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special features 
Shine Raju, MD; Subha Ghosh, MD; Atul C. Mehta, MD, FACP, FCCP
Topics: ,

Computed tomography (CT) of the chest is one of the most important imaging modalities available to a pulmonologist. The advent of high-resolution CT of the chest has led to its increasing use. While chest radiographs are still useful as an initial test, their utility is limited in the diagnosis of lung diseases which depend on higher resolution images such as interstitial lung diseases and pulmonary vascular diseases. Several metaphorical chest CT signs have been described linking abnormal imaging patterns to lung diseases. Some of these are specific to a disease, while others help narrow the differential diagnosis. Recognizing these imaging patterns and CT signs are thus of vital importance. In the following article, the authors attempt to describe a comprehensive list of the commonly encountered metaphorical chest CT signs and their clinical relevance.

point and counterpoint 
Vivek N. Ahya, M.D., MBA
No abstract is available for this article
point and counterpoint 
Marie Budev, DO, MPH FCCP
No abstract is available for this article
point and counterpoint 
Vivek N. Ahya, M.D., MBA
Topics: , , , ,
No abstract is available for this article
point and counterpoint 
Marie Budev, DO, MPH FCCP
Topics: , , , , , , , ,
No abstract is available for this article
original research 
Maurizio Zanobetti, M.D; Margherita Scorpiniti, M.D.; Chiara Gigli, M.D.; Peiman Nazerian, M.D.; Simone Vanni, M.D.; Francesca Innocenti, M.D.; Valerio T. Stefanone, M.D.; Caterina Savinelli, M.D.; Alessandro Coppa, M.D.; Sofia Bigiarini, M.D.; Francesca Caldi, M.D.; Irene Tassinari, M.D.; Alberto Conti, M.D.; Stefano Grifoni, M.D.; Riccardo Pini, M.D.
Topics: , ,

Background  Acute dyspnea is a common symptom in the emergency department (ED). Standard approach to dyspnea often relies on radiologic and laboratoristic results, causing excessive delay before adequate therapy is started; an integrated point-of-care ultrasonography (PoCUS) approach can shorten the time needed to formulate a diagnosis maintaining an acceptable safety profile.

Methods  Consecutive adult patients presenting with dyspnea and admitted after ED evaluation were prospectively enrolled. The gold standard was the final diagnosis assessed by two expert reviewers. Two physicians independently evaluated the patient: sonographer performed ultrasonography (US) evaluation of lung, heart and inferior vena cava, while treating physician requested traditional tests as needed. Time needed to formulate US and ED diagnosis was recorded and compared. Accuracy and concordance of US and ED diagnosis were calculated.

Results  2683 patients were enrolled. Average time needed to formulate US diagnosis was significantly lower than that required for ED diagnosis (24±10 min vs 186±72 min, p 0.025). US and ED diagnosis showed a good overall concordance (k=0.71). There were no statistically significant differences in the accuracy of PoCUS and standard ED workup for the diagnosis of acute coronary syndrome, pneumonia, pleural effusion, pericardial effusion, pneumothorax and dyspnea from other causes; PoCUS was significantly more sensitive for the diagnosis of heart failure, while standard ED workup performed better in the diagnosis of chronic obstructive pulmonary disease/asthma and pulmonary embolism.

Conclusions  PoCUS represents a feasible and reliable diagnostic approach to the dyspnoic patient, allowing a reduction of the diagnostic time. This protocol could help to stratify patients who should undergo a more detailed evaluation.

original research 
Agnes Juhasz, MD; Dalma Pap, MD; Imre Barta, PhD; Orsolya Drozdovszky, MSc; Andrea Egresi, PhD; Balazs Antus, MD, DSc
Topics: , ,

Background  Despite accumulating evidence about its adverse health effects, waterpipe tobacco smoking has become very popular among youth. The aim of this study was to compare smoke exposure and the kinetics of exhaled carbon monoxide (eCO) between waterpipe and cigarette smokers under different conditions.

Methods  Using a cross-over study design, changes in eCO and urinary cotinine levels were measured in a cohort of 32 healthy university students following sessions of waterpipe smoking indoor and outdoor. An indoor cigarette smoking session with equal amounts of tobacco was conducted for reference purposes. Both active and passive smokers participated in all sessions.

Results  In indoor sessions we found that among active participants eCO levels were ∼7.5-fold higher in waterpipe users compared to cigarette smokers. eCO levels remained significantly elevated even 10 hours after discontinuing waterpipe smoking. Notably, eCO levels in passive waterpipe smokers were in the same range as in active cigarette smokers. Compared to indoor sessions, eCO levels in active waterpipe users were reduced in outdoor environments. Nonetheless, levels were still higher in these subjects compared to those in active cigarette smokers measured in indoor sessions. Urinary cotinine levels were comparable in active waterpipe and cigarette smokers.

Conclusions  Our results suggest that waterpipe smoking is associated with significantly higher toxicant exposure than cigarette smoking even in outdoor environment. Furthermore, even passive, indoor waterpipe smoke exposure may have significant health hazards compared to those of active cigarette smoking.

original research 
Tamara L. Blake, MClSc; Anne B. Chang, PhD; Mark D. Chatfield, MSc; Helen L. Petsky, PhD; Leanne T. Rodwell, PhD; Michael G. Brown, MAppSc; Deb C. Hill, BSc Nurs; Margaret S. McElrea, PhD
Topics: ,

Background  Fractional exhaled nitric oxide (FeNO) is used clinically as a biomarker of eosinophilic airway inflammation. Awareness of the factors influencing FeNO values is important for valid clinical interpretation.

Methods  We undertook a systematic review of PubMed, Cochrane Library, Scopus and Web of Science databases, as well as reference lists of included articles to evaluate whether ethnicity influences FeNO values, and to determine if this influence affects clinical interpretation according to current guidelines. We included all studies that performed online FeNO measurements on at least 25 healthy, non-Caucasian individuals, and examined the effect of ethnicity on FeNO.

Results  From 62 potential studies, 12 studies were included. One study recruited only children (<12 years), six studies recruited children and/or adolescents, four studies recruited adults only, and a single study involved children, adolescents, and adults. In total, 16 different ethnic populations representing 11 ethnicities were studied. Ethnicity was considered a significant influencing factor in ten of the included studies. We found the geometric mean FeNO to be above the normal healthy range in two studies. We also identified five studies in which at least 5% of participants had FeNO results above the age-specific inflammatory ranges.

Conclusion  Ethnicity influences FeNO values and for some ethnic groups this influence likely affects clinical interpretation according to current guidelines. There is a need to establish healthy FeNO reference ranges for specific ethnic groups in order to improve clinical application.

original research 
Anna M. Civitarese, BS; Eric Ruggieri, PhD; J. Matthias Walz, MD; Deborah Ann Mack, RN, CIC; Stephen O. Heard, MD; Michael Mitchell, MD; Craig M. Lilly, MD; Karen E. Landry, BS; Richard T. Ellison, III, MD
Topics: , , ,

Objective  The rates of central line–associated bloodstream infections (CLABSIs) in United States intensive care units (ICU) have decreased significantly, and a parallel reduction in the rates of total hospital onset bacteremias in these units should also be expected. We report 10-year trends for total hospital onset ICU-associated bacteremias at a tertiary care academic medical center.

Design  This was a retrospective analysis of all positive blood cultures among patients admitted to seven adult ICUs for the period FY2005 through FY2014 according to Centers for Disease Control and Prevention National Healthcare Safety Network definitions. The rate of change for primary and secondary hospital onset BSIs was determined, as was the distribution of organisms responsible for these BSIs.

Setting  Three medical, two general surgical, one combined neurosurgical /trauma, and one cardiac/cardiac surgery adult intensive care units.

Results  Across all ICUs, the rates of primary BSIs progressively fell from 2.11/1000 patient days in FY05 to 0.32/1000 patient days in FY14; an 85.0% decrease (P<0.0001). Secondary BSIs also progressively decreased from 3.56/1000 to 0.66/1000 patient days; an 81.4% decrease (P<0.0001). The decrease of BSI rates remained significant after controlling for the number of blood cultures obtained and patient acuity.

Conclusions  An increased focus on reducing hospital onset infections at the academic medical center during the last 10 years, including multimodal multidisciplinary efforts to prevent central line associated BSIs, pneumonia, Clostridium difficile disease, surgical site infections, and urinary tract infections, was associated with progressive and sustained decreases for both primary and secondary hospital onset BSIs.

original research 
Yan Xu, MD; Sam Schulman, MD, PhD; Dar Dowlatshahi, MD, PhD; Anne M. Holbrook, MD, MSc; Christopher S. Simpson, MD; Lois E. Shepherd, MD; Philip S. Wells, MD, MSc; Antonio Giulivi, MD; Tara Gomes, MHSc; Muhammad Mamdani, PharmD, MPH; Wayne Khuu, MPH; Eliot Frymire, MA; Ana P. Johnson, PhD
Topics: , , ,

Background  Direct oral anticoagulants (DOACs) have expanded the armamentarium for antithrombotic therapy. While DOAC-related major bleeds were associated with favourable outcomes compared to warfarin in clinical trials, warfarin was reversed in <40% of cases, raising concerns about the generalizability of this finding.

Methods  Consecutive patients ≥66 years presenting to five tertiary care hospitals across three cities in Ontario, Canada with diagnoses that included hemorrhage from October 2010 to March 2015. Charts were screened for association with DOAC or warfarin use; eligible cases were abstracted and linked to administrative databases.

Results  Among 19,061 records screened, 2,002 (460 DOAC, 1542 warfarin) were eligible. Reversal agents were frequently used among warfarin bleeds (72.9% vitamin K, 40.7% prothrombin complex concentrates). Red blood cell transfusions occurred more often among DOAC bleeds than warfarin (52.0% vs. 39.5%, adjusted relative risk [aRR] 1.32 [95% CI 1.19 - 2.47]). However, units of blood products transfused were not different between the two groups. Thirty-four DOAC cases (7.4%) received activated prothrombin complex concentrates or recombinant factor VIIa. In-hospital mortality was lower following DOAC bleeding (9.8% vs. 15.2%, aRR 0.66 [95% CI 0.49 – 0.89], although differences in 30-day mortality did not reach statistical significance (12.6% vs. 16.3%, aRR 0.79 [95% CI 0.61 – 1.03]).

Conclusions  In this unselected cohort of patients with oral anticoagulant-related hemorrhage with high rates of warfarin reversal, in-hospital mortality was lower among DOAC-associated bleeds. These findings support the safety of DOACs in routine care and present useful baseline measures for evaluations of DOAC-specific reversal agents.

original research 
Sheila Ramjug, MBChB; Nehal Hussain, MBChB; Judith Hurdman, MD; Catherine Billings, PhD; Athanasios Charampopoulos, MD; Charlie A. Elliot, MD; David G. Kiely, MD; Ian Sabroe, PhD; Smitha Rajaram, MD; Andrew J. Swift, PhD; Robin Condliffe, MD
Topics: , , , ,

Background  Previous studies have identified survival in systemic sclerosis (SSc)-associated pulmonary arterial hypertension (SSc-PAH) to be worse than in idiopathic pulmonary arterial hypertension (IPAH). We investigated differences between these conditions by comparing demographic, haemodynamic and radiological characteristics and outcomes in a large cohort of incident patients.

Methods  651 patients diagnosed with IPAH or SSc-associated pre-capillary pulmonary hypertension were included. Patients with lung disease or ≥2 risk factors for left heart disease were identified leaving a primary analysis set of 375. Sub-group analysis of cardiac magnetic resonance imaging was performed.

Results  Median survival was 7.8 years in IPAH and 3 years in SSc-PAH (p<0.001). SSc-PAH patients were older with less severe haemodynamics but lower gas transfer (DLCO). Independent prognostic factors were age, SSc, DLCO, pulmonary artery saturation and stroke volume. After excluding patients with normal or only mildly elevated resistance there was no difference in the relationship between pulmonary vascular resistance and compliance in IPAH and SSc-PAH. The relationship between mean pulmonary arterial pressure (mPAP) and systolic pulmonary arterial pressure (sPAP) in IPAH was identical to that previously reported (mPAP = 0.61sPAP + 2mmHg). The relationship in SSc-PAH was similar: mPAP = 0.58sPAP + 2mmHg (p-value for difference with IPAH=0.095). The correlation between ventricular mass index assessed at cardiac magnetic resonance imaging and pulmonary vascular resistance was stronger in SSc-PAH.

Conclusion  The reasons for poorer outcomes in SSc-PAH are likely to be multifactorial including, but not limited to, older age and reduced gas transfer.

original research 
Ping Wang, MD; Kirk D. Jones, MD; Anatoly Urisman, MD; Brett M. Elicker, MD; Thomas Urbania, MD; Kerri A. Johannson, MD; Deborah Assayag, MD; Joyce Lee, MD; Paul J. Wolters, MD; Harold R. Collard, MD; Laura L. Koth, MD

Background  The ability of specific histopathological features to predict mortality or lung transplant in chronic hypersensitivity pneumonitis patients is unknown.

Methods  Patients with chronic hypersensitivity pneumonitis diagnosed by surgical lung biopsy were identified from an ongoing longitudinal cohort. The surgical lung biopsy slides were evaluated prospectively by an experienced thoracic pathologist using a standardized checklist to differentiate the major pathologic patterns and score the presence of specific histopathological features. Cox proportional hazard analysis was used to identify independent predictors of transplant-free survival, and Kaplan-Meier analysis was used to visualize outcomes.

Results  119 patients were identified. Patients with fibrotic non-specific interstitial pneumonia (f-NSIP) pattern, bronchiolocentric fibrosis (BF) pattern or usual interstitial pneumonia (UIP) pattern had significantly worse transplant-free survival than those with cellular NSIP (c-NSIP) pattern or peribronchiolar inflammation with poorly formed granulomas (PI-PFG) pattern. No survival difference among patients with f-NSIP pattern, BF pattern or UIP pattern was found. Fibroblastic foci were identified in a subset of biopsies from all pathological patterns. Peribronchiolar fibrosis was noted in all UIP cases. Independent predictors of time to death or transplant included the presence of fibroblast foci or dense collagen fibrosis.

Conclusions  Histopathologic patterns of c-NSIP and PI-PFG had a better transplant-free survival than UIP, f-NSIP and BF patterns. Presence of fibroblast foci or dense collagen fibrosis correlated with progression to death or lung transplantation. Identification of fibroblast foci on biopsies, regardless of the underlying histopathologic pattern, may be a clinically useful predictor of survival in HP patients.

original research 
Yaron B. Gesthalter, MD; Elisa Koppelman, MSW, MPH; Rendelle Bolton, MSW, MA; Christopher G. Slatore, MD, MS; Sue H. Yoon, MSN, NP-C; Hilary C. Cain, MD; Nichole T. Tanner, MD, MSCR; David H. Au, MD, MS; Jack A. Clark, PhD; Renda Soylemez Wiener, MD, MPH

Background  Guidelines recommend lung cancer screening and it is currently being adopted nationwide. The American College of Chest Physicians advises inclusion of specific programmatic components to ensure high-quality screening. However, little is known about how lung cancer screening has been implemented in practice. We sought to evaluate the experience of early-adopting programs, characterize barriers faced, and identify strategies to achieve successful implementation.

Methods  We performed qualitative evaluations of lung cancer screening implementation at three Veterans Health Administration facilities, conducting semi-structured interviews with key staff (n=29). Guided by the Promoting Action on Research Implementation in Health Services framework, we analyzed transcripts using principals of grounded theory.

Results  Programs successfully incorporated most recommended elements of lung cancer screening, although varying in approaches to patient selection, tobacco treatment, and quality audits. Barriers to implementation included managing workload to ensure appropriate evaluation of screen-detected pulmonary nodules and difficulty obtaining primary care buy-in. To manage workload, programs employed nurse coordinators to actively maintain screening registries, held multidisciplinary conferences that generated explicit management recommendations, and rolled out implementation in a staged fashion. Successful strategies to engage primary care included educational sessions, audit and feedback of local outcomes, and assisting with and assigning clear responsibility for nodule evaluation. Capitalizing on pre-existing relationships and including a designated program champion helped facilitate intra-disciplinary communication.

Conclusion  Lung cancer screening implementation is a complex undertaking requiring coordination at many levels. The insight gained from evaluation of these early-adopting programs may inform subsequent design and implementation of lung cancer screening programs.

original research 
Souheil El-Chemaly, MD; Angelo Taveira-Dasilva, MD; Hilary J. Goldberg, MD; Elizabeth Peters, RN; Mary Haughey, RN; Don Bienfang, MD; Amanda M. Jones, RN; Patricia Julien-Williams, RN; Ye Cui, PhD; Julian A. Villalba, MD; Shefali Bagwe, MBBS; Rie Maurer, PhD; Ivan O. Rosas, MD; Joel Moss, MD; Elizabeth P. Henske, MD
Topics: ,

Background  Animal and cellular studies support the importance of autophagy inhibition in lymphangioleiomyomatosis (LAM). In a cohort of subjects with LAM, we tested the hypothesis that treatment with sirolimus and hydroxycholoroquine (an autophagy inhibitor) at 2 different dose levels is safe and well tolerated. Secondary endpoints included changes in lung function.

Methods  This 48-week, two-center Phase I trial evaluated the safety of escalating oral hydroxychloroquine doses (100–200 mg) given twice a day in combination with sirolimus to eligible patients ≥18 years old with LAM. Subjects received combination therapy for 24 weeks followed by an observation phase off study drugs for an additional 24 weeks.

Results  Fourteen patients provided written, informed consent. Thirteen were treated in cohorts of three patients each with escalating hydroxychloroquine doses (200 and 400 mg) and an extension phase at the 400 mg dose. The most common adverse events were mucositis, headache, and diarrhea. No drug-related serious adverse events were reported. Secondary endpoints showed improvement in lung function at 24 weeks, with decrease in lung function at the 48 week time point. When the higher dose of hydroxychloroquine was analyzed separately, FEV1 and FVC remained stable at 48 weeks, but the 6 minute walk distance showed a decrease towards baseline.

Conclusions  The combination of sirolimus and hydroxychloroquine is well tolerated with no dose-limiting adverse events observed at 200 mg twice a day. Potential effects on lung function should be explored in larger trials.

original research 
Claudia Mannini, M.D.; Federico Lavorini, M.D; Alessandro Zanasi, M.D; Federico Saibene, M.D; Luigi Lanata, M.D; Giovanni Fontana, M.D
Topics: , , ,

Background  Cough is produced by the same neuronal pool implicated in respiratory rhythm generation and antitussive drugs acting at the central level, such as the opioids, may depress ventilation. Levodropropizine is classified as a non-opioid, peripherally-acting antitussive drug acting at the level of airway sensory nerves. However, the lack of a central action by Levodropropizine remains to be fully established. We set out to compare the effects of Levodropropizine and the opioid antitussive agent Dihydrocodeine on the respiratory responses to a conventional CO2 re-breathing test in patients with chronic cough of any origin.

Methods  Twenty-four outpatients (aged 39-70 years) with chronic cough were studied. On separate runs, each patient was randomly administered 60 mg Levodropropizine, or 15 mg Dihydrocodeine or matching placebo. Subsequently, patients breathed, for 5 min, a mixture of 93% oxygen and 7% CO2. Fractional end-tidal CO2 (FETCO2) and inspiratory minute ventilation (VI) were continuously monitored. Changes in breathing pattern variables were also assessed.

Results  At variance with Dihydrocodeine, Levodropropizine and placebo did not affect respiratory responses to hypercapnia (P<0.01). The ventilatory increases by hypercapnia were mainly accounted for by a rise in the volume components of the breathing pattern.

Conclusion  The results are consistent with a peripheral action by Levodropropizine; the assessment of ventilatory responses to CO2 may represent a useful tool to investigate the central respiratory effects of antitussives.

original research 
A.J.N. Raymakers, MSc; M. Sadatsafavi, PhD; D.D. Sin, MD; M.A. De Vera, PhD; L.D. Lynd, PhD
Topics: , ,

Background  Patients with chronic obstructive disease (COPD) are often prescribed statins due to the increased prevalence of cardiovascular disease (CVD). There is considerable debate about the benefits conferred by statins in patients with COPD. This study evaluates the association of statin use with all-cause and pulmonary-related mortality in COPD patients.

Methods  This study uses population-based administrative data for the province of British Columbia, Canada. A cohort of COPD patients was identified based on individual patients’ prescription records. Statin exposure was ascertained in the 1-year period after COPD ‘diagnosis’. The primary and secondary outcomes, all-cause and pulmonary-related mortality, respectively, were evaluated in the 1-year period thereafter using multivariate Cox proportional hazards models and several definitions of medication exposure.

Results  There were 39,678 COPD patients that met the study inclusion criteria. Of these, 7,775 (19.6%) had received at least one statin dispensed in the exposure ascertainment window. There were 1446 all-cause deaths recorded within the cohort in the 1-year period after exposure ascertainment. In multivariate analysis, the estimated hazard ratio for statin exposure was 0.79 (95% CI: 0.67-0.92, p=0.0016) suggesting a 21% reduction in the risk from statin use on all-cause mortality. For pulmonary-related mortality, there was also a considerable reduction in the risk all-cause mortality from statin use (HR: 0.55, 95: CI: 0.32-0.93, p=0.02454). These results were robust to different specifications of the exposure ascertainment window.

Conclusions  This study shows that statin use in a population-based cohort of COPD patients may confer benefits in terms of reduced pulmonary-related and all-cause mortality.

contemporary reviews in sleep medicine 
Simon A. Joosten, MBBS, PhD; Garun S. Hamilton, MBBS, PhD; Matthew T. Naughton, MD

The interaction between obesity and obstructive sleep apnea (OSA) is complex. Whilst it is often assumed that obesity is the major cause of OSA, and that treatment of the OSA might mitigate further weight gain, new evidence is emerging that suggest these statements may not be the case. Obesity explains about 60% of the variance of the apnea hypopnea index definition of OSA, mainly in those < 50 years and less so in the elderly. Moreover, long term treatment of OSA with continuous positive airway pressure is associated with small but significant weight gain. This weight gain effect may result from abolition of the increased work of breathing associated with OSA. Weight loss, by either medical or surgical techniques, which often cures type 2 diabetes, has a beneficial effect upon sleep apnoea unfortunately in a minority of patients. A short jaw length may be predictive of a better outcome. The slight fall in the overall apnea hypopnea index with weight loss, however may be associated with a larger drop in the non-supine apnea hypopnea index, thus converting some patients from non-positional to positional (ie supine only) OSA. Importantly, patients undergoing surgical weight loss need close monitoring to prevent complications. Finally, in patients with moderate to severe obesity related OSA, the combination of weight loss with CPAP appears more beneficial than either treatment in isolation.

original research 
Eric Kuhn, MD; Esther I. Schwarz, MD; Daniel J. Bratton, PhD; Valentina A. Rossi, MD; Malcolm Kohler, MD
Topics: ,

Background  Untreated obstructive sleep apnea (OSA) is associated with impaired health-related quality of life (QoL) and excessive daytime sleepiness which have been shown to improve with treatment. The aim was to compare the effects of continuous positive airway pressure (CPAP) and mandibular advancement devices (MAD) on health-related QoL in OSA.

Methods  MEDLINE and Cochrane Library were searched up to November 2015. Randomized controlled trials (RCTs) comparing the effect of CPAP, MADs or an inactive control on health-related QoL assessed by the 36-item short form (SF-36) in OSA. Extraction of study characteristics, quality and bias assessment were independently performed by three authors. A network meta-analysis using multivariate random-effects meta-regression was performed to assess treatment effects on the mental (MCS) and physical (PCS) component summary scores of the SF-36.

Results  Of 1491 identified studies, 23 RCTs were included in the meta-analysis (2342 patients). Compared with an inactive control, CPAP was associated with a 1.7 point (95%CI 0.1-3.2, p=0.036) improvement in the MCS and a 1.7 point (95%CI 0.5-2.9, p=0.005) improvement in the PCS. MAD was associated with a 2.4 points (95%CI 0.0-4.9, p=0.053) and a 1.5 point (95%CI -0.2-3.2, p=0.076) improvement in the MCS and PCS, respectively, compared to inactive controls. There were no statistically significant differences in treatment effects on the SF-36 scores between CPAP and MAD.

Conclusions  CPAP is effective in improving health-related quality of life in OSA, and MADs may be just as effective but further RCTs comparing the two treatments are required.

translating basic research into clinical practice 
Brittany M. Salter, PhD; Roma Sehmi, PhD

Airway eosinophilia is a hallmark of allergic asthma and understanding mechanisms that promote increases in lung eosinophil numbers is important for effective pharmaco-therapeutic development. It has become evident that expansion of hemopoietic compartments in the bone marrow promotes differentiation and trafficking of mature eosinophils to the airways. Hematopoietic progenitor cells egress the bone marrow and home to the lungs, where in-situ differentiative processes within the tissue provide an ongoing source of pro-inflammatory cells. In addition, hematopoietic progenitor cells in the airways can respond to locally-derived alarmins, to produce a panoply of cytokines thereby themselves acting as effector pro-inflammatory cells that potentiate type 2 responses in eosinophilic asthma. In this review, we will provide evidence for these findings and discuss novel targets for modulating eosinophilopoietic processes, migration and effector function of precursor cells.

evidence-based medicine  FREE TO VIEW
John J. Mullon, M.D.; Kristin M. Burkart, M.D., M.Sc.; Gerard Silvestri, M.D.; D. Kyle Hogarth, M.D.; Francisco Almeida, M.D.; David Berkowitz, M.D.; George Eapen, M.D.; David Feller-Kopman, M.D.; Henry E. Fessler, MD; Erik Folch, M.D.; Colin Gillespie, M.D.; Andrew Haas, M.D.; Shaheen Islam, M.D.; Carla Lamb, M.D.; Stephanie M. Levine, M.D.; Adnan Majid, M.D.; Fabien Maldonado, M.D.; Ali Musani, M.D.; Craig Piquette, MD; Cynthia Ray, M.D.; Chakravarthy Reddy, M.D.; Otis Rickman, D.O.; Michael Simoff, M.D.; Momen M. Wahidi, M.D., M.B.A.; Hans Lee, M.D.
Topics: ,

Interventional Pulmonology (IP) is a rapidly evolving subspecialty of pulmonary medicine. In the last ten years formal IP fellowships have increased substantially in number from just five to now over thirty. The vast majority of IP fellowship trainees are selected through the National Residency Matching Program, and validated in-service and certification exams for IP exist. Practice standards and training guidelines for IP fellowship programs have been published, however considerable variability in the environment, curriculum, and experience offered by the various fellowship programs still exists and there is currently no formal accreditation process in place to standardize IP fellowship training. Recognizing the need for more uniform training across the various fellowship programs, a multi-society accreditation committee was formed with the intent to establish common accreditation standards for all IP fellowship programs in the United States. This article provides a summary of those standards and can serve as an accreditation template for training programs and their offices of graduate medical education as they move through the accreditation process.

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    Print ISSN: 0012-3692
    Online ISSN: 1931-3543