LOS ANGELES – Patients with multiple sclerosis who are treated with subcutaneous interferon beta-1a have no increase in stroke risk, compared with those treated with placebo, according to pooled data from clinical trials and a safety database analysis.

Studies have shown that MS patients have a greater risk of stroke, compared with the general population, but the data with respect to the risk of stroke following interferon treatment are limited, Alan Gillett, PhD, explained in his presentation at the annual meeting of the American Academy of Neurology. He noted that a 2017 report on a series of nested case-control studies showed a 1.8-fold increased risk of stroke in relapsing-remitting MS patients who received interferon.

In the new analysis presented at the meeting, there was a trend toward decreased stroke incidence among patients treated with subcutaneous interferon beta-1a. Stroke incidence was 0.025 per 100 patient-years (25 events) in patients treated with subcutaneous interferon beta-1a vs. 0.051 per 100 patient-years (11 events) in patients who received placebo across 17 phase 2-4 clinical trials. The incidence rate ratio (IRR) and hazard ratio for stroke in interferon- vs. placebo-treated patients were 0.486 and 0.496, respectively, reported Dr. Gillett of EMD Serono, Mississauga, Ont.

Further, no significant difference in stroke incidence was seen between the treatment and placebo groups based on treatment duration, Dr. Gillett said. The IRR in patients treated for less than 2 years was 0.602 vs. 0.469 in those treated for 2 or more years.

“The incidence rate ratio [in both groups] was very comparable to that overall, so this indicates that treatment duration had little impact on the incidence rate of stroke,” he said.

The same was true in an analysis based on dose; the IRRs were similar in those exposed to 44 mcg vs. placebo, and in those receiving any dose vs. placebo, he noted.

The analysis is based on reports of 569 cerebrovascular events occurring over 19 years (2.7 per 10,000 patient-years) in 1,594,414 patient-years of follow-up through May 22, 2017, in the Global Patient Safety Database.

sworcester@mdedge.com

SOURCE: Sabidó M et al. Neurology. 2018 Apr 90(15 Suppl.):S36.008.

LOS ANGELES – Patients with multiple sclerosis who are treated with subcutaneous interferon beta-1a have no increase in stroke risk, compared with those treated with placebo, according to pooled data from clinical trials and a safety database analysis.

Studies have shown that MS patients have a greater risk of stroke, compared with the general population, but the data with respect to the risk of stroke following interferon treatment are limited, Alan Gillett, PhD, explained in his presentation at the annual meeting of the American Academy of Neurology. He noted that a 2017 report on a series of nested case-control studies showed a 1.8-fold increased risk of stroke in relapsing-remitting MS patients who received interferon.

In the new analysis presented at the meeting, there was a trend toward decreased stroke incidence among patients treated with subcutaneous interferon beta-1a. Stroke incidence was 0.025 per 100 patient-years (25 events) in patients treated with subcutaneous interferon beta-1a vs. 0.051 per 100 patient-years (11 events) in patients who received placebo across 17 phase 2-4 clinical trials. The incidence rate ratio (IRR) and hazard ratio for stroke in interferon- vs. placebo-treated patients were 0.486 and 0.496, respectively, reported Dr. Gillett of EMD Serono, Mississauga, Ont.

Further, no significant difference in stroke incidence was seen between the treatment and placebo groups based on treatment duration, Dr. Gillett said. The IRR in patients treated for less than 2 years was 0.602 vs. 0.469 in those treated for 2 or more years.

“The incidence rate ratio [in both groups] was very comparable to that overall, so this indicates that treatment duration had little impact on the incidence rate of stroke,” he said.

The same was true in an analysis based on dose; the IRRs were similar in those exposed to 44 mcg vs. placebo, and in those receiving any dose vs. placebo, he noted.

The analysis is based on reports of 569 cerebrovascular events occurring over 19 years (2.7 per 10,000 patient-years) in 1,594,414 patient-years of follow-up through May 22, 2017, in the Global Patient Safety Database.

sworcester@mdedge.com

SOURCE: Sabidó M et al. Neurology. 2018 Apr 90(15 Suppl.):S36.008.

LOS ANGELES – Patients with multiple sclerosis who are treated with subcutaneous interferon beta-1a have no increase in stroke risk, compared with those treated with placebo, according to pooled data from clinical trials and a safety database analysis.

Studies have shown that MS patients have a greater risk of stroke, compared with the general population, but the data with respect to the risk of stroke following interferon treatment are limited, Alan Gillett, PhD, explained in his presentation at the annual meeting of the American Academy of Neurology. He noted that a 2017 report on a series of nested case-control studies showed a 1.8-fold increased risk of stroke in relapsing-remitting MS patients who received interferon.

In the new analysis presented at the meeting, there was a trend toward decreased stroke incidence among patients treated with subcutaneous interferon beta-1a. Stroke incidence was 0.025 per 100 patient-years (25 events) in patients treated with subcutaneous interferon beta-1a vs. 0.051 per 100 patient-years (11 events) in patients who received placebo across 17 phase 2-4 clinical trials. The incidence rate ratio (IRR) and hazard ratio for stroke in interferon- vs. placebo-treated patients were 0.486 and 0.496, respectively, reported Dr. Gillett of EMD Serono, Mississauga, Ont.

Further, no significant difference in stroke incidence was seen between the treatment and placebo groups based on treatment duration, Dr. Gillett said. The IRR in patients treated for less than 2 years was 0.602 vs. 0.469 in those treated for 2 or more years.

“The incidence rate ratio [in both groups] was very comparable to that overall, so this indicates that treatment duration had little impact on the incidence rate of stroke,” he said.

The same was true in an analysis based on dose; the IRRs were similar in those exposed to 44 mcg vs. placebo, and in those receiving any dose vs. placebo, he noted.

The analysis is based on reports of 569 cerebrovascular events occurring over 19 years (2.7 per 10,000 patient-years) in 1,594,414 patient-years of follow-up through May 22, 2017, in the Global Patient Safety Database.

sworcester@mdedge.com

SOURCE: Sabidó M et al. Neurology. 2018 Apr 90(15 Suppl.):S36.008.

WASHINGTON – The evidence linking firearm access and suicide completion is largely ignored in current U.S. discussions on guns, Michael D. Anestis, PhD, said at the annual conference of the American Association of Suicidology.

“Only a tiny fraction of media discussions on gun deaths involve suicide. We must make a concerted and sustained effort to change this conversation,” said Dr. Anestis, a clinical psychologist at the University of Southern Mississippi in Hattiesburg. When the relationship between firearms and suicide is discussed, it often is as a “footnote” and includes a lot of inaccurate information.

Mitchel L. Zoler/MDedge News

Results from questionnaires given to 253 U.S. soldiers showed a link between accumulated combat experiences and an increased acquired capability for suicide. But additional research from his group showed that another route to acquiring “capability” for suicide, such as fearlessness of death, can occur through exposure to violent video games.

Dr. Anestis had no disclosures.

mzoler@mdedge.com

;
 

WASHINGTON – The evidence linking firearm access and suicide completion is largely ignored in current U.S. discussions on guns, Michael D. Anestis, PhD, said at the annual conference of the American Association of Suicidology.

“Only a tiny fraction of media discussions on gun deaths involve suicide. We must make a concerted and sustained effort to change this conversation,” said Dr. Anestis, a clinical psychologist at the University of Southern Mississippi in Hattiesburg. When the relationship between firearms and suicide is discussed, it often is as a “footnote” and includes a lot of inaccurate information.

Mitchel L. Zoler/MDedge News

Results from questionnaires given to 253 U.S. soldiers showed a link between accumulated combat experiences and an increased acquired capability for suicide. But additional research from his group showed that another route to acquiring “capability” for suicide, such as fearlessness of death, can occur through exposure to violent video games.

Dr. Anestis had no disclosures.

mzoler@mdedge.com

;
 

WASHINGTON – The evidence linking firearm access and suicide completion is largely ignored in current U.S. discussions on guns, Michael D. Anestis, PhD, said at the annual conference of the American Association of Suicidology.

“Only a tiny fraction of media discussions on gun deaths involve suicide. We must make a concerted and sustained effort to change this conversation,” said Dr. Anestis, a clinical psychologist at the University of Southern Mississippi in Hattiesburg. When the relationship between firearms and suicide is discussed, it often is as a “footnote” and includes a lot of inaccurate information.

Mitchel L. Zoler/MDedge News

Results from questionnaires given to 253 U.S. soldiers showed a link between accumulated combat experiences and an increased acquired capability for suicide. But additional research from his group showed that another route to acquiring “capability” for suicide, such as fearlessness of death, can occur through exposure to violent video games.

Dr. Anestis had no disclosures.

mzoler@mdedge.com

;
 

Editor’s note: The Hospitalist is pleased to introduce a new recurring column: “The Legacies of Hospital Medicine.” This will be a recurring feature submitted by some of the best and brightest hospitalists in the field who have helped shape our specialty into what it is today. It will be a series of articles that will reflect on hospital medicine and it’s evolution over time from a variety of unique and innovative perspectives. We hope you enjoy this series, and we welcome any feedback as it evolves!

Hearkening back to my early time as a hospital-based physician, I recall the pleasure of waking every day and feeling like I belonged to an exclusive club. I felt passion for my work, along with a tiny cohort of similarly situated docs. We lacked a kinship with other medical organizations, however. We had no union of our own and were invisible upstarts.

That transformed with time.

Like most hospitalists, my ticket in began after some sleuthing and calls to Win Whitcomb, MD, and John Nelson, MD – still trusted friends today. They will make their marks in future columns, but as I am the inaugural contributor, let me be the first to state they both had a sixth sense steering our group of disciples. They became the obvious chiefs, along with Bob Wachter, MD, and took the lead in articulating what we aspired to be. Sounds saccharine now, but it did not then.

Twenty years out, hospital medicine still feels like a figurative case of Moore’s law. I cannot keep up with the strange faces at annual meetings and membership size, the throng of published articles (I used to pride myself on knowing all the hospitalist studies – no longer), and the lengthy list of initiatives and Society of Hospital Medicine resources on hand.

Without question, SHM has been the most rewarding part of my professional life. Hospital medicine mates sustain and keep me in good stead and have done so since training. Their insights teach me more than journals or any day on the job could impart and have given me a learning windfall for the cost of a song.

I initiated my hospitalist path as a 20-something tenderfoot, but from my interactions with colleagues both liberal and conservative, urban and rural, corporate and academic, and specialist and generalist, I developed into a seasoned craftsman.

Countless times I strode into an SHM activity thinking one way, and through the intellect and conviction of my peers, I got smart. Working in the same setting for most of my career, unchallenged, I could have assimilated a sclerotic worldview, but my hospital medicine colleagues would have none of that – kudos and thanks to them for it.

I could cite endless anecdotes – and they are swirling as I write. Crucial positions discussed and adopted, roads taken and those not, specialties angered and appeased, wonderful meals had, and on and on. They are and were the building blocks of a journey – and a joyful one.

As truly notable memories go, however, for me, there is only one.

By far, watching and absorbing the lessons of how an organization develops – goes from zero to sixty – has been a master class in enterprise and execution.

A PGY4 sees a president, CEO, board, ad hoc committees, staff, big budgets, and capital outlays make things happen and assumes it just is. But an operational charter with an instruction manual in-tow didn’t just drop from on high; that’s not how things go down. The right personnel selections, value choices (“SHM is a big tent” was not an accident), affiliate alliances, assessment of risks, and strategies pursued occurred for a reason; keen minds had the vision to set the board right.

The privilege of participating in the SHM project has been an education no grant or scholarship could equal. To say I had a tiny role in all of that is just reward.

Through SHM I have made lifelong friends, advanced my perspective and development as a healer, acquired a nifty board certification (one of 1,400 with a Focused Practice in Hospital Medicine), gained a mastership, and yes, met President Obama.

As odysseys go, how many docs can make such lofty claims?

Dr. Flansbaum works for Geisinger Health System in Danville, Pa., in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996 and is a founding member of the Society of Hospital Medicine.

Editor’s note: The Hospitalist is pleased to introduce a new recurring column: “The Legacies of Hospital Medicine.” This will be a recurring feature submitted by some of the best and brightest hospitalists in the field who have helped shape our specialty into what it is today. It will be a series of articles that will reflect on hospital medicine and it’s evolution over time from a variety of unique and innovative perspectives. We hope you enjoy this series, and we welcome any feedback as it evolves!

Hearkening back to my early time as a hospital-based physician, I recall the pleasure of waking every day and feeling like I belonged to an exclusive club. I felt passion for my work, along with a tiny cohort of similarly situated docs. We lacked a kinship with other medical organizations, however. We had no union of our own and were invisible upstarts.

That transformed with time.

Like most hospitalists, my ticket in began after some sleuthing and calls to Win Whitcomb, MD, and John Nelson, MD – still trusted friends today. They will make their marks in future columns, but as I am the inaugural contributor, let me be the first to state they both had a sixth sense steering our group of disciples. They became the obvious chiefs, along with Bob Wachter, MD, and took the lead in articulating what we aspired to be. Sounds saccharine now, but it did not then.

Twenty years out, hospital medicine still feels like a figurative case of Moore’s law. I cannot keep up with the strange faces at annual meetings and membership size, the throng of published articles (I used to pride myself on knowing all the hospitalist studies – no longer), and the lengthy list of initiatives and Society of Hospital Medicine resources on hand.

Without question, SHM has been the most rewarding part of my professional life. Hospital medicine mates sustain and keep me in good stead and have done so since training. Their insights teach me more than journals or any day on the job could impart and have given me a learning windfall for the cost of a song.

I initiated my hospitalist path as a 20-something tenderfoot, but from my interactions with colleagues both liberal and conservative, urban and rural, corporate and academic, and specialist and generalist, I developed into a seasoned craftsman.

Countless times I strode into an SHM activity thinking one way, and through the intellect and conviction of my peers, I got smart. Working in the same setting for most of my career, unchallenged, I could have assimilated a sclerotic worldview, but my hospital medicine colleagues would have none of that – kudos and thanks to them for it.

I could cite endless anecdotes – and they are swirling as I write. Crucial positions discussed and adopted, roads taken and those not, specialties angered and appeased, wonderful meals had, and on and on. They are and were the building blocks of a journey – and a joyful one.

As truly notable memories go, however, for me, there is only one.

By far, watching and absorbing the lessons of how an organization develops – goes from zero to sixty – has been a master class in enterprise and execution.

A PGY4 sees a president, CEO, board, ad hoc committees, staff, big budgets, and capital outlays make things happen and assumes it just is. But an operational charter with an instruction manual in-tow didn’t just drop from on high; that’s not how things go down. The right personnel selections, value choices (“SHM is a big tent” was not an accident), affiliate alliances, assessment of risks, and strategies pursued occurred for a reason; keen minds had the vision to set the board right.

The privilege of participating in the SHM project has been an education no grant or scholarship could equal. To say I had a tiny role in all of that is just reward.

Through SHM I have made lifelong friends, advanced my perspective and development as a healer, acquired a nifty board certification (one of 1,400 with a Focused Practice in Hospital Medicine), gained a mastership, and yes, met President Obama.

As odysseys go, how many docs can make such lofty claims?

Dr. Flansbaum works for Geisinger Health System in Danville, Pa., in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996 and is a founding member of the Society of Hospital Medicine.

Editor’s note: The Hospitalist is pleased to introduce a new recurring column: “The Legacies of Hospital Medicine.” This will be a recurring feature submitted by some of the best and brightest hospitalists in the field who have helped shape our specialty into what it is today. It will be a series of articles that will reflect on hospital medicine and it’s evolution over time from a variety of unique and innovative perspectives. We hope you enjoy this series, and we welcome any feedback as it evolves!

Hearkening back to my early time as a hospital-based physician, I recall the pleasure of waking every day and feeling like I belonged to an exclusive club. I felt passion for my work, along with a tiny cohort of similarly situated docs. We lacked a kinship with other medical organizations, however. We had no union of our own and were invisible upstarts.

That transformed with time.

Like most hospitalists, my ticket in began after some sleuthing and calls to Win Whitcomb, MD, and John Nelson, MD – still trusted friends today. They will make their marks in future columns, but as I am the inaugural contributor, let me be the first to state they both had a sixth sense steering our group of disciples. They became the obvious chiefs, along with Bob Wachter, MD, and took the lead in articulating what we aspired to be. Sounds saccharine now, but it did not then.

Twenty years out, hospital medicine still feels like a figurative case of Moore’s law. I cannot keep up with the strange faces at annual meetings and membership size, the throng of published articles (I used to pride myself on knowing all the hospitalist studies – no longer), and the lengthy list of initiatives and Society of Hospital Medicine resources on hand.

Without question, SHM has been the most rewarding part of my professional life. Hospital medicine mates sustain and keep me in good stead and have done so since training. Their insights teach me more than journals or any day on the job could impart and have given me a learning windfall for the cost of a song.

I initiated my hospitalist path as a 20-something tenderfoot, but from my interactions with colleagues both liberal and conservative, urban and rural, corporate and academic, and specialist and generalist, I developed into a seasoned craftsman.

Countless times I strode into an SHM activity thinking one way, and through the intellect and conviction of my peers, I got smart. Working in the same setting for most of my career, unchallenged, I could have assimilated a sclerotic worldview, but my hospital medicine colleagues would have none of that – kudos and thanks to them for it.

I could cite endless anecdotes – and they are swirling as I write. Crucial positions discussed and adopted, roads taken and those not, specialties angered and appeased, wonderful meals had, and on and on. They are and were the building blocks of a journey – and a joyful one.

As truly notable memories go, however, for me, there is only one.

By far, watching and absorbing the lessons of how an organization develops – goes from zero to sixty – has been a master class in enterprise and execution.

A PGY4 sees a president, CEO, board, ad hoc committees, staff, big budgets, and capital outlays make things happen and assumes it just is. But an operational charter with an instruction manual in-tow didn’t just drop from on high; that’s not how things go down. The right personnel selections, value choices (“SHM is a big tent” was not an accident), affiliate alliances, assessment of risks, and strategies pursued occurred for a reason; keen minds had the vision to set the board right.

The privilege of participating in the SHM project has been an education no grant or scholarship could equal. To say I had a tiny role in all of that is just reward.

Through SHM I have made lifelong friends, advanced my perspective and development as a healer, acquired a nifty board certification (one of 1,400 with a Focused Practice in Hospital Medicine), gained a mastership, and yes, met President Obama.

As odysseys go, how many docs can make such lofty claims?

Dr. Flansbaum works for Geisinger Health System in Danville, Pa., in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996 and is a founding member of the Society of Hospital Medicine.

Are you ready for CHEST Annual Meeting 2018? Get ready with exclusive hotel deals for your trip to San Antonio from onPeak, the official hotel provider for CHEST 2018. Through onPeak, we are able to bring you the lowest rates, best hotels, and great amenities for your trip all along the beautiful San Antonio River Walk. onPeak also provides flexible booking policies, great group tools, and a full team of wonderful customer service agents to ensure you have a smooth booking process.

Marriott Rivercenter – HQ Hotel

The San Antonio Marriott Rivercenter, a magnificent 38-story hotel, is just steps away from premier shopping, dining, and entertainment destinations. Guests will enjoy supreme comfort conveniently located near many hot attractions, including Six Flags Fiesta Texas and the San Antonio Zoo. The Alamo, one of the nation’s most storied and revered landmarks, is within easy walking distance from the hotel.

Grand Hyatt San Antonio

Discover the distinctly diverse personality of the Alamo City in grand style. Also along the spectacular River Walk, Grand Hyatt San Antonio is steps from trendy downtown bars, Zagat-rated restaurants, and all the sites and attractions that make San Antonio one of the most culturally rich cities in the country.

Hilton Palacio Del Rio

Located in beautiful downtown San Antonio, the Hilton Palacio del Rio hotel is surrounded by Texas culture and attractions, including the Alamo, just two blocks away. The Hilton Palacio del Rio offers superior service, extensive guest amenities, and is the only hotel in downtown San Antonio that features a private balcony in every room. Tex’s Riverwalk Sports Bar & Grill, Durty Nelley’s Irish Pub, Ibiza Riverwalk Patio Restaurant & Bar, and the Rincon Allegre Lobby Bar await to satisfy individual tastes.

Hotel Contessa

Step into the marble lobby accented with glass sconces and towering palm trees and you’ll know you’ve made the right choice on where to stay. The ambiance of this 265 all-suite property with heated rooftop pool, full-service spa, gourmet restaurant, and modern meeting space is unmatched by any other downtown hotel. Our dedicated service team is devoted to making any stay – leisure or business – a memorable experience. The Hotel Contessa extends to her guests a relaxing respite in an urban setting coupled with all the amenities of a large resort.

Hyatt Regency San Antonio

Experience the heart of the River Walk at Hyatt Regency San Antonio. This is the only hotel on the River Walk directly overlooking the historic Alamo, connecting two of San Antonio’s top destinations through the 16-story atrium lobby. This four-diamond hotel includes contemporary guest rooms, a rooftop pool, Stay-Fit gym, and a relaxing spa. The experienced staff adds a genuine touch to world-class amenities.

Marriott Riverwalk

The San Antonio Marriott Riverwalk hotel charmingly captures the vibrant culture and style of this romantic city, welcoming you and ensuring an enchanting stay. This hotel is located in the heart of downtown San Antonio, offering sweeping balcony views of the fabulous River Walk district. The 30-story hotel invites guests into a contemporary lobby with Texas flair: chili-red walls, dark-wood trim, and wrought-iron accents. Explore the history, culture, and culinary delights along the River Walk.

Westin Riverwalk Hotel

The Westin Riverwalk Hotel boasts 473 rooms and luxury suites with Texan hospitality and warm residential style. This riverfront hotel is the perfect location to relax and recharge. Expect a warm welcome when you visit the best of San Antonio River Walk hotels. Enjoy delicious dark chocolates imported from Venezuela when you check in and amenities such as The Westin Heavenly Bed® and Heavenly Bath® products that will leave you feeling refreshed and rejuvenated. The hotel rooms also include sparkling city or river views and elegant, oversized marble bathrooms with pampering bath amenities.

Don’t forget to book your hotel before they sell out! View the official hotel block at http://onpeak.com/CHEST-2018.

Note that onPeak is the only official hotel provider associated with our event. While other hotel resellers may contact you offering accommodations for your trip, they are not endorsed by or affiliated with the meeting. Beware that entering into financial agreements with unendorsed companies can have costly consequences.
 

Hotel information provided by onPeak.

Are you ready for CHEST Annual Meeting 2018? Get ready with exclusive hotel deals for your trip to San Antonio from onPeak, the official hotel provider for CHEST 2018. Through onPeak, we are able to bring you the lowest rates, best hotels, and great amenities for your trip all along the beautiful San Antonio River Walk. onPeak also provides flexible booking policies, great group tools, and a full team of wonderful customer service agents to ensure you have a smooth booking process.

Marriott Rivercenter – HQ Hotel

The San Antonio Marriott Rivercenter, a magnificent 38-story hotel, is just steps away from premier shopping, dining, and entertainment destinations. Guests will enjoy supreme comfort conveniently located near many hot attractions, including Six Flags Fiesta Texas and the San Antonio Zoo. The Alamo, one of the nation’s most storied and revered landmarks, is within easy walking distance from the hotel.

Grand Hyatt San Antonio

Discover the distinctly diverse personality of the Alamo City in grand style. Also along the spectacular River Walk, Grand Hyatt San Antonio is steps from trendy downtown bars, Zagat-rated restaurants, and all the sites and attractions that make San Antonio one of the most culturally rich cities in the country.

Hilton Palacio Del Rio

Located in beautiful downtown San Antonio, the Hilton Palacio del Rio hotel is surrounded by Texas culture and attractions, including the Alamo, just two blocks away. The Hilton Palacio del Rio offers superior service, extensive guest amenities, and is the only hotel in downtown San Antonio that features a private balcony in every room. Tex’s Riverwalk Sports Bar & Grill, Durty Nelley’s Irish Pub, Ibiza Riverwalk Patio Restaurant & Bar, and the Rincon Allegre Lobby Bar await to satisfy individual tastes.

Hotel Contessa

Step into the marble lobby accented with glass sconces and towering palm trees and you’ll know you’ve made the right choice on where to stay. The ambiance of this 265 all-suite property with heated rooftop pool, full-service spa, gourmet restaurant, and modern meeting space is unmatched by any other downtown hotel. Our dedicated service team is devoted to making any stay – leisure or business – a memorable experience. The Hotel Contessa extends to her guests a relaxing respite in an urban setting coupled with all the amenities of a large resort.

Hyatt Regency San Antonio

Experience the heart of the River Walk at Hyatt Regency San Antonio. This is the only hotel on the River Walk directly overlooking the historic Alamo, connecting two of San Antonio’s top destinations through the 16-story atrium lobby. This four-diamond hotel includes contemporary guest rooms, a rooftop pool, Stay-Fit gym, and a relaxing spa. The experienced staff adds a genuine touch to world-class amenities.

Marriott Riverwalk

The San Antonio Marriott Riverwalk hotel charmingly captures the vibrant culture and style of this romantic city, welcoming you and ensuring an enchanting stay. This hotel is located in the heart of downtown San Antonio, offering sweeping balcony views of the fabulous River Walk district. The 30-story hotel invites guests into a contemporary lobby with Texas flair: chili-red walls, dark-wood trim, and wrought-iron accents. Explore the history, culture, and culinary delights along the River Walk.

Westin Riverwalk Hotel

The Westin Riverwalk Hotel boasts 473 rooms and luxury suites with Texan hospitality and warm residential style. This riverfront hotel is the perfect location to relax and recharge. Expect a warm welcome when you visit the best of San Antonio River Walk hotels. Enjoy delicious dark chocolates imported from Venezuela when you check in and amenities such as The Westin Heavenly Bed® and Heavenly Bath® products that will leave you feeling refreshed and rejuvenated. The hotel rooms also include sparkling city or river views and elegant, oversized marble bathrooms with pampering bath amenities.

Don’t forget to book your hotel before they sell out! View the official hotel block at http://onpeak.com/CHEST-2018.

Note that onPeak is the only official hotel provider associated with our event. While other hotel resellers may contact you offering accommodations for your trip, they are not endorsed by or affiliated with the meeting. Beware that entering into financial agreements with unendorsed companies can have costly consequences.
 

Hotel information provided by onPeak.

Are you ready for CHEST Annual Meeting 2018? Get ready with exclusive hotel deals for your trip to San Antonio from onPeak, the official hotel provider for CHEST 2018. Through onPeak, we are able to bring you the lowest rates, best hotels, and great amenities for your trip all along the beautiful San Antonio River Walk. onPeak also provides flexible booking policies, great group tools, and a full team of wonderful customer service agents to ensure you have a smooth booking process.

Marriott Rivercenter – HQ Hotel

The San Antonio Marriott Rivercenter, a magnificent 38-story hotel, is just steps away from premier shopping, dining, and entertainment destinations. Guests will enjoy supreme comfort conveniently located near many hot attractions, including Six Flags Fiesta Texas and the San Antonio Zoo. The Alamo, one of the nation’s most storied and revered landmarks, is within easy walking distance from the hotel.

Grand Hyatt San Antonio

Discover the distinctly diverse personality of the Alamo City in grand style. Also along the spectacular River Walk, Grand Hyatt San Antonio is steps from trendy downtown bars, Zagat-rated restaurants, and all the sites and attractions that make San Antonio one of the most culturally rich cities in the country.

Hilton Palacio Del Rio

Located in beautiful downtown San Antonio, the Hilton Palacio del Rio hotel is surrounded by Texas culture and attractions, including the Alamo, just two blocks away. The Hilton Palacio del Rio offers superior service, extensive guest amenities, and is the only hotel in downtown San Antonio that features a private balcony in every room. Tex’s Riverwalk Sports Bar & Grill, Durty Nelley’s Irish Pub, Ibiza Riverwalk Patio Restaurant & Bar, and the Rincon Allegre Lobby Bar await to satisfy individual tastes.

Hotel Contessa

Step into the marble lobby accented with glass sconces and towering palm trees and you’ll know you’ve made the right choice on where to stay. The ambiance of this 265 all-suite property with heated rooftop pool, full-service spa, gourmet restaurant, and modern meeting space is unmatched by any other downtown hotel. Our dedicated service team is devoted to making any stay – leisure or business – a memorable experience. The Hotel Contessa extends to her guests a relaxing respite in an urban setting coupled with all the amenities of a large resort.

Hyatt Regency San Antonio

Experience the heart of the River Walk at Hyatt Regency San Antonio. This is the only hotel on the River Walk directly overlooking the historic Alamo, connecting two of San Antonio’s top destinations through the 16-story atrium lobby. This four-diamond hotel includes contemporary guest rooms, a rooftop pool, Stay-Fit gym, and a relaxing spa. The experienced staff adds a genuine touch to world-class amenities.

Marriott Riverwalk

The San Antonio Marriott Riverwalk hotel charmingly captures the vibrant culture and style of this romantic city, welcoming you and ensuring an enchanting stay. This hotel is located in the heart of downtown San Antonio, offering sweeping balcony views of the fabulous River Walk district. The 30-story hotel invites guests into a contemporary lobby with Texas flair: chili-red walls, dark-wood trim, and wrought-iron accents. Explore the history, culture, and culinary delights along the River Walk.

Westin Riverwalk Hotel

The Westin Riverwalk Hotel boasts 473 rooms and luxury suites with Texan hospitality and warm residential style. This riverfront hotel is the perfect location to relax and recharge. Expect a warm welcome when you visit the best of San Antonio River Walk hotels. Enjoy delicious dark chocolates imported from Venezuela when you check in and amenities such as The Westin Heavenly Bed® and Heavenly Bath® products that will leave you feeling refreshed and rejuvenated. The hotel rooms also include sparkling city or river views and elegant, oversized marble bathrooms with pampering bath amenities.

Don’t forget to book your hotel before they sell out! View the official hotel block at http://onpeak.com/CHEST-2018.

Note that onPeak is the only official hotel provider associated with our event. While other hotel resellers may contact you offering accommodations for your trip, they are not endorsed by or affiliated with the meeting. Beware that entering into financial agreements with unendorsed companies can have costly consequences.
 

Hotel information provided by onPeak.

The introduction of multiple-gene sequencing led to a substantial increase in detection of pathogenic variants in a study of women with breast cancer treated in community practice, results of one retrospective study show.

Multiple-gene sequencing rapidly replaced BRCA1/2 only testing over a 2-year period in the study, driven in part by technological advances and regulatory changes that made comprehensive low-cost genetic testing more accessible, investigators wrote. The report was published in JAMA Oncology.

That quick uptake increased detection of genetic variants that could change care, with no associated increase in prophylactic mastectomy over that same time period, said Allison W. Kurian, MD, of Stanford (Calif.) University, and her coinvestigators.

“The greater yield of clinically relevant information with multiple-gene sequencing offers a major potential advantage over more limited BRCA1/2-only tests,” noted Dr. Kurian and her colleagues.

Their analysis included 5,026 women with stage 0-II breast cancer diagnosed from January 2013 to December 2015 and enrolled in the Individualized Cancer Care (iCan Care) study. That study started enrolling 1 month before a U.S. Supreme Court decision on gene patents, which led to lower costs for multiple-gene sequencing tests for breast cancer risk, Dr. Kurian and her coinvestigators said.

Overall, about one-quarter of women in the study had genetic testing, and that did not change over time. What did change over time was the number of women undergoing multiple-gene testing: In 2013, only 25.6% underwent multiple-gene sequencing, versus 74.4% for BRCA1/2-only testing; by 2015, those figures flipped to 66.5% and 33.5%, respectively.

Multiple-gene sequencing increased detection of pathogenic variants in women at average pretest risk (4.2% versus 2.2% for BRCA1/2-only testing), according to the reported data. Detection was increased in women at high pretest risk due to young age, triple-negative breast cancer, or other factors (12% versus 7.8%).

SOURCE: Kurian AW et al. JAMA Oncol. 2018 May 10. doi: 10.1001/jamaoncol.2018.0644.

The introduction of multiple-gene sequencing led to a substantial increase in detection of pathogenic variants in a study of women with breast cancer treated in community practice, results of one retrospective study show.

Multiple-gene sequencing rapidly replaced BRCA1/2 only testing over a 2-year period in the study, driven in part by technological advances and regulatory changes that made comprehensive low-cost genetic testing more accessible, investigators wrote. The report was published in JAMA Oncology.

That quick uptake increased detection of genetic variants that could change care, with no associated increase in prophylactic mastectomy over that same time period, said Allison W. Kurian, MD, of Stanford (Calif.) University, and her coinvestigators.

“The greater yield of clinically relevant information with multiple-gene sequencing offers a major potential advantage over more limited BRCA1/2-only tests,” noted Dr. Kurian and her colleagues.

Their analysis included 5,026 women with stage 0-II breast cancer diagnosed from January 2013 to December 2015 and enrolled in the Individualized Cancer Care (iCan Care) study. That study started enrolling 1 month before a U.S. Supreme Court decision on gene patents, which led to lower costs for multiple-gene sequencing tests for breast cancer risk, Dr. Kurian and her coinvestigators said.

Overall, about one-quarter of women in the study had genetic testing, and that did not change over time. What did change over time was the number of women undergoing multiple-gene testing: In 2013, only 25.6% underwent multiple-gene sequencing, versus 74.4% for BRCA1/2-only testing; by 2015, those figures flipped to 66.5% and 33.5%, respectively.

Multiple-gene sequencing increased detection of pathogenic variants in women at average pretest risk (4.2% versus 2.2% for BRCA1/2-only testing), according to the reported data. Detection was increased in women at high pretest risk due to young age, triple-negative breast cancer, or other factors (12% versus 7.8%).

SOURCE: Kurian AW et al. JAMA Oncol. 2018 May 10. doi: 10.1001/jamaoncol.2018.0644.

The introduction of multiple-gene sequencing led to a substantial increase in detection of pathogenic variants in a study of women with breast cancer treated in community practice, results of one retrospective study show.

Multiple-gene sequencing rapidly replaced BRCA1/2 only testing over a 2-year period in the study, driven in part by technological advances and regulatory changes that made comprehensive low-cost genetic testing more accessible, investigators wrote. The report was published in JAMA Oncology.

That quick uptake increased detection of genetic variants that could change care, with no associated increase in prophylactic mastectomy over that same time period, said Allison W. Kurian, MD, of Stanford (Calif.) University, and her coinvestigators.

“The greater yield of clinically relevant information with multiple-gene sequencing offers a major potential advantage over more limited BRCA1/2-only tests,” noted Dr. Kurian and her colleagues.

Their analysis included 5,026 women with stage 0-II breast cancer diagnosed from January 2013 to December 2015 and enrolled in the Individualized Cancer Care (iCan Care) study. That study started enrolling 1 month before a U.S. Supreme Court decision on gene patents, which led to lower costs for multiple-gene sequencing tests for breast cancer risk, Dr. Kurian and her coinvestigators said.

Overall, about one-quarter of women in the study had genetic testing, and that did not change over time. What did change over time was the number of women undergoing multiple-gene testing: In 2013, only 25.6% underwent multiple-gene sequencing, versus 74.4% for BRCA1/2-only testing; by 2015, those figures flipped to 66.5% and 33.5%, respectively.

Multiple-gene sequencing increased detection of pathogenic variants in women at average pretest risk (4.2% versus 2.2% for BRCA1/2-only testing), according to the reported data. Detection was increased in women at high pretest risk due to young age, triple-negative breast cancer, or other factors (12% versus 7.8%).

SOURCE: Kurian AW et al. JAMA Oncol. 2018 May 10. doi: 10.1001/jamaoncol.2018.0644.

When 14-year-old Ryan saw his pediatrician for his annual physical this past August, he was asked a few quick questions about whether he was having any problems, if he was feeling depressed or anxious, and if there was anything he wanted to discuss. Ryan said no to each question, then the doctor examined him, reminded him to get a flu shot, and signed off on the forms he needed to play team sports in high school. The doctor assured Ryan’s mother that he was healthy, and the visit was over. Next August, Ryan’s exam will likely include a more detailed look at his mental health.

In February 2018, the American Academy of Pediatrics updated its guidelines on screening for depression in adolescents in primary care settings. The guidelines address the problem of undiagnosed and untreated psychiatric illness in children over the age of 10 years, the shortage of available mental health professionals, and techniques primary care physicians might use to address psychiatric needs in adolescents. The AAP guidelines include a new recommendation for universal screening with an assessment tool: “Adolescent patients ages 12 years and older should be screened annually for depression [MDD or depressive disorders] with a formal self-report screening tool either on paper or electronically.”

KatarzynaBialasiewicz/Thinkstock

When 14-year-old Ryan saw his pediatrician for his annual physical this past August, he was asked a few quick questions about whether he was having any problems, if he was feeling depressed or anxious, and if there was anything he wanted to discuss. Ryan said no to each question, then the doctor examined him, reminded him to get a flu shot, and signed off on the forms he needed to play team sports in high school. The doctor assured Ryan’s mother that he was healthy, and the visit was over. Next August, Ryan’s exam will likely include a more detailed look at his mental health.

In February 2018, the American Academy of Pediatrics updated its guidelines on screening for depression in adolescents in primary care settings. The guidelines address the problem of undiagnosed and untreated psychiatric illness in children over the age of 10 years, the shortage of available mental health professionals, and techniques primary care physicians might use to address psychiatric needs in adolescents. The AAP guidelines include a new recommendation for universal screening with an assessment tool: “Adolescent patients ages 12 years and older should be screened annually for depression [MDD or depressive disorders] with a formal self-report screening tool either on paper or electronically.”

KatarzynaBialasiewicz/Thinkstock

When 14-year-old Ryan saw his pediatrician for his annual physical this past August, he was asked a few quick questions about whether he was having any problems, if he was feeling depressed or anxious, and if there was anything he wanted to discuss. Ryan said no to each question, then the doctor examined him, reminded him to get a flu shot, and signed off on the forms he needed to play team sports in high school. The doctor assured Ryan’s mother that he was healthy, and the visit was over. Next August, Ryan’s exam will likely include a more detailed look at his mental health.

In February 2018, the American Academy of Pediatrics updated its guidelines on screening for depression in adolescents in primary care settings. The guidelines address the problem of undiagnosed and untreated psychiatric illness in children over the age of 10 years, the shortage of available mental health professionals, and techniques primary care physicians might use to address psychiatric needs in adolescents. The AAP guidelines include a new recommendation for universal screening with an assessment tool: “Adolescent patients ages 12 years and older should be screened annually for depression [MDD or depressive disorders] with a formal self-report screening tool either on paper or electronically.”

KatarzynaBialasiewicz/Thinkstock

Thank you for all you do to champion lung health. Your donation supports projects, such as grant funding, which are boosting patient outcomes, improving community health, and advancing the research that continues to enhance the journey for those facing pulmonary illnesses. Each year, your generosity funds more than $550,000 in clinical research and community service grants, allowing CHEST members to develop and implement their ideas through securing preliminary data support, distinguishing themselves among their colleagues, and advancing chest medicine toward medical breakthroughs.

One such story of the advancements being made in communities around the world begins in New York City.

Though Dr. Lovinsky’s career as a researcher grew from the foundation grant, she says, “The benefit of this award specifically was the gateway to the CHEST Foundation and all of the other opportunities within CHEST.” She is actively involved in the Diversity and Inclusion Task Force and brings many ideas to the table for the future of the CHEST Foundation. “I am committed to being involved with CHEST because of how much the organization has impacted my career. I enjoy giving back by participating in the task force.” Her clinical research and involvement in CHEST demonstrates the direct impact your generous support has on physicians, patients, and lung health.

Thank you for making important research like this possible. Your generosity is the catalyst for change in a world where lung diseases are ranking as one of the top causes of death for men and women everywhere. You’re improving patient outcomes every day, and we thank you from the bottom of our hearts.

Your continued support will make it possible for the next generation of researchers to launch their careers. You can be a Champion for Lung Health and DONATE today through a new gift to the CHEST Foundation. We can meet our goals for the health professionals, patients, and caregivers we serve with your much appreciated and essential support.

To donate:

Web: chestfoundation.org/donate

Phone:224/521-9527

Again, thank you for all you do to improve patient outcomes. You are the lung health champions that patients and families count on to positively impact lung health.


Lisa K. Moores, MD, FCCP

President & Trustee

Mike E. Nelson, MD, FCCP

Immediate Past President & Trustee

Thank you for all you do to champion lung health. Your donation supports projects, such as grant funding, which are boosting patient outcomes, improving community health, and advancing the research that continues to enhance the journey for those facing pulmonary illnesses. Each year, your generosity funds more than $550,000 in clinical research and community service grants, allowing CHEST members to develop and implement their ideas through securing preliminary data support, distinguishing themselves among their colleagues, and advancing chest medicine toward medical breakthroughs.

One such story of the advancements being made in communities around the world begins in New York City.

Though Dr. Lovinsky’s career as a researcher grew from the foundation grant, she says, “The benefit of this award specifically was the gateway to the CHEST Foundation and all of the other opportunities within CHEST.” She is actively involved in the Diversity and Inclusion Task Force and brings many ideas to the table for the future of the CHEST Foundation. “I am committed to being involved with CHEST because of how much the organization has impacted my career. I enjoy giving back by participating in the task force.” Her clinical research and involvement in CHEST demonstrates the direct impact your generous support has on physicians, patients, and lung health.

Thank you for making important research like this possible. Your generosity is the catalyst for change in a world where lung diseases are ranking as one of the top causes of death for men and women everywhere. You’re improving patient outcomes every day, and we thank you from the bottom of our hearts.

Your continued support will make it possible for the next generation of researchers to launch their careers. You can be a Champion for Lung Health and DONATE today through a new gift to the CHEST Foundation. We can meet our goals for the health professionals, patients, and caregivers we serve with your much appreciated and essential support.

To donate:

Web: chestfoundation.org/donate

Phone:224/521-9527

Again, thank you for all you do to improve patient outcomes. You are the lung health champions that patients and families count on to positively impact lung health.


Lisa K. Moores, MD, FCCP

President & Trustee

Mike E. Nelson, MD, FCCP

Immediate Past President & Trustee

Thank you for all you do to champion lung health. Your donation supports projects, such as grant funding, which are boosting patient outcomes, improving community health, and advancing the research that continues to enhance the journey for those facing pulmonary illnesses. Each year, your generosity funds more than $550,000 in clinical research and community service grants, allowing CHEST members to develop and implement their ideas through securing preliminary data support, distinguishing themselves among their colleagues, and advancing chest medicine toward medical breakthroughs.

One such story of the advancements being made in communities around the world begins in New York City.

Though Dr. Lovinsky’s career as a researcher grew from the foundation grant, she says, “The benefit of this award specifically was the gateway to the CHEST Foundation and all of the other opportunities within CHEST.” She is actively involved in the Diversity and Inclusion Task Force and brings many ideas to the table for the future of the CHEST Foundation. “I am committed to being involved with CHEST because of how much the organization has impacted my career. I enjoy giving back by participating in the task force.” Her clinical research and involvement in CHEST demonstrates the direct impact your generous support has on physicians, patients, and lung health.

Thank you for making important research like this possible. Your generosity is the catalyst for change in a world where lung diseases are ranking as one of the top causes of death for men and women everywhere. You’re improving patient outcomes every day, and we thank you from the bottom of our hearts.

Your continued support will make it possible for the next generation of researchers to launch their careers. You can be a Champion for Lung Health and DONATE today through a new gift to the CHEST Foundation. We can meet our goals for the health professionals, patients, and caregivers we serve with your much appreciated and essential support.

To donate:

Web: chestfoundation.org/donate

Phone:224/521-9527

Again, thank you for all you do to improve patient outcomes. You are the lung health champions that patients and families count on to positively impact lung health.


Lisa K. Moores, MD, FCCP

President & Trustee

Mike E. Nelson, MD, FCCP

Immediate Past President & Trustee

To remain at the forefront of expanding evidence-based practices in all aspects of critical care, facilities must include teleICUs.

In 2013, the American Association of Critical-Care Nurses (AACN) first defined standards for the emerging telenursing practice in the ICU and has recently published an update, AACN TeleICU Nursing Practice: An Expert Consensus Statement Supporting High Acuity, Progressive and Critical Care.¹

The new consensus statement, which creates a framework for implementing, evaluating, and improving teleICU nursing practice, addresses the new findings in this fast-growing area of health care. It also establishes a model for achieving excellence and optimal patient care outcomes through the following:

• Shared knowledge and goals

• Mutual respect

• Skilled communication

• True collaboration

• Authentic leadership

• Optimized technology

• Practice excellence

A 12-person task force, including teleICU nurse leaders, contributed to the statement and brought a fresh perspective to this area of practice.

Task force co-chair Pat Herr, clinical integration director of eCARE ICU at Avera Health, says it was important to harness the energy and lessons learned from experienced teleICU leaders.

“TeleICUs continue to evolve to meet the needs of patients and health systems,” Herr adds. “New technology options and new partnership models are available, and nurse leaders play an important part in using these tools to improve patient care.”

The earliest teleICU design concepts employed a physician-only model of care, but it quickly became clear that critical-care nursing was a necessary component. Today, the most effective teleICU models implement collaborative care that includes physicians, nurses, information technology, and administrative support personnel.Opportunities in teleICU are one way to retain knowledgeable nurses, who can bridge clinical expertise gaps and provide an additional layer of skilled critical care. TeleICU care ensures delivery of both optimal patient outcomes and timely knowledge to support physicians, nurses, and the entire bedside care team.

Task force member Lisa-Mae Williams, operations director of telehealth and eICU at Baptist Health South Florida, says telemedicine doesn’t mean fewer jobs for bedside nurses; it’s an extra set of eyes to surveil vitals and support a clinical workforce that may be stretched thin.

“At the bedside, when teleICU came to my unit, I was very skeptical,” Williams recalls. “But after seeing for myself what those extra nurses brought to the table – the available technology and time they had to assess trends and really delve into what’s going on – it turned out to be the best tool to care for our patients.”

In addition to knowledge gaps, nurse turnover is on the rise, according to the “2017 Survey of Registered Nurses: Viewpoints on Leadership, Nursing, Shortages and Their Profession” from AMN Healthcare, San Diego.² The survey also finds that more than one in four nurses plan to retire within a year, and 73% of baby boomers expect to retire in 3 years or less.

The shortfall is already more pronounced in rural hospitals facing staffing challenges and in specialty areas where additional education, training, and experience are critical to improve patient safety and outcomes.

The expertise and dynamic, front-line viewpoint of teleICU experts has resulted in a comprehensive, patient-centric update. Their experience delivering both bedside and remote care was instrumental in developing valuable clinical scenarios. The scenarios in the statement are genuine examples of how each key recommendation is implemented by physicians and bedside and teleICU nurses to provide continuity of care; identify high-risk patients; and decrease mortality rates by filling gaps in monitoring and staff expertise.

As a leader in the delivery of evidence-based practices, AACN offers CCRN-E specialty certification³ for nurses who primarily provide acute or critical care for adult patients in a teleICU setting, which is connected to the bedside via audiovisual communication and computer systems. Visit www.aacn.org > Certification > Get Certified > CCRN-E Adult to learn more.

The expert consensus statement is available for AACN members to download or to purchase a hard copy.⁴

References

1. https://www.aacn.org/nursing-excellence/standards/aacn-teleicu-nursing-consensus-statement

2. https://www.amnhealthcare.com/uploadedFiles/MainSite/Content/Campaigns/AMN%20Healthcare%202017%20RN%20Survey%20-%20Full%20Report.pdf 3. https://www.aacn.org/certification/get-certified/ccrn-e-adult

4. https://www.aacn.org/nursing-excellence/standards/aacn-teleicu-nursing-consensus-statement

To remain at the forefront of expanding evidence-based practices in all aspects of critical care, facilities must include teleICUs.

In 2013, the American Association of Critical-Care Nurses (AACN) first defined standards for the emerging telenursing practice in the ICU and has recently published an update, AACN TeleICU Nursing Practice: An Expert Consensus Statement Supporting High Acuity, Progressive and Critical Care.¹

The new consensus statement, which creates a framework for implementing, evaluating, and improving teleICU nursing practice, addresses the new findings in this fast-growing area of health care. It also establishes a model for achieving excellence and optimal patient care outcomes through the following:

• Shared knowledge and goals

• Mutual respect

• Skilled communication

• True collaboration

• Authentic leadership

• Optimized technology

• Practice excellence

A 12-person task force, including teleICU nurse leaders, contributed to the statement and brought a fresh perspective to this area of practice.

Task force co-chair Pat Herr, clinical integration director of eCARE ICU at Avera Health, says it was important to harness the energy and lessons learned from experienced teleICU leaders.

“TeleICUs continue to evolve to meet the needs of patients and health systems,” Herr adds. “New technology options and new partnership models are available, and nurse leaders play an important part in using these tools to improve patient care.”

The earliest teleICU design concepts employed a physician-only model of care, but it quickly became clear that critical-care nursing was a necessary component. Today, the most effective teleICU models implement collaborative care that includes physicians, nurses, information technology, and administrative support personnel.Opportunities in teleICU are one way to retain knowledgeable nurses, who can bridge clinical expertise gaps and provide an additional layer of skilled critical care. TeleICU care ensures delivery of both optimal patient outcomes and timely knowledge to support physicians, nurses, and the entire bedside care team.

Task force member Lisa-Mae Williams, operations director of telehealth and eICU at Baptist Health South Florida, says telemedicine doesn’t mean fewer jobs for bedside nurses; it’s an extra set of eyes to surveil vitals and support a clinical workforce that may be stretched thin.

“At the bedside, when teleICU came to my unit, I was very skeptical,” Williams recalls. “But after seeing for myself what those extra nurses brought to the table – the available technology and time they had to assess trends and really delve into what’s going on – it turned out to be the best tool to care for our patients.”

In addition to knowledge gaps, nurse turnover is on the rise, according to the “2017 Survey of Registered Nurses: Viewpoints on Leadership, Nursing, Shortages and Their Profession” from AMN Healthcare, San Diego.² The survey also finds that more than one in four nurses plan to retire within a year, and 73% of baby boomers expect to retire in 3 years or less.

The shortfall is already more pronounced in rural hospitals facing staffing challenges and in specialty areas where additional education, training, and experience are critical to improve patient safety and outcomes.

The expertise and dynamic, front-line viewpoint of teleICU experts has resulted in a comprehensive, patient-centric update. Their experience delivering both bedside and remote care was instrumental in developing valuable clinical scenarios. The scenarios in the statement are genuine examples of how each key recommendation is implemented by physicians and bedside and teleICU nurses to provide continuity of care; identify high-risk patients; and decrease mortality rates by filling gaps in monitoring and staff expertise.

As a leader in the delivery of evidence-based practices, AACN offers CCRN-E specialty certification³ for nurses who primarily provide acute or critical care for adult patients in a teleICU setting, which is connected to the bedside via audiovisual communication and computer systems. Visit www.aacn.org > Certification > Get Certified > CCRN-E Adult to learn more.

The expert consensus statement is available for AACN members to download or to purchase a hard copy.⁴

References

1. https://www.aacn.org/nursing-excellence/standards/aacn-teleicu-nursing-consensus-statement

2. https://www.amnhealthcare.com/uploadedFiles/MainSite/Content/Campaigns/AMN%20Healthcare%202017%20RN%20Survey%20-%20Full%20Report.pdf 3. https://www.aacn.org/certification/get-certified/ccrn-e-adult

4. https://www.aacn.org/nursing-excellence/standards/aacn-teleicu-nursing-consensus-statement

To remain at the forefront of expanding evidence-based practices in all aspects of critical care, facilities must include teleICUs.

In 2013, the American Association of Critical-Care Nurses (AACN) first defined standards for the emerging telenursing practice in the ICU and has recently published an update, AACN TeleICU Nursing Practice: An Expert Consensus Statement Supporting High Acuity, Progressive and Critical Care.¹

The new consensus statement, which creates a framework for implementing, evaluating, and improving teleICU nursing practice, addresses the new findings in this fast-growing area of health care. It also establishes a model for achieving excellence and optimal patient care outcomes through the following:

• Shared knowledge and goals

• Mutual respect

• Skilled communication

• True collaboration

• Authentic leadership

• Optimized technology

• Practice excellence

A 12-person task force, including teleICU nurse leaders, contributed to the statement and brought a fresh perspective to this area of practice.

Task force co-chair Pat Herr, clinical integration director of eCARE ICU at Avera Health, says it was important to harness the energy and lessons learned from experienced teleICU leaders.

“TeleICUs continue to evolve to meet the needs of patients and health systems,” Herr adds. “New technology options and new partnership models are available, and nurse leaders play an important part in using these tools to improve patient care.”

The earliest teleICU design concepts employed a physician-only model of care, but it quickly became clear that critical-care nursing was a necessary component. Today, the most effective teleICU models implement collaborative care that includes physicians, nurses, information technology, and administrative support personnel.Opportunities in teleICU are one way to retain knowledgeable nurses, who can bridge clinical expertise gaps and provide an additional layer of skilled critical care. TeleICU care ensures delivery of both optimal patient outcomes and timely knowledge to support physicians, nurses, and the entire bedside care team.

Task force member Lisa-Mae Williams, operations director of telehealth and eICU at Baptist Health South Florida, says telemedicine doesn’t mean fewer jobs for bedside nurses; it’s an extra set of eyes to surveil vitals and support a clinical workforce that may be stretched thin.

“At the bedside, when teleICU came to my unit, I was very skeptical,” Williams recalls. “But after seeing for myself what those extra nurses brought to the table – the available technology and time they had to assess trends and really delve into what’s going on – it turned out to be the best tool to care for our patients.”

In addition to knowledge gaps, nurse turnover is on the rise, according to the “2017 Survey of Registered Nurses: Viewpoints on Leadership, Nursing, Shortages and Their Profession” from AMN Healthcare, San Diego.² The survey also finds that more than one in four nurses plan to retire within a year, and 73% of baby boomers expect to retire in 3 years or less.

The shortfall is already more pronounced in rural hospitals facing staffing challenges and in specialty areas where additional education, training, and experience are critical to improve patient safety and outcomes.

The expertise and dynamic, front-line viewpoint of teleICU experts has resulted in a comprehensive, patient-centric update. Their experience delivering both bedside and remote care was instrumental in developing valuable clinical scenarios. The scenarios in the statement are genuine examples of how each key recommendation is implemented by physicians and bedside and teleICU nurses to provide continuity of care; identify high-risk patients; and decrease mortality rates by filling gaps in monitoring and staff expertise.

As a leader in the delivery of evidence-based practices, AACN offers CCRN-E specialty certification³ for nurses who primarily provide acute or critical care for adult patients in a teleICU setting, which is connected to the bedside via audiovisual communication and computer systems. Visit www.aacn.org > Certification > Get Certified > CCRN-E Adult to learn more.

The expert consensus statement is available for AACN members to download or to purchase a hard copy.⁴

References

1. https://www.aacn.org/nursing-excellence/standards/aacn-teleicu-nursing-consensus-statement

2. https://www.amnhealthcare.com/uploadedFiles/MainSite/Content/Campaigns/AMN%20Healthcare%202017%20RN%20Survey%20-%20Full%20Report.pdf 3. https://www.aacn.org/certification/get-certified/ccrn-e-adult

4. https://www.aacn.org/nursing-excellence/standards/aacn-teleicu-nursing-consensus-statement

Drs. Neil Freedman and Barbara Phillips represented CHEST at an FDA workshop on April 16 on “Study Design Considerations for Devices Including Digital Health Technologies for Sleep-Disordered Breathing (SDB) in Adults. The other organizational participants were The American Academy of Dental Sleep Medicine; The American Academy of Neurology; the American Academy of Otolaryngology, Head and Neck Surgery; The American Academy of Sleep Medicine; and The American Sleep Apnea Association. Here are the questions that the FDA asked the panelists:

1. FDA is seeking to promote innovation and expedite the clinical development of devices intended for the diagnosis and treatment of sleep-disordered breathing (SDB). How should the following conditions (including their severity, eg, mild, moderate, severe, if appropriate) be defined for the purpose of creating appropriate inclusion/exclusion criteria for a clinical study for SDB devices?

a. Apnea

b. Hypopnea

c. Sleep-Disordered Breathing (SDB)

d. Obstructive Sleep Apnea Syndrome (OSAS)

e. Central Sleep Apnea Syndrome (CSAS)

f. Primary Snoring

2. Polysomnography (PSG) has been widely accepted as the “gold standard” test for the diagnosis of OSA and primary snoring. However, home sleep apnea testing (HSAT) has emerged in recent years as an alternative or complementary diagnostic tool for SDB.

a. Can HSAT be used for establishing a baseline diagnosis and for the collection of clinical performance data for device trials for OSA, CSA, or primary snoring? If so, what are the recommended parameters that should be collected by an HSAT (eg, nasal pressure, oximetry, chest and abdominal respiratory inductance plethysmography)?

b. What constitutes a technically adequate test (either PSG or HSAT, if appropriate) for establishing a baseline diagnosis of SDB for device studies (eg, number of hours, number of nights)?

3. FDA has received an increasing number of premarket applications for devices intended to treat SDB. How should studies for the various technologies (eg, intra-oral appliances, externally worn devices, electrosurgical devices for tissue reduction, and passive or active implantable devices of the upper airway) be designed with respect to the following factors (please consider whether your recommendations would vary if the device was an implant vs an externally worn device):

a. What is the most appropriate control group (eg, comparison to baseline measures, randomization to a concurrent control group)?

b. What is the minimum duration of the study? For implants and surgical procedures, how long after the intervention should the effectiveness endpoint be assessed?

c. What objective parameter or combination of parameters should be used for the primary effectiveness endpoints (eg, AHI, ODI, T90, or other non-PSG/HSAT parameters)?

d. What would be a clinically meaningful difference for the above primary effectiveness endpoint(s) between/among study arms or within a study arm?

e. What patient-reported outcomes (PROs) are appropriate in the evaluation of SDB devices?

4. What are the safety and effectiveness concerns when a digital health device provides a diagnosis and monitoring of SDB?

a. What factors are important in developing a reference database (eg, demographics, validation)?b. What are the important safety and effectiveness concerns for SDB digital health devices used in the following settings:

i. A physician office or sleep center environment?

ii. A nonclinical environment?

iii. Prescription vs OTC use?

There was significant discussion and quite a bit of controversy. Among the recommendations to the FDA were that home testing is adequate and acceptable for clinical trials, that the ODI4 is more predictive and reliable than the AHI, and that the syndrome of OSAHS includes symptoms, one of the most important of which is sleepiness. It was acknowledged that digital health devices have the potential to greatly increase access to diagnosis, but access to treatment will need to be addressed, as well. I think this was a very important meeting, and the outcome will likely impact our members. The ultimate goal is to publish a paper about recommended techniques, outcomes, and inclusion characteristics/definitions to be used in clinical trials for new devices to diagnose or treat sleep apnea.

Drs. Neil Freedman and Barbara Phillips represented CHEST at an FDA workshop on April 16 on “Study Design Considerations for Devices Including Digital Health Technologies for Sleep-Disordered Breathing (SDB) in Adults. The other organizational participants were The American Academy of Dental Sleep Medicine; The American Academy of Neurology; the American Academy of Otolaryngology, Head and Neck Surgery; The American Academy of Sleep Medicine; and The American Sleep Apnea Association. Here are the questions that the FDA asked the panelists:

1. FDA is seeking to promote innovation and expedite the clinical development of devices intended for the diagnosis and treatment of sleep-disordered breathing (SDB). How should the following conditions (including their severity, eg, mild, moderate, severe, if appropriate) be defined for the purpose of creating appropriate inclusion/exclusion criteria for a clinical study for SDB devices?

a. Apnea

b. Hypopnea

c. Sleep-Disordered Breathing (SDB)

d. Obstructive Sleep Apnea Syndrome (OSAS)

e. Central Sleep Apnea Syndrome (CSAS)

f. Primary Snoring

2. Polysomnography (PSG) has been widely accepted as the “gold standard” test for the diagnosis of OSA and primary snoring. However, home sleep apnea testing (HSAT) has emerged in recent years as an alternative or complementary diagnostic tool for SDB.

a. Can HSAT be used for establishing a baseline diagnosis and for the collection of clinical performance data for device trials for OSA, CSA, or primary snoring? If so, what are the recommended parameters that should be collected by an HSAT (eg, nasal pressure, oximetry, chest and abdominal respiratory inductance plethysmography)?

b. What constitutes a technically adequate test (either PSG or HSAT, if appropriate) for establishing a baseline diagnosis of SDB for device studies (eg, number of hours, number of nights)?

3. FDA has received an increasing number of premarket applications for devices intended to treat SDB. How should studies for the various technologies (eg, intra-oral appliances, externally worn devices, electrosurgical devices for tissue reduction, and passive or active implantable devices of the upper airway) be designed with respect to the following factors (please consider whether your recommendations would vary if the device was an implant vs an externally worn device):

a. What is the most appropriate control group (eg, comparison to baseline measures, randomization to a concurrent control group)?

b. What is the minimum duration of the study? For implants and surgical procedures, how long after the intervention should the effectiveness endpoint be assessed?

c. What objective parameter or combination of parameters should be used for the primary effectiveness endpoints (eg, AHI, ODI, T90, or other non-PSG/HSAT parameters)?

d. What would be a clinically meaningful difference for the above primary effectiveness endpoint(s) between/among study arms or within a study arm?

e. What patient-reported outcomes (PROs) are appropriate in the evaluation of SDB devices?

4. What are the safety and effectiveness concerns when a digital health device provides a diagnosis and monitoring of SDB?

a. What factors are important in developing a reference database (eg, demographics, validation)?b. What are the important safety and effectiveness concerns for SDB digital health devices used in the following settings:

i. A physician office or sleep center environment?

ii. A nonclinical environment?

iii. Prescription vs OTC use?

There was significant discussion and quite a bit of controversy. Among the recommendations to the FDA were that home testing is adequate and acceptable for clinical trials, that the ODI4 is more predictive and reliable than the AHI, and that the syndrome of OSAHS includes symptoms, one of the most important of which is sleepiness. It was acknowledged that digital health devices have the potential to greatly increase access to diagnosis, but access to treatment will need to be addressed, as well. I think this was a very important meeting, and the outcome will likely impact our members. The ultimate goal is to publish a paper about recommended techniques, outcomes, and inclusion characteristics/definitions to be used in clinical trials for new devices to diagnose or treat sleep apnea.

Drs. Neil Freedman and Barbara Phillips represented CHEST at an FDA workshop on April 16 on “Study Design Considerations for Devices Including Digital Health Technologies for Sleep-Disordered Breathing (SDB) in Adults. The other organizational participants were The American Academy of Dental Sleep Medicine; The American Academy of Neurology; the American Academy of Otolaryngology, Head and Neck Surgery; The American Academy of Sleep Medicine; and The American Sleep Apnea Association. Here are the questions that the FDA asked the panelists:

1. FDA is seeking to promote innovation and expedite the clinical development of devices intended for the diagnosis and treatment of sleep-disordered breathing (SDB). How should the following conditions (including their severity, eg, mild, moderate, severe, if appropriate) be defined for the purpose of creating appropriate inclusion/exclusion criteria for a clinical study for SDB devices?

a. Apnea

b. Hypopnea

c. Sleep-Disordered Breathing (SDB)

d. Obstructive Sleep Apnea Syndrome (OSAS)

e. Central Sleep Apnea Syndrome (CSAS)

f. Primary Snoring

2. Polysomnography (PSG) has been widely accepted as the “gold standard” test for the diagnosis of OSA and primary snoring. However, home sleep apnea testing (HSAT) has emerged in recent years as an alternative or complementary diagnostic tool for SDB.

a. Can HSAT be used for establishing a baseline diagnosis and for the collection of clinical performance data for device trials for OSA, CSA, or primary snoring? If so, what are the recommended parameters that should be collected by an HSAT (eg, nasal pressure, oximetry, chest and abdominal respiratory inductance plethysmography)?

b. What constitutes a technically adequate test (either PSG or HSAT, if appropriate) for establishing a baseline diagnosis of SDB for device studies (eg, number of hours, number of nights)?

3. FDA has received an increasing number of premarket applications for devices intended to treat SDB. How should studies for the various technologies (eg, intra-oral appliances, externally worn devices, electrosurgical devices for tissue reduction, and passive or active implantable devices of the upper airway) be designed with respect to the following factors (please consider whether your recommendations would vary if the device was an implant vs an externally worn device):

a. What is the most appropriate control group (eg, comparison to baseline measures, randomization to a concurrent control group)?

b. What is the minimum duration of the study? For implants and surgical procedures, how long after the intervention should the effectiveness endpoint be assessed?

c. What objective parameter or combination of parameters should be used for the primary effectiveness endpoints (eg, AHI, ODI, T90, or other non-PSG/HSAT parameters)?

d. What would be a clinically meaningful difference for the above primary effectiveness endpoint(s) between/among study arms or within a study arm?

e. What patient-reported outcomes (PROs) are appropriate in the evaluation of SDB devices?

4. What are the safety and effectiveness concerns when a digital health device provides a diagnosis and monitoring of SDB?

a. What factors are important in developing a reference database (eg, demographics, validation)?b. What are the important safety and effectiveness concerns for SDB digital health devices used in the following settings:

i. A physician office or sleep center environment?

ii. A nonclinical environment?

iii. Prescription vs OTC use?

There was significant discussion and quite a bit of controversy. Among the recommendations to the FDA were that home testing is adequate and acceptable for clinical trials, that the ODI4 is more predictive and reliable than the AHI, and that the syndrome of OSAHS includes symptoms, one of the most important of which is sleepiness. It was acknowledged that digital health devices have the potential to greatly increase access to diagnosis, but access to treatment will need to be addressed, as well. I think this was a very important meeting, and the outcome will likely impact our members. The ultimate goal is to publish a paper about recommended techniques, outcomes, and inclusion characteristics/definitions to be used in clinical trials for new devices to diagnose or treat sleep apnea.

Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) each affect at least 10% of the general adult population and, thus, both disorders together, commonly referred to as the overlap syndrome, could be expected in at least 1% of adults by chance alone. However, there is evidence of important interactions between the disorders that influence the prevalence of the overlap, which have implications for the development of comorbidities,and also for management (McNicholas WT. Chest. 2017; 152[6]:1318). Furthermore, sleep quality is typically poor in COPD, which has been linked to worse pulmonary function and lung hyperinflation and may contribute to daytime fatigue.

Interactions between COPD and OSA that may influence the prevalence of overlap

Previous reports have presented conflicting results regarding the likely association between COPD and OSA, which may partly reflect different definitions of OSA, patient populations, and methodologies of investigation. However, COPD represents a spectrum of clinical phenotypes ranging from the hyperinflated patient with low BMI (predominant emphysema phenotype) to the patient with higher BMI and tendency to right-sided heart failure (predominant chronic bronchitis phenotype). The predominant emphysema phenotype may predispose to a lower likelihood of OSA, and there is recent evidence that lung hyperinflation is protective against the development of OSA by lowering the critical closing pressure of the upper airway during sleep. Furthermore, the degree of emphysema and gas trapping on CT scan of the thorax correlates inversely with apnea-hypopnia index in patients with severe COPD (Krachman SL et al. Ann Am Thorac Soc. 2016;13[7]:1129).

In contrast, the predominant chronic bronchitis phenotype predisposes to a higher likelihood of OSA because of higher BMI and likelihood of right-sided heart failure. Peripheral fluid retention in such patients predisposes to OSA because of the rostral fluid shift that occurs during sleep in the supine position, predisposing to upper airway obstruction by airway narrowing. The COPDGene study reports that the chronic bronchitis phenotype has a higher prevalence of OSA even in the absence of differences in BMI and lung function (Kim V et al. Chest. 2011;140[3]:626). Upper airway inflammation associated with cigarette smoking may also contribute to the development of OSA, and corticosteroid therapy may adversely affect upper airway muscle function. OSA also appears to exacerbate lower airway inflammation in COPD. In practice, most patients with COPD have a mixture of emphysema and chronic bronchitis, and the probability of OSA will represent the balance of these protective and promoting factors in individual patients (Fig 1).

While there is evidence of increased mortality in patients with COPD and OSA alone, a recent report based on the Sleep Heart Health Study somewhat surprisingly found that the incremental contribution of declining lung function to mortality diminished with increasing severity of SDB measured by AHI (Putcha N et al. Am J Respir Crit Care Med. 2016;194[8]:1007). Thus, the epidemiologic relationship of COPD and OSA and related clinical outcomes remains an important research topic comparing different clinical phenotypes.
 

Mechanisms of interaction in the overlap syndrome and implications for comorbidity

COPD and OSA are associated with several overlapping physiological and biological disturbances, including hypoxia and inflammation, which may contribute to cardiovascular and other comorbidities. Thus, the probability should be high that the overlap syndrome will be associated with a greater risk of comorbidity than with either disease alone. Patients with the overlap syndrome demonstrate greater degrees of oxygen desaturation predisposing to pulmonary hypertension, which is especially common in these patients.

COPD and OSA are each associated with systemic inflammation and oxidative stress, and C-reactive protein (CRP) has been identified as a measure of systemic inflammation that is commonly elevated in both disorders, although in OSA, concurrent obesity is an important confounding factor. Systemic inflammation contributes to the development of cardiovascular disease, which is a common complication of both COPD and OSA. Thus, one could expect that cardiovascular disease is particularly prevalent in patients with overlap syndrome, but there are limited data on this relationship, which represents an important research topic.
 

Clinical assessment

Patients with the overlap syndrome present with typical clinical features of each disorder and additional features that reflect the higher prevalence of hypoxemia, hypercapnia, and pulmonary hypertension. Thus, morning headaches reflecting hypercapnia and peripheral edema reflecting right-sided heart failure may be especially common. Screening questionnaires may be helpful in the initial evaluation of likely OSA in patients with COPD, and objective clinical data, including anthropometrics such as age, sex, and BMI, and medical history such as cardiovascular comorbidity, are especially useful in clinical prediction (McNicholas WT. Lancet Respir Med. 2016;4[9]:683). Thus, screening for OSA in patients with COPD should not be complicated, and the widespread failure to do so may reflect a lack of awareness of the possible association by the clinician involved.

The specific diagnosis of OSA in COPD requires some form of overnight sleep study, and there is a growing move toward ambulatory studies that focus on cardiorespiratory variables. Overnight monitoring of oxygen saturation is especially useful, particularly if linked to special analysis software, and may be sufficient in many cases. Full polysomnography can be reserved for select cases where the diagnosis remains in doubt.
 

Management and outcomes

Nocturnal hypoxemia in patients with COPD benefits from inhaled, long-acting beta-agonist and anticholinergic therapy, and mean nocturnal oxygen saturation is 2% to 3% higher on each medication compared with placebo. Supplemental oxygen may be indicated when nocturnal oxygen desaturation persists despite optimum pharmacotherapy and does not appear to be associated with significant additional risk of hypercapnia.

However, in patients with COPD-OSA overlap, nonnvasive pressure support is the most appropriate management option. In patients with predominant OSA, continuous positive airway pressure therapy (CPAP) is the preferred option, but where COPD is the dominant component, noninvasive ventilation (NIV) in the form of bi-level positive airway pressure (BIPAP) may be more appropriate. Recent reports in severe COPD indicate that NIV targeted to markedly reduce hypercapnia is associated with improved quality of life and prolonged survival (Köhnlein T et al. Lancet Respir Med. 2014;2[9]:698), and patients with COPD with persistent hypercapnia following hospitalization with an acute exacerbation show improved clinical outcomes and survival with continuing home NIV (Murphy PB et al. JAMA. 2017;317[21]:2177).

The recognition of co-existing OSA in patients with COPD has important clinical relevance as the management of patients with overlap syndrome is different from COPD alone, and the long-term survival of patients with overlap syndrome not treated with nocturnal positive airway pressure is significantly inferior to those patients with overlap syndrome appropriately treated (Marin JM et al. Am J Respir Crit Care Med. 2010;182[3]:325).
 

Dr. McNicholas is with the Department of Respiratory and Sleep Medicine, St. Vincent’s University Hospital, Dublin School of Medicine, University College Dublin, Ireland.

Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) each affect at least 10% of the general adult population and, thus, both disorders together, commonly referred to as the overlap syndrome, could be expected in at least 1% of adults by chance alone. However, there is evidence of important interactions between the disorders that influence the prevalence of the overlap, which have implications for the development of comorbidities,and also for management (McNicholas WT. Chest. 2017; 152[6]:1318). Furthermore, sleep quality is typically poor in COPD, which has been linked to worse pulmonary function and lung hyperinflation and may contribute to daytime fatigue.

Interactions between COPD and OSA that may influence the prevalence of overlap

Previous reports have presented conflicting results regarding the likely association between COPD and OSA, which may partly reflect different definitions of OSA, patient populations, and methodologies of investigation. However, COPD represents a spectrum of clinical phenotypes ranging from the hyperinflated patient with low BMI (predominant emphysema phenotype) to the patient with higher BMI and tendency to right-sided heart failure (predominant chronic bronchitis phenotype). The predominant emphysema phenotype may predispose to a lower likelihood of OSA, and there is recent evidence that lung hyperinflation is protective against the development of OSA by lowering the critical closing pressure of the upper airway during sleep. Furthermore, the degree of emphysema and gas trapping on CT scan of the thorax correlates inversely with apnea-hypopnia index in patients with severe COPD (Krachman SL et al. Ann Am Thorac Soc. 2016;13[7]:1129).

In contrast, the predominant chronic bronchitis phenotype predisposes to a higher likelihood of OSA because of higher BMI and likelihood of right-sided heart failure. Peripheral fluid retention in such patients predisposes to OSA because of the rostral fluid shift that occurs during sleep in the supine position, predisposing to upper airway obstruction by airway narrowing. The COPDGene study reports that the chronic bronchitis phenotype has a higher prevalence of OSA even in the absence of differences in BMI and lung function (Kim V et al. Chest. 2011;140[3]:626). Upper airway inflammation associated with cigarette smoking may also contribute to the development of OSA, and corticosteroid therapy may adversely affect upper airway muscle function. OSA also appears to exacerbate lower airway inflammation in COPD. In practice, most patients with COPD have a mixture of emphysema and chronic bronchitis, and the probability of OSA will represent the balance of these protective and promoting factors in individual patients (Fig 1).

While there is evidence of increased mortality in patients with COPD and OSA alone, a recent report based on the Sleep Heart Health Study somewhat surprisingly found that the incremental contribution of declining lung function to mortality diminished with increasing severity of SDB measured by AHI (Putcha N et al. Am J Respir Crit Care Med. 2016;194[8]:1007). Thus, the epidemiologic relationship of COPD and OSA and related clinical outcomes remains an important research topic comparing different clinical phenotypes.
 

Mechanisms of interaction in the overlap syndrome and implications for comorbidity

COPD and OSA are associated with several overlapping physiological and biological disturbances, including hypoxia and inflammation, which may contribute to cardiovascular and other comorbidities. Thus, the probability should be high that the overlap syndrome will be associated with a greater risk of comorbidity than with either disease alone. Patients with the overlap syndrome demonstrate greater degrees of oxygen desaturation predisposing to pulmonary hypertension, which is especially common in these patients.

COPD and OSA are each associated with systemic inflammation and oxidative stress, and C-reactive protein (CRP) has been identified as a measure of systemic inflammation that is commonly elevated in both disorders, although in OSA, concurrent obesity is an important confounding factor. Systemic inflammation contributes to the development of cardiovascular disease, which is a common complication of both COPD and OSA. Thus, one could expect that cardiovascular disease is particularly prevalent in patients with overlap syndrome, but there are limited data on this relationship, which represents an important research topic.
 

Clinical assessment

Patients with the overlap syndrome present with typical clinical features of each disorder and additional features that reflect the higher prevalence of hypoxemia, hypercapnia, and pulmonary hypertension. Thus, morning headaches reflecting hypercapnia and peripheral edema reflecting right-sided heart failure may be especially common. Screening questionnaires may be helpful in the initial evaluation of likely OSA in patients with COPD, and objective clinical data, including anthropometrics such as age, sex, and BMI, and medical history such as cardiovascular comorbidity, are especially useful in clinical prediction (McNicholas WT. Lancet Respir Med. 2016;4[9]:683). Thus, screening for OSA in patients with COPD should not be complicated, and the widespread failure to do so may reflect a lack of awareness of the possible association by the clinician involved.

The specific diagnosis of OSA in COPD requires some form of overnight sleep study, and there is a growing move toward ambulatory studies that focus on cardiorespiratory variables. Overnight monitoring of oxygen saturation is especially useful, particularly if linked to special analysis software, and may be sufficient in many cases. Full polysomnography can be reserved for select cases where the diagnosis remains in doubt.
 

Management and outcomes

Nocturnal hypoxemia in patients with COPD benefits from inhaled, long-acting beta-agonist and anticholinergic therapy, and mean nocturnal oxygen saturation is 2% to 3% higher on each medication compared with placebo. Supplemental oxygen may be indicated when nocturnal oxygen desaturation persists despite optimum pharmacotherapy and does not appear to be associated with significant additional risk of hypercapnia.

However, in patients with COPD-OSA overlap, nonnvasive pressure support is the most appropriate management option. In patients with predominant OSA, continuous positive airway pressure therapy (CPAP) is the preferred option, but where COPD is the dominant component, noninvasive ventilation (NIV) in the form of bi-level positive airway pressure (BIPAP) may be more appropriate. Recent reports in severe COPD indicate that NIV targeted to markedly reduce hypercapnia is associated with improved quality of life and prolonged survival (Köhnlein T et al. Lancet Respir Med. 2014;2[9]:698), and patients with COPD with persistent hypercapnia following hospitalization with an acute exacerbation show improved clinical outcomes and survival with continuing home NIV (Murphy PB et al. JAMA. 2017;317[21]:2177).

The recognition of co-existing OSA in patients with COPD has important clinical relevance as the management of patients with overlap syndrome is different from COPD alone, and the long-term survival of patients with overlap syndrome not treated with nocturnal positive airway pressure is significantly inferior to those patients with overlap syndrome appropriately treated (Marin JM et al. Am J Respir Crit Care Med. 2010;182[3]:325).
 

Dr. McNicholas is with the Department of Respiratory and Sleep Medicine, St. Vincent’s University Hospital, Dublin School of Medicine, University College Dublin, Ireland.

Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) each affect at least 10% of the general adult population and, thus, both disorders together, commonly referred to as the overlap syndrome, could be expected in at least 1% of adults by chance alone. However, there is evidence of important interactions between the disorders that influence the prevalence of the overlap, which have implications for the development of comorbidities,and also for management (McNicholas WT. Chest. 2017; 152[6]:1318). Furthermore, sleep quality is typically poor in COPD, which has been linked to worse pulmonary function and lung hyperinflation and may contribute to daytime fatigue.

Interactions between COPD and OSA that may influence the prevalence of overlap

Previous reports have presented conflicting results regarding the likely association between COPD and OSA, which may partly reflect different definitions of OSA, patient populations, and methodologies of investigation. However, COPD represents a spectrum of clinical phenotypes ranging from the hyperinflated patient with low BMI (predominant emphysema phenotype) to the patient with higher BMI and tendency to right-sided heart failure (predominant chronic bronchitis phenotype). The predominant emphysema phenotype may predispose to a lower likelihood of OSA, and there is recent evidence that lung hyperinflation is protective against the development of OSA by lowering the critical closing pressure of the upper airway during sleep. Furthermore, the degree of emphysema and gas trapping on CT scan of the thorax correlates inversely with apnea-hypopnia index in patients with severe COPD (Krachman SL et al. Ann Am Thorac Soc. 2016;13[7]:1129).

In contrast, the predominant chronic bronchitis phenotype predisposes to a higher likelihood of OSA because of higher BMI and likelihood of right-sided heart failure. Peripheral fluid retention in such patients predisposes to OSA because of the rostral fluid shift that occurs during sleep in the supine position, predisposing to upper airway obstruction by airway narrowing. The COPDGene study reports that the chronic bronchitis phenotype has a higher prevalence of OSA even in the absence of differences in BMI and lung function (Kim V et al. Chest. 2011;140[3]:626). Upper airway inflammation associated with cigarette smoking may also contribute to the development of OSA, and corticosteroid therapy may adversely affect upper airway muscle function. OSA also appears to exacerbate lower airway inflammation in COPD. In practice, most patients with COPD have a mixture of emphysema and chronic bronchitis, and the probability of OSA will represent the balance of these protective and promoting factors in individual patients (Fig 1).

While there is evidence of increased mortality in patients with COPD and OSA alone, a recent report based on the Sleep Heart Health Study somewhat surprisingly found that the incremental contribution of declining lung function to mortality diminished with increasing severity of SDB measured by AHI (Putcha N et al. Am J Respir Crit Care Med. 2016;194[8]:1007). Thus, the epidemiologic relationship of COPD and OSA and related clinical outcomes remains an important research topic comparing different clinical phenotypes.
 

Mechanisms of interaction in the overlap syndrome and implications for comorbidity

COPD and OSA are associated with several overlapping physiological and biological disturbances, including hypoxia and inflammation, which may contribute to cardiovascular and other comorbidities. Thus, the probability should be high that the overlap syndrome will be associated with a greater risk of comorbidity than with either disease alone. Patients with the overlap syndrome demonstrate greater degrees of oxygen desaturation predisposing to pulmonary hypertension, which is especially common in these patients.

COPD and OSA are each associated with systemic inflammation and oxidative stress, and C-reactive protein (CRP) has been identified as a measure of systemic inflammation that is commonly elevated in both disorders, although in OSA, concurrent obesity is an important confounding factor. Systemic inflammation contributes to the development of cardiovascular disease, which is a common complication of both COPD and OSA. Thus, one could expect that cardiovascular disease is particularly prevalent in patients with overlap syndrome, but there are limited data on this relationship, which represents an important research topic.
 

Clinical assessment

Patients with the overlap syndrome present with typical clinical features of each disorder and additional features that reflect the higher prevalence of hypoxemia, hypercapnia, and pulmonary hypertension. Thus, morning headaches reflecting hypercapnia and peripheral edema reflecting right-sided heart failure may be especially common. Screening questionnaires may be helpful in the initial evaluation of likely OSA in patients with COPD, and objective clinical data, including anthropometrics such as age, sex, and BMI, and medical history such as cardiovascular comorbidity, are especially useful in clinical prediction (McNicholas WT. Lancet Respir Med. 2016;4[9]:683). Thus, screening for OSA in patients with COPD should not be complicated, and the widespread failure to do so may reflect a lack of awareness of the possible association by the clinician involved.

The specific diagnosis of OSA in COPD requires some form of overnight sleep study, and there is a growing move toward ambulatory studies that focus on cardiorespiratory variables. Overnight monitoring of oxygen saturation is especially useful, particularly if linked to special analysis software, and may be sufficient in many cases. Full polysomnography can be reserved for select cases where the diagnosis remains in doubt.
 

Management and outcomes

Nocturnal hypoxemia in patients with COPD benefits from inhaled, long-acting beta-agonist and anticholinergic therapy, and mean nocturnal oxygen saturation is 2% to 3% higher on each medication compared with placebo. Supplemental oxygen may be indicated when nocturnal oxygen desaturation persists despite optimum pharmacotherapy and does not appear to be associated with significant additional risk of hypercapnia.

However, in patients with COPD-OSA overlap, nonnvasive pressure support is the most appropriate management option. In patients with predominant OSA, continuous positive airway pressure therapy (CPAP) is the preferred option, but where COPD is the dominant component, noninvasive ventilation (NIV) in the form of bi-level positive airway pressure (BIPAP) may be more appropriate. Recent reports in severe COPD indicate that NIV targeted to markedly reduce hypercapnia is associated with improved quality of life and prolonged survival (Köhnlein T et al. Lancet Respir Med. 2014;2[9]:698), and patients with COPD with persistent hypercapnia following hospitalization with an acute exacerbation show improved clinical outcomes and survival with continuing home NIV (Murphy PB et al. JAMA. 2017;317[21]:2177).

The recognition of co-existing OSA in patients with COPD has important clinical relevance as the management of patients with overlap syndrome is different from COPD alone, and the long-term survival of patients with overlap syndrome not treated with nocturnal positive airway pressure is significantly inferior to those patients with overlap syndrome appropriately treated (Marin JM et al. Am J Respir Crit Care Med. 2010;182[3]:325).
 

Dr. McNicholas is with the Department of Respiratory and Sleep Medicine, St. Vincent’s University Hospital, Dublin School of Medicine, University College Dublin, Ireland.