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Experts release new management strategies for malignant colorectal polyps
Early identification and removal of cancerous colorectal polyps is critical to preventing the progression of colorectal cancer and improving survival rates. The U.S. Multisociety Task Force (U.S. MSTF) on Colorectal Cancer has released new guidance for endoscopists on how to assess colorectal lesions for features associated with cancer, discuss how these factors guide management and outline when to advise surgery after malignant polyp removal.
Key recommendations from the U.S. Multisociety Task Force on Colorectal Cancer, which is comprised of leading experts representing AGA, ACG and ASGE, include:
1. Management of malignant polyps must begin with a thorough and knowledgeable endoscopic assessment designed to identify features of deep submucosal invasion.
2. In nonpedunculated lesions with features of deep submucosal invasion, endoscopic biopsy and tattooing should be followed by surgical resection.
3. Nonpedunculated lesions with high risk of superficial submucosal invasion should be considered for en bloc resection and proper specimen handling.
4. When pathology reports cancer in a lesion that was completely resected endoscopically, the decision to recommend surgery is based on polyp shape, whether there was en bloc resection and adequate histologic assessment, the presence or absence of unfavorable histologic features, the patient’s risk for surgical mortality and morbidity, and patient preferences.
For more information, review the full publication: Endoscopic Recognition and Management Strategies for Malignant Colorectal Polyps: Recommendations of the US Multi-Society Task Force on Colorectal Cancer. The U.S. MSTF recommendations are published jointly in Gastroenterology, The American Journal of Gastroenterology, and Gastrointestinal Endoscopy.
Early identification and removal of cancerous colorectal polyps is critical to preventing the progression of colorectal cancer and improving survival rates. The U.S. Multisociety Task Force (U.S. MSTF) on Colorectal Cancer has released new guidance for endoscopists on how to assess colorectal lesions for features associated with cancer, discuss how these factors guide management and outline when to advise surgery after malignant polyp removal.
Key recommendations from the U.S. Multisociety Task Force on Colorectal Cancer, which is comprised of leading experts representing AGA, ACG and ASGE, include:
1. Management of malignant polyps must begin with a thorough and knowledgeable endoscopic assessment designed to identify features of deep submucosal invasion.
2. In nonpedunculated lesions with features of deep submucosal invasion, endoscopic biopsy and tattooing should be followed by surgical resection.
3. Nonpedunculated lesions with high risk of superficial submucosal invasion should be considered for en bloc resection and proper specimen handling.
4. When pathology reports cancer in a lesion that was completely resected endoscopically, the decision to recommend surgery is based on polyp shape, whether there was en bloc resection and adequate histologic assessment, the presence or absence of unfavorable histologic features, the patient’s risk for surgical mortality and morbidity, and patient preferences.
For more information, review the full publication: Endoscopic Recognition and Management Strategies for Malignant Colorectal Polyps: Recommendations of the US Multi-Society Task Force on Colorectal Cancer. The U.S. MSTF recommendations are published jointly in Gastroenterology, The American Journal of Gastroenterology, and Gastrointestinal Endoscopy.
Early identification and removal of cancerous colorectal polyps is critical to preventing the progression of colorectal cancer and improving survival rates. The U.S. Multisociety Task Force (U.S. MSTF) on Colorectal Cancer has released new guidance for endoscopists on how to assess colorectal lesions for features associated with cancer, discuss how these factors guide management and outline when to advise surgery after malignant polyp removal.
Key recommendations from the U.S. Multisociety Task Force on Colorectal Cancer, which is comprised of leading experts representing AGA, ACG and ASGE, include:
1. Management of malignant polyps must begin with a thorough and knowledgeable endoscopic assessment designed to identify features of deep submucosal invasion.
2. In nonpedunculated lesions with features of deep submucosal invasion, endoscopic biopsy and tattooing should be followed by surgical resection.
3. Nonpedunculated lesions with high risk of superficial submucosal invasion should be considered for en bloc resection and proper specimen handling.
4. When pathology reports cancer in a lesion that was completely resected endoscopically, the decision to recommend surgery is based on polyp shape, whether there was en bloc resection and adequate histologic assessment, the presence or absence of unfavorable histologic features, the patient’s risk for surgical mortality and morbidity, and patient preferences.
For more information, review the full publication: Endoscopic Recognition and Management Strategies for Malignant Colorectal Polyps: Recommendations of the US Multi-Society Task Force on Colorectal Cancer. The U.S. MSTF recommendations are published jointly in Gastroenterology, The American Journal of Gastroenterology, and Gastrointestinal Endoscopy.
Launching a virtual Listening Tour
How do we discuss race and lung health issues that impact our most deserving, underserved communities? Continuously and uncomfortably. As the Executive Director of the CHEST Foundation and as a young Black man, I am hopeful that we, as CHEST, can lead these uncomfortable conversations to better our communities. Our ability to listen and deliver support to our most-deserving communities is critical in how we fulfill our mission. CHEST continues to be a leader in lung health because we choose to give a voice and a platform in support of better lung health – especially to those who are disproportionately affected by lung disease, specifically addressing the quality of care they receive and bringing to light the fact that too often these patients are forgotten by the rest of society.
As cases of COVID-19 and civil unrest continue to swell across our nation, we, the CHEST Foundation, have launched a virtual Listening Tour. We are taking this pragmatic, and more importantly, passionate approach to addressing health disparities by identifying and addressing barriers and issues affecting our most deserving and disproportionately underserved communities. By bringing together these communities’ patients and caregivers, local leaders, involved businesses, and our CHEST members in a virtual community gathering, we intend to clearly define the needs of each community, elevate those needs to a national level, and work to collaborate with and support these local communities and leaders to address their most-pressing issues.
Stories are what connect us and move us forward. We are confident that this virtual Listening Tour will be an opportunity for constituents to tell their own stories and learn from each other, while allowing the CHEST organization, through the CHEST Foundation, to act as the arbiter for pulmonary health and provide a path forward to create equity for those suffering from chronic lung disease.
We need your support to challenge these longstanding disparities in chest medicine. Help us advance these critical conversations and move the needle toward equality by contributing today at chestfoundation.org/donate.
How do we discuss race and lung health issues that impact our most deserving, underserved communities? Continuously and uncomfortably. As the Executive Director of the CHEST Foundation and as a young Black man, I am hopeful that we, as CHEST, can lead these uncomfortable conversations to better our communities. Our ability to listen and deliver support to our most-deserving communities is critical in how we fulfill our mission. CHEST continues to be a leader in lung health because we choose to give a voice and a platform in support of better lung health – especially to those who are disproportionately affected by lung disease, specifically addressing the quality of care they receive and bringing to light the fact that too often these patients are forgotten by the rest of society.
As cases of COVID-19 and civil unrest continue to swell across our nation, we, the CHEST Foundation, have launched a virtual Listening Tour. We are taking this pragmatic, and more importantly, passionate approach to addressing health disparities by identifying and addressing barriers and issues affecting our most deserving and disproportionately underserved communities. By bringing together these communities’ patients and caregivers, local leaders, involved businesses, and our CHEST members in a virtual community gathering, we intend to clearly define the needs of each community, elevate those needs to a national level, and work to collaborate with and support these local communities and leaders to address their most-pressing issues.
Stories are what connect us and move us forward. We are confident that this virtual Listening Tour will be an opportunity for constituents to tell their own stories and learn from each other, while allowing the CHEST organization, through the CHEST Foundation, to act as the arbiter for pulmonary health and provide a path forward to create equity for those suffering from chronic lung disease.
We need your support to challenge these longstanding disparities in chest medicine. Help us advance these critical conversations and move the needle toward equality by contributing today at chestfoundation.org/donate.
How do we discuss race and lung health issues that impact our most deserving, underserved communities? Continuously and uncomfortably. As the Executive Director of the CHEST Foundation and as a young Black man, I am hopeful that we, as CHEST, can lead these uncomfortable conversations to better our communities. Our ability to listen and deliver support to our most-deserving communities is critical in how we fulfill our mission. CHEST continues to be a leader in lung health because we choose to give a voice and a platform in support of better lung health – especially to those who are disproportionately affected by lung disease, specifically addressing the quality of care they receive and bringing to light the fact that too often these patients are forgotten by the rest of society.
As cases of COVID-19 and civil unrest continue to swell across our nation, we, the CHEST Foundation, have launched a virtual Listening Tour. We are taking this pragmatic, and more importantly, passionate approach to addressing health disparities by identifying and addressing barriers and issues affecting our most deserving and disproportionately underserved communities. By bringing together these communities’ patients and caregivers, local leaders, involved businesses, and our CHEST members in a virtual community gathering, we intend to clearly define the needs of each community, elevate those needs to a national level, and work to collaborate with and support these local communities and leaders to address their most-pressing issues.
Stories are what connect us and move us forward. We are confident that this virtual Listening Tour will be an opportunity for constituents to tell their own stories and learn from each other, while allowing the CHEST organization, through the CHEST Foundation, to act as the arbiter for pulmonary health and provide a path forward to create equity for those suffering from chronic lung disease.
We need your support to challenge these longstanding disparities in chest medicine. Help us advance these critical conversations and move the needle toward equality by contributing today at chestfoundation.org/donate.
This month in the journal CHEST®
Editor’s picks
International perspective on the new 2019 IDSA/ATS CAP guideline: A critical appraisal by a global expert panel. By Dr. Mathias Pletz, et al.
Development of an accurate bedside swallowing evaluation decision tree algorithm for detecting aspiration in acute respiratory failure survivors. By Dr. Marc Moss, et al.
How I Do It: Managing fatigue in patients with interstitial lung disease. By Dr. Marlies Wijsenbeek, et al.
Life-threatening and non-life-threatening complications associated with coughing: A scoping review. By Dr. Richard S. Irwin, MD, Master FCCP, et al.
Obstructive Sleep Apnea in Professional Transport Operations: Safety, Regulatory, and Economic Impact. By Dr. Indira Gurubhagavatula, et al.
Editor’s picks
Editor’s picks
International perspective on the new 2019 IDSA/ATS CAP guideline: A critical appraisal by a global expert panel. By Dr. Mathias Pletz, et al.
Development of an accurate bedside swallowing evaluation decision tree algorithm for detecting aspiration in acute respiratory failure survivors. By Dr. Marc Moss, et al.
How I Do It: Managing fatigue in patients with interstitial lung disease. By Dr. Marlies Wijsenbeek, et al.
Life-threatening and non-life-threatening complications associated with coughing: A scoping review. By Dr. Richard S. Irwin, MD, Master FCCP, et al.
Obstructive Sleep Apnea in Professional Transport Operations: Safety, Regulatory, and Economic Impact. By Dr. Indira Gurubhagavatula, et al.
International perspective on the new 2019 IDSA/ATS CAP guideline: A critical appraisal by a global expert panel. By Dr. Mathias Pletz, et al.
Development of an accurate bedside swallowing evaluation decision tree algorithm for detecting aspiration in acute respiratory failure survivors. By Dr. Marc Moss, et al.
How I Do It: Managing fatigue in patients with interstitial lung disease. By Dr. Marlies Wijsenbeek, et al.
Life-threatening and non-life-threatening complications associated with coughing: A scoping review. By Dr. Richard S. Irwin, MD, Master FCCP, et al.
Obstructive Sleep Apnea in Professional Transport Operations: Safety, Regulatory, and Economic Impact. By Dr. Indira Gurubhagavatula, et al.
CHEST and ATS respond to proposed fee schedule
CHEST and the American Thoracic Society (ATS) submitted joint comments regarding the proposed Medicare Physician Fee Schedule for 2021 to CMS Administrator Seema Verma on topics of direct interest to members. The letter focuses on:
Medicare payment for critical care services: Further to the joint letter from CHEST, ATS, and the Society of Critical Care Medicine to Department of Health and Human Services Secretary Azar (see article in September 2020 Washington Watchline), the concerns related to the proposed 8% reduction in reimbursement for critical care services are explained, particularly relating to the role of critical care providers during the pandemic. They call for waiving budget neutrality or utilizing the public health emergency declaration to ensure appropriate patient care.
E/M payment changes: ATS and CHEST voice support for the proposed changes to evaluation and management (E/M) office visits and the increased reimbursement for the cognitive component of E/M medicine. They urge CMS to use its authority to waive the budget neutrality requirements while implementing the E/M changes.
Adoption of RUC-recommended values for pulmonary services: They urge CMS to finalize values for specific pulmonary services while acknowledging thanks for the adoption of the Relative Value Scale Update Committee (RUC)-recommended physician work values for a range of Current Procedural Terminology codes.
Telehealth services: While commending CMS for actions related to telehealth to provide care during the pandemic, they suggest it is now appropriate to sunset the telehealth listing for critical care services as providers have acquired additional experience in treating COVID-19.
GPC1X descriptors and utilization projections: They urge CMS to clarify the descriptors and seek additional comments on primary and ongoing health-care services.
Watch for reports of ongoing efforts from CHEST as the fee schedule process continues. Details of other activities in support of CHEST members appear in the November issue of Washington Watchline.
Reprinted from the November 2020 issue of Washington Watchline.
CHEST and the American Thoracic Society (ATS) submitted joint comments regarding the proposed Medicare Physician Fee Schedule for 2021 to CMS Administrator Seema Verma on topics of direct interest to members. The letter focuses on:
Medicare payment for critical care services: Further to the joint letter from CHEST, ATS, and the Society of Critical Care Medicine to Department of Health and Human Services Secretary Azar (see article in September 2020 Washington Watchline), the concerns related to the proposed 8% reduction in reimbursement for critical care services are explained, particularly relating to the role of critical care providers during the pandemic. They call for waiving budget neutrality or utilizing the public health emergency declaration to ensure appropriate patient care.
E/M payment changes: ATS and CHEST voice support for the proposed changes to evaluation and management (E/M) office visits and the increased reimbursement for the cognitive component of E/M medicine. They urge CMS to use its authority to waive the budget neutrality requirements while implementing the E/M changes.
Adoption of RUC-recommended values for pulmonary services: They urge CMS to finalize values for specific pulmonary services while acknowledging thanks for the adoption of the Relative Value Scale Update Committee (RUC)-recommended physician work values for a range of Current Procedural Terminology codes.
Telehealth services: While commending CMS for actions related to telehealth to provide care during the pandemic, they suggest it is now appropriate to sunset the telehealth listing for critical care services as providers have acquired additional experience in treating COVID-19.
GPC1X descriptors and utilization projections: They urge CMS to clarify the descriptors and seek additional comments on primary and ongoing health-care services.
Watch for reports of ongoing efforts from CHEST as the fee schedule process continues. Details of other activities in support of CHEST members appear in the November issue of Washington Watchline.
Reprinted from the November 2020 issue of Washington Watchline.
CHEST and the American Thoracic Society (ATS) submitted joint comments regarding the proposed Medicare Physician Fee Schedule for 2021 to CMS Administrator Seema Verma on topics of direct interest to members. The letter focuses on:
Medicare payment for critical care services: Further to the joint letter from CHEST, ATS, and the Society of Critical Care Medicine to Department of Health and Human Services Secretary Azar (see article in September 2020 Washington Watchline), the concerns related to the proposed 8% reduction in reimbursement for critical care services are explained, particularly relating to the role of critical care providers during the pandemic. They call for waiving budget neutrality or utilizing the public health emergency declaration to ensure appropriate patient care.
E/M payment changes: ATS and CHEST voice support for the proposed changes to evaluation and management (E/M) office visits and the increased reimbursement for the cognitive component of E/M medicine. They urge CMS to use its authority to waive the budget neutrality requirements while implementing the E/M changes.
Adoption of RUC-recommended values for pulmonary services: They urge CMS to finalize values for specific pulmonary services while acknowledging thanks for the adoption of the Relative Value Scale Update Committee (RUC)-recommended physician work values for a range of Current Procedural Terminology codes.
Telehealth services: While commending CMS for actions related to telehealth to provide care during the pandemic, they suggest it is now appropriate to sunset the telehealth listing for critical care services as providers have acquired additional experience in treating COVID-19.
GPC1X descriptors and utilization projections: They urge CMS to clarify the descriptors and seek additional comments on primary and ongoing health-care services.
Watch for reports of ongoing efforts from CHEST as the fee schedule process continues. Details of other activities in support of CHEST members appear in the November issue of Washington Watchline.
Reprinted from the November 2020 issue of Washington Watchline.
Be among the first to commit to AGA Giving Day
Our patients face racial health disparities daily, leading to inequalities in care and poorer health outcomes.
At this important moment in history, the AGA Research Foundation is uniquely qualified to push forward innovative research in health disparities in gastroenterology. With donations from AGA members to our new initiative called AGA Giving Day, we can provide researchers with a secure source of funding that helps understand the causes of known health disparities, understand why the disparity exists, and develop interventions to reduce and eliminate health disparities.
The AGA Research Foundation invites you to support AGA Giving Day today through Dec. 3. Contributors will be recognized as supporters of our fight to achieve equity and eradicate disparities in digestive diseases.
Learn more at gastro.org/agagivingday.
[email protected]
Our patients face racial health disparities daily, leading to inequalities in care and poorer health outcomes.
At this important moment in history, the AGA Research Foundation is uniquely qualified to push forward innovative research in health disparities in gastroenterology. With donations from AGA members to our new initiative called AGA Giving Day, we can provide researchers with a secure source of funding that helps understand the causes of known health disparities, understand why the disparity exists, and develop interventions to reduce and eliminate health disparities.
The AGA Research Foundation invites you to support AGA Giving Day today through Dec. 3. Contributors will be recognized as supporters of our fight to achieve equity and eradicate disparities in digestive diseases.
Learn more at gastro.org/agagivingday.
[email protected]
Our patients face racial health disparities daily, leading to inequalities in care and poorer health outcomes.
At this important moment in history, the AGA Research Foundation is uniquely qualified to push forward innovative research in health disparities in gastroenterology. With donations from AGA members to our new initiative called AGA Giving Day, we can provide researchers with a secure source of funding that helps understand the causes of known health disparities, understand why the disparity exists, and develop interventions to reduce and eliminate health disparities.
The AGA Research Foundation invites you to support AGA Giving Day today through Dec. 3. Contributors will be recognized as supporters of our fight to achieve equity and eradicate disparities in digestive diseases.
Learn more at gastro.org/agagivingday.
[email protected]
AGA releases largest real-world report on safety and effectiveness of fecal microbiota transplantation
Ninety percent of patients tracked in the AGA FMT National Registry were cured of Clostridioides difficile infection with few serious side effects.
AGA has released the first results from the NIH-funded AGA Fecal Microbiota Transplantation (FMT) National Registry, the largest real-world study on the safety and effectiveness of FMT. Few serious side effects were reported.
“While the value of fecal microbiota transplantation for treating recurrent C. difficile infection is clear from research studies, the potential long-term consequences of altering a patient’s gut microbiota are not fully known,” says Colleen R. Kelly, MD, AGAF, associate professor of medicine at Brown University in Providence, R.I. and co-principal investigator of the AGA FMT National Registry. “Releasing the initial results of the AGA FMT National Registry is an important step toward understanding the true risks and benefits of microbiota therapeutics in a real-world setting.”
This new report details effectiveness and safety outcomes from the first 259 patients enrolled in the registry between December 2017 and September 2019. Almost all participants received FMT using an unknown donor from stool banks. The most common method of FMT delivery was colonoscopy followed by upper endoscopy. Of the 222 participants who returned for the one-month follow-up, 200 participants (90%) had their C. difficile infection cured with 197 of those requiring only a single FMT. Infections were reported in 11 participants, but only 2 were thought to be possibly related to the procedure. FMT response was deemed durable, with recurrence of C. difficile infection in the 6 months after successful FMT occurring in only 4% of participants. This data includes patients with comorbidities, such as inflammatory bowel disease and immunocompromised status, who are typically excluded from FMT clinical trials.
“These initial results show a high success rate of FMT in the real-world setting. We’ll continue to track these patients for 10 years to assess long-term safety, which will be critical to determining the full safety profile of FMT,” added Dr. Kelly.
Ninety percent of patients tracked in the AGA FMT National Registry were cured of Clostridioides difficile infection with few serious side effects.
AGA has released the first results from the NIH-funded AGA Fecal Microbiota Transplantation (FMT) National Registry, the largest real-world study on the safety and effectiveness of FMT. Few serious side effects were reported.
“While the value of fecal microbiota transplantation for treating recurrent C. difficile infection is clear from research studies, the potential long-term consequences of altering a patient’s gut microbiota are not fully known,” says Colleen R. Kelly, MD, AGAF, associate professor of medicine at Brown University in Providence, R.I. and co-principal investigator of the AGA FMT National Registry. “Releasing the initial results of the AGA FMT National Registry is an important step toward understanding the true risks and benefits of microbiota therapeutics in a real-world setting.”
This new report details effectiveness and safety outcomes from the first 259 patients enrolled in the registry between December 2017 and September 2019. Almost all participants received FMT using an unknown donor from stool banks. The most common method of FMT delivery was colonoscopy followed by upper endoscopy. Of the 222 participants who returned for the one-month follow-up, 200 participants (90%) had their C. difficile infection cured with 197 of those requiring only a single FMT. Infections were reported in 11 participants, but only 2 were thought to be possibly related to the procedure. FMT response was deemed durable, with recurrence of C. difficile infection in the 6 months after successful FMT occurring in only 4% of participants. This data includes patients with comorbidities, such as inflammatory bowel disease and immunocompromised status, who are typically excluded from FMT clinical trials.
“These initial results show a high success rate of FMT in the real-world setting. We’ll continue to track these patients for 10 years to assess long-term safety, which will be critical to determining the full safety profile of FMT,” added Dr. Kelly.
Ninety percent of patients tracked in the AGA FMT National Registry were cured of Clostridioides difficile infection with few serious side effects.
AGA has released the first results from the NIH-funded AGA Fecal Microbiota Transplantation (FMT) National Registry, the largest real-world study on the safety and effectiveness of FMT. Few serious side effects were reported.
“While the value of fecal microbiota transplantation for treating recurrent C. difficile infection is clear from research studies, the potential long-term consequences of altering a patient’s gut microbiota are not fully known,” says Colleen R. Kelly, MD, AGAF, associate professor of medicine at Brown University in Providence, R.I. and co-principal investigator of the AGA FMT National Registry. “Releasing the initial results of the AGA FMT National Registry is an important step toward understanding the true risks and benefits of microbiota therapeutics in a real-world setting.”
This new report details effectiveness and safety outcomes from the first 259 patients enrolled in the registry between December 2017 and September 2019. Almost all participants received FMT using an unknown donor from stool banks. The most common method of FMT delivery was colonoscopy followed by upper endoscopy. Of the 222 participants who returned for the one-month follow-up, 200 participants (90%) had their C. difficile infection cured with 197 of those requiring only a single FMT. Infections were reported in 11 participants, but only 2 were thought to be possibly related to the procedure. FMT response was deemed durable, with recurrence of C. difficile infection in the 6 months after successful FMT occurring in only 4% of participants. This data includes patients with comorbidities, such as inflammatory bowel disease and immunocompromised status, who are typically excluded from FMT clinical trials.
“These initial results show a high success rate of FMT in the real-world setting. We’ll continue to track these patients for 10 years to assess long-term safety, which will be critical to determining the full safety profile of FMT,” added Dr. Kelly.
Engage rather than react: A call for hepatologists
In a new practice management commentary, Dr. Meena B. Bansal challenges hepatologists to champion value-based care.
In the September issue of Clinical Gastroenterology and Hepatology, Meena B. Bansal, MD, FAASLD, from Icahn School of Medicine at Mount Sinai, New York, provides clinicians with practical guidance on their essential role in value-based health care. Read the article, which appears in CGH’s Practice Management: The Road Ahead column: How Hepatologists Can Contribute to Value-Based Care.
Since hepatologists care for some of the sickest patients in the system, their role in documenting and managing chronic conditions is paramount to a system’s success in value-based care. Hepatologists can expand their reach by:
- Advocating for improvement of coding specificity.
- Participating in quality improvement work.
- Supporting efforts to create a shift in the cost curve for their high-risk patients.
By highlighting how they can shift the cost curve while improving outcomes, they can advocate for the additional resources needed to care for this high-risk population and can have the opportunity to show the return on investment. With this outlook, hepatologists who “engage” rather than “react” can make a real impact on system leadership and play a key role in this dynamic health care landscape.
Read the full article in the September issue of Clinical Gastroenterology and Hepatology.
In a new practice management commentary, Dr. Meena B. Bansal challenges hepatologists to champion value-based care.
In the September issue of Clinical Gastroenterology and Hepatology, Meena B. Bansal, MD, FAASLD, from Icahn School of Medicine at Mount Sinai, New York, provides clinicians with practical guidance on their essential role in value-based health care. Read the article, which appears in CGH’s Practice Management: The Road Ahead column: How Hepatologists Can Contribute to Value-Based Care.
Since hepatologists care for some of the sickest patients in the system, their role in documenting and managing chronic conditions is paramount to a system’s success in value-based care. Hepatologists can expand their reach by:
- Advocating for improvement of coding specificity.
- Participating in quality improvement work.
- Supporting efforts to create a shift in the cost curve for their high-risk patients.
By highlighting how they can shift the cost curve while improving outcomes, they can advocate for the additional resources needed to care for this high-risk population and can have the opportunity to show the return on investment. With this outlook, hepatologists who “engage” rather than “react” can make a real impact on system leadership and play a key role in this dynamic health care landscape.
Read the full article in the September issue of Clinical Gastroenterology and Hepatology.
In a new practice management commentary, Dr. Meena B. Bansal challenges hepatologists to champion value-based care.
In the September issue of Clinical Gastroenterology and Hepatology, Meena B. Bansal, MD, FAASLD, from Icahn School of Medicine at Mount Sinai, New York, provides clinicians with practical guidance on their essential role in value-based health care. Read the article, which appears in CGH’s Practice Management: The Road Ahead column: How Hepatologists Can Contribute to Value-Based Care.
Since hepatologists care for some of the sickest patients in the system, their role in documenting and managing chronic conditions is paramount to a system’s success in value-based care. Hepatologists can expand their reach by:
- Advocating for improvement of coding specificity.
- Participating in quality improvement work.
- Supporting efforts to create a shift in the cost curve for their high-risk patients.
By highlighting how they can shift the cost curve while improving outcomes, they can advocate for the additional resources needed to care for this high-risk population and can have the opportunity to show the return on investment. With this outlook, hepatologists who “engage” rather than “react” can make a real impact on system leadership and play a key role in this dynamic health care landscape.
Read the full article in the September issue of Clinical Gastroenterology and Hepatology.
President’s final report
As I am writing my final presidential report, my presidential year is coming to a close. It was certainly not what I could have anticipated, but an incredible opportunity for my personal and professional growth, and a year in which CHEST adapted and grew, as well. We accomplished a great deal during this unprecedented year, and I will take this opportunity for a year-in-review!
In the winter, As COVID-19 appeared across the globe, we established a COVID-19 Task Force led by then incoming President, Dr. Steve Simpson, with the goal of keeping our members updated on the latest research and clinical management of COVID-19 illness, as well as distilling and delivering the latest COVID-19 related information quickly to those on the front lines. We have held weekly COVID-19 webinars, disseminated infographics, and developed an interactive COVID-19 quiz. CHEST also published several COVID-19-related guideline statements and expert panel reports on bronchoscopy, tracheostomy, lung nodule management, and venous thromboembolism in the setting of COVID-19.
Knowing the stress that our health-care workers were under, we also established a CHEST Wellness Center. This longitudinal, webinar-based curriculum, led by Dr. Alex Niven, had its impetus with COVID-19 but will continue and be extended to general wellness topics.
In March, we joined forces with NAMDRC, under the CHEST umbrella and a combination of our board members and their former board members now make up our Health Policy and Advocacy Committee (HPAC), led by Drs. Neil Freedman and Jim Lamberti, with CHEST Past-President, Dr. John Studdard, also actively involved. Our HPAC is already focusing on home ventilation and competitive bidding, oxygen prescribing, education and access, pulmonary rehabilitation, and tobacco and vaping. The monthly Washington Watchline online publication features the latest on advocacy-related issues of interest to our membership. Last month, the HPAC held a multiorganizational technical expert panel meeting on nocturnal noninvasive ventilation, with plans to submit a manuscript on outcomes from the meeting to the journal CHEST®. These activities are an answer to our member’s requests and needs in the areas of advocacy.
With the onset of the pandemic, we pivoted the delivery of our signature education to virtual platforms beginning with a successful global congress in Bologna in June with 3,500 registered attendees. This was a wonderful way to provide education to our global audience. I want to thank co-chairs Dr. Bill Kelly and Dr. Girolamo Pelaia, and Dr. Francesco de Blasio from our Italian Delegation for their innovative leadership. In August, we held our first virtual Board Review Courses in Pulmonary Medicine, Critical Care Medicine, and Pediatric Pulmonary Medicine, attended by 775 registered attendees complete with didactic sessions, audience response sessions, SEEK sessions and live Q&A with the faculty. The on-demand versions of these courses are also available.
The CHEST® journal, in its second year with Dr. Peter Mazzone at the helm, continues to be a leading source of clinically relevant research and patient management guidance for pulmonary, critical care, and sleep medicine clinicians worldwide. The year 2020 has been a year like no other -- submission rates have doubled since the start of the pandemic, with nearly 5,000 manuscript submissions so far, this year. The journal has rapidly built a robust and growing COVID-19 topic collection, with relevant original research, guidelines, commentaries, and more, published online, within days of acceptance. The journal will continue to seek innovative ways to meet the needs of its readers and contributors during this time when our members and their patients urgently need current and high-quality information.
This year, CHEST hit a publishing milestone, with the publication of SEEK Critical Care 30, and the SEEK program is celebrating 30 years! Those who registered for CHEST 2020 by October 15 received the announcement regarding the commemorative “30 years of SEEK” collection.
Our Guidelines Oversight Committee has continued to publish evidence-based guidelines in the areas of cough and cryobiopsy, with a guideline on hypersensitivity pneumonitis and updated guidelines in our core topics of lung cancer and venous thromboembolism in the works.
Under the leadership of Dr. Aneesa Das, the NetWorks Task Force started work to accomplish the goal of increasing member engagement and reach by developing pilot projects focusing on infographics interviews with key opinion leaders and social media communications. Additionally, the Digital Strategy Task Force launched a redesigned website for the Foundation, which you can see at chestfoundation.org, and look for exciting changes coming to the CHEST website in the very near future.
We have continued our collaborative partnerships with our sister societies. We established the volunteer clinician matching program with the American Thoracic Society (ATS) to send clinicians to areas of need during the pandemic, and partnered on other COVID-19 related activities. We held a virtual fellow’s graduation with ATS and the Association of Pulmonary and Critical Care Medicine Program Directors. CHEST leadership attended the Asian Pacific Respiratory Society in Vietnam in November, the Society of Critical Care Medicine, and Forum of International Respiratory Societies in February and the recent virtual meetings of ATS, European Respiratory Society, and the Brazilian Thoracic Society.
The CHEST Foundation has continued on their mission to champion lung health and make a difference through their successful fundraising. This was highlighted with a tremendous foundation gala in San Antonio in December, The Golden Era of Erin Popovich, attended by more than 500 people. Since COVID-19, the Foundation held several creative virtual fundraising events ranging from wine tastings to poker night to bingo night to a recent trivia night, as well as actively participating in COVID-19-related campaigns, such as the partnership with ATS for COVID-19 public service announcements directed to those affected by COVID-19, and other fundraising campaigns, such as the Buy-a-Mask Give-a-Mask campaign. In addition, the Foundation has continued with their support for clinical research grants, community service grants, and patient education resources and toolkits. For example, they have developed an oxygen tool kit to provide access and empowerment to patients in need.
Thank you to all our donors for continuing to support these CHEST Foundation initiatives. The Foundation couldn’t continue to do this amazing work to create an impact and raise awareness for lung health without you.
As the movement to combat racism and racial disparity swept across our nation, we issued a statement of equity in early June. In September, the CHEST Foundation launched the first of a series of Listening Tours to hear from community needs in the areas of trust, access, and equity. Information from these tours will be used to launch a designated fund to have the power to transform these needs into action. CHEST is now actively developing a strategic plan focusing on how CHEST can make an impactful difference in this arena. We want to ensure we take this essential time to listen, reflect, and make appropriate plans for ways we can truly make a difference. Expect more to come on this in the coming year.
The year concluded with CHEST 2020. CHEST 2020 had the highest number of case reports and abstracts ever submitted to a CHEST Annual meeting, and a total registration of more than 4,000. At CHEST 2020, you had an opportunity to see a reimagined virtual annual meeting with combinations of interactive live and prerecorded didactic sessions, audience response sessions, live Q&A with the faculty, educational games at the CHEST Gaming Hub, CHEST Challenge Championship, networking opportunities, narrated abstracts, case reports, original research presentations, COVID-19 update sessions, industry-sponsored programs, a virtual exhibit hall, and surprises, to deliver the in–person CHEST experience virtually. In addition, this came with the greatest number of CME/MOC credits we have ever offered! And, CHEST 2020 education will continue throughout the year with ongoing postgraduate courses creating the ultimate longitudinal educational experience. While nothing can replace the opportunity to connect with our community in person, I hope you found that this year’s meeting provided a wealth of learning, connection, and fun.
My sincere thanks to the CHEST 2020 Program Chair, Dr. Victor Test, to the entire Scientific Program Committee, and to our incredible CHEST staff, for the immense amount of hard work over the past year to reimagine CHEST 2020 and make it a reality. Little did Victor know that he would be planning three meetings, a live meeting, a hybrid meeting, and, ultimately, a virtual meeting. Thank you for all you did to make CHEST 2020 a meeting to remember. We plan to continue our efforts to maintain and grow educational innovation year-round through more e-learning, virtual learning, and, hopefully soon, live learning, both locally, nationally, and internationally.
As my year closes, you are in excellent hands with Dr. Steven Simpson, your 83rd President, who will lead the organization forward. You will hear more from him, but you are in the hands of a thoughtful and dedicated leader with a long history of CHEST experience, strong expertise in critical care, and a thought leader in the COVID-19 pandemic, including serving on the NIH COVID-19 Treatment Guidelines Panel.
There are so many people to thank! I want to thank my family, my husband and children, and my work family, the faculty and fellows of my division, for their unwavering support. I also want to thank my Co-President lineage group for their counsel and wisdom, several Past Presidents who I have called on over this past year for advice, Drs. John Studdard, Gerard Silvestri, and Darcy Marciniuk among others, the Board (who I only saw face-to-face once!), our CHEST leadership and educators, and the incredible CHEST staff, the Executive Leadership Team, and our superb, hard-working CEO/EVP Bob Musacchio. Last, and most importantly, I would like to thank our members for being in the trenches this year as we all dealt with COVID-19. You are the heroes! At the beginning of my term last year, I told you that my goal was to be “the welcoming home” for interprofessional health-care team members seeking to obtain the best possible educational experiences and patient outcomes. I had no idea how absolutely needed this would be for our chest medicine family this year. CHEST has always been your connection to relevant clinical information and late-breaking updates in our field – but this year, our CHEST community has been even more than that. Through this year of crisis and change, you all have shown resilience; a resilience molded by being flexible. Not only have you embodied flexibility at your home institutions, you’ve embodied flexibility in your learning, teaching, and connecting. You’ve joined us as we’ve reimagined what learning at CHEST is all about – I sincerely thank you for that!
As I am writing my final presidential report, my presidential year is coming to a close. It was certainly not what I could have anticipated, but an incredible opportunity for my personal and professional growth, and a year in which CHEST adapted and grew, as well. We accomplished a great deal during this unprecedented year, and I will take this opportunity for a year-in-review!
In the winter, As COVID-19 appeared across the globe, we established a COVID-19 Task Force led by then incoming President, Dr. Steve Simpson, with the goal of keeping our members updated on the latest research and clinical management of COVID-19 illness, as well as distilling and delivering the latest COVID-19 related information quickly to those on the front lines. We have held weekly COVID-19 webinars, disseminated infographics, and developed an interactive COVID-19 quiz. CHEST also published several COVID-19-related guideline statements and expert panel reports on bronchoscopy, tracheostomy, lung nodule management, and venous thromboembolism in the setting of COVID-19.
Knowing the stress that our health-care workers were under, we also established a CHEST Wellness Center. This longitudinal, webinar-based curriculum, led by Dr. Alex Niven, had its impetus with COVID-19 but will continue and be extended to general wellness topics.
In March, we joined forces with NAMDRC, under the CHEST umbrella and a combination of our board members and their former board members now make up our Health Policy and Advocacy Committee (HPAC), led by Drs. Neil Freedman and Jim Lamberti, with CHEST Past-President, Dr. John Studdard, also actively involved. Our HPAC is already focusing on home ventilation and competitive bidding, oxygen prescribing, education and access, pulmonary rehabilitation, and tobacco and vaping. The monthly Washington Watchline online publication features the latest on advocacy-related issues of interest to our membership. Last month, the HPAC held a multiorganizational technical expert panel meeting on nocturnal noninvasive ventilation, with plans to submit a manuscript on outcomes from the meeting to the journal CHEST®. These activities are an answer to our member’s requests and needs in the areas of advocacy.
With the onset of the pandemic, we pivoted the delivery of our signature education to virtual platforms beginning with a successful global congress in Bologna in June with 3,500 registered attendees. This was a wonderful way to provide education to our global audience. I want to thank co-chairs Dr. Bill Kelly and Dr. Girolamo Pelaia, and Dr. Francesco de Blasio from our Italian Delegation for their innovative leadership. In August, we held our first virtual Board Review Courses in Pulmonary Medicine, Critical Care Medicine, and Pediatric Pulmonary Medicine, attended by 775 registered attendees complete with didactic sessions, audience response sessions, SEEK sessions and live Q&A with the faculty. The on-demand versions of these courses are also available.
The CHEST® journal, in its second year with Dr. Peter Mazzone at the helm, continues to be a leading source of clinically relevant research and patient management guidance for pulmonary, critical care, and sleep medicine clinicians worldwide. The year 2020 has been a year like no other -- submission rates have doubled since the start of the pandemic, with nearly 5,000 manuscript submissions so far, this year. The journal has rapidly built a robust and growing COVID-19 topic collection, with relevant original research, guidelines, commentaries, and more, published online, within days of acceptance. The journal will continue to seek innovative ways to meet the needs of its readers and contributors during this time when our members and their patients urgently need current and high-quality information.
This year, CHEST hit a publishing milestone, with the publication of SEEK Critical Care 30, and the SEEK program is celebrating 30 years! Those who registered for CHEST 2020 by October 15 received the announcement regarding the commemorative “30 years of SEEK” collection.
Our Guidelines Oversight Committee has continued to publish evidence-based guidelines in the areas of cough and cryobiopsy, with a guideline on hypersensitivity pneumonitis and updated guidelines in our core topics of lung cancer and venous thromboembolism in the works.
Under the leadership of Dr. Aneesa Das, the NetWorks Task Force started work to accomplish the goal of increasing member engagement and reach by developing pilot projects focusing on infographics interviews with key opinion leaders and social media communications. Additionally, the Digital Strategy Task Force launched a redesigned website for the Foundation, which you can see at chestfoundation.org, and look for exciting changes coming to the CHEST website in the very near future.
We have continued our collaborative partnerships with our sister societies. We established the volunteer clinician matching program with the American Thoracic Society (ATS) to send clinicians to areas of need during the pandemic, and partnered on other COVID-19 related activities. We held a virtual fellow’s graduation with ATS and the Association of Pulmonary and Critical Care Medicine Program Directors. CHEST leadership attended the Asian Pacific Respiratory Society in Vietnam in November, the Society of Critical Care Medicine, and Forum of International Respiratory Societies in February and the recent virtual meetings of ATS, European Respiratory Society, and the Brazilian Thoracic Society.
The CHEST Foundation has continued on their mission to champion lung health and make a difference through their successful fundraising. This was highlighted with a tremendous foundation gala in San Antonio in December, The Golden Era of Erin Popovich, attended by more than 500 people. Since COVID-19, the Foundation held several creative virtual fundraising events ranging from wine tastings to poker night to bingo night to a recent trivia night, as well as actively participating in COVID-19-related campaigns, such as the partnership with ATS for COVID-19 public service announcements directed to those affected by COVID-19, and other fundraising campaigns, such as the Buy-a-Mask Give-a-Mask campaign. In addition, the Foundation has continued with their support for clinical research grants, community service grants, and patient education resources and toolkits. For example, they have developed an oxygen tool kit to provide access and empowerment to patients in need.
Thank you to all our donors for continuing to support these CHEST Foundation initiatives. The Foundation couldn’t continue to do this amazing work to create an impact and raise awareness for lung health without you.
As the movement to combat racism and racial disparity swept across our nation, we issued a statement of equity in early June. In September, the CHEST Foundation launched the first of a series of Listening Tours to hear from community needs in the areas of trust, access, and equity. Information from these tours will be used to launch a designated fund to have the power to transform these needs into action. CHEST is now actively developing a strategic plan focusing on how CHEST can make an impactful difference in this arena. We want to ensure we take this essential time to listen, reflect, and make appropriate plans for ways we can truly make a difference. Expect more to come on this in the coming year.
The year concluded with CHEST 2020. CHEST 2020 had the highest number of case reports and abstracts ever submitted to a CHEST Annual meeting, and a total registration of more than 4,000. At CHEST 2020, you had an opportunity to see a reimagined virtual annual meeting with combinations of interactive live and prerecorded didactic sessions, audience response sessions, live Q&A with the faculty, educational games at the CHEST Gaming Hub, CHEST Challenge Championship, networking opportunities, narrated abstracts, case reports, original research presentations, COVID-19 update sessions, industry-sponsored programs, a virtual exhibit hall, and surprises, to deliver the in–person CHEST experience virtually. In addition, this came with the greatest number of CME/MOC credits we have ever offered! And, CHEST 2020 education will continue throughout the year with ongoing postgraduate courses creating the ultimate longitudinal educational experience. While nothing can replace the opportunity to connect with our community in person, I hope you found that this year’s meeting provided a wealth of learning, connection, and fun.
My sincere thanks to the CHEST 2020 Program Chair, Dr. Victor Test, to the entire Scientific Program Committee, and to our incredible CHEST staff, for the immense amount of hard work over the past year to reimagine CHEST 2020 and make it a reality. Little did Victor know that he would be planning three meetings, a live meeting, a hybrid meeting, and, ultimately, a virtual meeting. Thank you for all you did to make CHEST 2020 a meeting to remember. We plan to continue our efforts to maintain and grow educational innovation year-round through more e-learning, virtual learning, and, hopefully soon, live learning, both locally, nationally, and internationally.
As my year closes, you are in excellent hands with Dr. Steven Simpson, your 83rd President, who will lead the organization forward. You will hear more from him, but you are in the hands of a thoughtful and dedicated leader with a long history of CHEST experience, strong expertise in critical care, and a thought leader in the COVID-19 pandemic, including serving on the NIH COVID-19 Treatment Guidelines Panel.
There are so many people to thank! I want to thank my family, my husband and children, and my work family, the faculty and fellows of my division, for their unwavering support. I also want to thank my Co-President lineage group for their counsel and wisdom, several Past Presidents who I have called on over this past year for advice, Drs. John Studdard, Gerard Silvestri, and Darcy Marciniuk among others, the Board (who I only saw face-to-face once!), our CHEST leadership and educators, and the incredible CHEST staff, the Executive Leadership Team, and our superb, hard-working CEO/EVP Bob Musacchio. Last, and most importantly, I would like to thank our members for being in the trenches this year as we all dealt with COVID-19. You are the heroes! At the beginning of my term last year, I told you that my goal was to be “the welcoming home” for interprofessional health-care team members seeking to obtain the best possible educational experiences and patient outcomes. I had no idea how absolutely needed this would be for our chest medicine family this year. CHEST has always been your connection to relevant clinical information and late-breaking updates in our field – but this year, our CHEST community has been even more than that. Through this year of crisis and change, you all have shown resilience; a resilience molded by being flexible. Not only have you embodied flexibility at your home institutions, you’ve embodied flexibility in your learning, teaching, and connecting. You’ve joined us as we’ve reimagined what learning at CHEST is all about – I sincerely thank you for that!
As I am writing my final presidential report, my presidential year is coming to a close. It was certainly not what I could have anticipated, but an incredible opportunity for my personal and professional growth, and a year in which CHEST adapted and grew, as well. We accomplished a great deal during this unprecedented year, and I will take this opportunity for a year-in-review!
In the winter, As COVID-19 appeared across the globe, we established a COVID-19 Task Force led by then incoming President, Dr. Steve Simpson, with the goal of keeping our members updated on the latest research and clinical management of COVID-19 illness, as well as distilling and delivering the latest COVID-19 related information quickly to those on the front lines. We have held weekly COVID-19 webinars, disseminated infographics, and developed an interactive COVID-19 quiz. CHEST also published several COVID-19-related guideline statements and expert panel reports on bronchoscopy, tracheostomy, lung nodule management, and venous thromboembolism in the setting of COVID-19.
Knowing the stress that our health-care workers were under, we also established a CHEST Wellness Center. This longitudinal, webinar-based curriculum, led by Dr. Alex Niven, had its impetus with COVID-19 but will continue and be extended to general wellness topics.
In March, we joined forces with NAMDRC, under the CHEST umbrella and a combination of our board members and their former board members now make up our Health Policy and Advocacy Committee (HPAC), led by Drs. Neil Freedman and Jim Lamberti, with CHEST Past-President, Dr. John Studdard, also actively involved. Our HPAC is already focusing on home ventilation and competitive bidding, oxygen prescribing, education and access, pulmonary rehabilitation, and tobacco and vaping. The monthly Washington Watchline online publication features the latest on advocacy-related issues of interest to our membership. Last month, the HPAC held a multiorganizational technical expert panel meeting on nocturnal noninvasive ventilation, with plans to submit a manuscript on outcomes from the meeting to the journal CHEST®. These activities are an answer to our member’s requests and needs in the areas of advocacy.
With the onset of the pandemic, we pivoted the delivery of our signature education to virtual platforms beginning with a successful global congress in Bologna in June with 3,500 registered attendees. This was a wonderful way to provide education to our global audience. I want to thank co-chairs Dr. Bill Kelly and Dr. Girolamo Pelaia, and Dr. Francesco de Blasio from our Italian Delegation for their innovative leadership. In August, we held our first virtual Board Review Courses in Pulmonary Medicine, Critical Care Medicine, and Pediatric Pulmonary Medicine, attended by 775 registered attendees complete with didactic sessions, audience response sessions, SEEK sessions and live Q&A with the faculty. The on-demand versions of these courses are also available.
The CHEST® journal, in its second year with Dr. Peter Mazzone at the helm, continues to be a leading source of clinically relevant research and patient management guidance for pulmonary, critical care, and sleep medicine clinicians worldwide. The year 2020 has been a year like no other -- submission rates have doubled since the start of the pandemic, with nearly 5,000 manuscript submissions so far, this year. The journal has rapidly built a robust and growing COVID-19 topic collection, with relevant original research, guidelines, commentaries, and more, published online, within days of acceptance. The journal will continue to seek innovative ways to meet the needs of its readers and contributors during this time when our members and their patients urgently need current and high-quality information.
This year, CHEST hit a publishing milestone, with the publication of SEEK Critical Care 30, and the SEEK program is celebrating 30 years! Those who registered for CHEST 2020 by October 15 received the announcement regarding the commemorative “30 years of SEEK” collection.
Our Guidelines Oversight Committee has continued to publish evidence-based guidelines in the areas of cough and cryobiopsy, with a guideline on hypersensitivity pneumonitis and updated guidelines in our core topics of lung cancer and venous thromboembolism in the works.
Under the leadership of Dr. Aneesa Das, the NetWorks Task Force started work to accomplish the goal of increasing member engagement and reach by developing pilot projects focusing on infographics interviews with key opinion leaders and social media communications. Additionally, the Digital Strategy Task Force launched a redesigned website for the Foundation, which you can see at chestfoundation.org, and look for exciting changes coming to the CHEST website in the very near future.
We have continued our collaborative partnerships with our sister societies. We established the volunteer clinician matching program with the American Thoracic Society (ATS) to send clinicians to areas of need during the pandemic, and partnered on other COVID-19 related activities. We held a virtual fellow’s graduation with ATS and the Association of Pulmonary and Critical Care Medicine Program Directors. CHEST leadership attended the Asian Pacific Respiratory Society in Vietnam in November, the Society of Critical Care Medicine, and Forum of International Respiratory Societies in February and the recent virtual meetings of ATS, European Respiratory Society, and the Brazilian Thoracic Society.
The CHEST Foundation has continued on their mission to champion lung health and make a difference through their successful fundraising. This was highlighted with a tremendous foundation gala in San Antonio in December, The Golden Era of Erin Popovich, attended by more than 500 people. Since COVID-19, the Foundation held several creative virtual fundraising events ranging from wine tastings to poker night to bingo night to a recent trivia night, as well as actively participating in COVID-19-related campaigns, such as the partnership with ATS for COVID-19 public service announcements directed to those affected by COVID-19, and other fundraising campaigns, such as the Buy-a-Mask Give-a-Mask campaign. In addition, the Foundation has continued with their support for clinical research grants, community service grants, and patient education resources and toolkits. For example, they have developed an oxygen tool kit to provide access and empowerment to patients in need.
Thank you to all our donors for continuing to support these CHEST Foundation initiatives. The Foundation couldn’t continue to do this amazing work to create an impact and raise awareness for lung health without you.
As the movement to combat racism and racial disparity swept across our nation, we issued a statement of equity in early June. In September, the CHEST Foundation launched the first of a series of Listening Tours to hear from community needs in the areas of trust, access, and equity. Information from these tours will be used to launch a designated fund to have the power to transform these needs into action. CHEST is now actively developing a strategic plan focusing on how CHEST can make an impactful difference in this arena. We want to ensure we take this essential time to listen, reflect, and make appropriate plans for ways we can truly make a difference. Expect more to come on this in the coming year.
The year concluded with CHEST 2020. CHEST 2020 had the highest number of case reports and abstracts ever submitted to a CHEST Annual meeting, and a total registration of more than 4,000. At CHEST 2020, you had an opportunity to see a reimagined virtual annual meeting with combinations of interactive live and prerecorded didactic sessions, audience response sessions, live Q&A with the faculty, educational games at the CHEST Gaming Hub, CHEST Challenge Championship, networking opportunities, narrated abstracts, case reports, original research presentations, COVID-19 update sessions, industry-sponsored programs, a virtual exhibit hall, and surprises, to deliver the in–person CHEST experience virtually. In addition, this came with the greatest number of CME/MOC credits we have ever offered! And, CHEST 2020 education will continue throughout the year with ongoing postgraduate courses creating the ultimate longitudinal educational experience. While nothing can replace the opportunity to connect with our community in person, I hope you found that this year’s meeting provided a wealth of learning, connection, and fun.
My sincere thanks to the CHEST 2020 Program Chair, Dr. Victor Test, to the entire Scientific Program Committee, and to our incredible CHEST staff, for the immense amount of hard work over the past year to reimagine CHEST 2020 and make it a reality. Little did Victor know that he would be planning three meetings, a live meeting, a hybrid meeting, and, ultimately, a virtual meeting. Thank you for all you did to make CHEST 2020 a meeting to remember. We plan to continue our efforts to maintain and grow educational innovation year-round through more e-learning, virtual learning, and, hopefully soon, live learning, both locally, nationally, and internationally.
As my year closes, you are in excellent hands with Dr. Steven Simpson, your 83rd President, who will lead the organization forward. You will hear more from him, but you are in the hands of a thoughtful and dedicated leader with a long history of CHEST experience, strong expertise in critical care, and a thought leader in the COVID-19 pandemic, including serving on the NIH COVID-19 Treatment Guidelines Panel.
There are so many people to thank! I want to thank my family, my husband and children, and my work family, the faculty and fellows of my division, for their unwavering support. I also want to thank my Co-President lineage group for their counsel and wisdom, several Past Presidents who I have called on over this past year for advice, Drs. John Studdard, Gerard Silvestri, and Darcy Marciniuk among others, the Board (who I only saw face-to-face once!), our CHEST leadership and educators, and the incredible CHEST staff, the Executive Leadership Team, and our superb, hard-working CEO/EVP Bob Musacchio. Last, and most importantly, I would like to thank our members for being in the trenches this year as we all dealt with COVID-19. You are the heroes! At the beginning of my term last year, I told you that my goal was to be “the welcoming home” for interprofessional health-care team members seeking to obtain the best possible educational experiences and patient outcomes. I had no idea how absolutely needed this would be for our chest medicine family this year. CHEST has always been your connection to relevant clinical information and late-breaking updates in our field – but this year, our CHEST community has been even more than that. Through this year of crisis and change, you all have shown resilience; a resilience molded by being flexible. Not only have you embodied flexibility at your home institutions, you’ve embodied flexibility in your learning, teaching, and connecting. You’ve joined us as we’ve reimagined what learning at CHEST is all about – I sincerely thank you for that!
Top AGA Community patient cases
Physicians with difficult patient scenarios regularly bring their questions to the AGA Community (https://community.gastro.org) to seek advice from colleagues about therapy and disease management options, best practices, and diagnoses. The upgraded networking platform now features a newsfeed for difficult patient scenarios and regularly scheduled Roundtable discussions with experts in the field.
In case you missed it, here are some clinical discussions and Roundtables in the newsfeed this month:
- Initial results from the FMT National Registry (https://community.gastro.org/posts/22693)
- Practice update: Reducing rates of post endoscopy esophageal adenocarcinoma (https://community.gastro.org/posts/22805)
- Patient case: Eosinophilic gastrointestinal disease (https://community.gastro.org/posts/22743)
- Patient case: Repeat colonoscopy following splenic injury (https://community.gastro.org/posts/22739)
- Windows on Clinical GI Roundtables: Crohn’s disease and gastroparesis
View upcoming Roundtables in the community at https://community.gastro.org/discussions.
Physicians with difficult patient scenarios regularly bring their questions to the AGA Community (https://community.gastro.org) to seek advice from colleagues about therapy and disease management options, best practices, and diagnoses. The upgraded networking platform now features a newsfeed for difficult patient scenarios and regularly scheduled Roundtable discussions with experts in the field.
In case you missed it, here are some clinical discussions and Roundtables in the newsfeed this month:
- Initial results from the FMT National Registry (https://community.gastro.org/posts/22693)
- Practice update: Reducing rates of post endoscopy esophageal adenocarcinoma (https://community.gastro.org/posts/22805)
- Patient case: Eosinophilic gastrointestinal disease (https://community.gastro.org/posts/22743)
- Patient case: Repeat colonoscopy following splenic injury (https://community.gastro.org/posts/22739)
- Windows on Clinical GI Roundtables: Crohn’s disease and gastroparesis
View upcoming Roundtables in the community at https://community.gastro.org/discussions.
Physicians with difficult patient scenarios regularly bring their questions to the AGA Community (https://community.gastro.org) to seek advice from colleagues about therapy and disease management options, best practices, and diagnoses. The upgraded networking platform now features a newsfeed for difficult patient scenarios and regularly scheduled Roundtable discussions with experts in the field.
In case you missed it, here are some clinical discussions and Roundtables in the newsfeed this month:
- Initial results from the FMT National Registry (https://community.gastro.org/posts/22693)
- Practice update: Reducing rates of post endoscopy esophageal adenocarcinoma (https://community.gastro.org/posts/22805)
- Patient case: Eosinophilic gastrointestinal disease (https://community.gastro.org/posts/22743)
- Patient case: Repeat colonoscopy following splenic injury (https://community.gastro.org/posts/22739)
- Windows on Clinical GI Roundtables: Crohn’s disease and gastroparesis
View upcoming Roundtables in the community at https://community.gastro.org/discussions.
Patients with non-advanced LC. Boxed warning for montelukast. The happy hypoxic. COVID-19 and pulmonary vasculature.
Interventional chest and diagnostic procedures
Impact of COVID-19 pandemic in patients with non-advanced LC
The COVID-19 pandemic has challenged the way we screen for, diagnose, and treat lung cancer.1, 2 Knowing that these patients are at higher risk of respiratory failure, and that COVID-19 causes poor outcomes in cancer patients,1,3,4 valid concerns regarding viral transmission to patients and health-care workers have hampered the expedited care this population needs.
In recent months, efforts to manage the pandemic have been herculean. With the goal of limiting transmission, expert panels have offered guidance including limiting access to medical facilities, decreasing aerosolizing procedures, and prioritizing curative treatments.2,5 In general, lung cancer screening should be delayed, and patients with highly suspicious localized pulmonary lesions could receive empiric regimens, surgery, or stereotactic radiotherapy.1,3-5
The conundrum occurs when diagnostic bronchoscopy is required for staging, acquiring tissue for targeted therapy, or a moderate-risk pulmonary nodule with indeterminate PET-CT and/or high-risk for CT-guided biopsy. Thoughtful balancing of risks and benefits depends on patient comorbidities, hospital resources – such preprocedural COVID screening, adequate protective personal equipment- and rate of local viral prevalence.6,7 Delaying diagnosis and staging could lead to progression of cancer and preclude curative or adjuvant therapy for appropriate candidates. Furthermore, we should not dismiss the appalling psychological impact of delayed care on our patients.
While the pandemic continues and challenges arise in the care of patients with lung cancer, the value of a multidisciplinary input and individualized care cannot be overstated, with focus on providing the best care possible while both minimizing transmission and increasing the chances of acceptable outcomes.
Jose De Cardenas MD, FCCP – Steering Committee Member
Abdul Hamid Alraiyes MD, FCCP – Steering Committee Member
References
1. Mazzone PJ, et al. Chest. 2020;158(1):406-415. doi: 10.1016/j.chest.2020.04.020.
2. Banna G, et al. ESMO Open. 2020;5(2):e000765. doi: 10.1136/esmoopen-2020-000765.
3. Liang W, et al. Lancet Oncol. 2020;21(3):335-337. doi: 10.1016/S1470-2045(20)30096-6.
4. Singh AP, et al. JCO Oncol Pract. 2020 May 26;OP2000286. doi: 10.1200/OP.20.00286.
5. Dingemans AC, et al. J Thorac Oncol. 2020;15(7):1119-1136. doi: 10.1016/j.jtho.2020.05.001.
6. Wahidi MM, et al. J Bronchology Interv Pulmonol. 2020 Mar 18. doi: 10.1097/LBR.0000000000000681.
7. Pritchett MA, et al. J Thorac Dis. 2020;12(5):1781-1798. doi: 10.21037/jtd.2020.04.32.
Pediatric chest medicine
FDA strengthens the boxed warning for montelukast
Early this year the Food and Drug Administration (FDA) updated the boxed warning for montelukast (Singulair), related to the potential for serious mental health side effects, such as agitation, aggressive behavior, depression, hallucinations, and suicidal thoughts and actions. Since its approval in 1998, montelukast is part of the therapeutic approach for persistent asthma in children age 1 year and older, allergic rhinitis from 6 months and older, and exercises induced bronchospasm in children age 6 years and older. In 2018, around 2.3 million children younger than 17 years received a prescription for montelukast.
The FDA reviewed data from their Sentinel System comparing children receiving montelukast vs inhaled corticosteroids, and this study failed to demonstrate significant increased risk of hospitalized depressive disorders, outpatient depressive disorders, self-harm, or suicide. However, a focused evaluation by the FDA of suicides identified 82 cases of completed suicides associated with montelukast, and 19 of these cases were in children younger than 17 years of age.
Post-marketing case reports submitted to the FDA, published observational and animal studies were evaluated along with the Sentinel System study that led to the new recommendations.
Finally, on March 4, 2020, the FDA updated the Singulair®/montelukast black box warning, focusing on the importance of advising patients and caregivers about the potential for serious neuropsychiatric side effects and advice to immediately discontinue use if symptoms occurred. The warning contains a strong recommendation to reserve use of Singulair®/montelukast to patients with allergic rhinitis who have an inadequate response or intolerance to alternate therapies.
Endy Dominguez Silveyra, MD - Fellow-in-Training Member
References
1. FDA requires boxed warning about serious mental health side effects for asthma and allergy drug montelukast (Singulair); advises restricting use for allergic rhinitis. FDA Drug Safety Communication, March 4, 2020.
2. Neuropsychiatric events following montelukast use: A propensity score matched analysis. Sentinel, Sept. 27, 2019.
Pulmonary physiology, function, and rehabilitation
The happy hypoxic
In early December 2019, the novel coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified. Over the ensuing months, SARS-CoV-2 would cause a wide range of pulmonary symptoms from cough and mild shortness of breath to acute respiratory distress syndrome (ARDS) with severe hypoxia that puzzled intensivists worldwide.
One such mystifying presentation was finding patients with critically low oxygen levels who did not appear to be short of breath. This concept was dubbed “happy or silent hypoxemia.” Novel mechanisms of the SARS-Co-V-2 virus on the respiratory system have been proposed to explain this paradox, but recent literature suggests that foundational pulmonary physiology concepts can explain most of these findings.1
Breathing is centrally controlled by the respiratory center in the brain stem and is influenced mainly by dissolved carbon dioxide and pH.2 Hypercapnia is, therefore, a powerful stimulus to breathe and increase minute ventilation. It can cause dyspnea if this demand is not met.3
Hypoxia, on the other hand, is less powerful and does not evoke dyspnea until the PaO2 drops below 60 mm Hg.4 Hypercapnia potentiates this response: the higher the PaCO2, the higher the hypoxic response. Patients with a PaCO2 of 39 mm Hg or less may not experience dyspnea even when hypoxia is severe.1
Other possible explanations for silent hypoxemia include the poor accuracy of the pulse oximeter for estimating oxygen saturation of less than 80%,1 especially in the critically ill5 and the leftward shift of the oxygen dissociation curve due to fever, making the oxygen saturation lower for any given PaO2.1
In conclusion, the clinical management of COVID-19 pneumonia with a broad range of clinical features presents many unknowns, but it is reassuring to find an anchor in good old pulmonary physiology concepts.5
It is back to the basics for us all and that might be a good thing.
Oriade Adeoye, MD – Fellow-in-Training Member
References
1. Tobin MJ, et al. Am J Respir Crit Care Med. 2020;202(3):356-360. doi: 10.1164/rccm.202006-2157CP.
2. Vaporidi K, et al. Am J Respir Crit Care Med. 2020;201(1):20-32. doi: 10.1164/rccm.201903-0596SO.
3. Dhont S, et al. Respir Res. 2020;21(1):198. doi:10.1186/s12931-020-01462-5.
4. Weil JV, et al. J Clin Invest. 1970;49(6):1061-1072. doi:10.1172/JCI106322.
5. Tobin MJ. Am J Respir Crit Care Med. 2020;201(11):1319-1320. doi:10.1164/rccm.202004-1076ED.
Pulmonary vascular disease
COVID-19 and pulmonary vasculature: an intriguing relationship
Hypoxemia is the cardinal symptom in patients with severe coronavirus disease-2019 (COVID-19). However, hypoxemia disproportionate to radiographic opacities has led to growing suspicion that involvement of pulmonary vasculature (PV), leading to shunt physiology, may be a driver of this marked hypoxemia.
The virus’s affinity for PV is explained by presence of angiotensin-converting enzyme 2 receptor, which serves as the functional receptor for SARS-CoV-2, on pulmonary endothelium (Provencher, et al. Pulm Circ. 2020 Jun 10;10[3]:2045894020933088. doi: 10.1177/2045894020933088).
This increased affinity predisposes PV to pathologic effects of SARS-CoV-2, noted in COVID-19 patients’ autopsies, which revealed pulmonary endothelial injury and abnormal vessel growth (intussusceptive angiogenesis). These changes, along with profound inflammatory response, further predispose the PV to thrombosis and microangiopathy in COVID-19 (Ackermann, et al. N Engl J Med. 2020 Jul 9;383[2]:120-128).
These autopsy results also explain the radiologic findings of PV in COVID-19. Dual energy CT scanning, used to evaluate lung perfusion in these patients, has demonstrated PV thickening, mosaicism, and pulmonary vessel dilation; the latter likely occurring due to aberrations in physiologic hypoxic pulmonary vasoconstriction (Lang, et al. Lancet. 2020 Apr 30;S1473-3099[20]30367).
Despite PV’s involvement, only few cases of COVID-19 have been reported in patients with pulmonary arterial hypertension (PAH) , leading to the hypothesis that pre-existing vascular changes may have a protective effect in PAH patients (Horn, et al. Pulm Circ. 2020;10(2):1-2).
The above discussion details the complex and multifaceted relationship between COVID-19 and PV which underscores the value of understanding this interaction further and may prove to be insightful for discovering potential therapeutic targets in COVID-19.
Humna Abid Memon, MD – Fellow-in-Training Member
Interventional chest and diagnostic procedures
Impact of COVID-19 pandemic in patients with non-advanced LC
The COVID-19 pandemic has challenged the way we screen for, diagnose, and treat lung cancer.1, 2 Knowing that these patients are at higher risk of respiratory failure, and that COVID-19 causes poor outcomes in cancer patients,1,3,4 valid concerns regarding viral transmission to patients and health-care workers have hampered the expedited care this population needs.
In recent months, efforts to manage the pandemic have been herculean. With the goal of limiting transmission, expert panels have offered guidance including limiting access to medical facilities, decreasing aerosolizing procedures, and prioritizing curative treatments.2,5 In general, lung cancer screening should be delayed, and patients with highly suspicious localized pulmonary lesions could receive empiric regimens, surgery, or stereotactic radiotherapy.1,3-5
The conundrum occurs when diagnostic bronchoscopy is required for staging, acquiring tissue for targeted therapy, or a moderate-risk pulmonary nodule with indeterminate PET-CT and/or high-risk for CT-guided biopsy. Thoughtful balancing of risks and benefits depends on patient comorbidities, hospital resources – such preprocedural COVID screening, adequate protective personal equipment- and rate of local viral prevalence.6,7 Delaying diagnosis and staging could lead to progression of cancer and preclude curative or adjuvant therapy for appropriate candidates. Furthermore, we should not dismiss the appalling psychological impact of delayed care on our patients.
While the pandemic continues and challenges arise in the care of patients with lung cancer, the value of a multidisciplinary input and individualized care cannot be overstated, with focus on providing the best care possible while both minimizing transmission and increasing the chances of acceptable outcomes.
Jose De Cardenas MD, FCCP – Steering Committee Member
Abdul Hamid Alraiyes MD, FCCP – Steering Committee Member
References
1. Mazzone PJ, et al. Chest. 2020;158(1):406-415. doi: 10.1016/j.chest.2020.04.020.
2. Banna G, et al. ESMO Open. 2020;5(2):e000765. doi: 10.1136/esmoopen-2020-000765.
3. Liang W, et al. Lancet Oncol. 2020;21(3):335-337. doi: 10.1016/S1470-2045(20)30096-6.
4. Singh AP, et al. JCO Oncol Pract. 2020 May 26;OP2000286. doi: 10.1200/OP.20.00286.
5. Dingemans AC, et al. J Thorac Oncol. 2020;15(7):1119-1136. doi: 10.1016/j.jtho.2020.05.001.
6. Wahidi MM, et al. J Bronchology Interv Pulmonol. 2020 Mar 18. doi: 10.1097/LBR.0000000000000681.
7. Pritchett MA, et al. J Thorac Dis. 2020;12(5):1781-1798. doi: 10.21037/jtd.2020.04.32.
Pediatric chest medicine
FDA strengthens the boxed warning for montelukast
Early this year the Food and Drug Administration (FDA) updated the boxed warning for montelukast (Singulair), related to the potential for serious mental health side effects, such as agitation, aggressive behavior, depression, hallucinations, and suicidal thoughts and actions. Since its approval in 1998, montelukast is part of the therapeutic approach for persistent asthma in children age 1 year and older, allergic rhinitis from 6 months and older, and exercises induced bronchospasm in children age 6 years and older. In 2018, around 2.3 million children younger than 17 years received a prescription for montelukast.
The FDA reviewed data from their Sentinel System comparing children receiving montelukast vs inhaled corticosteroids, and this study failed to demonstrate significant increased risk of hospitalized depressive disorders, outpatient depressive disorders, self-harm, or suicide. However, a focused evaluation by the FDA of suicides identified 82 cases of completed suicides associated with montelukast, and 19 of these cases were in children younger than 17 years of age.
Post-marketing case reports submitted to the FDA, published observational and animal studies were evaluated along with the Sentinel System study that led to the new recommendations.
Finally, on March 4, 2020, the FDA updated the Singulair®/montelukast black box warning, focusing on the importance of advising patients and caregivers about the potential for serious neuropsychiatric side effects and advice to immediately discontinue use if symptoms occurred. The warning contains a strong recommendation to reserve use of Singulair®/montelukast to patients with allergic rhinitis who have an inadequate response or intolerance to alternate therapies.
Endy Dominguez Silveyra, MD - Fellow-in-Training Member
References
1. FDA requires boxed warning about serious mental health side effects for asthma and allergy drug montelukast (Singulair); advises restricting use for allergic rhinitis. FDA Drug Safety Communication, March 4, 2020.
2. Neuropsychiatric events following montelukast use: A propensity score matched analysis. Sentinel, Sept. 27, 2019.
Pulmonary physiology, function, and rehabilitation
The happy hypoxic
In early December 2019, the novel coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified. Over the ensuing months, SARS-CoV-2 would cause a wide range of pulmonary symptoms from cough and mild shortness of breath to acute respiratory distress syndrome (ARDS) with severe hypoxia that puzzled intensivists worldwide.
One such mystifying presentation was finding patients with critically low oxygen levels who did not appear to be short of breath. This concept was dubbed “happy or silent hypoxemia.” Novel mechanisms of the SARS-Co-V-2 virus on the respiratory system have been proposed to explain this paradox, but recent literature suggests that foundational pulmonary physiology concepts can explain most of these findings.1
Breathing is centrally controlled by the respiratory center in the brain stem and is influenced mainly by dissolved carbon dioxide and pH.2 Hypercapnia is, therefore, a powerful stimulus to breathe and increase minute ventilation. It can cause dyspnea if this demand is not met.3
Hypoxia, on the other hand, is less powerful and does not evoke dyspnea until the PaO2 drops below 60 mm Hg.4 Hypercapnia potentiates this response: the higher the PaCO2, the higher the hypoxic response. Patients with a PaCO2 of 39 mm Hg or less may not experience dyspnea even when hypoxia is severe.1
Other possible explanations for silent hypoxemia include the poor accuracy of the pulse oximeter for estimating oxygen saturation of less than 80%,1 especially in the critically ill5 and the leftward shift of the oxygen dissociation curve due to fever, making the oxygen saturation lower for any given PaO2.1
In conclusion, the clinical management of COVID-19 pneumonia with a broad range of clinical features presents many unknowns, but it is reassuring to find an anchor in good old pulmonary physiology concepts.5
It is back to the basics for us all and that might be a good thing.
Oriade Adeoye, MD – Fellow-in-Training Member
References
1. Tobin MJ, et al. Am J Respir Crit Care Med. 2020;202(3):356-360. doi: 10.1164/rccm.202006-2157CP.
2. Vaporidi K, et al. Am J Respir Crit Care Med. 2020;201(1):20-32. doi: 10.1164/rccm.201903-0596SO.
3. Dhont S, et al. Respir Res. 2020;21(1):198. doi:10.1186/s12931-020-01462-5.
4. Weil JV, et al. J Clin Invest. 1970;49(6):1061-1072. doi:10.1172/JCI106322.
5. Tobin MJ. Am J Respir Crit Care Med. 2020;201(11):1319-1320. doi:10.1164/rccm.202004-1076ED.
Pulmonary vascular disease
COVID-19 and pulmonary vasculature: an intriguing relationship
Hypoxemia is the cardinal symptom in patients with severe coronavirus disease-2019 (COVID-19). However, hypoxemia disproportionate to radiographic opacities has led to growing suspicion that involvement of pulmonary vasculature (PV), leading to shunt physiology, may be a driver of this marked hypoxemia.
The virus’s affinity for PV is explained by presence of angiotensin-converting enzyme 2 receptor, which serves as the functional receptor for SARS-CoV-2, on pulmonary endothelium (Provencher, et al. Pulm Circ. 2020 Jun 10;10[3]:2045894020933088. doi: 10.1177/2045894020933088).
This increased affinity predisposes PV to pathologic effects of SARS-CoV-2, noted in COVID-19 patients’ autopsies, which revealed pulmonary endothelial injury and abnormal vessel growth (intussusceptive angiogenesis). These changes, along with profound inflammatory response, further predispose the PV to thrombosis and microangiopathy in COVID-19 (Ackermann, et al. N Engl J Med. 2020 Jul 9;383[2]:120-128).
These autopsy results also explain the radiologic findings of PV in COVID-19. Dual energy CT scanning, used to evaluate lung perfusion in these patients, has demonstrated PV thickening, mosaicism, and pulmonary vessel dilation; the latter likely occurring due to aberrations in physiologic hypoxic pulmonary vasoconstriction (Lang, et al. Lancet. 2020 Apr 30;S1473-3099[20]30367).
Despite PV’s involvement, only few cases of COVID-19 have been reported in patients with pulmonary arterial hypertension (PAH) , leading to the hypothesis that pre-existing vascular changes may have a protective effect in PAH patients (Horn, et al. Pulm Circ. 2020;10(2):1-2).
The above discussion details the complex and multifaceted relationship between COVID-19 and PV which underscores the value of understanding this interaction further and may prove to be insightful for discovering potential therapeutic targets in COVID-19.
Humna Abid Memon, MD – Fellow-in-Training Member
Interventional chest and diagnostic procedures
Impact of COVID-19 pandemic in patients with non-advanced LC
The COVID-19 pandemic has challenged the way we screen for, diagnose, and treat lung cancer.1, 2 Knowing that these patients are at higher risk of respiratory failure, and that COVID-19 causes poor outcomes in cancer patients,1,3,4 valid concerns regarding viral transmission to patients and health-care workers have hampered the expedited care this population needs.
In recent months, efforts to manage the pandemic have been herculean. With the goal of limiting transmission, expert panels have offered guidance including limiting access to medical facilities, decreasing aerosolizing procedures, and prioritizing curative treatments.2,5 In general, lung cancer screening should be delayed, and patients with highly suspicious localized pulmonary lesions could receive empiric regimens, surgery, or stereotactic radiotherapy.1,3-5
The conundrum occurs when diagnostic bronchoscopy is required for staging, acquiring tissue for targeted therapy, or a moderate-risk pulmonary nodule with indeterminate PET-CT and/or high-risk for CT-guided biopsy. Thoughtful balancing of risks and benefits depends on patient comorbidities, hospital resources – such preprocedural COVID screening, adequate protective personal equipment- and rate of local viral prevalence.6,7 Delaying diagnosis and staging could lead to progression of cancer and preclude curative or adjuvant therapy for appropriate candidates. Furthermore, we should not dismiss the appalling psychological impact of delayed care on our patients.
While the pandemic continues and challenges arise in the care of patients with lung cancer, the value of a multidisciplinary input and individualized care cannot be overstated, with focus on providing the best care possible while both minimizing transmission and increasing the chances of acceptable outcomes.
Jose De Cardenas MD, FCCP – Steering Committee Member
Abdul Hamid Alraiyes MD, FCCP – Steering Committee Member
References
1. Mazzone PJ, et al. Chest. 2020;158(1):406-415. doi: 10.1016/j.chest.2020.04.020.
2. Banna G, et al. ESMO Open. 2020;5(2):e000765. doi: 10.1136/esmoopen-2020-000765.
3. Liang W, et al. Lancet Oncol. 2020;21(3):335-337. doi: 10.1016/S1470-2045(20)30096-6.
4. Singh AP, et al. JCO Oncol Pract. 2020 May 26;OP2000286. doi: 10.1200/OP.20.00286.
5. Dingemans AC, et al. J Thorac Oncol. 2020;15(7):1119-1136. doi: 10.1016/j.jtho.2020.05.001.
6. Wahidi MM, et al. J Bronchology Interv Pulmonol. 2020 Mar 18. doi: 10.1097/LBR.0000000000000681.
7. Pritchett MA, et al. J Thorac Dis. 2020;12(5):1781-1798. doi: 10.21037/jtd.2020.04.32.
Pediatric chest medicine
FDA strengthens the boxed warning for montelukast
Early this year the Food and Drug Administration (FDA) updated the boxed warning for montelukast (Singulair), related to the potential for serious mental health side effects, such as agitation, aggressive behavior, depression, hallucinations, and suicidal thoughts and actions. Since its approval in 1998, montelukast is part of the therapeutic approach for persistent asthma in children age 1 year and older, allergic rhinitis from 6 months and older, and exercises induced bronchospasm in children age 6 years and older. In 2018, around 2.3 million children younger than 17 years received a prescription for montelukast.
The FDA reviewed data from their Sentinel System comparing children receiving montelukast vs inhaled corticosteroids, and this study failed to demonstrate significant increased risk of hospitalized depressive disorders, outpatient depressive disorders, self-harm, or suicide. However, a focused evaluation by the FDA of suicides identified 82 cases of completed suicides associated with montelukast, and 19 of these cases were in children younger than 17 years of age.
Post-marketing case reports submitted to the FDA, published observational and animal studies were evaluated along with the Sentinel System study that led to the new recommendations.
Finally, on March 4, 2020, the FDA updated the Singulair®/montelukast black box warning, focusing on the importance of advising patients and caregivers about the potential for serious neuropsychiatric side effects and advice to immediately discontinue use if symptoms occurred. The warning contains a strong recommendation to reserve use of Singulair®/montelukast to patients with allergic rhinitis who have an inadequate response or intolerance to alternate therapies.
Endy Dominguez Silveyra, MD - Fellow-in-Training Member
References
1. FDA requires boxed warning about serious mental health side effects for asthma and allergy drug montelukast (Singulair); advises restricting use for allergic rhinitis. FDA Drug Safety Communication, March 4, 2020.
2. Neuropsychiatric events following montelukast use: A propensity score matched analysis. Sentinel, Sept. 27, 2019.
Pulmonary physiology, function, and rehabilitation
The happy hypoxic
In early December 2019, the novel coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified. Over the ensuing months, SARS-CoV-2 would cause a wide range of pulmonary symptoms from cough and mild shortness of breath to acute respiratory distress syndrome (ARDS) with severe hypoxia that puzzled intensivists worldwide.
One such mystifying presentation was finding patients with critically low oxygen levels who did not appear to be short of breath. This concept was dubbed “happy or silent hypoxemia.” Novel mechanisms of the SARS-Co-V-2 virus on the respiratory system have been proposed to explain this paradox, but recent literature suggests that foundational pulmonary physiology concepts can explain most of these findings.1
Breathing is centrally controlled by the respiratory center in the brain stem and is influenced mainly by dissolved carbon dioxide and pH.2 Hypercapnia is, therefore, a powerful stimulus to breathe and increase minute ventilation. It can cause dyspnea if this demand is not met.3
Hypoxia, on the other hand, is less powerful and does not evoke dyspnea until the PaO2 drops below 60 mm Hg.4 Hypercapnia potentiates this response: the higher the PaCO2, the higher the hypoxic response. Patients with a PaCO2 of 39 mm Hg or less may not experience dyspnea even when hypoxia is severe.1
Other possible explanations for silent hypoxemia include the poor accuracy of the pulse oximeter for estimating oxygen saturation of less than 80%,1 especially in the critically ill5 and the leftward shift of the oxygen dissociation curve due to fever, making the oxygen saturation lower for any given PaO2.1
In conclusion, the clinical management of COVID-19 pneumonia with a broad range of clinical features presents many unknowns, but it is reassuring to find an anchor in good old pulmonary physiology concepts.5
It is back to the basics for us all and that might be a good thing.
Oriade Adeoye, MD – Fellow-in-Training Member
References
1. Tobin MJ, et al. Am J Respir Crit Care Med. 2020;202(3):356-360. doi: 10.1164/rccm.202006-2157CP.
2. Vaporidi K, et al. Am J Respir Crit Care Med. 2020;201(1):20-32. doi: 10.1164/rccm.201903-0596SO.
3. Dhont S, et al. Respir Res. 2020;21(1):198. doi:10.1186/s12931-020-01462-5.
4. Weil JV, et al. J Clin Invest. 1970;49(6):1061-1072. doi:10.1172/JCI106322.
5. Tobin MJ. Am J Respir Crit Care Med. 2020;201(11):1319-1320. doi:10.1164/rccm.202004-1076ED.
Pulmonary vascular disease
COVID-19 and pulmonary vasculature: an intriguing relationship
Hypoxemia is the cardinal symptom in patients with severe coronavirus disease-2019 (COVID-19). However, hypoxemia disproportionate to radiographic opacities has led to growing suspicion that involvement of pulmonary vasculature (PV), leading to shunt physiology, may be a driver of this marked hypoxemia.
The virus’s affinity for PV is explained by presence of angiotensin-converting enzyme 2 receptor, which serves as the functional receptor for SARS-CoV-2, on pulmonary endothelium (Provencher, et al. Pulm Circ. 2020 Jun 10;10[3]:2045894020933088. doi: 10.1177/2045894020933088).
This increased affinity predisposes PV to pathologic effects of SARS-CoV-2, noted in COVID-19 patients’ autopsies, which revealed pulmonary endothelial injury and abnormal vessel growth (intussusceptive angiogenesis). These changes, along with profound inflammatory response, further predispose the PV to thrombosis and microangiopathy in COVID-19 (Ackermann, et al. N Engl J Med. 2020 Jul 9;383[2]:120-128).
These autopsy results also explain the radiologic findings of PV in COVID-19. Dual energy CT scanning, used to evaluate lung perfusion in these patients, has demonstrated PV thickening, mosaicism, and pulmonary vessel dilation; the latter likely occurring due to aberrations in physiologic hypoxic pulmonary vasoconstriction (Lang, et al. Lancet. 2020 Apr 30;S1473-3099[20]30367).
Despite PV’s involvement, only few cases of COVID-19 have been reported in patients with pulmonary arterial hypertension (PAH) , leading to the hypothesis that pre-existing vascular changes may have a protective effect in PAH patients (Horn, et al. Pulm Circ. 2020;10(2):1-2).
The above discussion details the complex and multifaceted relationship between COVID-19 and PV which underscores the value of understanding this interaction further and may prove to be insightful for discovering potential therapeutic targets in COVID-19.
Humna Abid Memon, MD – Fellow-in-Training Member