part video demonstrating a basic systematic approach toward understanding the combinations of findings one often sees when performing a CPET. A comprehensive understanding cannot be shown in a 40-minute video series, but, hopefully, this will give a starting point to make this task easier and more enjoyable.

Zachary Morris, MD, FCCP

Steering Committee Member

Pulmonary Vascular Disease

BMPR2 mutation regulates singular millimetric fibrovascular lesions in bronchial circulation in PAH

Patients with PAH with BMPR2 mutation are younger with worse hemodynamics, ie, higher mean PAP with higher PVR and a lower cardiac index in comparison to the noncarriers. A systematic analysis of pulmonary imaging using CT angiography or magnetic resonance imaging in patients with PAH demonstrated increased bronchial arterial hypertrophy in BMPR2 mutation carriers compared with those without the mutation. Moreover, hemoptysis is more frequently encountered in patients with PAH with BMPR2 mutation and presumably related to bronchial artery remodeling and angiogenesis. French investigators described, in histopathology findings of explanted lungs of 44 patients with PAH (23 carriers of BMPR2 and 21 noncarriers), unusual singular millimetric fibrovascular lesions (SiMFi) in patients with BMPR2 mutations. The SiMFi is a structure of millimetric dimension with fibrovascular characteristics that are extremely rich in collagen and displayed more than one vascular channel. SiMFi did not show a classic glomeruloid pattern with predominant endothelial cell proliferation as seen in plexiform lesions but rather a large conglomerate of hypertrophic vessels. Performing an ink injection experiment in a freshly explanted lung highlighted a patent connection between bronchial/systemic vessels and pulmonary septal veins. SiMFis had an increased amount of bronchial microvessels and showed increased hypertrophy of larger bronchial arteries. SiMFi is directly related to hypertrophy and/or angiogenesis of vasa vasorum/bronchial arteries in the vicinity of the diseased artery. In patients with PAH with BMPR2 mutations, bronchial angiogenesis is more prevalent compared with patients with PAH lacking these mutations. This highlights the role of bronchial arteries in the spectrum of PAH.

Hector Cajigas, MD, FCCP

Sandeep Sahay, MD, FCCP

Steering Committee Members

References

1.Ghigna MR, et al. BMPR2 mutation status influences bronchial vascular changes in pulmonary arterial hypertension. Eur Respir J. 2016;48[6]:1668. Epub 2016 Nov 3.

2. Tio D, et al. Risk factors for hemoptysis in idiopathic and hereditary pulmonary arterial hypertension. PLoS One. 2013;8:e78132.

3. Elliott CG, et al. Relationship of BMPR2 mutations to vasoreactivity in pulmonary arterial hypertension. Circulation. 2006;113[21]:2509.

Thoracic Oncology

We have a lung cancer screening test but we could use it better

The American Lung Association recently demonstrated the majority of current and former smokers don’t know about lung cancer screening (LCS) with low-dose CT scanning.¹ Researchers estimate less than 5% of eligible persons received LCS.² Awareness campaigns targeting patients and health care providers at the local level can improve LCS uptake.^3,4 While any new clinical practice has an expected implementation delay, LCS has another implementation barrier: complex eligibility criteria (age 55 – 80 years PLUS 30+ pack-year smoking history PLUS quit time less than 15 years). Electronic health record (EHR) tools might accelerate the adoption curve to identify eligible persons.⁵ Moreover, assessing and recording a qualitative smoking history is challenging, at best. One center showed 96.2% discordance between EHR smoking history and that obtained during shared decision-making visit for LCS.⁶ Mostly, the EHR underreported quantitative pack-year history; meaning LCS-eligible patients might fail to be identified by EHR review alone. Another small pilot showed that some patients age 55 – 79 years will update their EHR smoking history using patient portal, but this will not be effective for all patients.⁷ For current smokers, age alone may be an effective identification strategy, given the average start time for most smokers.⁸

Even though current LCS guidelines leave out some individuals at high risk for lung cancer, we must continue efforts to offer this potentially life-saving service to patients now eligible. Using EHR tools may help proactively identify those who are eligible for lung cancer screening.

A bbie Begnaud, MD

NetWork Member

References

1. New Study from American Lung Association’s LUNG FORCE Reveals Low Awareness of Lifesaving Lung Cancer Screening Among Those at Greatest Risk. (2017). http://www.lung.org/about-us/media/press-releases/new-study-lung-cancer-screening.html. Accessed April 19, 2018.

2. Soneji S, et al. Underuse of Chest Radiography Versus Computed Tomography for Lung Cancer Screening. Am J Public Health. 2017;107(8):1248.

3. Cardarelli R, et al. Terminate lung cancer (TLC) study-A mixed-methods population approach to increase lung cancer screening awareness and low-dose computed tomography in Eastern Kentucky. Cancer Epidemiol. 2017;46:1.

4. Jessup, DL, et al. Implementation of digital awareness strategies to engage patients and providers in a lung cancer screening program: retrospective study. J Med Internet Res. 2018;20(2):e52.

5. Comparison of the Electronic Medical Record versus a Shared Decision Making Conversation. Ann Am Thorac Soc. 2018. In press.

6. Modin HE, et al. Pack-year cigarette smoking history for determination of lung cancer screening eligibility. Ann Am Thorac Soc. 2017 Aug;14(8):1320-1325.

7. Begnaud AL, et al. Randomized electronic promotion of lung cancer screening: a pilot. JCO Clinical Cancer Informatics(1), 1-6. doi:10.1200/cci.17.00033

8. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. (2014). Atlanta, GA.

The gender gap exists for women in pulmonary medicine. According to the Medscape Pulmonologist Compensation Report 2017, women pulmonologists earned 23% less than their male counterparts even though:

• 2% of women pulmonologists work part time vs 8% of men;
• more women (66%) than men (48%) reported seeking promotion. (Grisham, 2017)

If we take a look at a recent report done by Doximity that analyzed responses on more than 65,000 licensed US doctors across the country, the report reveals that the gap between female and male physicians across the nation, women on average make about $91,000 less annually (Doximity, 2018).

Despite ever-growing enrollment rates for women in medical schools, female physicians are often underrepresented in academic and research settings. According to a study published in the Journal of National Medical Association, “between 80 and 90 percent of leadership roles in medicine, like medical school deans, are filled by men.” (Morton & Sonnad, 2007)

These astounding gaps do not stop at the clinician’s door. This gender inequality is evident in the women who are receiving medical treatment, as well. There are two major issues that exist for women seeking treatment:
 

1. Not being taken as seriously as male patients:

• Women are more likely to be prescribed sedatives for their pain, and men are more likely to be prescribed pain medication. (L. Calderone, 1990)
• Women are more likely to be treated less aggressively in their initial encounters with the health-care system until they prove that they are as sick as male patients with similar symptoms. (Hoffmann & Tarzian, 2001)
• Nationwide, men wait an average of 49 minutes before receiving an analgesic for acute abdominal pain. Women wait an average of 65 minutes for the same thing. (Chen, et al., 2008)
• Multiple studies have shown that female patients’ symptoms are less likely to be taken seriously by doctors, and women are more likely to be misdiagnosed, have their symptoms go unrecognized, or be told what they’re experiencing is psychosomatic. (Hoffmann & Tarzian, 2001) (Carnlöf, Iwarzon, Jensen-Urstad, Gadler, & Insulander, 2017)

2. Being diagnosed and treated the same as male patients

• Up until 1993 when the National Institutes of Health Revitalization Act mandated that all women and minorities be included in clinical trials funded by the NIH, the guidelines and diagnosis for treatment have historically been based off the archetypal patient: a 154-pound white male. Because of this, women are often misdiagnosed or receive treatments that are ineffective or potentially harmful to their health. Even still, researchers frequently do not enroll an adequate number of women or fail to analyze or report data separately by sex. (MHC Center, 2014)
• Women and men metabolize drugs differently, yet dosages are rarely broken down by sex. Women also experience different side effects and derive different benefits from the same treatments. (Soldin & Mattison, 2009)
• Female patients have a 1.5 to 1.7 times higher chance of having an adverse drug reaction. (Rademaker, 2001)
• There are many diseases and conditions that are alarmingly more prevalent among women. Nonsmoking women are three times more likely to get lung cancer than nonsmoking men, according to a comprehensive 2014 report by Brigham and Women’s Hospital in Boston, called “Women’s Health Can’t Wait.” (MHC Center, 2014)

“While the number of women participating in lung cancer clinical trials has risen, women—particularly those from racial and ethnic minorities—are still less likely to enroll in these trials than men. Even when studies include women, researchers often fail to analyze data by sex or include hormone status or other gender-specific factors, making it difficult to uncover differences in incidence, prevalence, and survivability between men and women and to replicate the studies.” (MHC Center, 2014)In the pulmonary space, there is growing evidence that a number of pulmonary diseases affect women differently and with a greater degree of severity than men. Respiratory conditions that impact women nearly exclusively include pulmonary hypertension, catamenial diseases, and pregnancy-associated asthma exacerbation. (Pinkerton, et al., 2015) According to the CDC, cancer is the number one cause of death for women ages 35-64, and the number one cancer killer in women is lung cancer. Women have been taught to care and take notice of the symptoms of breast cancer, HPV, ovarian cancer, and other “women’s diseases,” and, yet, more women die every day from lung cancer than from breast, ovarian, and uterine cancers combined.
 

Why CHEST?

Now, why does this matter to us at CHEST? What can we do about it? How do we begin to tackle such a large issue that permeates nearly every facet of society?

CHEST is in a unique position to not only address the professional development needs of our female membership, but with the help and leadership of the CHEST Foundation and a new partnership with HealthyWomen, we are poised to address the gaps in education for our clinicians, patients, and the public.

To address these needs, the Women in Pulmonary program was created. Women in Pulmonary started as a yearly luncheon and has expanded into a yearlong program that will work to fill these gaps by not only elevating the wants and needs of women in pulmonary medicine, but also by bringing awareness to clinicians, patients, and the public on diseases that are not typically considered “women’s issues.”

CHEST and HealthyWomen are working to provide education, in the form of free webinars, multimedia resources, and live events to achieve the following outcomes:

Women in Pulmonary Medicine: CHEST and HealthyWomen aim to create the tools and educational opportunities that will empower our female clinicians to elevate their voices and become advocates for their career advancement, as well as improved diagnosis and treatment of women with pulmonary diseases.

Patients, Caregivers, and the Public: With this initiative, CHEST and HealthyWomen strive to empower women with the knowledge they need to become champions of their lung health. We will provide them with talking points, questions and awareness of symptoms of pulmonary conditions and diseases, such as: lung cancer, ILD/IPF, COPD, pulmonary hypertension, and asthma so that they are better able to go to their doctor appointments ready to advocate for the care they need.

Clinicians: CHEST and HealthyWomen will aim to equip all clinicians, not just women, with exposure and education that address gender differences in treatment and diagnosis of diseases like lung cancer, asthma, COPD, PH, and ILD/IPF.

Women in Pulmonary aims to provide essential education to every clinician treating women, promote awareness among patients and the public on key information to improve conversations with their health-care providers, and create opportunities for women in chest medicine to advance their careers through professional development, engagement, networking, and mentorship connections. This program will be one step in the direction of changing how women are viewed in medicine and how diseases are perceived across genders.
 

Bibliography

Calderone K. The influence of gender on the frequency of pain and sedative medication administered to postoperative patients. Sex Roles. 1990;23(11-12): 713-725.

Carnlöf C, et al. Women with PSVY are often misdiagnosed, referred later than men, and have more symptoms after ablation. Scand Cardiovasc J. 2017; 51(6): 299-307.

Chen EH, et al. Gender disparity in analgesic treatment of emergency departmetn patietns with acute abdominal pain. Acad Emerg Med. 2008;15(5):414-418.

Doximity. 2018 Physician Compensation Report. Doximity.

Grisham S. Medscape Pulmonologist Compensation Report 2017. https://www.medscape.com/slideshow/compensation-2017-pulmonary-medicine-6008586. Accessed Jan 16, 2018.

Hoffmann DE, Tarzian AJ. The girl who cried pain: a bias against women in the treatment of pain. J Law Med Ethics. 2001;29(1):13-27.

MHC Center. Sex-Specific Medical Research: Why Women’s Health Can’t Wait. Brigham and Women’s Hospital, Mary Horrigan Connors Center for Women’s Health & Gender Biology. Brigham and Women’s Hospital;2014.

Morton MJ, Sonnad SS. Women on professional society and journal editorial boards. J National Med Assoc. 2007;99(7):764-771.

Pinkerton K, et al. Women and lung disease. sex differences and global health disparities. Am J Respir Crit Care Med. 2015;192(1):11-16.

Rademaker M. (2001). Do women have more adverse drug reactions? Am J Clin Dermatol. 2001;2(6): 349-351.

Soldin O, Mattison M. Sex differences in pharmacokinetics and pharmacodynamics. Clin Pharmacokinetics. 2009;48(3):143-157.

The gender gap exists for women in pulmonary medicine. According to the Medscape Pulmonologist Compensation Report 2017, women pulmonologists earned 23% less than their male counterparts even though:

• 2% of women pulmonologists work part time vs 8% of men;
• more women (66%) than men (48%) reported seeking promotion. (Grisham, 2017)

If we take a look at a recent report done by Doximity that analyzed responses on more than 65,000 licensed US doctors across the country, the report reveals that the gap between female and male physicians across the nation, women on average make about $91,000 less annually (Doximity, 2018).

Despite ever-growing enrollment rates for women in medical schools, female physicians are often underrepresented in academic and research settings. According to a study published in the Journal of National Medical Association, “between 80 and 90 percent of leadership roles in medicine, like medical school deans, are filled by men.” (Morton & Sonnad, 2007)

These astounding gaps do not stop at the clinician’s door. This gender inequality is evident in the women who are receiving medical treatment, as well. There are two major issues that exist for women seeking treatment:
 

1. Not being taken as seriously as male patients:

• Women are more likely to be prescribed sedatives for their pain, and men are more likely to be prescribed pain medication. (L. Calderone, 1990)
• Women are more likely to be treated less aggressively in their initial encounters with the health-care system until they prove that they are as sick as male patients with similar symptoms. (Hoffmann & Tarzian, 2001)
• Nationwide, men wait an average of 49 minutes before receiving an analgesic for acute abdominal pain. Women wait an average of 65 minutes for the same thing. (Chen, et al., 2008)
• Multiple studies have shown that female patients’ symptoms are less likely to be taken seriously by doctors, and women are more likely to be misdiagnosed, have their symptoms go unrecognized, or be told what they’re experiencing is psychosomatic. (Hoffmann & Tarzian, 2001) (Carnlöf, Iwarzon, Jensen-Urstad, Gadler, & Insulander, 2017)

2. Being diagnosed and treated the same as male patients

• Up until 1993 when the National Institutes of Health Revitalization Act mandated that all women and minorities be included in clinical trials funded by the NIH, the guidelines and diagnosis for treatment have historically been based off the archetypal patient: a 154-pound white male. Because of this, women are often misdiagnosed or receive treatments that are ineffective or potentially harmful to their health. Even still, researchers frequently do not enroll an adequate number of women or fail to analyze or report data separately by sex. (MHC Center, 2014)
• Women and men metabolize drugs differently, yet dosages are rarely broken down by sex. Women also experience different side effects and derive different benefits from the same treatments. (Soldin & Mattison, 2009)
• Female patients have a 1.5 to 1.7 times higher chance of having an adverse drug reaction. (Rademaker, 2001)
• There are many diseases and conditions that are alarmingly more prevalent among women. Nonsmoking women are three times more likely to get lung cancer than nonsmoking men, according to a comprehensive 2014 report by Brigham and Women’s Hospital in Boston, called “Women’s Health Can’t Wait.” (MHC Center, 2014)

“While the number of women participating in lung cancer clinical trials has risen, women—particularly those from racial and ethnic minorities—are still less likely to enroll in these trials than men. Even when studies include women, researchers often fail to analyze data by sex or include hormone status or other gender-specific factors, making it difficult to uncover differences in incidence, prevalence, and survivability between men and women and to replicate the studies.” (MHC Center, 2014)In the pulmonary space, there is growing evidence that a number of pulmonary diseases affect women differently and with a greater degree of severity than men. Respiratory conditions that impact women nearly exclusively include pulmonary hypertension, catamenial diseases, and pregnancy-associated asthma exacerbation. (Pinkerton, et al., 2015) According to the CDC, cancer is the number one cause of death for women ages 35-64, and the number one cancer killer in women is lung cancer. Women have been taught to care and take notice of the symptoms of breast cancer, HPV, ovarian cancer, and other “women’s diseases,” and, yet, more women die every day from lung cancer than from breast, ovarian, and uterine cancers combined.
 

Why CHEST?

Now, why does this matter to us at CHEST? What can we do about it? How do we begin to tackle such a large issue that permeates nearly every facet of society?

CHEST is in a unique position to not only address the professional development needs of our female membership, but with the help and leadership of the CHEST Foundation and a new partnership with HealthyWomen, we are poised to address the gaps in education for our clinicians, patients, and the public.

To address these needs, the Women in Pulmonary program was created. Women in Pulmonary started as a yearly luncheon and has expanded into a yearlong program that will work to fill these gaps by not only elevating the wants and needs of women in pulmonary medicine, but also by bringing awareness to clinicians, patients, and the public on diseases that are not typically considered “women’s issues.”

CHEST and HealthyWomen are working to provide education, in the form of free webinars, multimedia resources, and live events to achieve the following outcomes:

Women in Pulmonary Medicine: CHEST and HealthyWomen aim to create the tools and educational opportunities that will empower our female clinicians to elevate their voices and become advocates for their career advancement, as well as improved diagnosis and treatment of women with pulmonary diseases.

Patients, Caregivers, and the Public: With this initiative, CHEST and HealthyWomen strive to empower women with the knowledge they need to become champions of their lung health. We will provide them with talking points, questions and awareness of symptoms of pulmonary conditions and diseases, such as: lung cancer, ILD/IPF, COPD, pulmonary hypertension, and asthma so that they are better able to go to their doctor appointments ready to advocate for the care they need.

Clinicians: CHEST and HealthyWomen will aim to equip all clinicians, not just women, with exposure and education that address gender differences in treatment and diagnosis of diseases like lung cancer, asthma, COPD, PH, and ILD/IPF.

Women in Pulmonary aims to provide essential education to every clinician treating women, promote awareness among patients and the public on key information to improve conversations with their health-care providers, and create opportunities for women in chest medicine to advance their careers through professional development, engagement, networking, and mentorship connections. This program will be one step in the direction of changing how women are viewed in medicine and how diseases are perceived across genders.
 

Bibliography

Calderone K. The influence of gender on the frequency of pain and sedative medication administered to postoperative patients. Sex Roles. 1990;23(11-12): 713-725.

Carnlöf C, et al. Women with PSVY are often misdiagnosed, referred later than men, and have more symptoms after ablation. Scand Cardiovasc J. 2017; 51(6): 299-307.

Chen EH, et al. Gender disparity in analgesic treatment of emergency departmetn patietns with acute abdominal pain. Acad Emerg Med. 2008;15(5):414-418.

Doximity. 2018 Physician Compensation Report. Doximity.

Grisham S. Medscape Pulmonologist Compensation Report 2017. https://www.medscape.com/slideshow/compensation-2017-pulmonary-medicine-6008586. Accessed Jan 16, 2018.

Hoffmann DE, Tarzian AJ. The girl who cried pain: a bias against women in the treatment of pain. J Law Med Ethics. 2001;29(1):13-27.

MHC Center. Sex-Specific Medical Research: Why Women’s Health Can’t Wait. Brigham and Women’s Hospital, Mary Horrigan Connors Center for Women’s Health & Gender Biology. Brigham and Women’s Hospital;2014.

Morton MJ, Sonnad SS. Women on professional society and journal editorial boards. J National Med Assoc. 2007;99(7):764-771.

Pinkerton K, et al. Women and lung disease. sex differences and global health disparities. Am J Respir Crit Care Med. 2015;192(1):11-16.

Rademaker M. (2001). Do women have more adverse drug reactions? Am J Clin Dermatol. 2001;2(6): 349-351.

Soldin O, Mattison M. Sex differences in pharmacokinetics and pharmacodynamics. Clin Pharmacokinetics. 2009;48(3):143-157.

The gender gap exists for women in pulmonary medicine. According to the Medscape Pulmonologist Compensation Report 2017, women pulmonologists earned 23% less than their male counterparts even though:

• 2% of women pulmonologists work part time vs 8% of men;
• more women (66%) than men (48%) reported seeking promotion. (Grisham, 2017)

If we take a look at a recent report done by Doximity that analyzed responses on more than 65,000 licensed US doctors across the country, the report reveals that the gap between female and male physicians across the nation, women on average make about $91,000 less annually (Doximity, 2018).

Despite ever-growing enrollment rates for women in medical schools, female physicians are often underrepresented in academic and research settings. According to a study published in the Journal of National Medical Association, “between 80 and 90 percent of leadership roles in medicine, like medical school deans, are filled by men.” (Morton & Sonnad, 2007)

These astounding gaps do not stop at the clinician’s door. This gender inequality is evident in the women who are receiving medical treatment, as well. There are two major issues that exist for women seeking treatment:
 

1. Not being taken as seriously as male patients:

• Women are more likely to be prescribed sedatives for their pain, and men are more likely to be prescribed pain medication. (L. Calderone, 1990)
• Women are more likely to be treated less aggressively in their initial encounters with the health-care system until they prove that they are as sick as male patients with similar symptoms. (Hoffmann & Tarzian, 2001)
• Nationwide, men wait an average of 49 minutes before receiving an analgesic for acute abdominal pain. Women wait an average of 65 minutes for the same thing. (Chen, et al., 2008)
• Multiple studies have shown that female patients’ symptoms are less likely to be taken seriously by doctors, and women are more likely to be misdiagnosed, have their symptoms go unrecognized, or be told what they’re experiencing is psychosomatic. (Hoffmann & Tarzian, 2001) (Carnlöf, Iwarzon, Jensen-Urstad, Gadler, & Insulander, 2017)

2. Being diagnosed and treated the same as male patients

• Up until 1993 when the National Institutes of Health Revitalization Act mandated that all women and minorities be included in clinical trials funded by the NIH, the guidelines and diagnosis for treatment have historically been based off the archetypal patient: a 154-pound white male. Because of this, women are often misdiagnosed or receive treatments that are ineffective or potentially harmful to their health. Even still, researchers frequently do not enroll an adequate number of women or fail to analyze or report data separately by sex. (MHC Center, 2014)
• Women and men metabolize drugs differently, yet dosages are rarely broken down by sex. Women also experience different side effects and derive different benefits from the same treatments. (Soldin & Mattison, 2009)
• Female patients have a 1.5 to 1.7 times higher chance of having an adverse drug reaction. (Rademaker, 2001)
• There are many diseases and conditions that are alarmingly more prevalent among women. Nonsmoking women are three times more likely to get lung cancer than nonsmoking men, according to a comprehensive 2014 report by Brigham and Women’s Hospital in Boston, called “Women’s Health Can’t Wait.” (MHC Center, 2014)

“While the number of women participating in lung cancer clinical trials has risen, women—particularly those from racial and ethnic minorities—are still less likely to enroll in these trials than men. Even when studies include women, researchers often fail to analyze data by sex or include hormone status or other gender-specific factors, making it difficult to uncover differences in incidence, prevalence, and survivability between men and women and to replicate the studies.” (MHC Center, 2014)In the pulmonary space, there is growing evidence that a number of pulmonary diseases affect women differently and with a greater degree of severity than men. Respiratory conditions that impact women nearly exclusively include pulmonary hypertension, catamenial diseases, and pregnancy-associated asthma exacerbation. (Pinkerton, et al., 2015) According to the CDC, cancer is the number one cause of death for women ages 35-64, and the number one cancer killer in women is lung cancer. Women have been taught to care and take notice of the symptoms of breast cancer, HPV, ovarian cancer, and other “women’s diseases,” and, yet, more women die every day from lung cancer than from breast, ovarian, and uterine cancers combined.
 

Why CHEST?

Now, why does this matter to us at CHEST? What can we do about it? How do we begin to tackle such a large issue that permeates nearly every facet of society?

CHEST is in a unique position to not only address the professional development needs of our female membership, but with the help and leadership of the CHEST Foundation and a new partnership with HealthyWomen, we are poised to address the gaps in education for our clinicians, patients, and the public.

To address these needs, the Women in Pulmonary program was created. Women in Pulmonary started as a yearly luncheon and has expanded into a yearlong program that will work to fill these gaps by not only elevating the wants and needs of women in pulmonary medicine, but also by bringing awareness to clinicians, patients, and the public on diseases that are not typically considered “women’s issues.”

CHEST and HealthyWomen are working to provide education, in the form of free webinars, multimedia resources, and live events to achieve the following outcomes:

Women in Pulmonary Medicine: CHEST and HealthyWomen aim to create the tools and educational opportunities that will empower our female clinicians to elevate their voices and become advocates for their career advancement, as well as improved diagnosis and treatment of women with pulmonary diseases.

Patients, Caregivers, and the Public: With this initiative, CHEST and HealthyWomen strive to empower women with the knowledge they need to become champions of their lung health. We will provide them with talking points, questions and awareness of symptoms of pulmonary conditions and diseases, such as: lung cancer, ILD/IPF, COPD, pulmonary hypertension, and asthma so that they are better able to go to their doctor appointments ready to advocate for the care they need.

Clinicians: CHEST and HealthyWomen will aim to equip all clinicians, not just women, with exposure and education that address gender differences in treatment and diagnosis of diseases like lung cancer, asthma, COPD, PH, and ILD/IPF.

Women in Pulmonary aims to provide essential education to every clinician treating women, promote awareness among patients and the public on key information to improve conversations with their health-care providers, and create opportunities for women in chest medicine to advance their careers through professional development, engagement, networking, and mentorship connections. This program will be one step in the direction of changing how women are viewed in medicine and how diseases are perceived across genders.
 

Bibliography

Calderone K. The influence of gender on the frequency of pain and sedative medication administered to postoperative patients. Sex Roles. 1990;23(11-12): 713-725.

Carnlöf C, et al. Women with PSVY are often misdiagnosed, referred later than men, and have more symptoms after ablation. Scand Cardiovasc J. 2017; 51(6): 299-307.

Chen EH, et al. Gender disparity in analgesic treatment of emergency departmetn patietns with acute abdominal pain. Acad Emerg Med. 2008;15(5):414-418.

Doximity. 2018 Physician Compensation Report. Doximity.

Grisham S. Medscape Pulmonologist Compensation Report 2017. https://www.medscape.com/slideshow/compensation-2017-pulmonary-medicine-6008586. Accessed Jan 16, 2018.

Hoffmann DE, Tarzian AJ. The girl who cried pain: a bias against women in the treatment of pain. J Law Med Ethics. 2001;29(1):13-27.

MHC Center. Sex-Specific Medical Research: Why Women’s Health Can’t Wait. Brigham and Women’s Hospital, Mary Horrigan Connors Center for Women’s Health & Gender Biology. Brigham and Women’s Hospital;2014.

Morton MJ, Sonnad SS. Women on professional society and journal editorial boards. J National Med Assoc. 2007;99(7):764-771.

Pinkerton K, et al. Women and lung disease. sex differences and global health disparities. Am J Respir Crit Care Med. 2015;192(1):11-16.

Rademaker M. (2001). Do women have more adverse drug reactions? Am J Clin Dermatol. 2001;2(6): 349-351.

Soldin O, Mattison M. Sex differences in pharmacokinetics and pharmacodynamics. Clin Pharmacokinetics. 2009;48(3):143-157.

CHEST has been informed of the following members’ deaths. We extend our sincere condolences to friends and family.

Nagesh V Salian, MD, FCCP (2016)



Ted A Calinog, MD, FCCP (2017)



Azam Ansari, MD

(2017)



Arthur E. Schmidt, MD, FCCP (2017)



W. Gerald Rainer, MD, FCCP (2017)

CHEST has been informed of the following members’ deaths. We extend our sincere condolences to friends and family.

Nagesh V Salian, MD, FCCP (2016)



Ted A Calinog, MD, FCCP (2017)



Azam Ansari, MD

(2017)



Arthur E. Schmidt, MD, FCCP (2017)



W. Gerald Rainer, MD, FCCP (2017)

CHEST has been informed of the following members’ deaths. We extend our sincere condolences to friends and family.

Nagesh V Salian, MD, FCCP (2016)



Ted A Calinog, MD, FCCP (2017)



Azam Ansari, MD

(2017)



Arthur E. Schmidt, MD, FCCP (2017)



W. Gerald Rainer, MD, FCCP (2017)

Looking for a research opportunity? Check our website for current programs in your area. If your institution has an opportunity to promote, let us know at [email protected]

Looking for a research opportunity? Check our website for current programs in your area. If your institution has an opportunity to promote, let us know at [email protected]

Looking for a research opportunity? Check our website for current programs in your area. If your institution has an opportunity to promote, let us know at [email protected]

Speaking of the Vascular Annual Meeting, have you registered yet? You won’t want to miss a minute, with postgraduate courses, workshops, concurrent and breakfast sessions, scientific sessions, opportunities to get tips and tricks and to ask the experts and to meet up with old friends and greet all your colleagues. Book your housing by May 22 for discounted rates and the VAM room blocks. Get a rundown of event at the VAM Planner here. Register here; book your hotel here. And … see you in Boston.

Speaking of the Vascular Annual Meeting, have you registered yet? You won’t want to miss a minute, with postgraduate courses, workshops, concurrent and breakfast sessions, scientific sessions, opportunities to get tips and tricks and to ask the experts and to meet up with old friends and greet all your colleagues. Book your housing by May 22 for discounted rates and the VAM room blocks. Get a rundown of event at the VAM Planner here. Register here; book your hotel here. And … see you in Boston.

Speaking of the Vascular Annual Meeting, have you registered yet? You won’t want to miss a minute, with postgraduate courses, workshops, concurrent and breakfast sessions, scientific sessions, opportunities to get tips and tricks and to ask the experts and to meet up with old friends and greet all your colleagues. Book your housing by May 22 for discounted rates and the VAM room blocks. Get a rundown of event at the VAM Planner here. Register here; book your hotel here. And … see you in Boston.

The SVS is debuting a new “Ask the Expert” series at the Vascular Annual Meeting this year, and we need members’ help to build it. “Expert” will consist of four, one-hour sessions, one daily Wednesday through Friday, with cases submitted by members. Please submit a case study you wish to be considered for discussion with one of our experts -- and we hope you attend if your case is selected. The deadline will be in mid-May. Topics are Coding, Aortic Care for Occlusive Disease, Hemodialysis and PAD. Submit your cases here. Email education@vascularsociety with questions.

The SVS is debuting a new “Ask the Expert” series at the Vascular Annual Meeting this year, and we need members’ help to build it. “Expert” will consist of four, one-hour sessions, one daily Wednesday through Friday, with cases submitted by members. Please submit a case study you wish to be considered for discussion with one of our experts -- and we hope you attend if your case is selected. The deadline will be in mid-May. Topics are Coding, Aortic Care for Occlusive Disease, Hemodialysis and PAD. Submit your cases here. Email education@vascularsociety with questions.

The SVS is debuting a new “Ask the Expert” series at the Vascular Annual Meeting this year, and we need members’ help to build it. “Expert” will consist of four, one-hour sessions, one daily Wednesday through Friday, with cases submitted by members. Please submit a case study you wish to be considered for discussion with one of our experts -- and we hope you attend if your case is selected. The deadline will be in mid-May. Topics are Coding, Aortic Care for Occlusive Disease, Hemodialysis and PAD. Submit your cases here. Email education@vascularsociety with questions.

The SVS is debuting a new “Ask the Expert” series at the Vascular Annual Meeting this year, and we need members’ help to build it. “Expert” will consist of four, one-hour sessions, one daily Wednesday through Friday, with cases submitted by members. Please submit a case study you wish to be considered for discussion with one of our experts -- and we hope you attend if your case is selected. The deadline will be in mid-May. Topics are Coding, Aortic Care for Occlusive Disease, Hemodialysis and PAD. Submit your cases here. Email education@vascularsociety with questions

The SVS is debuting a new “Ask the Expert” series at the Vascular Annual Meeting this year, and we need members’ help to build it. “Expert” will consist of four, one-hour sessions, one daily Wednesday through Friday, with cases submitted by members. Please submit a case study you wish to be considered for discussion with one of our experts -- and we hope you attend if your case is selected. The deadline will be in mid-May. Topics are Coding, Aortic Care for Occlusive Disease, Hemodialysis and PAD. Submit your cases here. Email education@vascularsociety with questions

The SVS is debuting a new “Ask the Expert” series at the Vascular Annual Meeting this year, and we need members’ help to build it. “Expert” will consist of four, one-hour sessions, one daily Wednesday through Friday, with cases submitted by members. Please submit a case study you wish to be considered for discussion with one of our experts -- and we hope you attend if your case is selected. The deadline will be in mid-May. Topics are Coding, Aortic Care for Occlusive Disease, Hemodialysis and PAD. Submit your cases here. Email education@vascularsociety with questions

Digestive Disease Week^® (DDW) is approaching rapidly. One might say, with strong justification, that the overarching theme for DDW is a celebration of diversity. We are entering the era of “omics” and current research suggests a microbiome rich in diversity is associated with health, while a less-diverse biome is associated with digestive disorders – inflammatory bowel disease for example. Multiple abstracts and presentations will be related to research into microbiome alterations in disease. In nature, diversity is a key to survival.

Farmers know the value of diversity and the devastating effects of restricted diversity. When fields are restricted to a single crop year after year, artificial fertilizers must be used to restore fertility. Organic farmers understand the need for diversity in the form of crop rotation. No forest can survive for long without rich biological diversity. Even cancer reminds us of the importance of diversity. Restricted diversity in the form of cellular monoclonality is one of the hallmarks of malignant growth.

DDW, our annual hallmark meeting, emphasizes our need for diverse thoughts and intellectual discourse as we advance the science of gastroenterology, endoscopy, hepatology, and surgery. Biology does not tolerate restrictions on diversity for long. Diversity makes DDW great.

In this month’s issue of GI & Hepatology News, we are reassured that PPIs are not linked to cognitive decline. Sessile serrated polyps, often missed at colonoscopy and CT colography might be detected with noninvasive testing as the field of blood-based cancer screening advances. Pay attention to the exciting bleeding-edge technology emerging from the AGA Tech Summit – especially technologies to treat obesity. Read about some of the continuing barriers to CRC screening in underserved populations – if we are to achieve 80% screening rates we must focus on people challenged to access our health care system.

Finally, consider the AGA Clinical Practice Update about Barrett’s esophagus. I spent a morning with Joel Richter, MD, last month and he reminded me that our current surveillance system is failing to impact annual incidence of esophageal adenocarcinoma. Perhaps we should focus on a one-time screen for those most at risk, catching prevalent disease at an early stage.
 

John I. Allen, MD, MBA, AGAF
Editor in Chief

Digestive Disease Week^® (DDW) is approaching rapidly. One might say, with strong justification, that the overarching theme for DDW is a celebration of diversity. We are entering the era of “omics” and current research suggests a microbiome rich in diversity is associated with health, while a less-diverse biome is associated with digestive disorders – inflammatory bowel disease for example. Multiple abstracts and presentations will be related to research into microbiome alterations in disease. In nature, diversity is a key to survival.

Farmers know the value of diversity and the devastating effects of restricted diversity. When fields are restricted to a single crop year after year, artificial fertilizers must be used to restore fertility. Organic farmers understand the need for diversity in the form of crop rotation. No forest can survive for long without rich biological diversity. Even cancer reminds us of the importance of diversity. Restricted diversity in the form of cellular monoclonality is one of the hallmarks of malignant growth.

DDW, our annual hallmark meeting, emphasizes our need for diverse thoughts and intellectual discourse as we advance the science of gastroenterology, endoscopy, hepatology, and surgery. Biology does not tolerate restrictions on diversity for long. Diversity makes DDW great.

In this month’s issue of GI & Hepatology News, we are reassured that PPIs are not linked to cognitive decline. Sessile serrated polyps, often missed at colonoscopy and CT colography might be detected with noninvasive testing as the field of blood-based cancer screening advances. Pay attention to the exciting bleeding-edge technology emerging from the AGA Tech Summit – especially technologies to treat obesity. Read about some of the continuing barriers to CRC screening in underserved populations – if we are to achieve 80% screening rates we must focus on people challenged to access our health care system.

Finally, consider the AGA Clinical Practice Update about Barrett’s esophagus. I spent a morning with Joel Richter, MD, last month and he reminded me that our current surveillance system is failing to impact annual incidence of esophageal adenocarcinoma. Perhaps we should focus on a one-time screen for those most at risk, catching prevalent disease at an early stage.
 

John I. Allen, MD, MBA, AGAF
Editor in Chief

Digestive Disease Week^® (DDW) is approaching rapidly. One might say, with strong justification, that the overarching theme for DDW is a celebration of diversity. We are entering the era of “omics” and current research suggests a microbiome rich in diversity is associated with health, while a less-diverse biome is associated with digestive disorders – inflammatory bowel disease for example. Multiple abstracts and presentations will be related to research into microbiome alterations in disease. In nature, diversity is a key to survival.

Farmers know the value of diversity and the devastating effects of restricted diversity. When fields are restricted to a single crop year after year, artificial fertilizers must be used to restore fertility. Organic farmers understand the need for diversity in the form of crop rotation. No forest can survive for long without rich biological diversity. Even cancer reminds us of the importance of diversity. Restricted diversity in the form of cellular monoclonality is one of the hallmarks of malignant growth.

DDW, our annual hallmark meeting, emphasizes our need for diverse thoughts and intellectual discourse as we advance the science of gastroenterology, endoscopy, hepatology, and surgery. Biology does not tolerate restrictions on diversity for long. Diversity makes DDW great.

In this month’s issue of GI & Hepatology News, we are reassured that PPIs are not linked to cognitive decline. Sessile serrated polyps, often missed at colonoscopy and CT colography might be detected with noninvasive testing as the field of blood-based cancer screening advances. Pay attention to the exciting bleeding-edge technology emerging from the AGA Tech Summit – especially technologies to treat obesity. Read about some of the continuing barriers to CRC screening in underserved populations – if we are to achieve 80% screening rates we must focus on people challenged to access our health care system.

Finally, consider the AGA Clinical Practice Update about Barrett’s esophagus. I spent a morning with Joel Richter, MD, last month and he reminded me that our current surveillance system is failing to impact annual incidence of esophageal adenocarcinoma. Perhaps we should focus on a one-time screen for those most at risk, catching prevalent disease at an early stage.
 

John I. Allen, MD, MBA, AGAF
Editor in Chief

Learn about emerging vascular science, engage with researchers, network with colleagues, and support your peers at VRIC, our ‘Annual Meeting’ for basic and translational vascular researchers. Online registration has ended by attendees can register in person the day of the conference. VRIC 2018 will be held at the Hilton San Francisco Union Square, on May 9. Learn more and find the program schedule here.

Learn about emerging vascular science, engage with researchers, network with colleagues, and support your peers at VRIC, our ‘Annual Meeting’ for basic and translational vascular researchers. Online registration has ended by attendees can register in person the day of the conference. VRIC 2018 will be held at the Hilton San Francisco Union Square, on May 9. Learn more and find the program schedule here.

Learn about emerging vascular science, engage with researchers, network with colleagues, and support your peers at VRIC, our ‘Annual Meeting’ for basic and translational vascular researchers. Online registration has ended by attendees can register in person the day of the conference. VRIC 2018 will be held at the Hilton San Francisco Union Square, on May 9. Learn more and find the program schedule here.

For more information about upcoming events and award deadlines, please visit http://www.gastro.org/education and http://www.gastro.org/research-funding.

June 2-5, 2018
DIGESTIVE DISEASE WEEK^® (DDW) 2018 – WASHINGTON, DC
DDW^® is the premier meeting for the GI professional. Every year, it attracts approximately 15,000 physicians, researchers, and academics from around the world who desire to stay up to date in the field.

AGA Trainee and Early-Career GI Sessions

Join your colleagues at special sessions to meet the unique needs of physicians who are new to the field. Participants will learn about all aspects of starting a career in clinical practice or research, have the opportunity to network with mentors and peers, and review board material.

• June 2, 8:15 a.m.–5:30 p.m.; June 3, 8:30 a.m.–12:35 p.m.
  AGA Postgraduate Course: From Abstract to Reality
  Attend this multi-topic course to get practical, useful information to push your practice to the next level. The 2018 course will provide a comprehensive look at the latest medical, surgical, and technological advances over the past 12 months that aim to keep you up to date in a field that is rapidly changing. Each presenter will turn abstract ideas into concrete action items that you can immediately implement in your practice. AGA member trainees and early-career GIs receive discounted pricing for this course.
• June 3, 4–5:30 p.m.
  Difficult Conversations: Navigating People, Negotiations, Promotions, and Complications
  During this session, attendees will obtain effective negotiation techniques and learn how to navigate difficult situations in clinical and research environments.
• June 3, 6-7 p.m.
  AGA Early Career Networking Hour
  This event is open to all DDW trainee and early career GI attendees and provides a casual atmosphere to bond with your peers. Complimentary food and drinks will be available. 
• June 4, 4–5:30 p.m.
  Advancing Clinical Practice: Gastroenterology Fellow–Directed Quality-Improvement Projects
  This trainee-focused session will showcase selected abstracts from GI fellows based on quality improvement with a state-of-the-art lecture. Attendees will be provided with information that defines practical approaches to quality improvement from start to finish. A limited supply of coffee and tea will be provided during the session.
• June 5, 1:30–5:30 p.m.
  Board Review Course
  This session, designed using content from DDSEP^® 8, serves as a primer for third-year fellows preparing for the board exam as well as a review course for others wanting to test their knowledge. Session attendees will receive a $50 coupon to use at the AGA Store at DDW to purchase DDSEP 8.

UPCOMING EVENTS
 

June 4-8, 2018
Exosomes/Microvesicles: Heterogeneity, Biogenesis, Function, and Therapeutic Developments (E2)
Deepen your understanding of the structural and functional complexity of extracellular vesicles, their biogenesis and function in health and disease, cargo enrichment, potential as ideal biomarkers, and breakthroughs in their use as therapeutic targets/agents.
Breckenridge, CO

June 13-14; Aug. 15-16; Sept. 19-20; Oct. 10-11, 2018
Two-Day, In-Depth Coding and Billing Seminar
Become a certified GI coder with a two-day, in-depth training course provided by McVey Associates, Inc.
Nashville, TN (6/13-6/14); Baltimore, MD (8/15-8/16); Atlanta, GA (9/19-9/20); Las Vegas, NV (10/10-10/11)

Aug. 10–12, 2018
Principles of GI for the NP and PA
Hear from the experts as they provide you with critical updates on treating and managing patients with a variety of GI disorders.
Chicago, IL

Aug. 18-19, 2018
James W. Freston Conference: Obesity and Metabolic Disease – Integrating New Paradigms in Pathophysiology to Advance Treatment
Collaborate with researchers and clinicians to help advance obesity treatment and enhance the continuum of obesity care.
Arlington, VA

Feb. 7-9, 2019
Crohn’s & Colitis Congress™ (A Partnership of the Crohn’s & Colitis Foundation and American Gastroenterological Association)
Expand your knowledge, network with IBD leaders, spark innovative research and get inspired to improve patient care.
Las Vegas, NV

For more information about upcoming events and award deadlines, please visit http://www.gastro.org/education and http://www.gastro.org/research-funding.

June 2-5, 2018
DIGESTIVE DISEASE WEEK^® (DDW) 2018 – WASHINGTON, DC
DDW^® is the premier meeting for the GI professional. Every year, it attracts approximately 15,000 physicians, researchers, and academics from around the world who desire to stay up to date in the field.

AGA Trainee and Early-Career GI Sessions

Join your colleagues at special sessions to meet the unique needs of physicians who are new to the field. Participants will learn about all aspects of starting a career in clinical practice or research, have the opportunity to network with mentors and peers, and review board material.

• June 2, 8:15 a.m.–5:30 p.m.; June 3, 8:30 a.m.–12:35 p.m.
  AGA Postgraduate Course: From Abstract to Reality
  Attend this multi-topic course to get practical, useful information to push your practice to the next level. The 2018 course will provide a comprehensive look at the latest medical, surgical, and technological advances over the past 12 months that aim to keep you up to date in a field that is rapidly changing. Each presenter will turn abstract ideas into concrete action items that you can immediately implement in your practice. AGA member trainees and early-career GIs receive discounted pricing for this course.
• June 3, 4–5:30 p.m.
  Difficult Conversations: Navigating People, Negotiations, Promotions, and Complications
  During this session, attendees will obtain effective negotiation techniques and learn how to navigate difficult situations in clinical and research environments.
• June 3, 6-7 p.m.
  AGA Early Career Networking Hour
  This event is open to all DDW trainee and early career GI attendees and provides a casual atmosphere to bond with your peers. Complimentary food and drinks will be available. 
• June 4, 4–5:30 p.m.
  Advancing Clinical Practice: Gastroenterology Fellow–Directed Quality-Improvement Projects
  This trainee-focused session will showcase selected abstracts from GI fellows based on quality improvement with a state-of-the-art lecture. Attendees will be provided with information that defines practical approaches to quality improvement from start to finish. A limited supply of coffee and tea will be provided during the session.
• June 5, 1:30–5:30 p.m.
  Board Review Course
  This session, designed using content from DDSEP^® 8, serves as a primer for third-year fellows preparing for the board exam as well as a review course for others wanting to test their knowledge. Session attendees will receive a $50 coupon to use at the AGA Store at DDW to purchase DDSEP 8.

UPCOMING EVENTS
 

June 4-8, 2018
Exosomes/Microvesicles: Heterogeneity, Biogenesis, Function, and Therapeutic Developments (E2)
Deepen your understanding of the structural and functional complexity of extracellular vesicles, their biogenesis and function in health and disease, cargo enrichment, potential as ideal biomarkers, and breakthroughs in their use as therapeutic targets/agents.
Breckenridge, CO

June 13-14; Aug. 15-16; Sept. 19-20; Oct. 10-11, 2018
Two-Day, In-Depth Coding and Billing Seminar
Become a certified GI coder with a two-day, in-depth training course provided by McVey Associates, Inc.
Nashville, TN (6/13-6/14); Baltimore, MD (8/15-8/16); Atlanta, GA (9/19-9/20); Las Vegas, NV (10/10-10/11)

Aug. 10–12, 2018
Principles of GI for the NP and PA
Hear from the experts as they provide you with critical updates on treating and managing patients with a variety of GI disorders.
Chicago, IL

Aug. 18-19, 2018
James W. Freston Conference: Obesity and Metabolic Disease – Integrating New Paradigms in Pathophysiology to Advance Treatment
Collaborate with researchers and clinicians to help advance obesity treatment and enhance the continuum of obesity care.
Arlington, VA

Feb. 7-9, 2019
Crohn’s & Colitis Congress™ (A Partnership of the Crohn’s & Colitis Foundation and American Gastroenterological Association)
Expand your knowledge, network with IBD leaders, spark innovative research and get inspired to improve patient care.
Las Vegas, NV

For more information about upcoming events and award deadlines, please visit http://www.gastro.org/education and http://www.gastro.org/research-funding.

June 2-5, 2018
DIGESTIVE DISEASE WEEK^® (DDW) 2018 – WASHINGTON, DC
DDW^® is the premier meeting for the GI professional. Every year, it attracts approximately 15,000 physicians, researchers, and academics from around the world who desire to stay up to date in the field.

AGA Trainee and Early-Career GI Sessions

Join your colleagues at special sessions to meet the unique needs of physicians who are new to the field. Participants will learn about all aspects of starting a career in clinical practice or research, have the opportunity to network with mentors and peers, and review board material.

• June 2, 8:15 a.m.–5:30 p.m.; June 3, 8:30 a.m.–12:35 p.m.
  AGA Postgraduate Course: From Abstract to Reality
  Attend this multi-topic course to get practical, useful information to push your practice to the next level. The 2018 course will provide a comprehensive look at the latest medical, surgical, and technological advances over the past 12 months that aim to keep you up to date in a field that is rapidly changing. Each presenter will turn abstract ideas into concrete action items that you can immediately implement in your practice. AGA member trainees and early-career GIs receive discounted pricing for this course.
• June 3, 4–5:30 p.m.
  Difficult Conversations: Navigating People, Negotiations, Promotions, and Complications
  During this session, attendees will obtain effective negotiation techniques and learn how to navigate difficult situations in clinical and research environments.
• June 3, 6-7 p.m.
  AGA Early Career Networking Hour
  This event is open to all DDW trainee and early career GI attendees and provides a casual atmosphere to bond with your peers. Complimentary food and drinks will be available. 
• June 4, 4–5:30 p.m.
  Advancing Clinical Practice: Gastroenterology Fellow–Directed Quality-Improvement Projects
  This trainee-focused session will showcase selected abstracts from GI fellows based on quality improvement with a state-of-the-art lecture. Attendees will be provided with information that defines practical approaches to quality improvement from start to finish. A limited supply of coffee and tea will be provided during the session.
• June 5, 1:30–5:30 p.m.
  Board Review Course
  This session, designed using content from DDSEP^® 8, serves as a primer for third-year fellows preparing for the board exam as well as a review course for others wanting to test their knowledge. Session attendees will receive a $50 coupon to use at the AGA Store at DDW to purchase DDSEP 8.

UPCOMING EVENTS
 

June 4-8, 2018
Exosomes/Microvesicles: Heterogeneity, Biogenesis, Function, and Therapeutic Developments (E2)
Deepen your understanding of the structural and functional complexity of extracellular vesicles, their biogenesis and function in health and disease, cargo enrichment, potential as ideal biomarkers, and breakthroughs in their use as therapeutic targets/agents.
Breckenridge, CO

June 13-14; Aug. 15-16; Sept. 19-20; Oct. 10-11, 2018
Two-Day, In-Depth Coding and Billing Seminar
Become a certified GI coder with a two-day, in-depth training course provided by McVey Associates, Inc.
Nashville, TN (6/13-6/14); Baltimore, MD (8/15-8/16); Atlanta, GA (9/19-9/20); Las Vegas, NV (10/10-10/11)

Aug. 10–12, 2018
Principles of GI for the NP and PA
Hear from the experts as they provide you with critical updates on treating and managing patients with a variety of GI disorders.
Chicago, IL

Aug. 18-19, 2018
James W. Freston Conference: Obesity and Metabolic Disease – Integrating New Paradigms in Pathophysiology to Advance Treatment
Collaborate with researchers and clinicians to help advance obesity treatment and enhance the continuum of obesity care.
Arlington, VA

Feb. 7-9, 2019
Crohn’s & Colitis Congress™ (A Partnership of the Crohn’s & Colitis Foundation and American Gastroenterological Association)
Expand your knowledge, network with IBD leaders, spark innovative research and get inspired to improve patient care.
Las Vegas, NV