Society News

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.
 

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

CHEST’s premier event in pulmonary, critical care, and sleep medicine is just around the corner! Join us for CHEST Annual Meeting 2020, taking place October 18-21. We know it’s hard to plan out your schedule during an ever-changing pandemic, which is why this year’s meeting is being brought to you on a virtual platform. You’ll be able to access the meeting content from any device, in any location, at any time. It’s that convenient! Plus, you can join in immersive, interactive live sessions taught by expert faculty and followed by Q&As, or listen to prerecorded content at your own pace. Don’t worry if you’re unable to attend a session — all meeting content will be available to registrants until January 2021.

This year, you can expect:

• A keynote address by Anthony Fauci, MD, covering COVID-19.

• Over 88 live sessions, including panel and case-based discussions.

• Critically relevant sessions focusing on COVID-19 and cultural diversity.

• Original investigation presentations with new, unpublished science.

• Unique networking opportunities.

• Fun and interactive CHEST Games.

Register Today

Chestmeeting.chestnet.org

CHEST’s premier event in pulmonary, critical care, and sleep medicine is just around the corner! Join us for CHEST Annual Meeting 2020, taking place October 18-21. We know it’s hard to plan out your schedule during an ever-changing pandemic, which is why this year’s meeting is being brought to you on a virtual platform. You’ll be able to access the meeting content from any device, in any location, at any time. It’s that convenient! Plus, you can join in immersive, interactive live sessions taught by expert faculty and followed by Q&As, or listen to prerecorded content at your own pace. Don’t worry if you’re unable to attend a session — all meeting content will be available to registrants until January 2021.

This year, you can expect:

• A keynote address by Anthony Fauci, MD, covering COVID-19.

• Over 88 live sessions, including panel and case-based discussions.

• Critically relevant sessions focusing on COVID-19 and cultural diversity.

• Original investigation presentations with new, unpublished science.

• Unique networking opportunities.

• Fun and interactive CHEST Games.

Register Today

Chestmeeting.chestnet.org

CHEST’s premier event in pulmonary, critical care, and sleep medicine is just around the corner! Join us for CHEST Annual Meeting 2020, taking place October 18-21. We know it’s hard to plan out your schedule during an ever-changing pandemic, which is why this year’s meeting is being brought to you on a virtual platform. You’ll be able to access the meeting content from any device, in any location, at any time. It’s that convenient! Plus, you can join in immersive, interactive live sessions taught by expert faculty and followed by Q&As, or listen to prerecorded content at your own pace. Don’t worry if you’re unable to attend a session — all meeting content will be available to registrants until January 2021.

This year, you can expect:

• A keynote address by Anthony Fauci, MD, covering COVID-19.

• Over 88 live sessions, including panel and case-based discussions.

• Critically relevant sessions focusing on COVID-19 and cultural diversity.

• Original investigation presentations with new, unpublished science.

• Unique networking opportunities.

• Fun and interactive CHEST Games.

Register Today

Chestmeeting.chestnet.org

Individualizing risk prediction for positive COVID-19 testing: results from 11,672 patients. By Dr. Lara Jehi, et al.



Airway clearance techniques in bronchiectasis: Analysis from the United States Bronchiectasis and NTM research registry. By Dr. Ashwin Basavaraj, et al.



Emotional experiences and coping strategies of family members of critically ill patients. By Dr. Emily Harlan, et al.



Coronavirus disease and smoking: How and why we implemented a tobacco treatment campaign. By Dr. Adam Lang, et al.

Individualizing risk prediction for positive COVID-19 testing: results from 11,672 patients. By Dr. Lara Jehi, et al.



Airway clearance techniques in bronchiectasis: Analysis from the United States Bronchiectasis and NTM research registry. By Dr. Ashwin Basavaraj, et al.



Emotional experiences and coping strategies of family members of critically ill patients. By Dr. Emily Harlan, et al.



Coronavirus disease and smoking: How and why we implemented a tobacco treatment campaign. By Dr. Adam Lang, et al.

Individualizing risk prediction for positive COVID-19 testing: results from 11,672 patients. By Dr. Lara Jehi, et al.



Airway clearance techniques in bronchiectasis: Analysis from the United States Bronchiectasis and NTM research registry. By Dr. Ashwin Basavaraj, et al.



Emotional experiences and coping strategies of family members of critically ill patients. By Dr. Emily Harlan, et al.



Coronavirus disease and smoking: How and why we implemented a tobacco treatment campaign. By Dr. Adam Lang, et al.

Join the CHEST Foundation at one of its many virtual events designed around the three pillars of the organization—access, empowerment, and research—during CHEST 2020. Please check CHESTMeeting.chestnet.org for more details on each event.
 

Virtual Champion’s Circle Donor Lounge

The virtual donor lounge will act as the hub of a wheel – linking the spokes of Foundation programming and events to a central location for easy accessibility. Foundation staff and Board of Trustee members will staff the donor lounge throughout the meeting.
 

Women & Pulmonary Event – Sunday, October 18 at 11:00 AM – 12:30 PM CT

Connect with key thought leaders and participants to support the advancement of women in the fields of pulmonary, critical care, sleep medicine, and in leadership. The event includes a panel discussion on How to remain in control during a pandemic: family, career and mental wellness, followed by an intimate roundtable discussion moderated by the Women & Pulmonary council. RSVPs are necessary to attend this event.
 

CHEST Foundation Donor Reception– Sunday, October 18 7:30 PM CT

Join your colleagues and CHEST leadership for a night of fun and networking. Learn to play Texas Hold’em in a complimentary, casual poker tournament and join the high stakes tournament later this month!

Wine Night with CEO Bob Musacchio – Invite Only – Sunday, October 18 7:30 CST

Join CHEST’s CEO, Bob Musacchio for an interactive, exclusive wine night. The evening will include wine chosen from Bob’s personal favorites and kick off the CHEST 2020 annual meeting as we have never done before!
 

Young Professionals Reception – Monday, October 19, 2020 at 8:00 PM CT – Invite Only

Join your colleagues for a fun evening of trivia, prizes, and celebration! Let the Foundation show some appreciation for your commitment to chest medicine and come learn more about our work!

 

Join the CHEST Foundation at one of its many virtual events designed around the three pillars of the organization—access, empowerment, and research—during CHEST 2020. Please check CHESTMeeting.chestnet.org for more details on each event.
 

Virtual Champion’s Circle Donor Lounge

The virtual donor lounge will act as the hub of a wheel – linking the spokes of Foundation programming and events to a central location for easy accessibility. Foundation staff and Board of Trustee members will staff the donor lounge throughout the meeting.
 

Women & Pulmonary Event – Sunday, October 18 at 11:00 AM – 12:30 PM CT

Connect with key thought leaders and participants to support the advancement of women in the fields of pulmonary, critical care, sleep medicine, and in leadership. The event includes a panel discussion on How to remain in control during a pandemic: family, career and mental wellness, followed by an intimate roundtable discussion moderated by the Women & Pulmonary council. RSVPs are necessary to attend this event.
 

CHEST Foundation Donor Reception– Sunday, October 18 7:30 PM CT

Join your colleagues and CHEST leadership for a night of fun and networking. Learn to play Texas Hold’em in a complimentary, casual poker tournament and join the high stakes tournament later this month!

Wine Night with CEO Bob Musacchio – Invite Only – Sunday, October 18 7:30 CST

Join CHEST’s CEO, Bob Musacchio for an interactive, exclusive wine night. The evening will include wine chosen from Bob’s personal favorites and kick off the CHEST 2020 annual meeting as we have never done before!
 

Young Professionals Reception – Monday, October 19, 2020 at 8:00 PM CT – Invite Only

Join your colleagues for a fun evening of trivia, prizes, and celebration! Let the Foundation show some appreciation for your commitment to chest medicine and come learn more about our work!

 

Join the CHEST Foundation at one of its many virtual events designed around the three pillars of the organization—access, empowerment, and research—during CHEST 2020. Please check CHESTMeeting.chestnet.org for more details on each event.
 

Virtual Champion’s Circle Donor Lounge

The virtual donor lounge will act as the hub of a wheel – linking the spokes of Foundation programming and events to a central location for easy accessibility. Foundation staff and Board of Trustee members will staff the donor lounge throughout the meeting.
 

Women & Pulmonary Event – Sunday, October 18 at 11:00 AM – 12:30 PM CT

Connect with key thought leaders and participants to support the advancement of women in the fields of pulmonary, critical care, sleep medicine, and in leadership. The event includes a panel discussion on How to remain in control during a pandemic: family, career and mental wellness, followed by an intimate roundtable discussion moderated by the Women & Pulmonary council. RSVPs are necessary to attend this event.
 

CHEST Foundation Donor Reception– Sunday, October 18 7:30 PM CT

Join your colleagues and CHEST leadership for a night of fun and networking. Learn to play Texas Hold’em in a complimentary, casual poker tournament and join the high stakes tournament later this month!

Wine Night with CEO Bob Musacchio – Invite Only – Sunday, October 18 7:30 CST

Join CHEST’s CEO, Bob Musacchio for an interactive, exclusive wine night. The evening will include wine chosen from Bob’s personal favorites and kick off the CHEST 2020 annual meeting as we have never done before!
 

Young Professionals Reception – Monday, October 19, 2020 at 8:00 PM CT – Invite Only

Join your colleagues for a fun evening of trivia, prizes, and celebration! Let the Foundation show some appreciation for your commitment to chest medicine and come learn more about our work!

 

When COVID-19 hit, the AGA Research Foundation quickly announced the AGA-Takeda COVID-19 Rapid Response Research Awards to provide funding to kick-start research into the virus’ impact on the digestive tract. We’re excited to share our three award recipients with you. Read about their research projects below.

David A. Drew, PhD, and Long H. Nguyen, MD, MS, from Massachusetts General Hospital and Harvard Medical School will test their hypothesis that gut microbial communities mediate the relationship between GI symptoms and the varied clinical presentations and outcomes in patients with COVID-19. To accomplish this goal, they will jointly develop and rapidly deploy a multinational digital infrastructure for large-scale epidemiologic studies during the current global pandemic. By characterizing the GI symptoms most predictive of COVID-19 infection risk and severity, their work will offer timely insights into the ongoing pandemic and offer a foundation for further study on the effects of COVID-19 on human gut microbial communities.

Jeffrey Wade Brown from Washington University is evaluating the infective potential of the metaplastic GI foregut. For this project Dr. Brown and his team will use a novel, unique, and unpublished organoid system that propagates the features of upper GI human metaplasia in vitro to study a potential role for metaplasia in the predisposition to COVID-19. Dr. Brown hopes this research will directly help by making a previously naive population know that they are potentially at higher risk. Further, the high-throughput screening technology they are developing will not only be useful here but also could quickly be adapted to other pandemics.

Congratulations to Drs. David A. Drew, Long H. Nguyen, and Jeffrey Wade Brown — recipients of our AGA-Takeda COVID-19 Rapid Response Research Awards from the AGA Research Foundation.

[email protected]

When COVID-19 hit, the AGA Research Foundation quickly announced the AGA-Takeda COVID-19 Rapid Response Research Awards to provide funding to kick-start research into the virus’ impact on the digestive tract. We’re excited to share our three award recipients with you. Read about their research projects below.

David A. Drew, PhD, and Long H. Nguyen, MD, MS, from Massachusetts General Hospital and Harvard Medical School will test their hypothesis that gut microbial communities mediate the relationship between GI symptoms and the varied clinical presentations and outcomes in patients with COVID-19. To accomplish this goal, they will jointly develop and rapidly deploy a multinational digital infrastructure for large-scale epidemiologic studies during the current global pandemic. By characterizing the GI symptoms most predictive of COVID-19 infection risk and severity, their work will offer timely insights into the ongoing pandemic and offer a foundation for further study on the effects of COVID-19 on human gut microbial communities.

Jeffrey Wade Brown from Washington University is evaluating the infective potential of the metaplastic GI foregut. For this project Dr. Brown and his team will use a novel, unique, and unpublished organoid system that propagates the features of upper GI human metaplasia in vitro to study a potential role for metaplasia in the predisposition to COVID-19. Dr. Brown hopes this research will directly help by making a previously naive population know that they are potentially at higher risk. Further, the high-throughput screening technology they are developing will not only be useful here but also could quickly be adapted to other pandemics.

Congratulations to Drs. David A. Drew, Long H. Nguyen, and Jeffrey Wade Brown — recipients of our AGA-Takeda COVID-19 Rapid Response Research Awards from the AGA Research Foundation.

[email protected]

When COVID-19 hit, the AGA Research Foundation quickly announced the AGA-Takeda COVID-19 Rapid Response Research Awards to provide funding to kick-start research into the virus’ impact on the digestive tract. We’re excited to share our three award recipients with you. Read about their research projects below.

David A. Drew, PhD, and Long H. Nguyen, MD, MS, from Massachusetts General Hospital and Harvard Medical School will test their hypothesis that gut microbial communities mediate the relationship between GI symptoms and the varied clinical presentations and outcomes in patients with COVID-19. To accomplish this goal, they will jointly develop and rapidly deploy a multinational digital infrastructure for large-scale epidemiologic studies during the current global pandemic. By characterizing the GI symptoms most predictive of COVID-19 infection risk and severity, their work will offer timely insights into the ongoing pandemic and offer a foundation for further study on the effects of COVID-19 on human gut microbial communities.

Jeffrey Wade Brown from Washington University is evaluating the infective potential of the metaplastic GI foregut. For this project Dr. Brown and his team will use a novel, unique, and unpublished organoid system that propagates the features of upper GI human metaplasia in vitro to study a potential role for metaplasia in the predisposition to COVID-19. Dr. Brown hopes this research will directly help by making a previously naive population know that they are potentially at higher risk. Further, the high-throughput screening technology they are developing will not only be useful here but also could quickly be adapted to other pandemics.

Congratulations to Drs. David A. Drew, Long H. Nguyen, and Jeffrey Wade Brown — recipients of our AGA-Takeda COVID-19 Rapid Response Research Awards from the AGA Research Foundation.

[email protected]

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:
 

• Patient case: Crohn’s patient with three different strictures (https://community.gastro.org/posts/22491)
• Patient case: Alcoholic hepatitis and positive anti-smooth muscle antibody (https://community.gastro.org/posts/22407)
• COVID-19: The importance of preparedness in independent GI practices (https://community.gastro.org/posts/22340)
• Patient case: Crohn’s patient with no tissue (https://community.gastro.org/posts/22472)

Roundtables (https://community.gastro.org/discussions/)

• Roadmap for the future of colorectal cancer screening in the U.S.
• Windows on Clinical GI lecture series: NAFLD, Crohn’s disease and gastroparesis

View all 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:
 

• Patient case: Crohn’s patient with three different strictures (https://community.gastro.org/posts/22491)
• Patient case: Alcoholic hepatitis and positive anti-smooth muscle antibody (https://community.gastro.org/posts/22407)
• COVID-19: The importance of preparedness in independent GI practices (https://community.gastro.org/posts/22340)
• Patient case: Crohn’s patient with no tissue (https://community.gastro.org/posts/22472)

Roundtables (https://community.gastro.org/discussions/)

• Roadmap for the future of colorectal cancer screening in the U.S.
• Windows on Clinical GI lecture series: NAFLD, Crohn’s disease and gastroparesis

View all 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:
 

• Patient case: Crohn’s patient with three different strictures (https://community.gastro.org/posts/22491)
• Patient case: Alcoholic hepatitis and positive anti-smooth muscle antibody (https://community.gastro.org/posts/22407)
• COVID-19: The importance of preparedness in independent GI practices (https://community.gastro.org/posts/22340)
• Patient case: Crohn’s patient with no tissue (https://community.gastro.org/posts/22472)

Roundtables (https://community.gastro.org/discussions/)

• Roadmap for the future of colorectal cancer screening in the U.S.
• Windows on Clinical GI lecture series: NAFLD, Crohn’s disease and gastroparesis

View all upcoming Roundtables in the community at https://community.gastro.org/discussions.

Gastroenterology is proud to announce the release of a special collection of colorectal cancer articles. This curated collection includes some of the top colorectal cancer research published over the last 3 years with new research being added to the collection as it’s published.

View the special collection on Gastroenterology’s website, which is designed to help you quickly scan recent colorectal cancer research and easily navigate to studies of interest. Recent articles include:
 

• Use of Artificial Intelligence-Based Analytics From Live Colonoscopies to Optimize the Quality of the Colonoscopy Examination in Real Time: Proof of Concept
• Risk Factors for Early-Onset Colorectal Cancer
• Causes of Post-Colonoscopy Colorectal Cancers Based on World Endoscopy Organization System of Analysis

To view all of Gastroenterology’s curated article collections, please visit gastro.org/GastroCollections.

[email protected]

Gastroenterology is proud to announce the release of a special collection of colorectal cancer articles. This curated collection includes some of the top colorectal cancer research published over the last 3 years with new research being added to the collection as it’s published.

View the special collection on Gastroenterology’s website, which is designed to help you quickly scan recent colorectal cancer research and easily navigate to studies of interest. Recent articles include:
 

• Use of Artificial Intelligence-Based Analytics From Live Colonoscopies to Optimize the Quality of the Colonoscopy Examination in Real Time: Proof of Concept
• Risk Factors for Early-Onset Colorectal Cancer
• Causes of Post-Colonoscopy Colorectal Cancers Based on World Endoscopy Organization System of Analysis

To view all of Gastroenterology’s curated article collections, please visit gastro.org/GastroCollections.

[email protected]

Gastroenterology is proud to announce the release of a special collection of colorectal cancer articles. This curated collection includes some of the top colorectal cancer research published over the last 3 years with new research being added to the collection as it’s published.

View the special collection on Gastroenterology’s website, which is designed to help you quickly scan recent colorectal cancer research and easily navigate to studies of interest. Recent articles include:
 

• Use of Artificial Intelligence-Based Analytics From Live Colonoscopies to Optimize the Quality of the Colonoscopy Examination in Real Time: Proof of Concept
• Risk Factors for Early-Onset Colorectal Cancer
• Causes of Post-Colonoscopy Colorectal Cancers Based on World Endoscopy Organization System of Analysis

To view all of Gastroenterology’s curated article collections, please visit gastro.org/GastroCollections.

[email protected]

The burden of community-acquired pneumonia requiring admission to an intensive care unit in the United States.By Dr. R. Cavallazzi, et al.



Practical considerations for the diagnosis and treatment of fibrotic interstitial lung disease during the COVID-19 pandemic. By Dr. C. J. Ryerson, et al.



Pulmonary hypertension by the method of Paul Wood. By Dr. J. Newman.



Patient vs clinician perspectives on communication about results of lung cancer screening: A Qualitative Study. By Dr. R. Wiener, et al.
 

The Use of Bronchoscopy During the COVID-19 Pandemic: CHEST/AABIP Guideline and Expert Panel Report. By Dr. M. Wahidi, et al.

The burden of community-acquired pneumonia requiring admission to an intensive care unit in the United States.By Dr. R. Cavallazzi, et al.



Practical considerations for the diagnosis and treatment of fibrotic interstitial lung disease during the COVID-19 pandemic. By Dr. C. J. Ryerson, et al.



Pulmonary hypertension by the method of Paul Wood. By Dr. J. Newman.



Patient vs clinician perspectives on communication about results of lung cancer screening: A Qualitative Study. By Dr. R. Wiener, et al.
 

The Use of Bronchoscopy During the COVID-19 Pandemic: CHEST/AABIP Guideline and Expert Panel Report. By Dr. M. Wahidi, et al.

The burden of community-acquired pneumonia requiring admission to an intensive care unit in the United States.By Dr. R. Cavallazzi, et al.



Practical considerations for the diagnosis and treatment of fibrotic interstitial lung disease during the COVID-19 pandemic. By Dr. C. J. Ryerson, et al.



Pulmonary hypertension by the method of Paul Wood. By Dr. J. Newman.



Patient vs clinician perspectives on communication about results of lung cancer screening: A Qualitative Study. By Dr. R. Wiener, et al.
 

The Use of Bronchoscopy During the COVID-19 Pandemic: CHEST/AABIP Guideline and Expert Panel Report. By Dr. M. Wahidi, et al.