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Thoracic Oncology and Chest Procedures Network
Pleural Disease Section
Aspirate or wait: changing the paradigm for PSP care
Although observation for small asymptomatic PSP is supported by current guidelines, management recommendations for larger PSP remains unclear (MacDuff, et al. Thorax. 2010;65[Suppl 2]:ii18-ii31; Tschopp JM, et al. Eur Respir J. 2015;46[2]:321). Two recent RCTs explore conservative vs intervention-based management in those with larger or symptomatic PSP. In the PSP trial, Brown and colleagues prospectively randomized 316 patients with moderate to large PSP to either conservative management (≥ 4 hour observation) or small-bore chest tube without suction (Brown, et al. N Engl J Med. 2020;382[5]:405). Although noninferiority criteria were met, the primary outcome of radiographic resolution of pneumothorax within 8 weeks of randomization was not statistically robust to conservative assumptions about missing data. They concluded that conservative management was noninferior to intervention, and it resulted in a lower risk of serious adverse events or PSP recurrence than interventional management. The multicenter randomized Ambulatory Management of Primary Pneumothorax (RAMPP) trial compared ambulatory management of PSP using an 8F drainage device to a guideline-driven approach (drainage, aspiration, or both) amongst 236 patients with symptomatic PSP. Intervention shortened length of hospital stay (median 0 vs 4 days, P<.0001), but the intervention arm experienced more adverse events (including enlargement of pneumothorax, as well as device malfunction) (Hallifax RJ, et al. Lancet. 2020;396[10243]:39). These two trials challenge the current guidelines for management for patients with PSP, but both had limitations. Though more data are needed to establish a clear consensus, these studies suggest that a conservative pathway for PSP warrants further consideration.
Tejaswi R. Nadig, MBBS
Member-at-Large
Yaron Gesthalter, MD
Member-at-Large
Priya P. Nath, MD
Member-at-Large
Pleural Disease Section
Aspirate or wait: changing the paradigm for PSP care
Although observation for small asymptomatic PSP is supported by current guidelines, management recommendations for larger PSP remains unclear (MacDuff, et al. Thorax. 2010;65[Suppl 2]:ii18-ii31; Tschopp JM, et al. Eur Respir J. 2015;46[2]:321). Two recent RCTs explore conservative vs intervention-based management in those with larger or symptomatic PSP. In the PSP trial, Brown and colleagues prospectively randomized 316 patients with moderate to large PSP to either conservative management (≥ 4 hour observation) or small-bore chest tube without suction (Brown, et al. N Engl J Med. 2020;382[5]:405). Although noninferiority criteria were met, the primary outcome of radiographic resolution of pneumothorax within 8 weeks of randomization was not statistically robust to conservative assumptions about missing data. They concluded that conservative management was noninferior to intervention, and it resulted in a lower risk of serious adverse events or PSP recurrence than interventional management. The multicenter randomized Ambulatory Management of Primary Pneumothorax (RAMPP) trial compared ambulatory management of PSP using an 8F drainage device to a guideline-driven approach (drainage, aspiration, or both) amongst 236 patients with symptomatic PSP. Intervention shortened length of hospital stay (median 0 vs 4 days, P<.0001), but the intervention arm experienced more adverse events (including enlargement of pneumothorax, as well as device malfunction) (Hallifax RJ, et al. Lancet. 2020;396[10243]:39). These two trials challenge the current guidelines for management for patients with PSP, but both had limitations. Though more data are needed to establish a clear consensus, these studies suggest that a conservative pathway for PSP warrants further consideration.
Tejaswi R. Nadig, MBBS
Member-at-Large
Yaron Gesthalter, MD
Member-at-Large
Priya P. Nath, MD
Member-at-Large
Pleural Disease Section
Aspirate or wait: changing the paradigm for PSP care
Although observation for small asymptomatic PSP is supported by current guidelines, management recommendations for larger PSP remains unclear (MacDuff, et al. Thorax. 2010;65[Suppl 2]:ii18-ii31; Tschopp JM, et al. Eur Respir J. 2015;46[2]:321). Two recent RCTs explore conservative vs intervention-based management in those with larger or symptomatic PSP. In the PSP trial, Brown and colleagues prospectively randomized 316 patients with moderate to large PSP to either conservative management (≥ 4 hour observation) or small-bore chest tube without suction (Brown, et al. N Engl J Med. 2020;382[5]:405). Although noninferiority criteria were met, the primary outcome of radiographic resolution of pneumothorax within 8 weeks of randomization was not statistically robust to conservative assumptions about missing data. They concluded that conservative management was noninferior to intervention, and it resulted in a lower risk of serious adverse events or PSP recurrence than interventional management. The multicenter randomized Ambulatory Management of Primary Pneumothorax (RAMPP) trial compared ambulatory management of PSP using an 8F drainage device to a guideline-driven approach (drainage, aspiration, or both) amongst 236 patients with symptomatic PSP. Intervention shortened length of hospital stay (median 0 vs 4 days, P<.0001), but the intervention arm experienced more adverse events (including enlargement of pneumothorax, as well as device malfunction) (Hallifax RJ, et al. Lancet. 2020;396[10243]:39). These two trials challenge the current guidelines for management for patients with PSP, but both had limitations. Though more data are needed to establish a clear consensus, these studies suggest that a conservative pathway for PSP warrants further consideration.
Tejaswi R. Nadig, MBBS
Member-at-Large
Yaron Gesthalter, MD
Member-at-Large
Priya P. Nath, MD
Member-at-Large
2022 billing and coding updates
Telehealth and Teaching Physician Services and ICD-10 codes updates
In my previous article in June, 2022, we plowed through the billing and coding updates regarding critical care services, and, I hope that it helped our readers get more acquainted with the nuances of billing and coding in the ICU. In this piece, I would like to briefly elucidate three other areas of practice, which will be relevant to all physicians across various specialties.
Telehealth services
(PHE). Initially, the plan was to remove these from the list of covered services by the latter end of the COVID-19 PHE, which, created some uncertainty, or by December 31, 2021. Fortunately, CMS finalized that they will extend it through the end of the calendar year (CY) 2023. So, now all the telehealth services will remain on the CMS list until December 31, 2023. The general principle behind this ruling is to allow for more time for CMS and stakeholders to gather data and to submit support for requesting these services to be permanently added to the Medicare telehealth services list.
Not only has CMS extended the deadline for telehealth services but also they have gone far and beyond to extend some of the codes for cardiac and intensive cardiac rehabilitation until December 31, 2023, as well.
There has been a lot of debate regarding the geographic restrictions when it comes to telehealth visits for diagnosis, evaluation, or treatment of a mental health disorder. As per the latest Consolidated Appropriations Act of 2021 (Section 123), the home of the patient is a permissible site. But, the caveat is that there must be an in-person service with the practitioner/physician within 6 months prior to the initial telehealth visit. Additionally, there has to be a set frequency for subsequent in-person visits. And, usually the subsequent visits will need to be provided at least every 12 months. These requirements are not set in stone and can be changed on a case-by-case basis provided there is appropriate documentation in the chart.
Lastly, it is important to understand and use the appropriate telecommunication systems for the telehealth visits and the modifiers that are associated with them. By definition, it has to be audio and video equipment that allows two-way, real-time interactive communication between the patient and the provider when used for telehealth services for the diagnosis, evaluation, or treatment of mental health disorders. But, CMS is in the process of amending it to include audio-only communications technology. At this time, the use of audio-only interactive telecommunications system is limited to practitioners who have the capability to provide two-way audio/video communications but, where the patient is not capable, or does not consent to, the use of two-way audio/video technology. Modifier FQ should be attached to all the mental health services that were furnished using audio-only communications. And, mental health services can include services for treatment of substance use disorders (SUD). Please do not confuse modifier FQ with modifier 93 as FQ is only for behavioral health services. And, remember that the totality of the communication of information exchanged between the provider and the patient during the course of the synchronous telemedicine service (rendered via telephone or other real-time interactive audio only telecommunication system) must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.
Teaching physician services
As a general rule, a teaching physician can bill for the resident services only if they are present for the critical (key) portion of the service. But, there is one exception called the “primary care exception” under which in certain teaching hospital primary care centers, the teaching physician can bill for certain services as furnished independently by the resident without the teaching physician being physically present, but with the teaching physician’s review.
The current model to bill for office/outpatient E/M visit level is either based on either total time spent (personally) or medical-decision-making (MDM). When time is used to select the visit level only the time spent by the teaching physician in qualifying activities can be included for the purposes of the visit level selection. And, this includes the time the teaching physician was present with the resident performing those qualifying activities. Also, under the primary care exception, time cannot be used to select the visit level. This is to guard against the possibility of inappropriate coding that reflects residents’ inefficiencies rather than a measure of the total medically necessary time required to furnish the E/M services.
ICD-10 updates
Usually, the ICD-10 codes are updated annually and take effect every October 1. Some of the most relevant updates are as follows:
1. U09.9 Post COVID-19 condition, unspecified: This should be used to document sequelae of COVID-19 or “long COVID” conditions, after the acute illness has resolved. But, remember to code the conditions related to COVID-19 first and do not use this code with an active or current COVID-19 infection.
2. U07.0 Vaping-related disorder: This should be used for all vaping-related illnesses. However, additional codes for other diagnoses such as acute respiratory failure, acute respiratory distress syndrome, or pneumonitis can also be used with this code. Other respiratory signs and symptoms such as cough and shortness of breath should not be coded separately.
3. Cough is one of the most common reasons for referral to a pulmonologist. The CDC has expanded these codes so please remember to code the most specific diagnosis as deemed appropriate.
R05.1 Acute cough
R05.2 Subacute cough
R05.3 Chronic cough
R05.4 Cough, syncope
R05.8 Other specified cough
R05.9 Cough, unspecified
We will be back with some more exciting and intriguing billing and coding updates in our next article and hope to see everyone at CHEST 2022 in Nashville., TN.
Telehealth and Teaching Physician Services and ICD-10 codes updates
Telehealth and Teaching Physician Services and ICD-10 codes updates
In my previous article in June, 2022, we plowed through the billing and coding updates regarding critical care services, and, I hope that it helped our readers get more acquainted with the nuances of billing and coding in the ICU. In this piece, I would like to briefly elucidate three other areas of practice, which will be relevant to all physicians across various specialties.
Telehealth services
(PHE). Initially, the plan was to remove these from the list of covered services by the latter end of the COVID-19 PHE, which, created some uncertainty, or by December 31, 2021. Fortunately, CMS finalized that they will extend it through the end of the calendar year (CY) 2023. So, now all the telehealth services will remain on the CMS list until December 31, 2023. The general principle behind this ruling is to allow for more time for CMS and stakeholders to gather data and to submit support for requesting these services to be permanently added to the Medicare telehealth services list.
Not only has CMS extended the deadline for telehealth services but also they have gone far and beyond to extend some of the codes for cardiac and intensive cardiac rehabilitation until December 31, 2023, as well.
There has been a lot of debate regarding the geographic restrictions when it comes to telehealth visits for diagnosis, evaluation, or treatment of a mental health disorder. As per the latest Consolidated Appropriations Act of 2021 (Section 123), the home of the patient is a permissible site. But, the caveat is that there must be an in-person service with the practitioner/physician within 6 months prior to the initial telehealth visit. Additionally, there has to be a set frequency for subsequent in-person visits. And, usually the subsequent visits will need to be provided at least every 12 months. These requirements are not set in stone and can be changed on a case-by-case basis provided there is appropriate documentation in the chart.
Lastly, it is important to understand and use the appropriate telecommunication systems for the telehealth visits and the modifiers that are associated with them. By definition, it has to be audio and video equipment that allows two-way, real-time interactive communication between the patient and the provider when used for telehealth services for the diagnosis, evaluation, or treatment of mental health disorders. But, CMS is in the process of amending it to include audio-only communications technology. At this time, the use of audio-only interactive telecommunications system is limited to practitioners who have the capability to provide two-way audio/video communications but, where the patient is not capable, or does not consent to, the use of two-way audio/video technology. Modifier FQ should be attached to all the mental health services that were furnished using audio-only communications. And, mental health services can include services for treatment of substance use disorders (SUD). Please do not confuse modifier FQ with modifier 93 as FQ is only for behavioral health services. And, remember that the totality of the communication of information exchanged between the provider and the patient during the course of the synchronous telemedicine service (rendered via telephone or other real-time interactive audio only telecommunication system) must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.
Teaching physician services
As a general rule, a teaching physician can bill for the resident services only if they are present for the critical (key) portion of the service. But, there is one exception called the “primary care exception” under which in certain teaching hospital primary care centers, the teaching physician can bill for certain services as furnished independently by the resident without the teaching physician being physically present, but with the teaching physician’s review.
The current model to bill for office/outpatient E/M visit level is either based on either total time spent (personally) or medical-decision-making (MDM). When time is used to select the visit level only the time spent by the teaching physician in qualifying activities can be included for the purposes of the visit level selection. And, this includes the time the teaching physician was present with the resident performing those qualifying activities. Also, under the primary care exception, time cannot be used to select the visit level. This is to guard against the possibility of inappropriate coding that reflects residents’ inefficiencies rather than a measure of the total medically necessary time required to furnish the E/M services.
ICD-10 updates
Usually, the ICD-10 codes are updated annually and take effect every October 1. Some of the most relevant updates are as follows:
1. U09.9 Post COVID-19 condition, unspecified: This should be used to document sequelae of COVID-19 or “long COVID” conditions, after the acute illness has resolved. But, remember to code the conditions related to COVID-19 first and do not use this code with an active or current COVID-19 infection.
2. U07.0 Vaping-related disorder: This should be used for all vaping-related illnesses. However, additional codes for other diagnoses such as acute respiratory failure, acute respiratory distress syndrome, or pneumonitis can also be used with this code. Other respiratory signs and symptoms such as cough and shortness of breath should not be coded separately.
3. Cough is one of the most common reasons for referral to a pulmonologist. The CDC has expanded these codes so please remember to code the most specific diagnosis as deemed appropriate.
R05.1 Acute cough
R05.2 Subacute cough
R05.3 Chronic cough
R05.4 Cough, syncope
R05.8 Other specified cough
R05.9 Cough, unspecified
We will be back with some more exciting and intriguing billing and coding updates in our next article and hope to see everyone at CHEST 2022 in Nashville., TN.
In my previous article in June, 2022, we plowed through the billing and coding updates regarding critical care services, and, I hope that it helped our readers get more acquainted with the nuances of billing and coding in the ICU. In this piece, I would like to briefly elucidate three other areas of practice, which will be relevant to all physicians across various specialties.
Telehealth services
(PHE). Initially, the plan was to remove these from the list of covered services by the latter end of the COVID-19 PHE, which, created some uncertainty, or by December 31, 2021. Fortunately, CMS finalized that they will extend it through the end of the calendar year (CY) 2023. So, now all the telehealth services will remain on the CMS list until December 31, 2023. The general principle behind this ruling is to allow for more time for CMS and stakeholders to gather data and to submit support for requesting these services to be permanently added to the Medicare telehealth services list.
Not only has CMS extended the deadline for telehealth services but also they have gone far and beyond to extend some of the codes for cardiac and intensive cardiac rehabilitation until December 31, 2023, as well.
There has been a lot of debate regarding the geographic restrictions when it comes to telehealth visits for diagnosis, evaluation, or treatment of a mental health disorder. As per the latest Consolidated Appropriations Act of 2021 (Section 123), the home of the patient is a permissible site. But, the caveat is that there must be an in-person service with the practitioner/physician within 6 months prior to the initial telehealth visit. Additionally, there has to be a set frequency for subsequent in-person visits. And, usually the subsequent visits will need to be provided at least every 12 months. These requirements are not set in stone and can be changed on a case-by-case basis provided there is appropriate documentation in the chart.
Lastly, it is important to understand and use the appropriate telecommunication systems for the telehealth visits and the modifiers that are associated with them. By definition, it has to be audio and video equipment that allows two-way, real-time interactive communication between the patient and the provider when used for telehealth services for the diagnosis, evaluation, or treatment of mental health disorders. But, CMS is in the process of amending it to include audio-only communications technology. At this time, the use of audio-only interactive telecommunications system is limited to practitioners who have the capability to provide two-way audio/video communications but, where the patient is not capable, or does not consent to, the use of two-way audio/video technology. Modifier FQ should be attached to all the mental health services that were furnished using audio-only communications. And, mental health services can include services for treatment of substance use disorders (SUD). Please do not confuse modifier FQ with modifier 93 as FQ is only for behavioral health services. And, remember that the totality of the communication of information exchanged between the provider and the patient during the course of the synchronous telemedicine service (rendered via telephone or other real-time interactive audio only telecommunication system) must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.
Teaching physician services
As a general rule, a teaching physician can bill for the resident services only if they are present for the critical (key) portion of the service. But, there is one exception called the “primary care exception” under which in certain teaching hospital primary care centers, the teaching physician can bill for certain services as furnished independently by the resident without the teaching physician being physically present, but with the teaching physician’s review.
The current model to bill for office/outpatient E/M visit level is either based on either total time spent (personally) or medical-decision-making (MDM). When time is used to select the visit level only the time spent by the teaching physician in qualifying activities can be included for the purposes of the visit level selection. And, this includes the time the teaching physician was present with the resident performing those qualifying activities. Also, under the primary care exception, time cannot be used to select the visit level. This is to guard against the possibility of inappropriate coding that reflects residents’ inefficiencies rather than a measure of the total medically necessary time required to furnish the E/M services.
ICD-10 updates
Usually, the ICD-10 codes are updated annually and take effect every October 1. Some of the most relevant updates are as follows:
1. U09.9 Post COVID-19 condition, unspecified: This should be used to document sequelae of COVID-19 or “long COVID” conditions, after the acute illness has resolved. But, remember to code the conditions related to COVID-19 first and do not use this code with an active or current COVID-19 infection.
2. U07.0 Vaping-related disorder: This should be used for all vaping-related illnesses. However, additional codes for other diagnoses such as acute respiratory failure, acute respiratory distress syndrome, or pneumonitis can also be used with this code. Other respiratory signs and symptoms such as cough and shortness of breath should not be coded separately.
3. Cough is one of the most common reasons for referral to a pulmonologist. The CDC has expanded these codes so please remember to code the most specific diagnosis as deemed appropriate.
R05.1 Acute cough
R05.2 Subacute cough
R05.3 Chronic cough
R05.4 Cough, syncope
R05.8 Other specified cough
R05.9 Cough, unspecified
We will be back with some more exciting and intriguing billing and coding updates in our next article and hope to see everyone at CHEST 2022 in Nashville., TN.
Access unmatched asthma education from anywhere
CHEST is proud to announce the launch of the newest addition to our e-learning options: the CHEST Asthma Curriculum Pathway.
This unique offering combines a variety of bite-sized educational resources from among CHEST’s most popular and effective products, including case-based CHEST SEEK™ questions, podcasts and videos from asthma experts, the latest research from the journal CHEST®, and more.
The pathway comprises several different “paths,” or tracks, that enable clinicians to target their education based on their knowledge gaps and career level. Users can opt to follow the curriculum from start to finish to gain a comprehensive overview of asthma management. Or, they can select individual paths to focus their learning on topics including asthma pathophysiology, diagnosis and classification, exacerbations, phenotypes, and more.
According to early learners of the pathway: It helped a lot with the knowledge check-in.” Another commented: “It is very comprehensive on all aspects of asthma. I enjoyed the higher-level learning on the choice of biologics and asthma mimickers.” The education modalities were highlighted, as well, with this feedback: “I really enjoyed the variety of media (lectures, discussions, papers, games).”
Exploring the education
The Asthma Curriculum Pathway offers targeted education options to fit the career level and clinical interest of clinicians, ranging from trainees and early career physicians to experienced asthma specialists and advanced practice providers.
Paths include:
• Path 1: Pathophysiology
• Path 2: Diagnosis & Classification
• Path 3: Management
• Path 4: Mimickers
• Path 5: Comorbidities
• Path 6: Phenotypes
• Path 7: Exacerbations
• Path 8: Special Situations
Plus, each path offers claiming credit, including CME, for completion—all while driving clinicians to consistently advance best outcomes for their patients with asthma.
Visit (https://bit.ly/asthma-pathway) to access the best of CHEST’s asthma education with the new Asthma Curriculum Pathway, accessible via web or mobile device.
CHEST is proud to announce the launch of the newest addition to our e-learning options: the CHEST Asthma Curriculum Pathway.
This unique offering combines a variety of bite-sized educational resources from among CHEST’s most popular and effective products, including case-based CHEST SEEK™ questions, podcasts and videos from asthma experts, the latest research from the journal CHEST®, and more.
The pathway comprises several different “paths,” or tracks, that enable clinicians to target their education based on their knowledge gaps and career level. Users can opt to follow the curriculum from start to finish to gain a comprehensive overview of asthma management. Or, they can select individual paths to focus their learning on topics including asthma pathophysiology, diagnosis and classification, exacerbations, phenotypes, and more.
According to early learners of the pathway: It helped a lot with the knowledge check-in.” Another commented: “It is very comprehensive on all aspects of asthma. I enjoyed the higher-level learning on the choice of biologics and asthma mimickers.” The education modalities were highlighted, as well, with this feedback: “I really enjoyed the variety of media (lectures, discussions, papers, games).”
Exploring the education
The Asthma Curriculum Pathway offers targeted education options to fit the career level and clinical interest of clinicians, ranging from trainees and early career physicians to experienced asthma specialists and advanced practice providers.
Paths include:
• Path 1: Pathophysiology
• Path 2: Diagnosis & Classification
• Path 3: Management
• Path 4: Mimickers
• Path 5: Comorbidities
• Path 6: Phenotypes
• Path 7: Exacerbations
• Path 8: Special Situations
Plus, each path offers claiming credit, including CME, for completion—all while driving clinicians to consistently advance best outcomes for their patients with asthma.
Visit (https://bit.ly/asthma-pathway) to access the best of CHEST’s asthma education with the new Asthma Curriculum Pathway, accessible via web or mobile device.
CHEST is proud to announce the launch of the newest addition to our e-learning options: the CHEST Asthma Curriculum Pathway.
This unique offering combines a variety of bite-sized educational resources from among CHEST’s most popular and effective products, including case-based CHEST SEEK™ questions, podcasts and videos from asthma experts, the latest research from the journal CHEST®, and more.
The pathway comprises several different “paths,” or tracks, that enable clinicians to target their education based on their knowledge gaps and career level. Users can opt to follow the curriculum from start to finish to gain a comprehensive overview of asthma management. Or, they can select individual paths to focus their learning on topics including asthma pathophysiology, diagnosis and classification, exacerbations, phenotypes, and more.
According to early learners of the pathway: It helped a lot with the knowledge check-in.” Another commented: “It is very comprehensive on all aspects of asthma. I enjoyed the higher-level learning on the choice of biologics and asthma mimickers.” The education modalities were highlighted, as well, with this feedback: “I really enjoyed the variety of media (lectures, discussions, papers, games).”
Exploring the education
The Asthma Curriculum Pathway offers targeted education options to fit the career level and clinical interest of clinicians, ranging from trainees and early career physicians to experienced asthma specialists and advanced practice providers.
Paths include:
• Path 1: Pathophysiology
• Path 2: Diagnosis & Classification
• Path 3: Management
• Path 4: Mimickers
• Path 5: Comorbidities
• Path 6: Phenotypes
• Path 7: Exacerbations
• Path 8: Special Situations
Plus, each path offers claiming credit, including CME, for completion—all while driving clinicians to consistently advance best outcomes for their patients with asthma.
Visit (https://bit.ly/asthma-pathway) to access the best of CHEST’s asthma education with the new Asthma Curriculum Pathway, accessible via web or mobile device.
Advanced POCUS for us all?
Point-of-care ultrasound (POCUS) is a useful, practice-changing bedside tool that spans all medical and surgical specialties. While the definition of POCUS varies, most would agree it is an abbreviated exam that helps to answer a specific clinical question. With the expansion of POCUS training, the clinical questions being asked and answered have increased in scope and volume. The types of exams being utilized in “point of care ultrasound” have also increased and include transthoracic echocardiography; trans-esophageal echocardiography; and lung, gastric, abdominal, and ocular ultrasound. POCUS is used across multiple specialties, including critical care, anesthesiology, emergency medicine, and primary care.
Not only has POCUS become increasingly important clinically, but specialties now test these skills on their respective board examinations. Anesthesia is one of many such examples. The content outline for the American Board of Anesthesiology includes POCUS as a tested item on both the written and applied components of the exam. POCUS training must be directed toward both optimizing patient management and preparing learners for their board examination. A method for teaching this has yet to be defined (Naji A, et al. Cureus. 2021;13[5]:e15217).
One question – how should different specialties approach this educational challenge and should specialties train together? The answer is complicated. Many POCUS courses and certifications exist, and all vary in their content, didactics, and length. No true gold standard exists for POCUS certification for radiology or noncardiology providers. Additionally, there are no defined expectations or testing processes that certify a provider is “certified” to perform POCUS. While waiting for medical society guidelines to address these issues, many in graduate medical education (GME) are coming up with their own ways to incorporate POCUS into their respective training programs (Atkinson P, et al. CJEM. 2015 Mar;17[2]:161).
Who’s training whom?
Over the past decade, several expert committees, including those in critical care, have developed recommendations and consensus statements urging training facilities to independently create POCUS curriculums. The threshold for many programs to enter this realm of expertise is high and oftentimes unobtainable. We’ve seen emergency medicine and anesthesia raise the bar for ultrasound education in their residencies, but it’s unclear whether all fellowship-trained physicians can and should be tasked with obtaining official POCUS certification.
While specific specialties may require tailored certifications, there’s a considerable overlap in POCUS exam content across specialties. One approach to POCUS training could be developing and implementing a multidisciplinary curriculum. This would allow for pooling of resources (equipment, staff) and harnessing knowledge from providers familiar with different phases of patient care (ICU, perioperative, ED, outpatient clinics). By approaching POCUS from a multidisciplinary perspective, the quality of education may be enhanced (Mayo PH, et al. Intensive Care Med. 2014;40[5]:654). Is it then prudent for providers and trainees alike to share in didactics across all areas of the hospital and clinic? Would this close the knowledge gap between specialties who are facile with ultrasound and those not?
Determining the role of transesophageal echocardiography in a POCUS curriculum
This modality of imaging has been, until recently, reserved for cardiologists and anesthesiologists. More recently transesophageal echocardiography (TEE) has been utilized by emergency and critical care medicine physicians. TEE is part of recommended training for these specialties as a tool for diagnostic and rescue measures, including ventilator management, emergency procedures, and medication titration. Rescue TEE can also be utilized perioperatively where the transthoracic exam is limited by poor windows or the operative procedure precludes access to the chest. While transthoracic echocardiography (TTE) is often used in a point of care fashion, TEE is utilized less often. This may stem from the invasive nature of the procedure but likely also results from lack of equipment and training. Like POCUS overall, TEE POCUS will require incorporation into training programs to achieve widespread use and acceptance.
A deluge of research on TEE for the noncardiologist shows this modality is minimally invasive, safe, and effective. As it becomes more readily available and technology improves, there is no reason why an esophageal probe can’t be used in a patient with a secured airway (Wray TC, et al. J Intensive Care Med. 2021;36[1]:123).
Ultrasound for hemodynamic monitoring
There are many methods employed for hemodynamic monitoring in the ICU. Although echocardiographic and vascular parameters have been validated in the cardiac and perioperative fields, their application in the ICU setting for resuscitation and volume management remain somewhat controversial. The use of TEE and more advanced understanding of spectral doppler and pulmonary ultrasonography using TEE has revolutionized the way providers are managing critically ill patients. (Garcia YA, et al. Chest. 2017;152[4]:736).
In our opinion, physiology and imaging training for residents and fellows should be required for critical care medicine trainees. Delving into the nuances of frank-starling curves, stroke work, and diastolic function will enrich their understanding and highlight the applicability of ultrasonography. Furthermore, all clinicians caring for patients with critical illness should be privy to the nuances of physiologic derangement, and to that end, advanced echocardiographic principles and image acquisition. The heart-lung interactions are demonstrated in real time using POCUS and can clearly delineate treatment goals (Vieillard-Baron A, et al. Intensive Care Med. 2019;45[6]:770).
Documentation and billing
If clinicians are making medical decisions based off imaging gathered at the bedside and interpreted in real-time, documentation should reflect that. That documentation will invariably lead to billing and possibly audit or quality review by colleagues or other healthcare staff. Radiology and cardiology have perfected the billing process for image interpretation, but their form of documentation and interpretation may not easily be implemented in the perioperative or critical care settings. An abbreviated document with focused information should take the place of the formal study. With that, the credentialing and board certification process will allow providers to feel empowered to make clinical decisions based off these focused examinations.
Dr. Goertzen is Chief Fellow, Pulmonary/Critical Care; Dr. Knuf is Program Director, Department of Anesthesia; and Dr. Villalobos is Director of Medical ICU, Department of Internal Medicine, San Antonio Military Medical Center, San Antonio, Texas.
Point-of-care ultrasound (POCUS) is a useful, practice-changing bedside tool that spans all medical and surgical specialties. While the definition of POCUS varies, most would agree it is an abbreviated exam that helps to answer a specific clinical question. With the expansion of POCUS training, the clinical questions being asked and answered have increased in scope and volume. The types of exams being utilized in “point of care ultrasound” have also increased and include transthoracic echocardiography; trans-esophageal echocardiography; and lung, gastric, abdominal, and ocular ultrasound. POCUS is used across multiple specialties, including critical care, anesthesiology, emergency medicine, and primary care.
Not only has POCUS become increasingly important clinically, but specialties now test these skills on their respective board examinations. Anesthesia is one of many such examples. The content outline for the American Board of Anesthesiology includes POCUS as a tested item on both the written and applied components of the exam. POCUS training must be directed toward both optimizing patient management and preparing learners for their board examination. A method for teaching this has yet to be defined (Naji A, et al. Cureus. 2021;13[5]:e15217).
One question – how should different specialties approach this educational challenge and should specialties train together? The answer is complicated. Many POCUS courses and certifications exist, and all vary in their content, didactics, and length. No true gold standard exists for POCUS certification for radiology or noncardiology providers. Additionally, there are no defined expectations or testing processes that certify a provider is “certified” to perform POCUS. While waiting for medical society guidelines to address these issues, many in graduate medical education (GME) are coming up with their own ways to incorporate POCUS into their respective training programs (Atkinson P, et al. CJEM. 2015 Mar;17[2]:161).
Who’s training whom?
Over the past decade, several expert committees, including those in critical care, have developed recommendations and consensus statements urging training facilities to independently create POCUS curriculums. The threshold for many programs to enter this realm of expertise is high and oftentimes unobtainable. We’ve seen emergency medicine and anesthesia raise the bar for ultrasound education in their residencies, but it’s unclear whether all fellowship-trained physicians can and should be tasked with obtaining official POCUS certification.
While specific specialties may require tailored certifications, there’s a considerable overlap in POCUS exam content across specialties. One approach to POCUS training could be developing and implementing a multidisciplinary curriculum. This would allow for pooling of resources (equipment, staff) and harnessing knowledge from providers familiar with different phases of patient care (ICU, perioperative, ED, outpatient clinics). By approaching POCUS from a multidisciplinary perspective, the quality of education may be enhanced (Mayo PH, et al. Intensive Care Med. 2014;40[5]:654). Is it then prudent for providers and trainees alike to share in didactics across all areas of the hospital and clinic? Would this close the knowledge gap between specialties who are facile with ultrasound and those not?
Determining the role of transesophageal echocardiography in a POCUS curriculum
This modality of imaging has been, until recently, reserved for cardiologists and anesthesiologists. More recently transesophageal echocardiography (TEE) has been utilized by emergency and critical care medicine physicians. TEE is part of recommended training for these specialties as a tool for diagnostic and rescue measures, including ventilator management, emergency procedures, and medication titration. Rescue TEE can also be utilized perioperatively where the transthoracic exam is limited by poor windows or the operative procedure precludes access to the chest. While transthoracic echocardiography (TTE) is often used in a point of care fashion, TEE is utilized less often. This may stem from the invasive nature of the procedure but likely also results from lack of equipment and training. Like POCUS overall, TEE POCUS will require incorporation into training programs to achieve widespread use and acceptance.
A deluge of research on TEE for the noncardiologist shows this modality is minimally invasive, safe, and effective. As it becomes more readily available and technology improves, there is no reason why an esophageal probe can’t be used in a patient with a secured airway (Wray TC, et al. J Intensive Care Med. 2021;36[1]:123).
Ultrasound for hemodynamic monitoring
There are many methods employed for hemodynamic monitoring in the ICU. Although echocardiographic and vascular parameters have been validated in the cardiac and perioperative fields, their application in the ICU setting for resuscitation and volume management remain somewhat controversial. The use of TEE and more advanced understanding of spectral doppler and pulmonary ultrasonography using TEE has revolutionized the way providers are managing critically ill patients. (Garcia YA, et al. Chest. 2017;152[4]:736).
In our opinion, physiology and imaging training for residents and fellows should be required for critical care medicine trainees. Delving into the nuances of frank-starling curves, stroke work, and diastolic function will enrich their understanding and highlight the applicability of ultrasonography. Furthermore, all clinicians caring for patients with critical illness should be privy to the nuances of physiologic derangement, and to that end, advanced echocardiographic principles and image acquisition. The heart-lung interactions are demonstrated in real time using POCUS and can clearly delineate treatment goals (Vieillard-Baron A, et al. Intensive Care Med. 2019;45[6]:770).
Documentation and billing
If clinicians are making medical decisions based off imaging gathered at the bedside and interpreted in real-time, documentation should reflect that. That documentation will invariably lead to billing and possibly audit or quality review by colleagues or other healthcare staff. Radiology and cardiology have perfected the billing process for image interpretation, but their form of documentation and interpretation may not easily be implemented in the perioperative or critical care settings. An abbreviated document with focused information should take the place of the formal study. With that, the credentialing and board certification process will allow providers to feel empowered to make clinical decisions based off these focused examinations.
Dr. Goertzen is Chief Fellow, Pulmonary/Critical Care; Dr. Knuf is Program Director, Department of Anesthesia; and Dr. Villalobos is Director of Medical ICU, Department of Internal Medicine, San Antonio Military Medical Center, San Antonio, Texas.
Point-of-care ultrasound (POCUS) is a useful, practice-changing bedside tool that spans all medical and surgical specialties. While the definition of POCUS varies, most would agree it is an abbreviated exam that helps to answer a specific clinical question. With the expansion of POCUS training, the clinical questions being asked and answered have increased in scope and volume. The types of exams being utilized in “point of care ultrasound” have also increased and include transthoracic echocardiography; trans-esophageal echocardiography; and lung, gastric, abdominal, and ocular ultrasound. POCUS is used across multiple specialties, including critical care, anesthesiology, emergency medicine, and primary care.
Not only has POCUS become increasingly important clinically, but specialties now test these skills on their respective board examinations. Anesthesia is one of many such examples. The content outline for the American Board of Anesthesiology includes POCUS as a tested item on both the written and applied components of the exam. POCUS training must be directed toward both optimizing patient management and preparing learners for their board examination. A method for teaching this has yet to be defined (Naji A, et al. Cureus. 2021;13[5]:e15217).
One question – how should different specialties approach this educational challenge and should specialties train together? The answer is complicated. Many POCUS courses and certifications exist, and all vary in their content, didactics, and length. No true gold standard exists for POCUS certification for radiology or noncardiology providers. Additionally, there are no defined expectations or testing processes that certify a provider is “certified” to perform POCUS. While waiting for medical society guidelines to address these issues, many in graduate medical education (GME) are coming up with their own ways to incorporate POCUS into their respective training programs (Atkinson P, et al. CJEM. 2015 Mar;17[2]:161).
Who’s training whom?
Over the past decade, several expert committees, including those in critical care, have developed recommendations and consensus statements urging training facilities to independently create POCUS curriculums. The threshold for many programs to enter this realm of expertise is high and oftentimes unobtainable. We’ve seen emergency medicine and anesthesia raise the bar for ultrasound education in their residencies, but it’s unclear whether all fellowship-trained physicians can and should be tasked with obtaining official POCUS certification.
While specific specialties may require tailored certifications, there’s a considerable overlap in POCUS exam content across specialties. One approach to POCUS training could be developing and implementing a multidisciplinary curriculum. This would allow for pooling of resources (equipment, staff) and harnessing knowledge from providers familiar with different phases of patient care (ICU, perioperative, ED, outpatient clinics). By approaching POCUS from a multidisciplinary perspective, the quality of education may be enhanced (Mayo PH, et al. Intensive Care Med. 2014;40[5]:654). Is it then prudent for providers and trainees alike to share in didactics across all areas of the hospital and clinic? Would this close the knowledge gap between specialties who are facile with ultrasound and those not?
Determining the role of transesophageal echocardiography in a POCUS curriculum
This modality of imaging has been, until recently, reserved for cardiologists and anesthesiologists. More recently transesophageal echocardiography (TEE) has been utilized by emergency and critical care medicine physicians. TEE is part of recommended training for these specialties as a tool for diagnostic and rescue measures, including ventilator management, emergency procedures, and medication titration. Rescue TEE can also be utilized perioperatively where the transthoracic exam is limited by poor windows or the operative procedure precludes access to the chest. While transthoracic echocardiography (TTE) is often used in a point of care fashion, TEE is utilized less often. This may stem from the invasive nature of the procedure but likely also results from lack of equipment and training. Like POCUS overall, TEE POCUS will require incorporation into training programs to achieve widespread use and acceptance.
A deluge of research on TEE for the noncardiologist shows this modality is minimally invasive, safe, and effective. As it becomes more readily available and technology improves, there is no reason why an esophageal probe can’t be used in a patient with a secured airway (Wray TC, et al. J Intensive Care Med. 2021;36[1]:123).
Ultrasound for hemodynamic monitoring
There are many methods employed for hemodynamic monitoring in the ICU. Although echocardiographic and vascular parameters have been validated in the cardiac and perioperative fields, their application in the ICU setting for resuscitation and volume management remain somewhat controversial. The use of TEE and more advanced understanding of spectral doppler and pulmonary ultrasonography using TEE has revolutionized the way providers are managing critically ill patients. (Garcia YA, et al. Chest. 2017;152[4]:736).
In our opinion, physiology and imaging training for residents and fellows should be required for critical care medicine trainees. Delving into the nuances of frank-starling curves, stroke work, and diastolic function will enrich their understanding and highlight the applicability of ultrasonography. Furthermore, all clinicians caring for patients with critical illness should be privy to the nuances of physiologic derangement, and to that end, advanced echocardiographic principles and image acquisition. The heart-lung interactions are demonstrated in real time using POCUS and can clearly delineate treatment goals (Vieillard-Baron A, et al. Intensive Care Med. 2019;45[6]:770).
Documentation and billing
If clinicians are making medical decisions based off imaging gathered at the bedside and interpreted in real-time, documentation should reflect that. That documentation will invariably lead to billing and possibly audit or quality review by colleagues or other healthcare staff. Radiology and cardiology have perfected the billing process for image interpretation, but their form of documentation and interpretation may not easily be implemented in the perioperative or critical care settings. An abbreviated document with focused information should take the place of the formal study. With that, the credentialing and board certification process will allow providers to feel empowered to make clinical decisions based off these focused examinations.
Dr. Goertzen is Chief Fellow, Pulmonary/Critical Care; Dr. Knuf is Program Director, Department of Anesthesia; and Dr. Villalobos is Director of Medical ICU, Department of Internal Medicine, San Antonio Military Medical Center, San Antonio, Texas.
The possibilities are endless: A chat with the incoming CHEST Foundation President, Robert De Marco, MD, FCCP
As the presidency of the American College of Chest Physicians changes hands in January 2023, so will the role of President of the CHEST Foundation. To get to know the incoming President of the CHEST Foundation, we spoke with Robert (Bob) De Marco, MD, FCCP, about his philanthropy work and his goals for the philanthropic arm of CHEST.
Tell me about your history with philanthropy work.
My philanthropy work started long before the CHEST Foundation. While I’ve been a member of CHEST since my second year of fellowship, it wasn’t until much later that I became involved with the philanthropic side of the organization. Earlier in my career, I was involved more so with the American Cancer Society. I had gotten involved with them by chance – participating in an event of theirs – and was encouraged to get more involved by one of their board members. Being involved with them made a lot of sense seeing as a strong percentage of my patients at the time were being treated for lung cancer. My most notable accomplishments with the American Cancer Society were in serving as the Chairmen of my local Relay for Life program for 10 years, as a board member, and then as a president of my local chapter.
When did you get involved with the CHEST Foundation?
I had served in a handful of positions within CHEST, including Chair of the (since reinvented) Practice Management Committee, so I was deeply involved in the association, and I thought to myself, “I have experience in fundraising through my work with the American Cancer Society, why don’t I use it to help our association?” When I moved to Florida, I no longer had the local connection to the American Cancer Society, so it was an opportune time to transition over to the CHEST Foundation.
How has the Foundation changed in the time that you’ve been involved?
The Foundation has changed drastically since I first joined the Board of Trustees 9 years ago. When I first got involved, the primary goal of the Foundation was staying “out of the red.” At that time, we were an organization that gave away more than we made.
After years of building a corpus to fund our own projects, we’re in a really good place now with some phenomenal goals and some excellent initiatives to fundraise around, including a CHEST diversity initiative, First 5 Minutes™, and Bridging Specialties™: Timely Diagnosis for ILD Patients, which seeks to break down silos within medicine to improve patient care.
What will be a focus of your Foundation presidency?
You know, one thing I always appreciated about the American Cancer Society was that there were always notable accomplishments to point back to when supporting fundraising efforts. You could say, “Did you know that bone marrow transplantation was initially funded by the American Cancer Society?” and other examples that would truly inspire someone to want to get involved in supporting those efforts.
The CHEST Foundation may not have funded bone marrow transplantation, but in 25 years of awarding grants, there are equally good stories to share. The impact of the Foundation is tremendous, and we’ve only just begun to share examples of where grant recipients went with their research or community service projects.
A recent grant story that was shared with me was that of Panagis Galiatsatos, MD, MHS, who received a community service grant to start a program educating children in the Baltimore community about lung health. This program was so moving that it inspired one of the Baltimore teachers to pursue a career in medicine and that individual is now a practicing MD.
This is just one example of the Foundation’s impact and it’s through these stories that we share the “why” behind every dollar that is raised, and my first goal is to tell these stories.
Another key focus of not only my presidency, but Dr. Ian Nathanson’s, as well, as we collaborated a lot on our roles, will be on member involvement and awareness. Even I wasn’t involved in the CHEST Foundation until years into my CHEST membership, so I understand that there are competing demands. But I also know that there is a lot to be gained from the work with the Foundation. I want the CHEST members to be excited about the Foundation and to want to support its efforts.
These two goals go hand in hand, and I look forward to sharing the Foundation’s impact with a new audience and reinvigorating the support of our existing donors.
Is there anything else you’d like to say to the reader?
We cannot accomplish anything without the support of our donors, and I want to sincerely thank everyone who has donated to the CHEST Foundation. I also encourage those who have never donated or have yet to donate this year to visit the Foundation’s website (foundation.chestnet.org) and explore some of the inspiring initiatives you can support to strengthen the impact of the CHEST Foundation because the possibilities are truly endless.
As the presidency of the American College of Chest Physicians changes hands in January 2023, so will the role of President of the CHEST Foundation. To get to know the incoming President of the CHEST Foundation, we spoke with Robert (Bob) De Marco, MD, FCCP, about his philanthropy work and his goals for the philanthropic arm of CHEST.
Tell me about your history with philanthropy work.
My philanthropy work started long before the CHEST Foundation. While I’ve been a member of CHEST since my second year of fellowship, it wasn’t until much later that I became involved with the philanthropic side of the organization. Earlier in my career, I was involved more so with the American Cancer Society. I had gotten involved with them by chance – participating in an event of theirs – and was encouraged to get more involved by one of their board members. Being involved with them made a lot of sense seeing as a strong percentage of my patients at the time were being treated for lung cancer. My most notable accomplishments with the American Cancer Society were in serving as the Chairmen of my local Relay for Life program for 10 years, as a board member, and then as a president of my local chapter.
When did you get involved with the CHEST Foundation?
I had served in a handful of positions within CHEST, including Chair of the (since reinvented) Practice Management Committee, so I was deeply involved in the association, and I thought to myself, “I have experience in fundraising through my work with the American Cancer Society, why don’t I use it to help our association?” When I moved to Florida, I no longer had the local connection to the American Cancer Society, so it was an opportune time to transition over to the CHEST Foundation.
How has the Foundation changed in the time that you’ve been involved?
The Foundation has changed drastically since I first joined the Board of Trustees 9 years ago. When I first got involved, the primary goal of the Foundation was staying “out of the red.” At that time, we were an organization that gave away more than we made.
After years of building a corpus to fund our own projects, we’re in a really good place now with some phenomenal goals and some excellent initiatives to fundraise around, including a CHEST diversity initiative, First 5 Minutes™, and Bridging Specialties™: Timely Diagnosis for ILD Patients, which seeks to break down silos within medicine to improve patient care.
What will be a focus of your Foundation presidency?
You know, one thing I always appreciated about the American Cancer Society was that there were always notable accomplishments to point back to when supporting fundraising efforts. You could say, “Did you know that bone marrow transplantation was initially funded by the American Cancer Society?” and other examples that would truly inspire someone to want to get involved in supporting those efforts.
The CHEST Foundation may not have funded bone marrow transplantation, but in 25 years of awarding grants, there are equally good stories to share. The impact of the Foundation is tremendous, and we’ve only just begun to share examples of where grant recipients went with their research or community service projects.
A recent grant story that was shared with me was that of Panagis Galiatsatos, MD, MHS, who received a community service grant to start a program educating children in the Baltimore community about lung health. This program was so moving that it inspired one of the Baltimore teachers to pursue a career in medicine and that individual is now a practicing MD.
This is just one example of the Foundation’s impact and it’s through these stories that we share the “why” behind every dollar that is raised, and my first goal is to tell these stories.
Another key focus of not only my presidency, but Dr. Ian Nathanson’s, as well, as we collaborated a lot on our roles, will be on member involvement and awareness. Even I wasn’t involved in the CHEST Foundation until years into my CHEST membership, so I understand that there are competing demands. But I also know that there is a lot to be gained from the work with the Foundation. I want the CHEST members to be excited about the Foundation and to want to support its efforts.
These two goals go hand in hand, and I look forward to sharing the Foundation’s impact with a new audience and reinvigorating the support of our existing donors.
Is there anything else you’d like to say to the reader?
We cannot accomplish anything without the support of our donors, and I want to sincerely thank everyone who has donated to the CHEST Foundation. I also encourage those who have never donated or have yet to donate this year to visit the Foundation’s website (foundation.chestnet.org) and explore some of the inspiring initiatives you can support to strengthen the impact of the CHEST Foundation because the possibilities are truly endless.
As the presidency of the American College of Chest Physicians changes hands in January 2023, so will the role of President of the CHEST Foundation. To get to know the incoming President of the CHEST Foundation, we spoke with Robert (Bob) De Marco, MD, FCCP, about his philanthropy work and his goals for the philanthropic arm of CHEST.
Tell me about your history with philanthropy work.
My philanthropy work started long before the CHEST Foundation. While I’ve been a member of CHEST since my second year of fellowship, it wasn’t until much later that I became involved with the philanthropic side of the organization. Earlier in my career, I was involved more so with the American Cancer Society. I had gotten involved with them by chance – participating in an event of theirs – and was encouraged to get more involved by one of their board members. Being involved with them made a lot of sense seeing as a strong percentage of my patients at the time were being treated for lung cancer. My most notable accomplishments with the American Cancer Society were in serving as the Chairmen of my local Relay for Life program for 10 years, as a board member, and then as a president of my local chapter.
When did you get involved with the CHEST Foundation?
I had served in a handful of positions within CHEST, including Chair of the (since reinvented) Practice Management Committee, so I was deeply involved in the association, and I thought to myself, “I have experience in fundraising through my work with the American Cancer Society, why don’t I use it to help our association?” When I moved to Florida, I no longer had the local connection to the American Cancer Society, so it was an opportune time to transition over to the CHEST Foundation.
How has the Foundation changed in the time that you’ve been involved?
The Foundation has changed drastically since I first joined the Board of Trustees 9 years ago. When I first got involved, the primary goal of the Foundation was staying “out of the red.” At that time, we were an organization that gave away more than we made.
After years of building a corpus to fund our own projects, we’re in a really good place now with some phenomenal goals and some excellent initiatives to fundraise around, including a CHEST diversity initiative, First 5 Minutes™, and Bridging Specialties™: Timely Diagnosis for ILD Patients, which seeks to break down silos within medicine to improve patient care.
What will be a focus of your Foundation presidency?
You know, one thing I always appreciated about the American Cancer Society was that there were always notable accomplishments to point back to when supporting fundraising efforts. You could say, “Did you know that bone marrow transplantation was initially funded by the American Cancer Society?” and other examples that would truly inspire someone to want to get involved in supporting those efforts.
The CHEST Foundation may not have funded bone marrow transplantation, but in 25 years of awarding grants, there are equally good stories to share. The impact of the Foundation is tremendous, and we’ve only just begun to share examples of where grant recipients went with their research or community service projects.
A recent grant story that was shared with me was that of Panagis Galiatsatos, MD, MHS, who received a community service grant to start a program educating children in the Baltimore community about lung health. This program was so moving that it inspired one of the Baltimore teachers to pursue a career in medicine and that individual is now a practicing MD.
This is just one example of the Foundation’s impact and it’s through these stories that we share the “why” behind every dollar that is raised, and my first goal is to tell these stories.
Another key focus of not only my presidency, but Dr. Ian Nathanson’s, as well, as we collaborated a lot on our roles, will be on member involvement and awareness. Even I wasn’t involved in the CHEST Foundation until years into my CHEST membership, so I understand that there are competing demands. But I also know that there is a lot to be gained from the work with the Foundation. I want the CHEST members to be excited about the Foundation and to want to support its efforts.
These two goals go hand in hand, and I look forward to sharing the Foundation’s impact with a new audience and reinvigorating the support of our existing donors.
Is there anything else you’d like to say to the reader?
We cannot accomplish anything without the support of our donors, and I want to sincerely thank everyone who has donated to the CHEST Foundation. I also encourage those who have never donated or have yet to donate this year to visit the Foundation’s website (foundation.chestnet.org) and explore some of the inspiring initiatives you can support to strengthen the impact of the CHEST Foundation because the possibilities are truly endless.
Passing the ‘baton’ with pride
I was honored to be the third Editor-in-Chief of GIHN, from 2016 through 2021. GIHN is the official newspaper of the American Gastroenterological Association and has the widest readership of any AGA publication and is one that readers told us they read cover to cover. As such, each EIC and their Board of Editors must ensure balanced content that holds the interest of a diverse readership. I was privileged to work with a talented editorial board who reviewed articles, attended leadership meetings, and offered terrific suggestions throughout our tenure. I treasured their support and friendship.
Within each of the 60 monthly issues, we sought to highlight science, practice operations, national trends, and opinions and reviews that would be most important to basic scientists, clinical researchers, and academic and community clinicians, primarily from the United States but also from a worldwide readership. I was given a 300-word section to create editorial comments on pertinent topics that were important to gastroenterologists. Having a background in both community and academic practice, I tried to bring a balanced perspective to areas that often seem worlds apart.
The period between 2016 and 2021 also was a time of political upheaval in this country – something we could not ignore. I attempted to write about current events in a balanced way that kept a focus on patients and AGA’s core constituency. Not always an easy task. Sustainability of the Affordable Care Act was very much in question because of judicial and legislative challenges; had the ACA been overturned, our practices would be very different now.
In 2016, the first private equity–backed practice platform was created in south Florida. Little did we know how much that model would change community practice. Then, on Jan. 21, 2020, the first case of COVID 19 was diagnosed in Seattle (although earlier cases likely occurred). By March, many clinics and practices were closing, and we were altering our care delivery infrastructure in ways that would forever change practice. Trying to keep current with ever-changing science and policies was a challenge.
I will always treasure my time as EIC. I was happy (and proud) to pass this baton to Megan A. Adams MD, JD, MSc, my colleague and mentee at the University of Michigan. The partnership between AGA and Frontline Medical Communications has been successful for 15 years and will continue to be so.
Dr. Allen, now retired, was professor of medicine at the University of Michigan, Ann Arbor. He is secretary/treasurer for the American Gastroenterological Association, and declares no relevant conflicts of interest.
I was honored to be the third Editor-in-Chief of GIHN, from 2016 through 2021. GIHN is the official newspaper of the American Gastroenterological Association and has the widest readership of any AGA publication and is one that readers told us they read cover to cover. As such, each EIC and their Board of Editors must ensure balanced content that holds the interest of a diverse readership. I was privileged to work with a talented editorial board who reviewed articles, attended leadership meetings, and offered terrific suggestions throughout our tenure. I treasured their support and friendship.
Within each of the 60 monthly issues, we sought to highlight science, practice operations, national trends, and opinions and reviews that would be most important to basic scientists, clinical researchers, and academic and community clinicians, primarily from the United States but also from a worldwide readership. I was given a 300-word section to create editorial comments on pertinent topics that were important to gastroenterologists. Having a background in both community and academic practice, I tried to bring a balanced perspective to areas that often seem worlds apart.
The period between 2016 and 2021 also was a time of political upheaval in this country – something we could not ignore. I attempted to write about current events in a balanced way that kept a focus on patients and AGA’s core constituency. Not always an easy task. Sustainability of the Affordable Care Act was very much in question because of judicial and legislative challenges; had the ACA been overturned, our practices would be very different now.
In 2016, the first private equity–backed practice platform was created in south Florida. Little did we know how much that model would change community practice. Then, on Jan. 21, 2020, the first case of COVID 19 was diagnosed in Seattle (although earlier cases likely occurred). By March, many clinics and practices were closing, and we were altering our care delivery infrastructure in ways that would forever change practice. Trying to keep current with ever-changing science and policies was a challenge.
I will always treasure my time as EIC. I was happy (and proud) to pass this baton to Megan A. Adams MD, JD, MSc, my colleague and mentee at the University of Michigan. The partnership between AGA and Frontline Medical Communications has been successful for 15 years and will continue to be so.
Dr. Allen, now retired, was professor of medicine at the University of Michigan, Ann Arbor. He is secretary/treasurer for the American Gastroenterological Association, and declares no relevant conflicts of interest.
I was honored to be the third Editor-in-Chief of GIHN, from 2016 through 2021. GIHN is the official newspaper of the American Gastroenterological Association and has the widest readership of any AGA publication and is one that readers told us they read cover to cover. As such, each EIC and their Board of Editors must ensure balanced content that holds the interest of a diverse readership. I was privileged to work with a talented editorial board who reviewed articles, attended leadership meetings, and offered terrific suggestions throughout our tenure. I treasured their support and friendship.
Within each of the 60 monthly issues, we sought to highlight science, practice operations, national trends, and opinions and reviews that would be most important to basic scientists, clinical researchers, and academic and community clinicians, primarily from the United States but also from a worldwide readership. I was given a 300-word section to create editorial comments on pertinent topics that were important to gastroenterologists. Having a background in both community and academic practice, I tried to bring a balanced perspective to areas that often seem worlds apart.
The period between 2016 and 2021 also was a time of political upheaval in this country – something we could not ignore. I attempted to write about current events in a balanced way that kept a focus on patients and AGA’s core constituency. Not always an easy task. Sustainability of the Affordable Care Act was very much in question because of judicial and legislative challenges; had the ACA been overturned, our practices would be very different now.
In 2016, the first private equity–backed practice platform was created in south Florida. Little did we know how much that model would change community practice. Then, on Jan. 21, 2020, the first case of COVID 19 was diagnosed in Seattle (although earlier cases likely occurred). By March, many clinics and practices were closing, and we were altering our care delivery infrastructure in ways that would forever change practice. Trying to keep current with ever-changing science and policies was a challenge.
I will always treasure my time as EIC. I was happy (and proud) to pass this baton to Megan A. Adams MD, JD, MSc, my colleague and mentee at the University of Michigan. The partnership between AGA and Frontline Medical Communications has been successful for 15 years and will continue to be so.
Dr. Allen, now retired, was professor of medicine at the University of Michigan, Ann Arbor. He is secretary/treasurer for the American Gastroenterological Association, and declares no relevant conflicts of interest.
November 2022 - ICYMI
Gastroenterology
August 2022
Johnson-Laghi KA, Mattar MC. Integrating cognitive apprenticeship into gastroenterology clinical training. Gastroenterology. 2022 Aug;163(2):364-7. doi: 10.1053/j.gastro.2022.06.013.
Wood LD et al. Pancreatic cancer: Pathogenesis, screening, diagnosis, and treatment. Gastroenterology. 2022 Aug;163(2):386-402.e1. doi: 10.1053/j.gastro.2022.03.056.
Calderwood AH and Robertson DJ. Stopping surveillance in gastrointestinal conditions: Thoughts on the scope of the problem and potential solutions. Gastroenterology. 2022 Aug;163(2):345-9. doi: 10.1053/j.gastro.2022.04.009.
September 2022
Donnangelo LL et al. Disclosure and reflection after an adverse event: Tips for training and practice. Gastroenterology. 2022 Sep;163(3):568-71. doi: 10.1053/j.gastro.2022.07.003.
Chey WD et al. Vonoprazan triple and dual therapy for Helicobacter pylori infection in the United States and Europe: Randomized clinical trial. Gastroenterology. 2022 Sep;163(3):608-19. doi: 10.1053/j.gastro.2022.05.055.
Bushyhead D and Quigley EMM. Small intestinal bacterial overgrowth-pathophysiology and its implications for definition and management. Gastroenterology. 2022 Sep;163(3):593-607. doi: 10.1053/j.gastro.2022.04.002.
Long MT et al. AGA Clinical practice update: Diagnosis and management of nonalcoholic fatty liver disease in lean individuals: Expert review. Gastroenterology. 2022 Sep;163(3):764-74.e1. doi: 10.1053/j.gastro.2022.06.023.
CGH
August 2022
Lennon AM and Vege SS. Pancreatic cyst surveillance. Clin Gastroenterol Hepatol. 2022 Aug;20(8):1663-7.e1. doi: 10.1016/j.cgh.2022.03.002.
Crockett SD et al. Large Polyp Study Group Consortium. Clip closure does not reduce risk of bleeding after resection of large serrated polyps: Results from a randomized trial. Clin Gastroenterol Hepatol. 2022 Aug;20(8):1757-17--65.e4. doi: 10.1016/j.cgh.2021.12.036.
Martin P et al. Treatment algorithm for managing chronic hepatitis b virus infection in the United States: 2021 update. Clin Gastroenterol Hepatol. 2022 Aug;20(8):1766-75. doi: 10.1016/j.cgh.2021.07.036.
September 2022
Pawlak KM et al. How to train the next generation to provide high-quality peer-reviews. Clin Gastroenterol Hepatol. 2022 Sep;20(9):1902-6. doi: 10.1016/j.cgh.2022.05.018.
Choung RS et al. Collagenous gastritis: Characteristics and response to topical budesonide. Clin Gastroenterol Hepatol. 2022 Sep;20(9):1977-85.e1. doi: 10.1016/j.cgh.2021.11.033.
Basnayake C et al. Long-term outcome of multidisciplinary versus standard gastroenterologist care for functional gastrointestinal disorders: A randomized trial. Clin Gastroenterol Hepatol. 2022 Sep;20(9):2102-11.e9. doi: 10.1016/j.cgh.2021.12.005.
Deutsch-Link S et al. Alcohol-associated liver disease mortality increased from 2017 to 2020 and accelerated during the COVID-19 pandemic. Clin Gastroenterol Hepatol. 2022 Sep;20(9):2142-4.e2. doi: 10.1016/j.cgh.2022.03.017.
TIGE
Nakamatsu, Dai et al. Safety of cold snare polypectomy for small colorectal polyps in patients receiving antithrombotic therapy. Tech Innov Gastrointest Endosc. 2022 Apr 8;24[3]:246-53. doi: 10.1016/j.tige.2022.03.008.
Gastro Hep Advances
Brindusa Truta et al. Outcomes of continuation vs. discontinuation of adalimumab therapy during third trimester of pregnancy in inflammatory bowel disease. Gastro Hep Advances. 2022 Jan 1;1[5]:785-91. doi: 10.1016/j.gastha.2022.04.009.
Gastroenterology
August 2022
Johnson-Laghi KA, Mattar MC. Integrating cognitive apprenticeship into gastroenterology clinical training. Gastroenterology. 2022 Aug;163(2):364-7. doi: 10.1053/j.gastro.2022.06.013.
Wood LD et al. Pancreatic cancer: Pathogenesis, screening, diagnosis, and treatment. Gastroenterology. 2022 Aug;163(2):386-402.e1. doi: 10.1053/j.gastro.2022.03.056.
Calderwood AH and Robertson DJ. Stopping surveillance in gastrointestinal conditions: Thoughts on the scope of the problem and potential solutions. Gastroenterology. 2022 Aug;163(2):345-9. doi: 10.1053/j.gastro.2022.04.009.
September 2022
Donnangelo LL et al. Disclosure and reflection after an adverse event: Tips for training and practice. Gastroenterology. 2022 Sep;163(3):568-71. doi: 10.1053/j.gastro.2022.07.003.
Chey WD et al. Vonoprazan triple and dual therapy for Helicobacter pylori infection in the United States and Europe: Randomized clinical trial. Gastroenterology. 2022 Sep;163(3):608-19. doi: 10.1053/j.gastro.2022.05.055.
Bushyhead D and Quigley EMM. Small intestinal bacterial overgrowth-pathophysiology and its implications for definition and management. Gastroenterology. 2022 Sep;163(3):593-607. doi: 10.1053/j.gastro.2022.04.002.
Long MT et al. AGA Clinical practice update: Diagnosis and management of nonalcoholic fatty liver disease in lean individuals: Expert review. Gastroenterology. 2022 Sep;163(3):764-74.e1. doi: 10.1053/j.gastro.2022.06.023.
CGH
August 2022
Lennon AM and Vege SS. Pancreatic cyst surveillance. Clin Gastroenterol Hepatol. 2022 Aug;20(8):1663-7.e1. doi: 10.1016/j.cgh.2022.03.002.
Crockett SD et al. Large Polyp Study Group Consortium. Clip closure does not reduce risk of bleeding after resection of large serrated polyps: Results from a randomized trial. Clin Gastroenterol Hepatol. 2022 Aug;20(8):1757-17--65.e4. doi: 10.1016/j.cgh.2021.12.036.
Martin P et al. Treatment algorithm for managing chronic hepatitis b virus infection in the United States: 2021 update. Clin Gastroenterol Hepatol. 2022 Aug;20(8):1766-75. doi: 10.1016/j.cgh.2021.07.036.
September 2022
Pawlak KM et al. How to train the next generation to provide high-quality peer-reviews. Clin Gastroenterol Hepatol. 2022 Sep;20(9):1902-6. doi: 10.1016/j.cgh.2022.05.018.
Choung RS et al. Collagenous gastritis: Characteristics and response to topical budesonide. Clin Gastroenterol Hepatol. 2022 Sep;20(9):1977-85.e1. doi: 10.1016/j.cgh.2021.11.033.
Basnayake C et al. Long-term outcome of multidisciplinary versus standard gastroenterologist care for functional gastrointestinal disorders: A randomized trial. Clin Gastroenterol Hepatol. 2022 Sep;20(9):2102-11.e9. doi: 10.1016/j.cgh.2021.12.005.
Deutsch-Link S et al. Alcohol-associated liver disease mortality increased from 2017 to 2020 and accelerated during the COVID-19 pandemic. Clin Gastroenterol Hepatol. 2022 Sep;20(9):2142-4.e2. doi: 10.1016/j.cgh.2022.03.017.
TIGE
Nakamatsu, Dai et al. Safety of cold snare polypectomy for small colorectal polyps in patients receiving antithrombotic therapy. Tech Innov Gastrointest Endosc. 2022 Apr 8;24[3]:246-53. doi: 10.1016/j.tige.2022.03.008.
Gastro Hep Advances
Brindusa Truta et al. Outcomes of continuation vs. discontinuation of adalimumab therapy during third trimester of pregnancy in inflammatory bowel disease. Gastro Hep Advances. 2022 Jan 1;1[5]:785-91. doi: 10.1016/j.gastha.2022.04.009.
Gastroenterology
August 2022
Johnson-Laghi KA, Mattar MC. Integrating cognitive apprenticeship into gastroenterology clinical training. Gastroenterology. 2022 Aug;163(2):364-7. doi: 10.1053/j.gastro.2022.06.013.
Wood LD et al. Pancreatic cancer: Pathogenesis, screening, diagnosis, and treatment. Gastroenterology. 2022 Aug;163(2):386-402.e1. doi: 10.1053/j.gastro.2022.03.056.
Calderwood AH and Robertson DJ. Stopping surveillance in gastrointestinal conditions: Thoughts on the scope of the problem and potential solutions. Gastroenterology. 2022 Aug;163(2):345-9. doi: 10.1053/j.gastro.2022.04.009.
September 2022
Donnangelo LL et al. Disclosure and reflection after an adverse event: Tips for training and practice. Gastroenterology. 2022 Sep;163(3):568-71. doi: 10.1053/j.gastro.2022.07.003.
Chey WD et al. Vonoprazan triple and dual therapy for Helicobacter pylori infection in the United States and Europe: Randomized clinical trial. Gastroenterology. 2022 Sep;163(3):608-19. doi: 10.1053/j.gastro.2022.05.055.
Bushyhead D and Quigley EMM. Small intestinal bacterial overgrowth-pathophysiology and its implications for definition and management. Gastroenterology. 2022 Sep;163(3):593-607. doi: 10.1053/j.gastro.2022.04.002.
Long MT et al. AGA Clinical practice update: Diagnosis and management of nonalcoholic fatty liver disease in lean individuals: Expert review. Gastroenterology. 2022 Sep;163(3):764-74.e1. doi: 10.1053/j.gastro.2022.06.023.
CGH
August 2022
Lennon AM and Vege SS. Pancreatic cyst surveillance. Clin Gastroenterol Hepatol. 2022 Aug;20(8):1663-7.e1. doi: 10.1016/j.cgh.2022.03.002.
Crockett SD et al. Large Polyp Study Group Consortium. Clip closure does not reduce risk of bleeding after resection of large serrated polyps: Results from a randomized trial. Clin Gastroenterol Hepatol. 2022 Aug;20(8):1757-17--65.e4. doi: 10.1016/j.cgh.2021.12.036.
Martin P et al. Treatment algorithm for managing chronic hepatitis b virus infection in the United States: 2021 update. Clin Gastroenterol Hepatol. 2022 Aug;20(8):1766-75. doi: 10.1016/j.cgh.2021.07.036.
September 2022
Pawlak KM et al. How to train the next generation to provide high-quality peer-reviews. Clin Gastroenterol Hepatol. 2022 Sep;20(9):1902-6. doi: 10.1016/j.cgh.2022.05.018.
Choung RS et al. Collagenous gastritis: Characteristics and response to topical budesonide. Clin Gastroenterol Hepatol. 2022 Sep;20(9):1977-85.e1. doi: 10.1016/j.cgh.2021.11.033.
Basnayake C et al. Long-term outcome of multidisciplinary versus standard gastroenterologist care for functional gastrointestinal disorders: A randomized trial. Clin Gastroenterol Hepatol. 2022 Sep;20(9):2102-11.e9. doi: 10.1016/j.cgh.2021.12.005.
Deutsch-Link S et al. Alcohol-associated liver disease mortality increased from 2017 to 2020 and accelerated during the COVID-19 pandemic. Clin Gastroenterol Hepatol. 2022 Sep;20(9):2142-4.e2. doi: 10.1016/j.cgh.2022.03.017.
TIGE
Nakamatsu, Dai et al. Safety of cold snare polypectomy for small colorectal polyps in patients receiving antithrombotic therapy. Tech Innov Gastrointest Endosc. 2022 Apr 8;24[3]:246-53. doi: 10.1016/j.tige.2022.03.008.
Gastro Hep Advances
Brindusa Truta et al. Outcomes of continuation vs. discontinuation of adalimumab therapy during third trimester of pregnancy in inflammatory bowel disease. Gastro Hep Advances. 2022 Jan 1;1[5]:785-91. doi: 10.1016/j.gastha.2022.04.009.
Change the world without touching your income
Do you want to support the AGA Research Foundation, but feel overwhelmed by everyday living costs, such as the latest home repair, food expenses, and escalating gas prices?
There are two main benefits to this meaningful step:
- Your current income or assets remain the same.
- You can change your mind at any time.
The easiest and most popular way to support the AGA Research Foundation while putting your current financial needs first is to include a gift in your will or revocable living trust. It takes as little as one sentence to complete your gift.
Best of all, you have the option to leave a percentage of your estate or an asset so that no matter how the size of your estate changes, gifts to your family and nonprofits remain proportional.
Your gift directly supports the talented young researchers working to advance our understanding of digestive diseases. Make a tax-deductible donation to help spur innovation. Donate today at www.gastro.org/donateonline.
Do you want to support the AGA Research Foundation, but feel overwhelmed by everyday living costs, such as the latest home repair, food expenses, and escalating gas prices?
There are two main benefits to this meaningful step:
- Your current income or assets remain the same.
- You can change your mind at any time.
The easiest and most popular way to support the AGA Research Foundation while putting your current financial needs first is to include a gift in your will or revocable living trust. It takes as little as one sentence to complete your gift.
Best of all, you have the option to leave a percentage of your estate or an asset so that no matter how the size of your estate changes, gifts to your family and nonprofits remain proportional.
Your gift directly supports the talented young researchers working to advance our understanding of digestive diseases. Make a tax-deductible donation to help spur innovation. Donate today at www.gastro.org/donateonline.
Do you want to support the AGA Research Foundation, but feel overwhelmed by everyday living costs, such as the latest home repair, food expenses, and escalating gas prices?
There are two main benefits to this meaningful step:
- Your current income or assets remain the same.
- You can change your mind at any time.
The easiest and most popular way to support the AGA Research Foundation while putting your current financial needs first is to include a gift in your will or revocable living trust. It takes as little as one sentence to complete your gift.
Best of all, you have the option to leave a percentage of your estate or an asset so that no matter how the size of your estate changes, gifts to your family and nonprofits remain proportional.
Your gift directly supports the talented young researchers working to advance our understanding of digestive diseases. Make a tax-deductible donation to help spur innovation. Donate today at www.gastro.org/donateonline.
Thoracic Oncology & Chest Imaging Network
Lung Cancer Section
What is comprehensive biomarker testing and who should order it? For non–small cell lung cancer, comprehensive biomarker testing is generally defined as testing eligible patients for all biomarkers that direct the use of FDA-approved therapies (Mileham KF, et al. Cancer Med. 2022;11[2]:530. What comprises comprehensive testing has changed over time and will likely continue to change as advances in biomarkers, therapies, and indications for their use continue to evolve. There are also some potential benefits to testing biomarkers without FDA-approved therapies, such as assessing eligibility for treatment as part of a clinical trial or for identifying treatment options that gain FDA-approval in the future. As for who should be responsible for biomarker test ordering, this remains unclear and variable between institutions and practices (Fox AH, et al. Chest. 2021;160[6]:2293). All subspecialties involved, including pulmonology, pathology, interventional radiology, surgery, and oncology, have the potential for knowledge gaps surrounding biomarker testing (Gregg JP, et al. Transl Lung Cancer Res. 2019;8[3]:286; Smeltzer MP, et al. J Thorac Oncol. 2020;15[9]:1434). Those obtaining diagnostic tissue, including pulmonologists, surgeons, and interventional radiologists may not appreciate the downstream use of each biomarker but are in the place to order testing as soon as the time of biopsy. Pathologists may be unaware of clinical aspects to the patient’s case, such as the suspected clinical stage of disease. Oncologists arguably have the best chance of having the expertise to order testing but, ideally, biomarker results would be available by the time a patient meets with an oncologist to discuss treatment options. There is no perfect solution to this question at present, but if you are involved with the diagnosis of lung cancer, you should collaborate with your multidisciplinary team to streamline testing and strategize how to best serve patients.
Adam Fox, MD
Section Fellow-in-Training
Lung Cancer Section
What is comprehensive biomarker testing and who should order it? For non–small cell lung cancer, comprehensive biomarker testing is generally defined as testing eligible patients for all biomarkers that direct the use of FDA-approved therapies (Mileham KF, et al. Cancer Med. 2022;11[2]:530. What comprises comprehensive testing has changed over time and will likely continue to change as advances in biomarkers, therapies, and indications for their use continue to evolve. There are also some potential benefits to testing biomarkers without FDA-approved therapies, such as assessing eligibility for treatment as part of a clinical trial or for identifying treatment options that gain FDA-approval in the future. As for who should be responsible for biomarker test ordering, this remains unclear and variable between institutions and practices (Fox AH, et al. Chest. 2021;160[6]:2293). All subspecialties involved, including pulmonology, pathology, interventional radiology, surgery, and oncology, have the potential for knowledge gaps surrounding biomarker testing (Gregg JP, et al. Transl Lung Cancer Res. 2019;8[3]:286; Smeltzer MP, et al. J Thorac Oncol. 2020;15[9]:1434). Those obtaining diagnostic tissue, including pulmonologists, surgeons, and interventional radiologists may not appreciate the downstream use of each biomarker but are in the place to order testing as soon as the time of biopsy. Pathologists may be unaware of clinical aspects to the patient’s case, such as the suspected clinical stage of disease. Oncologists arguably have the best chance of having the expertise to order testing but, ideally, biomarker results would be available by the time a patient meets with an oncologist to discuss treatment options. There is no perfect solution to this question at present, but if you are involved with the diagnosis of lung cancer, you should collaborate with your multidisciplinary team to streamline testing and strategize how to best serve patients.
Adam Fox, MD
Section Fellow-in-Training
Lung Cancer Section
What is comprehensive biomarker testing and who should order it? For non–small cell lung cancer, comprehensive biomarker testing is generally defined as testing eligible patients for all biomarkers that direct the use of FDA-approved therapies (Mileham KF, et al. Cancer Med. 2022;11[2]:530. What comprises comprehensive testing has changed over time and will likely continue to change as advances in biomarkers, therapies, and indications for their use continue to evolve. There are also some potential benefits to testing biomarkers without FDA-approved therapies, such as assessing eligibility for treatment as part of a clinical trial or for identifying treatment options that gain FDA-approval in the future. As for who should be responsible for biomarker test ordering, this remains unclear and variable between institutions and practices (Fox AH, et al. Chest. 2021;160[6]:2293). All subspecialties involved, including pulmonology, pathology, interventional radiology, surgery, and oncology, have the potential for knowledge gaps surrounding biomarker testing (Gregg JP, et al. Transl Lung Cancer Res. 2019;8[3]:286; Smeltzer MP, et al. J Thorac Oncol. 2020;15[9]:1434). Those obtaining diagnostic tissue, including pulmonologists, surgeons, and interventional radiologists may not appreciate the downstream use of each biomarker but are in the place to order testing as soon as the time of biopsy. Pathologists may be unaware of clinical aspects to the patient’s case, such as the suspected clinical stage of disease. Oncologists arguably have the best chance of having the expertise to order testing but, ideally, biomarker results would be available by the time a patient meets with an oncologist to discuss treatment options. There is no perfect solution to this question at present, but if you are involved with the diagnosis of lung cancer, you should collaborate with your multidisciplinary team to streamline testing and strategize how to best serve patients.
Adam Fox, MD
Section Fellow-in-Training
Chest Infections & Disaster Response Network
Chest Infections Section
An evolving diagnostic tool: Microbial cell-free DNA
The diagnosis of the microbial etiology of pneumonia remains a significant challenge with <50% yield of blood and sputum cultures in most studies. More reliable samples, like bronchoalveolar lavage, require invasive procedures. Undifferentiated pneumonia hampers antimicrobial stewardship and increases the risk of suboptimal treatment. New diagnostic tools that detect degraded microbial DNA in plasma, known as microbial cell-free DNA (cfDNA), may offer improved diagnostic yield. Through metagenomic next-generation approaches, these tools sequence DNA fragments to identify viral, bacterial, and fungal sequences.
Earlier studies of cfDNA in pneumonia have been mixed, correctly identifying the pathogen in 55% to 86% of cases – though notably cfDNA was superior to PCR and cultures and provided early detection of VAP in some cases (Farnaes L, et al. Diagn Microbiol Infect Dis. 2019;94:188; Langelier C, et al. Am J Respir Crit Care Med. 2020;201:491). However, a recent study of cfDNA in severe complicated pediatric pneumonia had promising results with significant clinical impact. cfDNA provided an accurate microbial diagnosis in 89% of cases, with it being the only positive study in 70% of cases. Further, cfDNA narrowed the antimicrobial regimen in 81% of cases (Dworsky ZD, et al. Hosp Pediatr. 2022;12:377).
The use of cfDNA is still in its infancy. Limitations, such as a lack of validated thresholds to differentiate colonization vs infection are noted given its detection sensitivity. Its utility, including ideal timing and patient population, needs further investigation. However, diagnostic cfDNA may soon provide earlier and less invasive microbial diagnostics in patients with chest infections and beyond.
Gregory Wigger, MD
Section Fellow-in-Training
Chest Infections Section
An evolving diagnostic tool: Microbial cell-free DNA
The diagnosis of the microbial etiology of pneumonia remains a significant challenge with <50% yield of blood and sputum cultures in most studies. More reliable samples, like bronchoalveolar lavage, require invasive procedures. Undifferentiated pneumonia hampers antimicrobial stewardship and increases the risk of suboptimal treatment. New diagnostic tools that detect degraded microbial DNA in plasma, known as microbial cell-free DNA (cfDNA), may offer improved diagnostic yield. Through metagenomic next-generation approaches, these tools sequence DNA fragments to identify viral, bacterial, and fungal sequences.
Earlier studies of cfDNA in pneumonia have been mixed, correctly identifying the pathogen in 55% to 86% of cases – though notably cfDNA was superior to PCR and cultures and provided early detection of VAP in some cases (Farnaes L, et al. Diagn Microbiol Infect Dis. 2019;94:188; Langelier C, et al. Am J Respir Crit Care Med. 2020;201:491). However, a recent study of cfDNA in severe complicated pediatric pneumonia had promising results with significant clinical impact. cfDNA provided an accurate microbial diagnosis in 89% of cases, with it being the only positive study in 70% of cases. Further, cfDNA narrowed the antimicrobial regimen in 81% of cases (Dworsky ZD, et al. Hosp Pediatr. 2022;12:377).
The use of cfDNA is still in its infancy. Limitations, such as a lack of validated thresholds to differentiate colonization vs infection are noted given its detection sensitivity. Its utility, including ideal timing and patient population, needs further investigation. However, diagnostic cfDNA may soon provide earlier and less invasive microbial diagnostics in patients with chest infections and beyond.
Gregory Wigger, MD
Section Fellow-in-Training
Chest Infections Section
An evolving diagnostic tool: Microbial cell-free DNA
The diagnosis of the microbial etiology of pneumonia remains a significant challenge with <50% yield of blood and sputum cultures in most studies. More reliable samples, like bronchoalveolar lavage, require invasive procedures. Undifferentiated pneumonia hampers antimicrobial stewardship and increases the risk of suboptimal treatment. New diagnostic tools that detect degraded microbial DNA in plasma, known as microbial cell-free DNA (cfDNA), may offer improved diagnostic yield. Through metagenomic next-generation approaches, these tools sequence DNA fragments to identify viral, bacterial, and fungal sequences.
Earlier studies of cfDNA in pneumonia have been mixed, correctly identifying the pathogen in 55% to 86% of cases – though notably cfDNA was superior to PCR and cultures and provided early detection of VAP in some cases (Farnaes L, et al. Diagn Microbiol Infect Dis. 2019;94:188; Langelier C, et al. Am J Respir Crit Care Med. 2020;201:491). However, a recent study of cfDNA in severe complicated pediatric pneumonia had promising results with significant clinical impact. cfDNA provided an accurate microbial diagnosis in 89% of cases, with it being the only positive study in 70% of cases. Further, cfDNA narrowed the antimicrobial regimen in 81% of cases (Dworsky ZD, et al. Hosp Pediatr. 2022;12:377).
The use of cfDNA is still in its infancy. Limitations, such as a lack of validated thresholds to differentiate colonization vs infection are noted given its detection sensitivity. Its utility, including ideal timing and patient population, needs further investigation. However, diagnostic cfDNA may soon provide earlier and less invasive microbial diagnostics in patients with chest infections and beyond.
Gregory Wigger, MD
Section Fellow-in-Training