Patrice Wendling

Major Finding: Resolution of type 2 diabetes, hypertension, and hyperlipidemia was greatest among duodenal switch patients, at 82%, 67%, and 81%, vs. 64%, 39%, and 55% among Roux-en-Y gastric bypass patients.

Data Source: Data were taken from a chart review and prospective survey of 309 superobese patients.

Disclosures: Dr. Dorman reported no relevant conflicts of interest.

MADISON, WIS. – Total complication rates are high but comparable over the long term between duodenal switch surgery and Roux-en-Y gastric bypass, according to a propensity matched analysis of 309 superobese patients.

“Duodenal switch is a valid alternative to the Roux-en-Y gastric [RYGB] bypass,” especially if diabetes is present, Dr. Robert B. Dorman said. Duodenal switch appears to provide superior resolution of type 2 diabetes.

His conclusion is drawn from a study that focused on the long-term outcomes of 178 consecutive patients who underwent duodenal switch (DS) surgery and 139 propensity matched patients undergoing RYGB. In addition to a chart review, the University of Minnesota Bariatric Surgery Outcomes Survey tool was used to prospectively track patients' weight, comorbid illnesses, adverse outcomes, readmissions, and general health status. Mean follow-up was 3.7 years in the DS group and 6.2 years in the RYGB group.

There were five deaths in the DS group (postop day 38 and months 5, 7, 16, and 66) and three deaths in the RYGB group (postop months 3, 7, and 72), leaving 173 patients and 136 patients, respectively, in the analysis, Dr. Dorman said at the meeting.

Notably, weight loss in the two groups was comparable, decreasing from an average body mass index of 52 kg/m

Resolution of type 2 diabetes, hypertension, and hyperlipidemia was greatest among DS patients at 82%, 67%, and 81%, respectively, compared with 64%, 39%, and 55%, respectively, among RYGB patients.

DS patients, however, experienced significantly more loose stools, bloating, and heartburn than did RYGB patients, who had significantly more constipation. Nausea and emesis were comparable between the two groups.

With regard to complications, DS patients were significantly more likely to visit the emergency department than were RYGB patients (40% vs. 25%) and to experience hair loss (67% vs. 41%), Dr. Dorman said.

There was also a nonsignificant trend for DS patients to be readmitted more often than RYGB patients (25.4% vs. 23.5%) and to have more gastrointestinal leaks (1.7% vs. 0%), abdominal reoperations (29% vs. 23%), total parenteral nutrition/tube feeds (7.6% vs. 3%), and infusion therapy (28.5% vs. 23.5%). The RYGB patients, however, underwent more endoscopy (22% vs. 14%).

Dr. Dorman said providers should explain to patients the adverse symptoms they can expect following DS, but noted that the investigators “still feel DS should be limited to surgeons and centers with experience.”

Invited discussant Dr. James Wallace, a bariatric and general surgeon from the Medical College of Wisconsin, Milwaukee, described the 40% rate of ED visits in the DS group as “extreme,” and questioned the use of nutritional, vitamin, and protein supplementation – particularly in light of the observed hair loss. “I'm unconvinced that the incremental improvement in weight loss and resolution of metabolic derangements justifies the increased nutritional risk of the duodenal switch,” he said.

Dr. Dorman responded that the ED visits may represent a “knee-jerk reflex” on the part of DS patients when they experience a complication.

Duodenal switch seems to provide superior resolution to type 2 diabetes than Roux-en-Y gastric bypass, said Dr. Robert B. Dorman.

Source Patrice Wendling/IMNG Medical Media

Major Finding: Resolution of type 2 diabetes, hypertension, and hyperlipidemia was greatest among duodenal switch patients, at 82%, 67%, and 81%, vs. 64%, 39%, and 55% among Roux-en-Y gastric bypass patients.

Data Source: Data were taken from a chart review and prospective survey of 309 superobese patients.

Disclosures: Dr. Dorman reported no relevant conflicts of interest.

MADISON, WIS. – Total complication rates are high but comparable over the long term between duodenal switch surgery and Roux-en-Y gastric bypass, according to a propensity matched analysis of 309 superobese patients.

“Duodenal switch is a valid alternative to the Roux-en-Y gastric [RYGB] bypass,” especially if diabetes is present, Dr. Robert B. Dorman said. Duodenal switch appears to provide superior resolution of type 2 diabetes.

His conclusion is drawn from a study that focused on the long-term outcomes of 178 consecutive patients who underwent duodenal switch (DS) surgery and 139 propensity matched patients undergoing RYGB. In addition to a chart review, the University of Minnesota Bariatric Surgery Outcomes Survey tool was used to prospectively track patients' weight, comorbid illnesses, adverse outcomes, readmissions, and general health status. Mean follow-up was 3.7 years in the DS group and 6.2 years in the RYGB group.

There were five deaths in the DS group (postop day 38 and months 5, 7, 16, and 66) and three deaths in the RYGB group (postop months 3, 7, and 72), leaving 173 patients and 136 patients, respectively, in the analysis, Dr. Dorman said at the meeting.

Notably, weight loss in the two groups was comparable, decreasing from an average body mass index of 52 kg/m

Resolution of type 2 diabetes, hypertension, and hyperlipidemia was greatest among DS patients at 82%, 67%, and 81%, respectively, compared with 64%, 39%, and 55%, respectively, among RYGB patients.

DS patients, however, experienced significantly more loose stools, bloating, and heartburn than did RYGB patients, who had significantly more constipation. Nausea and emesis were comparable between the two groups.

With regard to complications, DS patients were significantly more likely to visit the emergency department than were RYGB patients (40% vs. 25%) and to experience hair loss (67% vs. 41%), Dr. Dorman said.

There was also a nonsignificant trend for DS patients to be readmitted more often than RYGB patients (25.4% vs. 23.5%) and to have more gastrointestinal leaks (1.7% vs. 0%), abdominal reoperations (29% vs. 23%), total parenteral nutrition/tube feeds (7.6% vs. 3%), and infusion therapy (28.5% vs. 23.5%). The RYGB patients, however, underwent more endoscopy (22% vs. 14%).

Dr. Dorman said providers should explain to patients the adverse symptoms they can expect following DS, but noted that the investigators “still feel DS should be limited to surgeons and centers with experience.”

Invited discussant Dr. James Wallace, a bariatric and general surgeon from the Medical College of Wisconsin, Milwaukee, described the 40% rate of ED visits in the DS group as “extreme,” and questioned the use of nutritional, vitamin, and protein supplementation – particularly in light of the observed hair loss. “I'm unconvinced that the incremental improvement in weight loss and resolution of metabolic derangements justifies the increased nutritional risk of the duodenal switch,” he said.

Dr. Dorman responded that the ED visits may represent a “knee-jerk reflex” on the part of DS patients when they experience a complication.

Duodenal switch seems to provide superior resolution to type 2 diabetes than Roux-en-Y gastric bypass, said Dr. Robert B. Dorman.

Source Patrice Wendling/IMNG Medical Media

Major Finding: Resolution of type 2 diabetes, hypertension, and hyperlipidemia was greatest among duodenal switch patients, at 82%, 67%, and 81%, vs. 64%, 39%, and 55% among Roux-en-Y gastric bypass patients.

Data Source: Data were taken from a chart review and prospective survey of 309 superobese patients.

Disclosures: Dr. Dorman reported no relevant conflicts of interest.

MADISON, WIS. – Total complication rates are high but comparable over the long term between duodenal switch surgery and Roux-en-Y gastric bypass, according to a propensity matched analysis of 309 superobese patients.

“Duodenal switch is a valid alternative to the Roux-en-Y gastric [RYGB] bypass,” especially if diabetes is present, Dr. Robert B. Dorman said. Duodenal switch appears to provide superior resolution of type 2 diabetes.

His conclusion is drawn from a study that focused on the long-term outcomes of 178 consecutive patients who underwent duodenal switch (DS) surgery and 139 propensity matched patients undergoing RYGB. In addition to a chart review, the University of Minnesota Bariatric Surgery Outcomes Survey tool was used to prospectively track patients' weight, comorbid illnesses, adverse outcomes, readmissions, and general health status. Mean follow-up was 3.7 years in the DS group and 6.2 years in the RYGB group.

There were five deaths in the DS group (postop day 38 and months 5, 7, 16, and 66) and three deaths in the RYGB group (postop months 3, 7, and 72), leaving 173 patients and 136 patients, respectively, in the analysis, Dr. Dorman said at the meeting.

Notably, weight loss in the two groups was comparable, decreasing from an average body mass index of 52 kg/m

Resolution of type 2 diabetes, hypertension, and hyperlipidemia was greatest among DS patients at 82%, 67%, and 81%, respectively, compared with 64%, 39%, and 55%, respectively, among RYGB patients.

DS patients, however, experienced significantly more loose stools, bloating, and heartburn than did RYGB patients, who had significantly more constipation. Nausea and emesis were comparable between the two groups.

With regard to complications, DS patients were significantly more likely to visit the emergency department than were RYGB patients (40% vs. 25%) and to experience hair loss (67% vs. 41%), Dr. Dorman said.

There was also a nonsignificant trend for DS patients to be readmitted more often than RYGB patients (25.4% vs. 23.5%) and to have more gastrointestinal leaks (1.7% vs. 0%), abdominal reoperations (29% vs. 23%), total parenteral nutrition/tube feeds (7.6% vs. 3%), and infusion therapy (28.5% vs. 23.5%). The RYGB patients, however, underwent more endoscopy (22% vs. 14%).

Dr. Dorman said providers should explain to patients the adverse symptoms they can expect following DS, but noted that the investigators “still feel DS should be limited to surgeons and centers with experience.”

Invited discussant Dr. James Wallace, a bariatric and general surgeon from the Medical College of Wisconsin, Milwaukee, described the 40% rate of ED visits in the DS group as “extreme,” and questioned the use of nutritional, vitamin, and protein supplementation – particularly in light of the observed hair loss. “I'm unconvinced that the incremental improvement in weight loss and resolution of metabolic derangements justifies the increased nutritional risk of the duodenal switch,” he said.

Dr. Dorman responded that the ED visits may represent a “knee-jerk reflex” on the part of DS patients when they experience a complication.

Duodenal switch seems to provide superior resolution to type 2 diabetes than Roux-en-Y gastric bypass, said Dr. Robert B. Dorman.

Source Patrice Wendling/IMNG Medical Media

LAS VEGAS – For the first time in years, financial constraints have been replaced as the most significant barrier to health IT implementation in the 23rd annual HIMSS Leadership Survey.

Instead, 22% of respondents cited IT staffing as their greatest challenge, up from 17% last year. Inadequate financial support was the top barrier to IT implementation last year for 18% of respondents, falling to 14% this year.

"Meaningful use regulations/incentives are creating an opportunity for health care [providers] to receive funding for IT adoption, and therefore more financial resources are being allocated to health IT in order to attain these financial incentives," HIMSS [Healthcare Information and Management Systems Society] president and chief executive officer H. Stephen Lieber said in an interview.

But the rapid adoption of health IT by so many organizations is placing a strain on staffing. Nearly two-thirds (61%) of respondents said they will hire more IT staff in the next year, with the greatest need in the area of clinical application support (43%).

The HIMSS survey is based on feedback from 302 health IT professionals, largely chief information officers and IT directors, representing more than 600 hospitals throughout the United States.

Achieving meaningful use was identified by 38% of respondents as the top IT priority to be addressed at their organization over the next 2 years. This is a notable decline from last year when 49% of respondents cited the federal meaningful use electronic health record (EHR) incentive program as their top IT priority.

This year’s number two IT priority was a focus on clinical systems such as computerized practitioner order entry, EHRs, or e-prescribing (15%), followed by leveraging information (13%).

Federal Incentives

Implementing International Classification of Diseases, 10th edition diagnosis and procedure codes (ICD-10) continues to be the top financial IT focus for 67% of respondents. The next closest item, upgrading the patient billing system, polled at just 6%.

"Federal initiatives continue to drive the IT decisions made by health care organizations," Mr. Lieber said.

The recent decision by the Health and Human Services department (HHS) to postpone the Oct. 1, 2013, deadline for ICD-10 implementation reverberated throughout the annual HIMSS conference, where the survey was released. Mr. Lieber pointed out that the statement from HHS Secretary Kathleen Sebelius stated that the ICD-10 deadline would be extended for "certain providers."

"I interpret ‘certain’ to mean that it may not be extended for all," he said, adding that no further clarification has been issued by HHS.

Regardless, institutions have spent considerable time and money on the federal initiatives. So far, 26% of respondents said their organization has attested to stage 1 meaningful use and were preparing to meet stage 2 requirements. In addition, 89% of respondents are on track to complete the ICD-10 conversion by the original deadline.

Although 43% of respondents could not say how much their institution had invested in converting to ICD-10, 29% said it was less than $1 million, 15% between $1 million and $4 million, and 4% spent $5 million or more.

Only 5% of respondents indicated that their organization made no additional investment in order to achieve stage 1 meaningful use. One-third reported they will invest less than $1 million, 27% between $1 million and $4 million, and 29% at least $5 million.

Those investments, however, are expected to pay off. A full 23% anticipate they will receive $2 million to $3 million, while 13% expect no less than $10 million in incentives.

IT Security Breaches Continue

The report notes that IT security breaches continue to plague health care organization, although the reduction in violations from 26% last year to 22% this year, suggests efforts to secure patient information are working.

Compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations and Centers for Medicare and Medicaid Services security audits are the top security concerns (34%). This displaces an internal breach of security (32%), which had been the primary security concern for the past several years. One-third of respondents (32%) also expressed concern that their organization’s security systems were inadequate.

"What this shows is that health IT executives continue to hold this as an area of critical importance and diligence," Mr. Lieber said.

Notably, only 6% of respondents expressed concern about the organization’s ability to secure information on mobile devices.

With regard to IT infrastructure priorities, mobile devices were a priority for 18% of organizations, just behind servers/virtual servers at 19%, which was also the top response in 2011. Virtual desktops/laptops and security systems were each identified by 16% of respondents as their primary infrastructure goal. Cloud computing and telemedicine were not on the radar of many organizations, polling at just 3% and 2%, respectively.

When asked to select areas where IT could have the most impact on patient care, the leading answer was once again improving clinical and quality outcomes (38%), followed by reducing medical errors/improving patient safety (22%), and standardization of clinical care using evidence-based medicine (16%).

LAS VEGAS – For the first time in years, financial constraints have been replaced as the most significant barrier to health IT implementation in the 23rd annual HIMSS Leadership Survey.

Instead, 22% of respondents cited IT staffing as their greatest challenge, up from 17% last year. Inadequate financial support was the top barrier to IT implementation last year for 18% of respondents, falling to 14% this year.

"Meaningful use regulations/incentives are creating an opportunity for health care [providers] to receive funding for IT adoption, and therefore more financial resources are being allocated to health IT in order to attain these financial incentives," HIMSS [Healthcare Information and Management Systems Society] president and chief executive officer H. Stephen Lieber said in an interview.

But the rapid adoption of health IT by so many organizations is placing a strain on staffing. Nearly two-thirds (61%) of respondents said they will hire more IT staff in the next year, with the greatest need in the area of clinical application support (43%).

The HIMSS survey is based on feedback from 302 health IT professionals, largely chief information officers and IT directors, representing more than 600 hospitals throughout the United States.

Achieving meaningful use was identified by 38% of respondents as the top IT priority to be addressed at their organization over the next 2 years. This is a notable decline from last year when 49% of respondents cited the federal meaningful use electronic health record (EHR) incentive program as their top IT priority.

This year’s number two IT priority was a focus on clinical systems such as computerized practitioner order entry, EHRs, or e-prescribing (15%), followed by leveraging information (13%).

Federal Incentives

Implementing International Classification of Diseases, 10th edition diagnosis and procedure codes (ICD-10) continues to be the top financial IT focus for 67% of respondents. The next closest item, upgrading the patient billing system, polled at just 6%.

"Federal initiatives continue to drive the IT decisions made by health care organizations," Mr. Lieber said.

The recent decision by the Health and Human Services department (HHS) to postpone the Oct. 1, 2013, deadline for ICD-10 implementation reverberated throughout the annual HIMSS conference, where the survey was released. Mr. Lieber pointed out that the statement from HHS Secretary Kathleen Sebelius stated that the ICD-10 deadline would be extended for "certain providers."

"I interpret ‘certain’ to mean that it may not be extended for all," he said, adding that no further clarification has been issued by HHS.

Regardless, institutions have spent considerable time and money on the federal initiatives. So far, 26% of respondents said their organization has attested to stage 1 meaningful use and were preparing to meet stage 2 requirements. In addition, 89% of respondents are on track to complete the ICD-10 conversion by the original deadline.

Although 43% of respondents could not say how much their institution had invested in converting to ICD-10, 29% said it was less than $1 million, 15% between $1 million and $4 million, and 4% spent $5 million or more.

Only 5% of respondents indicated that their organization made no additional investment in order to achieve stage 1 meaningful use. One-third reported they will invest less than $1 million, 27% between $1 million and $4 million, and 29% at least $5 million.

Those investments, however, are expected to pay off. A full 23% anticipate they will receive $2 million to $3 million, while 13% expect no less than $10 million in incentives.

IT Security Breaches Continue

The report notes that IT security breaches continue to plague health care organization, although the reduction in violations from 26% last year to 22% this year, suggests efforts to secure patient information are working.

Compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations and Centers for Medicare and Medicaid Services security audits are the top security concerns (34%). This displaces an internal breach of security (32%), which had been the primary security concern for the past several years. One-third of respondents (32%) also expressed concern that their organization’s security systems were inadequate.

"What this shows is that health IT executives continue to hold this as an area of critical importance and diligence," Mr. Lieber said.

Notably, only 6% of respondents expressed concern about the organization’s ability to secure information on mobile devices.

With regard to IT infrastructure priorities, mobile devices were a priority for 18% of organizations, just behind servers/virtual servers at 19%, which was also the top response in 2011. Virtual desktops/laptops and security systems were each identified by 16% of respondents as their primary infrastructure goal. Cloud computing and telemedicine were not on the radar of many organizations, polling at just 3% and 2%, respectively.

When asked to select areas where IT could have the most impact on patient care, the leading answer was once again improving clinical and quality outcomes (38%), followed by reducing medical errors/improving patient safety (22%), and standardization of clinical care using evidence-based medicine (16%).

LAS VEGAS – For the first time in years, financial constraints have been replaced as the most significant barrier to health IT implementation in the 23rd annual HIMSS Leadership Survey.

Instead, 22% of respondents cited IT staffing as their greatest challenge, up from 17% last year. Inadequate financial support was the top barrier to IT implementation last year for 18% of respondents, falling to 14% this year.

"Meaningful use regulations/incentives are creating an opportunity for health care [providers] to receive funding for IT adoption, and therefore more financial resources are being allocated to health IT in order to attain these financial incentives," HIMSS [Healthcare Information and Management Systems Society] president and chief executive officer H. Stephen Lieber said in an interview.

But the rapid adoption of health IT by so many organizations is placing a strain on staffing. Nearly two-thirds (61%) of respondents said they will hire more IT staff in the next year, with the greatest need in the area of clinical application support (43%).

The HIMSS survey is based on feedback from 302 health IT professionals, largely chief information officers and IT directors, representing more than 600 hospitals throughout the United States.

Achieving meaningful use was identified by 38% of respondents as the top IT priority to be addressed at their organization over the next 2 years. This is a notable decline from last year when 49% of respondents cited the federal meaningful use electronic health record (EHR) incentive program as their top IT priority.

This year’s number two IT priority was a focus on clinical systems such as computerized practitioner order entry, EHRs, or e-prescribing (15%), followed by leveraging information (13%).

Federal Incentives

Implementing International Classification of Diseases, 10th edition diagnosis and procedure codes (ICD-10) continues to be the top financial IT focus for 67% of respondents. The next closest item, upgrading the patient billing system, polled at just 6%.

"Federal initiatives continue to drive the IT decisions made by health care organizations," Mr. Lieber said.

The recent decision by the Health and Human Services department (HHS) to postpone the Oct. 1, 2013, deadline for ICD-10 implementation reverberated throughout the annual HIMSS conference, where the survey was released. Mr. Lieber pointed out that the statement from HHS Secretary Kathleen Sebelius stated that the ICD-10 deadline would be extended for "certain providers."

"I interpret ‘certain’ to mean that it may not be extended for all," he said, adding that no further clarification has been issued by HHS.

Regardless, institutions have spent considerable time and money on the federal initiatives. So far, 26% of respondents said their organization has attested to stage 1 meaningful use and were preparing to meet stage 2 requirements. In addition, 89% of respondents are on track to complete the ICD-10 conversion by the original deadline.

Although 43% of respondents could not say how much their institution had invested in converting to ICD-10, 29% said it was less than $1 million, 15% between $1 million and $4 million, and 4% spent $5 million or more.

Only 5% of respondents indicated that their organization made no additional investment in order to achieve stage 1 meaningful use. One-third reported they will invest less than $1 million, 27% between $1 million and $4 million, and 29% at least $5 million.

Those investments, however, are expected to pay off. A full 23% anticipate they will receive $2 million to $3 million, while 13% expect no less than $10 million in incentives.

IT Security Breaches Continue

The report notes that IT security breaches continue to plague health care organization, although the reduction in violations from 26% last year to 22% this year, suggests efforts to secure patient information are working.

Compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations and Centers for Medicare and Medicaid Services security audits are the top security concerns (34%). This displaces an internal breach of security (32%), which had been the primary security concern for the past several years. One-third of respondents (32%) also expressed concern that their organization’s security systems were inadequate.

"What this shows is that health IT executives continue to hold this as an area of critical importance and diligence," Mr. Lieber said.

Notably, only 6% of respondents expressed concern about the organization’s ability to secure information on mobile devices.

With regard to IT infrastructure priorities, mobile devices were a priority for 18% of organizations, just behind servers/virtual servers at 19%, which was also the top response in 2011. Virtual desktops/laptops and security systems were each identified by 16% of respondents as their primary infrastructure goal. Cloud computing and telemedicine were not on the radar of many organizations, polling at just 3% and 2%, respectively.

When asked to select areas where IT could have the most impact on patient care, the leading answer was once again improving clinical and quality outcomes (38%), followed by reducing medical errors/improving patient safety (22%), and standardization of clinical care using evidence-based medicine (16%).

UPDATED Feb. 24 to include information publication of the proposed federal regulations.

LAS VEGAS – Proposed stage 2 federal regulations for the meaningful use of electronic health records will require more effort from health care providers, but also promises to provide them with more flexibility.

"The main message is that we’ve stayed the course," Dr. Farzad Mostashari, national coordinator for health information technology, said at the HIMSS12 annual conference, where the regulations were previewed.

Patrice Wendling/Elsevier Global Medical News

Much of what providers will see in stage 2 will be familiar because Dr. Mostashari’s organization, the Office of the National Coordinator for Health Information Technology (ONC), largely adopted the recommendations of the health information technology policy and standards advisory committees, he said.

The proposed regulation were published late in the day Feb. 23 in the Federal Register; comments must be filed by 5 pm ET on Apr. 23. Stage 2 of the meaningful use pro­gram will not start, however, until Janu­ary 2014 for physicians and other eligible health care providers, and October 2013 for hospitals.

The proposed regulation has been sent to the Office of the Federal Register and should be published officially within days. Once published, the clock will start ticking on a 60-day public comment period. Stage 2 of the meaningful use program will not start, however, until January 2014 for physicians and other eligible health care providers, and October 2013 for hospitals.

There is a big push in the stage 2 regulations toward standards-based data exchange and interoperability, Dr. Mostashari said.

"We can’t wait 5 years to get standards-based exchange in this world," he added.

Specifically, in order to receive the federal incentive payment under Medicare or Medicaid, meaningful users will be required to use direct project protocols for secure e-mail, although they can instead opt for information-exchange certification through the SOAP (simple object access protocol) approach. For the first time, there is a single standard for transferring laboratory results, as well as messaging standards for public health, and standards for vocabulary.

To demonstrate compliance with data exchange requirements in stage 2, meaningful users will have to actually exchange data across organizational or vendor boundaries; a test exchange will not suffice, Dr. Mostashari emphasized. To that end, a summary of care must be sent to a recipient outside the meaningful user’s organization for more than 10% of referrals and transitions of care.

Under the proposed regulations, stage 2 also will put more emphasis on patient engagement. For physicians, it will no longer be enough merely to provide patients with access to their EHRs. At least 10% will have to access, download, or transmit the information to a third party. Also, more than half of patients must be provided with access to a summary of their treatment within 4 days.

Overall, the stage 2 regulations propose 17 core objectives plus 3 of 5 new menu objectives for eligible health care providers, and 16 core objectives plus 2 of 4 new menu items for hospitals. One menu objective includes the proposal that more than 40% of diagnostic medical scans and images be accessible through certified EHR technology, Centers for Medicare and Medicaid Services policy analyst Travis Broome said at the meeting. The electronic reporting of data to a cancer or specialty registry is also a new menu item.

Although stage 2 will further improve the meaningful use of EHRs, Dr. Mostashari said that the ONC also takes very seriously President Obama’s executive order that government agencies reduce regulatory burdens.

"In many parts, throughout both [regulations], we have done whatever we can to increase the flexibility and to reduce the burdens of these regulations," he said.

For example, the proposed rules allow group reporting of quality measures within a practice, instead of just individual reporting by physicians. Also, physicians and other health care providers can meet meaningful use requirements by using a complete EHR, a modular EHR, or a combination of modular EHRs.

Uptake of EHR technology has been good, but in an effort to further spur adoption, the Department of Health and Human Services announced last December that physicians who started efforts to participate in the Medicare EHR incentive program in 2011 would not have to meet stage 2 requirements until 2014, a full year later than originally planned.

"If there’s one thing that we’ve all learned, it’s that to truly make meaningful use of meaningful use, it takes time," Dr. Mostashari said.

He reported no conflicts of interest.

UPDATED Feb. 24 to include information publication of the proposed federal regulations.

LAS VEGAS – Proposed stage 2 federal regulations for the meaningful use of electronic health records will require more effort from health care providers, but also promises to provide them with more flexibility.

"The main message is that we’ve stayed the course," Dr. Farzad Mostashari, national coordinator for health information technology, said at the HIMSS12 annual conference, where the regulations were previewed.

Patrice Wendling/Elsevier Global Medical News

Much of what providers will see in stage 2 will be familiar because Dr. Mostashari’s organization, the Office of the National Coordinator for Health Information Technology (ONC), largely adopted the recommendations of the health information technology policy and standards advisory committees, he said.

The proposed regulation were published late in the day Feb. 23 in the Federal Register; comments must be filed by 5 pm ET on Apr. 23. Stage 2 of the meaningful use pro­gram will not start, however, until Janu­ary 2014 for physicians and other eligible health care providers, and October 2013 for hospitals.

The proposed regulation has been sent to the Office of the Federal Register and should be published officially within days. Once published, the clock will start ticking on a 60-day public comment period. Stage 2 of the meaningful use program will not start, however, until January 2014 for physicians and other eligible health care providers, and October 2013 for hospitals.

There is a big push in the stage 2 regulations toward standards-based data exchange and interoperability, Dr. Mostashari said.

"We can’t wait 5 years to get standards-based exchange in this world," he added.

Specifically, in order to receive the federal incentive payment under Medicare or Medicaid, meaningful users will be required to use direct project protocols for secure e-mail, although they can instead opt for information-exchange certification through the SOAP (simple object access protocol) approach. For the first time, there is a single standard for transferring laboratory results, as well as messaging standards for public health, and standards for vocabulary.

To demonstrate compliance with data exchange requirements in stage 2, meaningful users will have to actually exchange data across organizational or vendor boundaries; a test exchange will not suffice, Dr. Mostashari emphasized. To that end, a summary of care must be sent to a recipient outside the meaningful user’s organization for more than 10% of referrals and transitions of care.

Under the proposed regulations, stage 2 also will put more emphasis on patient engagement. For physicians, it will no longer be enough merely to provide patients with access to their EHRs. At least 10% will have to access, download, or transmit the information to a third party. Also, more than half of patients must be provided with access to a summary of their treatment within 4 days.

Overall, the stage 2 regulations propose 17 core objectives plus 3 of 5 new menu objectives for eligible health care providers, and 16 core objectives plus 2 of 4 new menu items for hospitals. One menu objective includes the proposal that more than 40% of diagnostic medical scans and images be accessible through certified EHR technology, Centers for Medicare and Medicaid Services policy analyst Travis Broome said at the meeting. The electronic reporting of data to a cancer or specialty registry is also a new menu item.

Although stage 2 will further improve the meaningful use of EHRs, Dr. Mostashari said that the ONC also takes very seriously President Obama’s executive order that government agencies reduce regulatory burdens.

"In many parts, throughout both [regulations], we have done whatever we can to increase the flexibility and to reduce the burdens of these regulations," he said.

For example, the proposed rules allow group reporting of quality measures within a practice, instead of just individual reporting by physicians. Also, physicians and other health care providers can meet meaningful use requirements by using a complete EHR, a modular EHR, or a combination of modular EHRs.

Uptake of EHR technology has been good, but in an effort to further spur adoption, the Department of Health and Human Services announced last December that physicians who started efforts to participate in the Medicare EHR incentive program in 2011 would not have to meet stage 2 requirements until 2014, a full year later than originally planned.

"If there’s one thing that we’ve all learned, it’s that to truly make meaningful use of meaningful use, it takes time," Dr. Mostashari said.

He reported no conflicts of interest.

UPDATED Feb. 24 to include information publication of the proposed federal regulations.

LAS VEGAS – Proposed stage 2 federal regulations for the meaningful use of electronic health records will require more effort from health care providers, but also promises to provide them with more flexibility.

"The main message is that we’ve stayed the course," Dr. Farzad Mostashari, national coordinator for health information technology, said at the HIMSS12 annual conference, where the regulations were previewed.

Patrice Wendling/Elsevier Global Medical News

Much of what providers will see in stage 2 will be familiar because Dr. Mostashari’s organization, the Office of the National Coordinator for Health Information Technology (ONC), largely adopted the recommendations of the health information technology policy and standards advisory committees, he said.

The proposed regulation were published late in the day Feb. 23 in the Federal Register; comments must be filed by 5 pm ET on Apr. 23. Stage 2 of the meaningful use pro­gram will not start, however, until Janu­ary 2014 for physicians and other eligible health care providers, and October 2013 for hospitals.

The proposed regulation has been sent to the Office of the Federal Register and should be published officially within days. Once published, the clock will start ticking on a 60-day public comment period. Stage 2 of the meaningful use program will not start, however, until January 2014 for physicians and other eligible health care providers, and October 2013 for hospitals.

There is a big push in the stage 2 regulations toward standards-based data exchange and interoperability, Dr. Mostashari said.

"We can’t wait 5 years to get standards-based exchange in this world," he added.

Specifically, in order to receive the federal incentive payment under Medicare or Medicaid, meaningful users will be required to use direct project protocols for secure e-mail, although they can instead opt for information-exchange certification through the SOAP (simple object access protocol) approach. For the first time, there is a single standard for transferring laboratory results, as well as messaging standards for public health, and standards for vocabulary.

To demonstrate compliance with data exchange requirements in stage 2, meaningful users will have to actually exchange data across organizational or vendor boundaries; a test exchange will not suffice, Dr. Mostashari emphasized. To that end, a summary of care must be sent to a recipient outside the meaningful user’s organization for more than 10% of referrals and transitions of care.

Under the proposed regulations, stage 2 also will put more emphasis on patient engagement. For physicians, it will no longer be enough merely to provide patients with access to their EHRs. At least 10% will have to access, download, or transmit the information to a third party. Also, more than half of patients must be provided with access to a summary of their treatment within 4 days.

Overall, the stage 2 regulations propose 17 core objectives plus 3 of 5 new menu objectives for eligible health care providers, and 16 core objectives plus 2 of 4 new menu items for hospitals. One menu objective includes the proposal that more than 40% of diagnostic medical scans and images be accessible through certified EHR technology, Centers for Medicare and Medicaid Services policy analyst Travis Broome said at the meeting. The electronic reporting of data to a cancer or specialty registry is also a new menu item.

Although stage 2 will further improve the meaningful use of EHRs, Dr. Mostashari said that the ONC also takes very seriously President Obama’s executive order that government agencies reduce regulatory burdens.

"In many parts, throughout both [regulations], we have done whatever we can to increase the flexibility and to reduce the burdens of these regulations," he said.

For example, the proposed rules allow group reporting of quality measures within a practice, instead of just individual reporting by physicians. Also, physicians and other health care providers can meet meaningful use requirements by using a complete EHR, a modular EHR, or a combination of modular EHRs.

Uptake of EHR technology has been good, but in an effort to further spur adoption, the Department of Health and Human Services announced last December that physicians who started efforts to participate in the Medicare EHR incentive program in 2011 would not have to meet stage 2 requirements until 2014, a full year later than originally planned.

"If there’s one thing that we’ve all learned, it’s that to truly make meaningful use of meaningful use, it takes time," Dr. Mostashari said.

He reported no conflicts of interest.

KEYSTONE, COLO.  – Chronic bronchitis and gender might provide more clinically meaningful clues to phenotyping patients with chronic obstructive pulmonary disease than does lung function, recent findings from the COPDGene study suggest.

"There are a lot of important features of COPD that we don’t capture by FEV₁ [forced expiratory volume in 1 second], and we need additional clinical features and radiographic information so we can tailor our therapies even more in the future," COPDGene investigator Dr. Barry J. Make said at a meeting on allergy and respiratory diseases.

Researchers with the ongoing COPD genetic epidemiology study used the ATS (American Thoracic Society) questionnaire to identify chronic bronchitis in 1,061 patients with GOLD (Global Initiative for Chronic Obstructive Lung Disease) stage 2-4 COPD. In all, 290 patients had chronic bronchitis, defined as cough and sputum for at least 3 months/year for at least 2 consecutive years, and 771 did not have chronic bronchitis.

The researchers found that chronic bronchitis is a predictor of future COPD exacerbations, said Dr. Make, codirector of the COPD program and medical director of respiratory care services at Denver’s National Jewish Health, which sponsored the meeting. The chronic bronchitis–positive group had 1.21 exacerbations/patient per year, compared with 0.63 exacerbations/patient per year in the chronic bronchitis–negative group (P less than .027). In addition, more patients in the chronic bronchitis–positive group reported severe exacerbations (26.6% vs. 20%; P = .024).

"We’re concerned about exacerbations, because if you’re hospitalized with an exacerbation of COPD, your mortality within the first year after you get out of the hospital is 20%," he said.

COPD patients with chronic bronchitis were younger, smoked more, were more often current smokers, and had more wheezing and nocturnal awakenings caused by cough and dyspnea. Dr. Make pointed out that the ATS questionnaire is validated to check for cough and sputum, but also emphasized the importance of using CT in assessing patients with COPD.

Notably, patients who have chronic bronchitis have thicker airways on chest CT, compared with the chronic bronchitis–negative group, as indicated by a higher mean segmental wall area percentage (63.2% vs. 62.6%; P = .013). Their percent gas trapping and lung emphysema were similar (Chest 2011;140:626-33).

A second COPDGene study in 1,002 COPD patients reported that each 1-mm increase in bronchial wall thickness on quantitative CT is associated with a 1.84-fold increase in annual COPD exacerbations after multivariate analysis that adjusted for lung function, Dr. Make said. The analysis also found that for patients with 35% or greater total emphysema, each 5% increase in emphysema was associated with a 1.18-fold increase in annual exacerbation rate (Radiology 2011;261:274-82).

Thus, COPD patients with chronic bronchitis and emphysema have more exacerbations, and "from CT exam, we can predict a patient’s future exacerbations," he said.

Dr. Make pointed out that a history of chronic bronchitis and at least one COPD exacerbation requiring systemic corticosteroids and/or hospitalization were among the inclusion criteria for two pivotal trials that led to the 2011 approval of the phosphodiesterase-4 inhibitor roflumilast (Daliresp). Pooled data from the multicenter trials demonstrated a significant 17% reduction with roflumilast in the rate of moderate or severe exacerbations per patient per year among adult outpatients with COPD (Lancet 2009;374:685-94).

"Here we have personalized medicine that has made it to the FDA [U.S. Food and Drug Administration], but in order to determine if this medication might be right for your patients, you need to collect the right information," he said.

Gender Differences

Women with COPD are known to have more exacerbations than men, to have lower lung function than men with the same cigarette exposure, and to have more symptoms than men with the same lung function. In addition, more women die of COPD, compared with men. Yet, data are limited regarding gender differences in lung anatomy that might explain this troubling paradox, at least in part. Dr. Make highlighted a recent study that identified gender differences in airway dimensions in 1,021 male and 1,026 female smokers in the COPDGene cohort (COPD 2011;8:285-92).

Multidetector CT scans of the chest revealed that in all airways measured, women smokers had higher wall area percentage but smaller luminal area, internal diameter, and airway wall thickness than did male smokers. Gender remained one of the most significant predictors for these differences on multivariate analysis, even after researchers adjusted for age, body size, and other confounders.

"So maybe we should look at women differently than men – think about why they’re different and how to treat them or prevent the disease differently," said Dr. Make, who coauthored the study.

To drive home the point, Dr. Make showed a slide depicting a rail-thin old man with emphysema alongside the rosy-cheeked model Christy Turlington, who revealed at age 31 that she had early-stage emphysema after maintaining a pack-a-day cigarette habit for nearly a decade.

Dr. Make reported having served as an advisory board member, speaker, or trial investigator for AstraZeneca, Boehringer-Ingelheim, Breathe, Forest, GlaxoSmithKline, Ikaria, MedImmune, Merck, Novartis, Pfizer, and Sunovion, as well as the National Heart, Lung, and Blood Institute.

KEYSTONE, COLO.  – Chronic bronchitis and gender might provide more clinically meaningful clues to phenotyping patients with chronic obstructive pulmonary disease than does lung function, recent findings from the COPDGene study suggest.

"There are a lot of important features of COPD that we don’t capture by FEV₁ [forced expiratory volume in 1 second], and we need additional clinical features and radiographic information so we can tailor our therapies even more in the future," COPDGene investigator Dr. Barry J. Make said at a meeting on allergy and respiratory diseases.

Researchers with the ongoing COPD genetic epidemiology study used the ATS (American Thoracic Society) questionnaire to identify chronic bronchitis in 1,061 patients with GOLD (Global Initiative for Chronic Obstructive Lung Disease) stage 2-4 COPD. In all, 290 patients had chronic bronchitis, defined as cough and sputum for at least 3 months/year for at least 2 consecutive years, and 771 did not have chronic bronchitis.

The researchers found that chronic bronchitis is a predictor of future COPD exacerbations, said Dr. Make, codirector of the COPD program and medical director of respiratory care services at Denver’s National Jewish Health, which sponsored the meeting. The chronic bronchitis–positive group had 1.21 exacerbations/patient per year, compared with 0.63 exacerbations/patient per year in the chronic bronchitis–negative group (P less than .027). In addition, more patients in the chronic bronchitis–positive group reported severe exacerbations (26.6% vs. 20%; P = .024).

"We’re concerned about exacerbations, because if you’re hospitalized with an exacerbation of COPD, your mortality within the first year after you get out of the hospital is 20%," he said.

COPD patients with chronic bronchitis were younger, smoked more, were more often current smokers, and had more wheezing and nocturnal awakenings caused by cough and dyspnea. Dr. Make pointed out that the ATS questionnaire is validated to check for cough and sputum, but also emphasized the importance of using CT in assessing patients with COPD.

Notably, patients who have chronic bronchitis have thicker airways on chest CT, compared with the chronic bronchitis–negative group, as indicated by a higher mean segmental wall area percentage (63.2% vs. 62.6%; P = .013). Their percent gas trapping and lung emphysema were similar (Chest 2011;140:626-33).

A second COPDGene study in 1,002 COPD patients reported that each 1-mm increase in bronchial wall thickness on quantitative CT is associated with a 1.84-fold increase in annual COPD exacerbations after multivariate analysis that adjusted for lung function, Dr. Make said. The analysis also found that for patients with 35% or greater total emphysema, each 5% increase in emphysema was associated with a 1.18-fold increase in annual exacerbation rate (Radiology 2011;261:274-82).

Thus, COPD patients with chronic bronchitis and emphysema have more exacerbations, and "from CT exam, we can predict a patient’s future exacerbations," he said.

Dr. Make pointed out that a history of chronic bronchitis and at least one COPD exacerbation requiring systemic corticosteroids and/or hospitalization were among the inclusion criteria for two pivotal trials that led to the 2011 approval of the phosphodiesterase-4 inhibitor roflumilast (Daliresp). Pooled data from the multicenter trials demonstrated a significant 17% reduction with roflumilast in the rate of moderate or severe exacerbations per patient per year among adult outpatients with COPD (Lancet 2009;374:685-94).

"Here we have personalized medicine that has made it to the FDA [U.S. Food and Drug Administration], but in order to determine if this medication might be right for your patients, you need to collect the right information," he said.

Gender Differences

Women with COPD are known to have more exacerbations than men, to have lower lung function than men with the same cigarette exposure, and to have more symptoms than men with the same lung function. In addition, more women die of COPD, compared with men. Yet, data are limited regarding gender differences in lung anatomy that might explain this troubling paradox, at least in part. Dr. Make highlighted a recent study that identified gender differences in airway dimensions in 1,021 male and 1,026 female smokers in the COPDGene cohort (COPD 2011;8:285-92).

Multidetector CT scans of the chest revealed that in all airways measured, women smokers had higher wall area percentage but smaller luminal area, internal diameter, and airway wall thickness than did male smokers. Gender remained one of the most significant predictors for these differences on multivariate analysis, even after researchers adjusted for age, body size, and other confounders.

"So maybe we should look at women differently than men – think about why they’re different and how to treat them or prevent the disease differently," said Dr. Make, who coauthored the study.

To drive home the point, Dr. Make showed a slide depicting a rail-thin old man with emphysema alongside the rosy-cheeked model Christy Turlington, who revealed at age 31 that she had early-stage emphysema after maintaining a pack-a-day cigarette habit for nearly a decade.

Dr. Make reported having served as an advisory board member, speaker, or trial investigator for AstraZeneca, Boehringer-Ingelheim, Breathe, Forest, GlaxoSmithKline, Ikaria, MedImmune, Merck, Novartis, Pfizer, and Sunovion, as well as the National Heart, Lung, and Blood Institute.

KEYSTONE, COLO.  – Chronic bronchitis and gender might provide more clinically meaningful clues to phenotyping patients with chronic obstructive pulmonary disease than does lung function, recent findings from the COPDGene study suggest.

"There are a lot of important features of COPD that we don’t capture by FEV₁ [forced expiratory volume in 1 second], and we need additional clinical features and radiographic information so we can tailor our therapies even more in the future," COPDGene investigator Dr. Barry J. Make said at a meeting on allergy and respiratory diseases.

Researchers with the ongoing COPD genetic epidemiology study used the ATS (American Thoracic Society) questionnaire to identify chronic bronchitis in 1,061 patients with GOLD (Global Initiative for Chronic Obstructive Lung Disease) stage 2-4 COPD. In all, 290 patients had chronic bronchitis, defined as cough and sputum for at least 3 months/year for at least 2 consecutive years, and 771 did not have chronic bronchitis.

The researchers found that chronic bronchitis is a predictor of future COPD exacerbations, said Dr. Make, codirector of the COPD program and medical director of respiratory care services at Denver’s National Jewish Health, which sponsored the meeting. The chronic bronchitis–positive group had 1.21 exacerbations/patient per year, compared with 0.63 exacerbations/patient per year in the chronic bronchitis–negative group (P less than .027). In addition, more patients in the chronic bronchitis–positive group reported severe exacerbations (26.6% vs. 20%; P = .024).

"We’re concerned about exacerbations, because if you’re hospitalized with an exacerbation of COPD, your mortality within the first year after you get out of the hospital is 20%," he said.

COPD patients with chronic bronchitis were younger, smoked more, were more often current smokers, and had more wheezing and nocturnal awakenings caused by cough and dyspnea. Dr. Make pointed out that the ATS questionnaire is validated to check for cough and sputum, but also emphasized the importance of using CT in assessing patients with COPD.

Notably, patients who have chronic bronchitis have thicker airways on chest CT, compared with the chronic bronchitis–negative group, as indicated by a higher mean segmental wall area percentage (63.2% vs. 62.6%; P = .013). Their percent gas trapping and lung emphysema were similar (Chest 2011;140:626-33).

A second COPDGene study in 1,002 COPD patients reported that each 1-mm increase in bronchial wall thickness on quantitative CT is associated with a 1.84-fold increase in annual COPD exacerbations after multivariate analysis that adjusted for lung function, Dr. Make said. The analysis also found that for patients with 35% or greater total emphysema, each 5% increase in emphysema was associated with a 1.18-fold increase in annual exacerbation rate (Radiology 2011;261:274-82).

Thus, COPD patients with chronic bronchitis and emphysema have more exacerbations, and "from CT exam, we can predict a patient’s future exacerbations," he said.

Dr. Make pointed out that a history of chronic bronchitis and at least one COPD exacerbation requiring systemic corticosteroids and/or hospitalization were among the inclusion criteria for two pivotal trials that led to the 2011 approval of the phosphodiesterase-4 inhibitor roflumilast (Daliresp). Pooled data from the multicenter trials demonstrated a significant 17% reduction with roflumilast in the rate of moderate or severe exacerbations per patient per year among adult outpatients with COPD (Lancet 2009;374:685-94).

"Here we have personalized medicine that has made it to the FDA [U.S. Food and Drug Administration], but in order to determine if this medication might be right for your patients, you need to collect the right information," he said.

Gender Differences

Women with COPD are known to have more exacerbations than men, to have lower lung function than men with the same cigarette exposure, and to have more symptoms than men with the same lung function. In addition, more women die of COPD, compared with men. Yet, data are limited regarding gender differences in lung anatomy that might explain this troubling paradox, at least in part. Dr. Make highlighted a recent study that identified gender differences in airway dimensions in 1,021 male and 1,026 female smokers in the COPDGene cohort (COPD 2011;8:285-92).

Multidetector CT scans of the chest revealed that in all airways measured, women smokers had higher wall area percentage but smaller luminal area, internal diameter, and airway wall thickness than did male smokers. Gender remained one of the most significant predictors for these differences on multivariate analysis, even after researchers adjusted for age, body size, and other confounders.

"So maybe we should look at women differently than men – think about why they’re different and how to treat them or prevent the disease differently," said Dr. Make, who coauthored the study.

To drive home the point, Dr. Make showed a slide depicting a rail-thin old man with emphysema alongside the rosy-cheeked model Christy Turlington, who revealed at age 31 that she had early-stage emphysema after maintaining a pack-a-day cigarette habit for nearly a decade.

Dr. Make reported having served as an advisory board member, speaker, or trial investigator for AstraZeneca, Boehringer-Ingelheim, Breathe, Forest, GlaxoSmithKline, Ikaria, MedImmune, Merck, Novartis, Pfizer, and Sunovion, as well as the National Heart, Lung, and Blood Institute.

KEYSTONE, COLO. – Adult asthma phenotypes offer little guidance in the identification and management of severe, therapy-resistant asthma in children.

Cluster analysis was recently used to identify two subgroups with discordance between symptom expression and eosinophilic airway inflammation specific to refractory adult asthma (Am. J. Respir. Crit. Care Med. 2008;178:218-24). In addition, a treatment strategy based on minimizing eosinophilic inflammation proved superior to standard care in reducing exacerbation frequency (Lancet 2002;360:1715-21).

Recent efforts to replicate the findings in severe pediatric asthma, however, met with disappointing results, study coauthor Dr. Andrew Bush said at a meeting on allergy and respiratory diseases. The ability to identify asthma phenotypes that exhibit differences in clinical response could enable more targeted therapy and spare children unlikely to benefit from exposure to powerful anti-inflammatories like methotrexate and cyclosporine. The pediatric study did include an unvalidated post hoc analysis showing that a sputum normalization strategy in the first month after changing treatment may reduce asthma exacerbations (Thorax 2012;67:193-8).

Persistent airflow limitation is also a hallmark of severe, therapy-resistant asthma (STRA) in adults, and is typically defined using a postcorticosteroid trial, postacute bronchodilator response in forced expiratory volume in 1 second (FEV₁), and z scores. What is not known for children, however, is what dose, route of administration, and duration of steroids is best, or what dose of bronchodilator is most effective.

"There really is no good pediatric evidence," said Dr. Bush, professor of pediatric respirology at the Royal Brompton Hospital and Imperial College in London. "The point in finding this out is that if you really do have persistent airflow obstruction [in] a child, there is no point in flogging them with more and more medications, if in fact they’re not going to open their airways."

Corticosteroid response is another cornerstone for identifying and managing STRA in adults. However, when Dr. Bush and his colleagues looked at corticosteroid response in a group of 50 children who had severe asthma by American Thoracic Society and American College of Surgeons criteria, 50% of the children had such good lung function that the adult definition of response, based on an FEV₁ of at least 80% or a 15% increase, could not be applied.

"The adult definition of corticosteroid response based on lung function does not work in kids," he said.

Clinical phenotypes such as female gender and obesity, which are associated with more severe asthma after childhood, have also proved unreliable. Another unpublished study by the group involving 40 boys and 36 girls (aged 6-19 years) with STRA found no sex differences; it also found that young people with STRA had an average body mass index of 19 kg/m², which was identical to the average BMI of a cohort of age-matched children with mild asthma and was lower than the mean of 20.4 kg/m² in age-matched controls.

The children with STRA had symptoms for an average of 2-6 years, an average of six steroid bursts (range, 1-30), and three hospital admissions (range, 0-21) in the previous year; 21% had ever been intubated because of their asthma.

Asthma Control Test scores were low in the children with STRA (average, 13.5), and lung function varied widely from an FEV₁ of 33% to 121% of predicted (average, 70%).

The children with STRA had a strong positive history of atopy (82%) and family history of atopy (84% in a first-degree relative), Dr. Bush noted.

"Indeed, if I see a child with alleged severe, therapy-resistant asthma who is not atopic, I take another further good hard look at the diagnosis," he said.

Getting the Basics Right

One of the most important steps in managing children with genuine STRA is to distinguish them from those with difficult asthma, in whom biologic therapies are not justified.

"In really severe childhood asthmatics, potentially reversible factors will be found in more than half of those not responding to treatment," Dr. Bush said at the meeting, sponsored by National Jewish Health.

The most important factors to look for are adherence, cigarettes, allergens, and psychosocial issues. He suggested that nurse-led home visits are particularly beneficial in identifying these factors. When nurses from Royal Brompton visited 71 "hard-core asthmatics," potentially modifiable factors were identified in 79%, and only 32 patients were thought to need further invasive investigation. A quarter could not produce a complete set of medications, a third were picking up fewer than half of their prescriptions, 38% did not have good inhaler technique despite multiple attempts at testing, and medication issues contributed to poor control in 48%.

"These guys know the nurses are coming; it’s not like the nurses come at 3:00 in the morning and bang on the door and say show me your medications," he said.

Dr. Bush reported no relevant financial disclosures.

KEYSTONE, COLO. – Adult asthma phenotypes offer little guidance in the identification and management of severe, therapy-resistant asthma in children.

Cluster analysis was recently used to identify two subgroups with discordance between symptom expression and eosinophilic airway inflammation specific to refractory adult asthma (Am. J. Respir. Crit. Care Med. 2008;178:218-24). In addition, a treatment strategy based on minimizing eosinophilic inflammation proved superior to standard care in reducing exacerbation frequency (Lancet 2002;360:1715-21).

Recent efforts to replicate the findings in severe pediatric asthma, however, met with disappointing results, study coauthor Dr. Andrew Bush said at a meeting on allergy and respiratory diseases. The ability to identify asthma phenotypes that exhibit differences in clinical response could enable more targeted therapy and spare children unlikely to benefit from exposure to powerful anti-inflammatories like methotrexate and cyclosporine. The pediatric study did include an unvalidated post hoc analysis showing that a sputum normalization strategy in the first month after changing treatment may reduce asthma exacerbations (Thorax 2012;67:193-8).

Persistent airflow limitation is also a hallmark of severe, therapy-resistant asthma (STRA) in adults, and is typically defined using a postcorticosteroid trial, postacute bronchodilator response in forced expiratory volume in 1 second (FEV₁), and z scores. What is not known for children, however, is what dose, route of administration, and duration of steroids is best, or what dose of bronchodilator is most effective.

"There really is no good pediatric evidence," said Dr. Bush, professor of pediatric respirology at the Royal Brompton Hospital and Imperial College in London. "The point in finding this out is that if you really do have persistent airflow obstruction [in] a child, there is no point in flogging them with more and more medications, if in fact they’re not going to open their airways."

Corticosteroid response is another cornerstone for identifying and managing STRA in adults. However, when Dr. Bush and his colleagues looked at corticosteroid response in a group of 50 children who had severe asthma by American Thoracic Society and American College of Surgeons criteria, 50% of the children had such good lung function that the adult definition of response, based on an FEV₁ of at least 80% or a 15% increase, could not be applied.

"The adult definition of corticosteroid response based on lung function does not work in kids," he said.

Clinical phenotypes such as female gender and obesity, which are associated with more severe asthma after childhood, have also proved unreliable. Another unpublished study by the group involving 40 boys and 36 girls (aged 6-19 years) with STRA found no sex differences; it also found that young people with STRA had an average body mass index of 19 kg/m², which was identical to the average BMI of a cohort of age-matched children with mild asthma and was lower than the mean of 20.4 kg/m² in age-matched controls.

The children with STRA had symptoms for an average of 2-6 years, an average of six steroid bursts (range, 1-30), and three hospital admissions (range, 0-21) in the previous year; 21% had ever been intubated because of their asthma.

Asthma Control Test scores were low in the children with STRA (average, 13.5), and lung function varied widely from an FEV₁ of 33% to 121% of predicted (average, 70%).

The children with STRA had a strong positive history of atopy (82%) and family history of atopy (84% in a first-degree relative), Dr. Bush noted.

"Indeed, if I see a child with alleged severe, therapy-resistant asthma who is not atopic, I take another further good hard look at the diagnosis," he said.

Getting the Basics Right

One of the most important steps in managing children with genuine STRA is to distinguish them from those with difficult asthma, in whom biologic therapies are not justified.

"In really severe childhood asthmatics, potentially reversible factors will be found in more than half of those not responding to treatment," Dr. Bush said at the meeting, sponsored by National Jewish Health.

The most important factors to look for are adherence, cigarettes, allergens, and psychosocial issues. He suggested that nurse-led home visits are particularly beneficial in identifying these factors. When nurses from Royal Brompton visited 71 "hard-core asthmatics," potentially modifiable factors were identified in 79%, and only 32 patients were thought to need further invasive investigation. A quarter could not produce a complete set of medications, a third were picking up fewer than half of their prescriptions, 38% did not have good inhaler technique despite multiple attempts at testing, and medication issues contributed to poor control in 48%.

"These guys know the nurses are coming; it’s not like the nurses come at 3:00 in the morning and bang on the door and say show me your medications," he said.

Dr. Bush reported no relevant financial disclosures.

KEYSTONE, COLO. – Adult asthma phenotypes offer little guidance in the identification and management of severe, therapy-resistant asthma in children.

Cluster analysis was recently used to identify two subgroups with discordance between symptom expression and eosinophilic airway inflammation specific to refractory adult asthma (Am. J. Respir. Crit. Care Med. 2008;178:218-24). In addition, a treatment strategy based on minimizing eosinophilic inflammation proved superior to standard care in reducing exacerbation frequency (Lancet 2002;360:1715-21).

Recent efforts to replicate the findings in severe pediatric asthma, however, met with disappointing results, study coauthor Dr. Andrew Bush said at a meeting on allergy and respiratory diseases. The ability to identify asthma phenotypes that exhibit differences in clinical response could enable more targeted therapy and spare children unlikely to benefit from exposure to powerful anti-inflammatories like methotrexate and cyclosporine. The pediatric study did include an unvalidated post hoc analysis showing that a sputum normalization strategy in the first month after changing treatment may reduce asthma exacerbations (Thorax 2012;67:193-8).

Persistent airflow limitation is also a hallmark of severe, therapy-resistant asthma (STRA) in adults, and is typically defined using a postcorticosteroid trial, postacute bronchodilator response in forced expiratory volume in 1 second (FEV₁), and z scores. What is not known for children, however, is what dose, route of administration, and duration of steroids is best, or what dose of bronchodilator is most effective.

"There really is no good pediatric evidence," said Dr. Bush, professor of pediatric respirology at the Royal Brompton Hospital and Imperial College in London. "The point in finding this out is that if you really do have persistent airflow obstruction [in] a child, there is no point in flogging them with more and more medications, if in fact they’re not going to open their airways."

Corticosteroid response is another cornerstone for identifying and managing STRA in adults. However, when Dr. Bush and his colleagues looked at corticosteroid response in a group of 50 children who had severe asthma by American Thoracic Society and American College of Surgeons criteria, 50% of the children had such good lung function that the adult definition of response, based on an FEV₁ of at least 80% or a 15% increase, could not be applied.

"The adult definition of corticosteroid response based on lung function does not work in kids," he said.

Clinical phenotypes such as female gender and obesity, which are associated with more severe asthma after childhood, have also proved unreliable. Another unpublished study by the group involving 40 boys and 36 girls (aged 6-19 years) with STRA found no sex differences; it also found that young people with STRA had an average body mass index of 19 kg/m², which was identical to the average BMI of a cohort of age-matched children with mild asthma and was lower than the mean of 20.4 kg/m² in age-matched controls.

The children with STRA had symptoms for an average of 2-6 years, an average of six steroid bursts (range, 1-30), and three hospital admissions (range, 0-21) in the previous year; 21% had ever been intubated because of their asthma.

Asthma Control Test scores were low in the children with STRA (average, 13.5), and lung function varied widely from an FEV₁ of 33% to 121% of predicted (average, 70%).

The children with STRA had a strong positive history of atopy (82%) and family history of atopy (84% in a first-degree relative), Dr. Bush noted.

"Indeed, if I see a child with alleged severe, therapy-resistant asthma who is not atopic, I take another further good hard look at the diagnosis," he said.

Getting the Basics Right

One of the most important steps in managing children with genuine STRA is to distinguish them from those with difficult asthma, in whom biologic therapies are not justified.

"In really severe childhood asthmatics, potentially reversible factors will be found in more than half of those not responding to treatment," Dr. Bush said at the meeting, sponsored by National Jewish Health.

The most important factors to look for are adherence, cigarettes, allergens, and psychosocial issues. He suggested that nurse-led home visits are particularly beneficial in identifying these factors. When nurses from Royal Brompton visited 71 "hard-core asthmatics," potentially modifiable factors were identified in 79%, and only 32 patients were thought to need further invasive investigation. A quarter could not produce a complete set of medications, a third were picking up fewer than half of their prescriptions, 38% did not have good inhaler technique despite multiple attempts at testing, and medication issues contributed to poor control in 48%.

"These guys know the nurses are coming; it’s not like the nurses come at 3:00 in the morning and bang on the door and say show me your medications," he said.

Dr. Bush reported no relevant financial disclosures.

LAS VEGAS – Merging the American Medical Association’s physician community portal with that of AT&T should provide physicians with a broader array of health information technology solutions, particularly for the physician on the go.

"[Physicians] will have access to tools such as electronic prescribing, registries, electronic medical records, and also sophisticated analytic and population-health tools that will come from the AT&T side," Dr. Steven Stack, chair-elect of the AMA board of trustees, said in an interview at this meeting after the announcement was made.

 The AMA’s AMAGINE physician community portal has focused on providing small- and mid-sized physician groups with access to affordable IT technology, while the AT&T Healthcare Community Online portal focused on integrated and larger health care systems. The decision to have AT&T own and operate the combined platform was a natural progression for both groups as they sought to provide a broader suite of services, and should appear seamless to users since both portals are hosted by Covisint, Dr. Stack said.

Smartphone usage among physicians is thought to be about 84%, while tablet usage is thought to be about 50%.

Keeping the mobile physician securely connected will be a large part of the new platform, but patients should also benefit through AT&T’s mobile patient care applications, Randall Porter, assistant vice president of AT&T ForHealth, said in an interview. For example, AT&T has an application specifically for diabetes patients that uses a smartphone in combination with the patient’s glucometer to provide real-time feedback about how to manage their disease.

"The physician would be brought into the loop through the integration of the data into the [electronic medical record] through the portal capability," Mr. Porter said.

Neither AMA nor AT&T would discuss the financial terms of the deal, but Mr. Porter said that existing contractual obligations and bundles will be honored for the roughly 6,000 physician/physician groups using the AMA AMAGINE portal. Future pricing should remain competitive, given the evolving nature of the market, he added.

Dr. Stack said the AMA will remain involved in the platform to provide expertise from the physician and patient point of view.

LAS VEGAS – Merging the American Medical Association’s physician community portal with that of AT&T should provide physicians with a broader array of health information technology solutions, particularly for the physician on the go.

"[Physicians] will have access to tools such as electronic prescribing, registries, electronic medical records, and also sophisticated analytic and population-health tools that will come from the AT&T side," Dr. Steven Stack, chair-elect of the AMA board of trustees, said in an interview at this meeting after the announcement was made.

 The AMA’s AMAGINE physician community portal has focused on providing small- and mid-sized physician groups with access to affordable IT technology, while the AT&T Healthcare Community Online portal focused on integrated and larger health care systems. The decision to have AT&T own and operate the combined platform was a natural progression for both groups as they sought to provide a broader suite of services, and should appear seamless to users since both portals are hosted by Covisint, Dr. Stack said.

Smartphone usage among physicians is thought to be about 84%, while tablet usage is thought to be about 50%.

Keeping the mobile physician securely connected will be a large part of the new platform, but patients should also benefit through AT&T’s mobile patient care applications, Randall Porter, assistant vice president of AT&T ForHealth, said in an interview. For example, AT&T has an application specifically for diabetes patients that uses a smartphone in combination with the patient’s glucometer to provide real-time feedback about how to manage their disease.

"The physician would be brought into the loop through the integration of the data into the [electronic medical record] through the portal capability," Mr. Porter said.

Neither AMA nor AT&T would discuss the financial terms of the deal, but Mr. Porter said that existing contractual obligations and bundles will be honored for the roughly 6,000 physician/physician groups using the AMA AMAGINE portal. Future pricing should remain competitive, given the evolving nature of the market, he added.

Dr. Stack said the AMA will remain involved in the platform to provide expertise from the physician and patient point of view.

LAS VEGAS – Merging the American Medical Association’s physician community portal with that of AT&T should provide physicians with a broader array of health information technology solutions, particularly for the physician on the go.

"[Physicians] will have access to tools such as electronic prescribing, registries, electronic medical records, and also sophisticated analytic and population-health tools that will come from the AT&T side," Dr. Steven Stack, chair-elect of the AMA board of trustees, said in an interview at this meeting after the announcement was made.

 The AMA’s AMAGINE physician community portal has focused on providing small- and mid-sized physician groups with access to affordable IT technology, while the AT&T Healthcare Community Online portal focused on integrated and larger health care systems. The decision to have AT&T own and operate the combined platform was a natural progression for both groups as they sought to provide a broader suite of services, and should appear seamless to users since both portals are hosted by Covisint, Dr. Stack said.

Smartphone usage among physicians is thought to be about 84%, while tablet usage is thought to be about 50%.

Keeping the mobile physician securely connected will be a large part of the new platform, but patients should also benefit through AT&T’s mobile patient care applications, Randall Porter, assistant vice president of AT&T ForHealth, said in an interview. For example, AT&T has an application specifically for diabetes patients that uses a smartphone in combination with the patient’s glucometer to provide real-time feedback about how to manage their disease.

"The physician would be brought into the loop through the integration of the data into the [electronic medical record] through the portal capability," Mr. Porter said.

Neither AMA nor AT&T would discuss the financial terms of the deal, but Mr. Porter said that existing contractual obligations and bundles will be honored for the roughly 6,000 physician/physician groups using the AMA AMAGINE portal. Future pricing should remain competitive, given the evolving nature of the market, he added.

Dr. Stack said the AMA will remain involved in the platform to provide expertise from the physician and patient point of view.

Who hasn’t wanted to chuck his or her cell phone, laptop, or tablet at least once a day? The idea of being continually tethered to technology can be crushing, but this interconnectedness will also be our salvation. At least that’s what one Wunderkind thinks.

“This may be hallucinatory optimism, but it gets to the point where the more connected we are, the smaller the world becomes and we think of ourselves as more empathetic, less as citizens of a particular state or city, but citizens of the world,” Twitter co-founder Biz Stone told several thousand attendees at the HIMSS12 Health IT conference in Las Vegas.

He spoke of the transformation that antiretrovirals can bring to AIDS patients in Africa that has been called “The Lazarus Effect,” powered by the social media efforts of RED and the Global Fund.

Patrice Wendling/Elsevier Global Medical News

He spoke of the potential for personal devices and technology to transform that truly American belief that ones body may be his own, but responsibility for its health lies in the hands of another.

With interconnectedness, diabetes patients and their physicians will be able to simultaneously track glucose levels via cloud sharing. Obese patients could link their scale to the Internet or wear a snappy personal device like the FitBit to track real-time activity stats, both of which Stone employed recently in shedding some 30 pounds.

When an attendee asked about the gap that inevitably occurs when new technology is out of reach by some in need, Stone replied that new technologies must be created in an atmosphere that “degrades gracefully” to the lowest common denominator.

“I think when you create technology of a global nature, you have to consider emerging nations where people aren’t all carrying around fancy $100 iPhones,” he said. “One of the reasons we made Twitter 140 characters was so it could fit within the international [messaging] limit of 160 characters or less, so it would work on any phone, not just a fancy phone.”

(Oh, so that’s why.)

Stone's keynote address also was peppered with childhood reminiscences and several well-worn aphorisms for would-be entrepreneurs that were dutifully tweeted and re-tweeted by attendees: “Creativity is a renewable resource” and “When you do business with somebody else, make sure it’s fair on both sides.”

Stone is by no means a polished public speaker, but he is on solid ground in his stated belief that advances like Twitter are not a triumph of technology, but of change.

Who hasn’t wanted to chuck his or her cell phone, laptop, or tablet at least once a day? The idea of being continually tethered to technology can be crushing, but this interconnectedness will also be our salvation. At least that’s what one Wunderkind thinks.

“This may be hallucinatory optimism, but it gets to the point where the more connected we are, the smaller the world becomes and we think of ourselves as more empathetic, less as citizens of a particular state or city, but citizens of the world,” Twitter co-founder Biz Stone told several thousand attendees at the HIMSS12 Health IT conference in Las Vegas.

He spoke of the transformation that antiretrovirals can bring to AIDS patients in Africa that has been called “The Lazarus Effect,” powered by the social media efforts of RED and the Global Fund.

Patrice Wendling/Elsevier Global Medical News

He spoke of the potential for personal devices and technology to transform that truly American belief that ones body may be his own, but responsibility for its health lies in the hands of another.

With interconnectedness, diabetes patients and their physicians will be able to simultaneously track glucose levels via cloud sharing. Obese patients could link their scale to the Internet or wear a snappy personal device like the FitBit to track real-time activity stats, both of which Stone employed recently in shedding some 30 pounds.

When an attendee asked about the gap that inevitably occurs when new technology is out of reach by some in need, Stone replied that new technologies must be created in an atmosphere that “degrades gracefully” to the lowest common denominator.

“I think when you create technology of a global nature, you have to consider emerging nations where people aren’t all carrying around fancy $100 iPhones,” he said. “One of the reasons we made Twitter 140 characters was so it could fit within the international [messaging] limit of 160 characters or less, so it would work on any phone, not just a fancy phone.”

(Oh, so that’s why.)

Stone's keynote address also was peppered with childhood reminiscences and several well-worn aphorisms for would-be entrepreneurs that were dutifully tweeted and re-tweeted by attendees: “Creativity is a renewable resource” and “When you do business with somebody else, make sure it’s fair on both sides.”

Stone is by no means a polished public speaker, but he is on solid ground in his stated belief that advances like Twitter are not a triumph of technology, but of change.

Who hasn’t wanted to chuck his or her cell phone, laptop, or tablet at least once a day? The idea of being continually tethered to technology can be crushing, but this interconnectedness will also be our salvation. At least that’s what one Wunderkind thinks.

“This may be hallucinatory optimism, but it gets to the point where the more connected we are, the smaller the world becomes and we think of ourselves as more empathetic, less as citizens of a particular state or city, but citizens of the world,” Twitter co-founder Biz Stone told several thousand attendees at the HIMSS12 Health IT conference in Las Vegas.

He spoke of the transformation that antiretrovirals can bring to AIDS patients in Africa that has been called “The Lazarus Effect,” powered by the social media efforts of RED and the Global Fund.

Patrice Wendling/Elsevier Global Medical News

He spoke of the potential for personal devices and technology to transform that truly American belief that ones body may be his own, but responsibility for its health lies in the hands of another.

With interconnectedness, diabetes patients and their physicians will be able to simultaneously track glucose levels via cloud sharing. Obese patients could link their scale to the Internet or wear a snappy personal device like the FitBit to track real-time activity stats, both of which Stone employed recently in shedding some 30 pounds.

When an attendee asked about the gap that inevitably occurs when new technology is out of reach by some in need, Stone replied that new technologies must be created in an atmosphere that “degrades gracefully” to the lowest common denominator.

“I think when you create technology of a global nature, you have to consider emerging nations where people aren’t all carrying around fancy $100 iPhones,” he said. “One of the reasons we made Twitter 140 characters was so it could fit within the international [messaging] limit of 160 characters or less, so it would work on any phone, not just a fancy phone.”

(Oh, so that’s why.)

Stone's keynote address also was peppered with childhood reminiscences and several well-worn aphorisms for would-be entrepreneurs that were dutifully tweeted and re-tweeted by attendees: “Creativity is a renewable resource” and “When you do business with somebody else, make sure it’s fair on both sides.”

Stone is by no means a polished public speaker, but he is on solid ground in his stated belief that advances like Twitter are not a triumph of technology, but of change.

Who hasn’t wanted to chuck his or her cell phone, laptop, or tablet at least once a day? The idea of being continually tethered to technology can be crushing, but this interconnectedness will also be our salvation. At least that’s what one Wunderkind thinks.

“This may be hallucinatory optimism, but it gets to the point where the more connected we are, the smaller the world becomes and we think of ourselves as more empathetic, less as citizens of a particular state or city, but citizens of the world,” Twitter co-founder Biz Stone told several thousand attendees at the HIMSS12 Health IT conference in Las Vegas.

He spoke of the transformation that antiretrovirals can bring to AIDS patients in Africa that has been called “The Lazarus Effect,” powered by the social media efforts of RED and the Global Fund.

Patrice Wendling/Elsevier Global Medical News

He spoke of the potential for personal devices and technology to transform that truly American belief that ones body may be his own, but responsibility for its health lies in the hands of another.

With interconnectedness, diabetes patients and their physicians will be able to simultaneously track glucose levels via cloud sharing. Obese patients could link their scale to the Internet or wear a snappy personal device like the FitBit to track real-time activity stats, both of which Stone employed recently in shedding some 30 pounds.

When an attendee asked about the gap that inevitably occurs when new technology is out of reach by some in need, Stone replied that new technologies must be created in an atmosphere that “degrades gracefully” to the lowest common denominator.

“I think when you create technology of a global nature, you have to consider emerging nations where people aren’t all carrying around fancy $100 iPhones,” he said. “One of the reasons we made Twitter 140 characters was so it could fit within the international [messaging] limit of 160 characters or less, so it would work on any phone, not just a fancy phone.”

(Oh, so that’s why.)

Stone's keynote address also was peppered with childhood reminiscences and several well-worn aphorisms for would-be entrepreneurs that were dutifully tweeted and re-tweeted by attendees: “Creativity is a renewable resource” and “When you do business with somebody else, make sure it’s fair on both sides.”

Stone is by no means a polished public speaker, but he is on solid ground in his stated belief that advances like Twitter are not a triumph of technology, but of change.

Who hasn’t wanted to chuck his or her cell phone, laptop, or tablet at least once a day? The idea of being continually tethered to technology can be crushing, but this interconnectedness will also be our salvation. At least that’s what one Wunderkind thinks.

“This may be hallucinatory optimism, but it gets to the point where the more connected we are, the smaller the world becomes and we think of ourselves as more empathetic, less as citizens of a particular state or city, but citizens of the world,” Twitter co-founder Biz Stone told several thousand attendees at the HIMSS12 Health IT conference in Las Vegas.

He spoke of the transformation that antiretrovirals can bring to AIDS patients in Africa that has been called “The Lazarus Effect,” powered by the social media efforts of RED and the Global Fund.

Patrice Wendling/Elsevier Global Medical News

He spoke of the potential for personal devices and technology to transform that truly American belief that ones body may be his own, but responsibility for its health lies in the hands of another.

With interconnectedness, diabetes patients and their physicians will be able to simultaneously track glucose levels via cloud sharing. Obese patients could link their scale to the Internet or wear a snappy personal device like the FitBit to track real-time activity stats, both of which Stone employed recently in shedding some 30 pounds.

When an attendee asked about the gap that inevitably occurs when new technology is out of reach by some in need, Stone replied that new technologies must be created in an atmosphere that “degrades gracefully” to the lowest common denominator.

“I think when you create technology of a global nature, you have to consider emerging nations where people aren’t all carrying around fancy $100 iPhones,” he said. “One of the reasons we made Twitter 140 characters was so it could fit within the international [messaging] limit of 160 characters or less, so it would work on any phone, not just a fancy phone.”

(Oh, so that’s why.)

Stone's keynote address also was peppered with childhood reminiscences and several well-worn aphorisms for would-be entrepreneurs that were dutifully tweeted and re-tweeted by attendees: “Creativity is a renewable resource” and “When you do business with somebody else, make sure it’s fair on both sides.”

Stone is by no means a polished public speaker, but he is on solid ground in his stated belief that advances like Twitter are not a triumph of technology, but of change.

Who hasn’t wanted to chuck his or her cell phone, laptop, or tablet at least once a day? The idea of being continually tethered to technology can be crushing, but this interconnectedness will also be our salvation. At least that’s what one Wunderkind thinks.

“This may be hallucinatory optimism, but it gets to the point where the more connected we are, the smaller the world becomes and we think of ourselves as more empathetic, less as citizens of a particular state or city, but citizens of the world,” Twitter co-founder Biz Stone told several thousand attendees at the HIMSS12 Health IT conference in Las Vegas.

He spoke of the transformation that antiretrovirals can bring to AIDS patients in Africa that has been called “The Lazarus Effect,” powered by the social media efforts of RED and the Global Fund.

Patrice Wendling/Elsevier Global Medical News

He spoke of the potential for personal devices and technology to transform that truly American belief that ones body may be his own, but responsibility for its health lies in the hands of another.

With interconnectedness, diabetes patients and their physicians will be able to simultaneously track glucose levels via cloud sharing. Obese patients could link their scale to the Internet or wear a snappy personal device like the FitBit to track real-time activity stats, both of which Stone employed recently in shedding some 30 pounds.

When an attendee asked about the gap that inevitably occurs when new technology is out of reach by some in need, Stone replied that new technologies must be created in an atmosphere that “degrades gracefully” to the lowest common denominator.

“I think when you create technology of a global nature, you have to consider emerging nations where people aren’t all carrying around fancy $100 iPhones,” he said. “One of the reasons we made Twitter 140 characters was so it could fit within the international [messaging] limit of 160 characters or less, so it would work on any phone, not just a fancy phone.”

(Oh, so that’s why.)

Stone's keynote address also was peppered with childhood reminiscences and several well-worn aphorisms for would-be entrepreneurs that were dutifully tweeted and re-tweeted by attendees: “Creativity is a renewable resource” and “When you do business with somebody else, make sure it’s fair on both sides.”

Stone is by no means a polished public speaker, but he is on solid ground in his stated belief that advances like Twitter are not a triumph of technology, but of change.

Who hasn’t wanted to chuck his or her cell phone, laptop, or tablet at least once a day? The idea of being continually tethered to technology can be crushing, but this interconnectedness will also be our salvation. At least that’s what one Wunderkind thinks.

“This may be hallucinatory optimism, but it gets to the point where the more connected we are, the smaller the world becomes and we think of ourselves as more empathetic, less as citizens of a particular state or city, but citizens of the world,” Twitter co-founder Biz Stone told several thousand attendees at the HIMSS12 Health IT conference in Las Vegas.

He spoke of the transformation that antiretrovirals can bring to AIDS patients in Africa that has been called “The Lazarus Effect,” powered by the social media efforts of RED and the Global Fund.

Patrice Wendling/Elsevier Global Medical News

He spoke of the potential for personal devices and technology to transform that truly American belief that ones body may be his own, but responsibility for its health lies in the hands of another.

With interconnectedness, diabetes patients and their physicians will be able to simultaneously track glucose levels via cloud sharing. Obese patients could link their scale to the Internet or wear a snappy personal device like the FitBit to track real-time activity stats, both of which Stone employed recently in shedding some 30 pounds.

When an attendee asked about the gap that inevitably occurs when new technology is out of reach by some in need, Stone replied that new technologies must be created in an atmosphere that “degrades gracefully” to the lowest common denominator.

“I think when you create technology of a global nature, you have to consider emerging nations where people aren’t all carrying around fancy $100 iPhones,” he said. “One of the reasons we made Twitter 140 characters was so it could fit within the international [messaging] limit of 160 characters or less, so it would work on any phone, not just a fancy phone.”

(Oh, so that’s why.)

Stone's keynote address also was peppered with childhood reminiscences and several well-worn aphorisms for would-be entrepreneurs that were dutifully tweeted and re-tweeted by attendees: “Creativity is a renewable resource” and “When you do business with somebody else, make sure it’s fair on both sides.”

Stone is by no means a polished public speaker, but he is on solid ground in his stated belief that advances like Twitter are not a triumph of technology, but of change.

Who hasn’t wanted to chuck his or her cell phone, laptop, or tablet at least once a day? The idea of being continually tethered to technology can be crushing, but this interconnectedness will also be our salvation. At least that’s what one Wunderkind thinks.

“This may be hallucinatory optimism, but it gets to the point where the more connected we are, the smaller the world becomes and we think of ourselves as more empathetic, less as citizens of a particular state or city, but citizens of the world,” Twitter co-founder Biz Stone told several thousand attendees at the HIMSS12 Health IT conference in Las Vegas.

He spoke of the transformation that antiretrovirals can bring to AIDS patients in Africa that has been called “The Lazarus Effect,” powered by the social media efforts of RED and the Global Fund.

Patrice Wendling/Elsevier Global Medical News

He spoke of the potential for personal devices and technology to transform that truly American belief that ones body may be his own, but responsibility for its health lies in the hands of another.

With interconnectedness, diabetes patients and their physicians will be able to simultaneously track glucose levels via cloud sharing. Obese patients could link their scale to the Internet or wear a snappy personal device like the FitBit to track real-time activity stats, both of which Stone employed recently in shedding some 30 pounds.

When an attendee asked about the gap that inevitably occurs when new technology is out of reach by some in need, Stone replied that new technologies must be created in an atmosphere that “degrades gracefully” to the lowest common denominator.

“I think when you create technology of a global nature, you have to consider emerging nations where people aren’t all carrying around fancy $100 iPhones,” he said. “One of the reasons we made Twitter 140 characters was so it could fit within the international [messaging] limit of 160 characters or less, so it would work on any phone, not just a fancy phone.”

(Oh, so that’s why.)

Stone's keynote address also was peppered with childhood reminiscences and several well-worn aphorisms for would-be entrepreneurs that were dutifully tweeted and re-tweeted by attendees: “Creativity is a renewable resource” and “When you do business with somebody else, make sure it’s fair on both sides.”

Stone is by no means a polished public speaker, but he is on solid ground in his stated belief that advances like Twitter are not a triumph of technology, but of change.

Who hasn’t wanted to chuck his or her cell phone, laptop, or tablet at least once a day? The idea of being continually tethered to technology can be crushing, but this interconnectedness will also be our salvation. At least that’s what one Wunderkind thinks.

“This may be hallucinatory optimism, but it gets to the point where the more connected we are, the smaller the world becomes and we think of ourselves as more empathetic, less as citizens of a particular state or city, but citizens of the world,” Twitter co-founder Biz Stone told several thousand attendees at the HIMSS12 Health IT conference in Las Vegas.

He spoke of the transformation that antiretrovirals can bring to AIDS patients in Africa that has been called “The Lazarus Effect,” powered by the social media efforts of RED and the Global Fund.

Patrice Wendling/Elsevier Global Medical News

He spoke of the potential for personal devices and technology to transform that truly American belief that ones body may be his own, but responsibility for its health lies in the hands of another.

With interconnectedness, diabetes patients and their physicians will be able to simultaneously track glucose levels via cloud sharing. Obese patients could link their scale to the Internet or wear a snappy personal device like the FitBit to track real-time activity stats, both of which Stone employed recently in shedding some 30 pounds.

When an attendee asked about the gap that inevitably occurs when new technology is out of reach by some in need, Stone replied that new technologies must be created in an atmosphere that “degrades gracefully” to the lowest common denominator.

“I think when you create technology of a global nature, you have to consider emerging nations where people aren’t all carrying around fancy $100 iPhones,” he said. “One of the reasons we made Twitter 140 characters was so it could fit within the international [messaging] limit of 160 characters or less, so it would work on any phone, not just a fancy phone.”

(Oh, so that’s why.)

Stone's keynote address also was peppered with childhood reminiscences and several well-worn aphorisms for would-be entrepreneurs that were dutifully tweeted and re-tweeted by attendees: “Creativity is a renewable resource” and “When you do business with somebody else, make sure it’s fair on both sides.”

Stone is by no means a polished public speaker, but he is on solid ground in his stated belief that advances like Twitter are not a triumph of technology, but of change.

KEYSTONE, COLO. – Understanding the quality of a patient’s dyspnea provides insights into the underlying physiologic mechanism and can guide management, according to Dr. James T. Good Jr., a pulmonologist at National Jewish Health in Denver.

Complaints that may represent dyspnea can be as vague as fatigue, lack of energy, or simply getting old, but most commonly are a sensation of air hunger, of work or effort to breathe, or of chest tightness. All three sensations are the result of a mismatch or neuromechanical dissociation between ongoing motor signals to the respiratory muscles and incoming afferent information from the lungs, chest wall, and upper airways, Dr. Good said at a meeting on allergy and respiratory diseases.

For the patient who describes air hunger, the sensation can be equated to being held underwater and is often so distressing that patients say they would prefer pain to air hunger. The sensation is mediated primarily through central and peripheral chemoreceptors and stimulated by hypercapnia or hypoxia in the presence of decreased arterial carbon dioxide (CO₂) partial pressure and oxygen partial pressure, Dr. Good said.

In the patient who describes work or effort when breathing, the sensation is stimulated by respiratory motor muscle contraction and muscle fatigue and is mediated through a combination of central motor discharge, chest wall receptors, and metaboreceptors located within skeletal muscle, he said at the meeting, which was sponsored by National Jewish Health.

In patients with chest tightness, the sensation is stimulated by bronchoconstriction and tends to be mediated primary through rapidly adapting stretch receptors (RARs) and C-fiber receptors in the pulmonary and respiratory tract. Chest tightness can occur with other dyspneic sensations but is fairly specific to asthma and chronic obstructive pulmonary disease (COPD).

The first question to ask patients who present with complaints of an uncomfortable sensation associated with breathing is whether it occurs at rest or with exertion, Dr. Good suggested. Dyspnea at rest implies an acute illness or moderate to severe cardiopulmonary disease. It also is very common in patients with anxiety, with or without underlying disease, and in patients with alterations in the respiratory drive. Dyspnea with exertion is most common in patients with cardiac dysfunction, pulmonary diseases, metabolic disorders, deconditioning, obesity, and anemia.

The next important question to ask is whether the patient with dyspnea has normal oxygen saturation (SaO₂), he said. A normal SaO₂ implies a mild disorder such as exercise-induced bronchospasm, while an abnormal SaO₂ implies moderate to severe cardiopulmonary disease if dyspnea occurs at rest, mild to moderate cardiopulmonary disease if dyspnea occurs during exercise, or sleep-disordered breathing if it occurs with sleep.

Dr. Good observed that many of his cardiology colleagues routinely obtain an electrocardiogram in their patients who are short of breath, which is an important part of the work-up, but that they overlook spirometry.

"If a patient has dyspnea they need to have spirometry," he said. "You have to start with that. It is absolutely key."

Dyspneic patients with normal spirometry are unlikely to have significant underlying COPD or interstitial lung disease (ILD), but they could have exercise-induced bronchospasm, mild or persistent asthma, or vocal cord dysfunction.

If an obstructive pattern is observed on spirometry, this could be a clue to evaluate for COPD or asthma. A restrictive pattern on spirometry should raise suspicion for ILD, neuromuscular disease, chest wall abnormalities, pleural effusion, or heart failure, he said.

Dr. Good presented several cases that highlighted the importance of a thorough work-up, including that of a 70-year-old retired engineer with increasing air hunger dyspnea on exertion. Spirometry revealed a normal forced expiratory volume in 1 second of 2.74 L, or 84% of predicted volume, and forced expiratory vital capacity of 4.91 L, or 111% of predicted volume. The FEV₁/FVC ratio was 56%, which is low, but not enough to explain the amount of dyspnea the patient was experiencing. Cardiac evaluation proved uneventful, but pulmonary function tests revealed a diffusion capacity of 17.2, or just 53% of predicted value.

Dr. Good said that pulmonologists frequently rely on diffusion capacity when spirometry is normal, and when values are less than 50% of predicted, patients are frequently dyspneic.

"Once the dyspnea evaluation is complete, it is usually possible to determine all factors that are contributing to the patient’s breathlessness and direct specific therapy" to the underlying disease process, he said.

Other therapeutic approaches include conditioning, fitness, and weight loss in obese patients with dyspnea, as well as beta-agonists and anticholinergics, theophylline, opiates, anxiolytics, and selective serotonin reuptake inhibitors. Supplemental oxygen usually relieves dyspnea in hypoxemic patients, making vagal afferents unlikely contributors, he said.

Dr. Good disclosed serving as an investigator and speaker for Genentech and as a speaker for GlaxoSmithKline and Merck.

KEYSTONE, COLO. – Understanding the quality of a patient’s dyspnea provides insights into the underlying physiologic mechanism and can guide management, according to Dr. James T. Good Jr., a pulmonologist at National Jewish Health in Denver.

Complaints that may represent dyspnea can be as vague as fatigue, lack of energy, or simply getting old, but most commonly are a sensation of air hunger, of work or effort to breathe, or of chest tightness. All three sensations are the result of a mismatch or neuromechanical dissociation between ongoing motor signals to the respiratory muscles and incoming afferent information from the lungs, chest wall, and upper airways, Dr. Good said at a meeting on allergy and respiratory diseases.

For the patient who describes air hunger, the sensation can be equated to being held underwater and is often so distressing that patients say they would prefer pain to air hunger. The sensation is mediated primarily through central and peripheral chemoreceptors and stimulated by hypercapnia or hypoxia in the presence of decreased arterial carbon dioxide (CO₂) partial pressure and oxygen partial pressure, Dr. Good said.

In the patient who describes work or effort when breathing, the sensation is stimulated by respiratory motor muscle contraction and muscle fatigue and is mediated through a combination of central motor discharge, chest wall receptors, and metaboreceptors located within skeletal muscle, he said at the meeting, which was sponsored by National Jewish Health.

In patients with chest tightness, the sensation is stimulated by bronchoconstriction and tends to be mediated primary through rapidly adapting stretch receptors (RARs) and C-fiber receptors in the pulmonary and respiratory tract. Chest tightness can occur with other dyspneic sensations but is fairly specific to asthma and chronic obstructive pulmonary disease (COPD).

The first question to ask patients who present with complaints of an uncomfortable sensation associated with breathing is whether it occurs at rest or with exertion, Dr. Good suggested. Dyspnea at rest implies an acute illness or moderate to severe cardiopulmonary disease. It also is very common in patients with anxiety, with or without underlying disease, and in patients with alterations in the respiratory drive. Dyspnea with exertion is most common in patients with cardiac dysfunction, pulmonary diseases, metabolic disorders, deconditioning, obesity, and anemia.

The next important question to ask is whether the patient with dyspnea has normal oxygen saturation (SaO₂), he said. A normal SaO₂ implies a mild disorder such as exercise-induced bronchospasm, while an abnormal SaO₂ implies moderate to severe cardiopulmonary disease if dyspnea occurs at rest, mild to moderate cardiopulmonary disease if dyspnea occurs during exercise, or sleep-disordered breathing if it occurs with sleep.

Dr. Good observed that many of his cardiology colleagues routinely obtain an electrocardiogram in their patients who are short of breath, which is an important part of the work-up, but that they overlook spirometry.

"If a patient has dyspnea they need to have spirometry," he said. "You have to start with that. It is absolutely key."

Dyspneic patients with normal spirometry are unlikely to have significant underlying COPD or interstitial lung disease (ILD), but they could have exercise-induced bronchospasm, mild or persistent asthma, or vocal cord dysfunction.

If an obstructive pattern is observed on spirometry, this could be a clue to evaluate for COPD or asthma. A restrictive pattern on spirometry should raise suspicion for ILD, neuromuscular disease, chest wall abnormalities, pleural effusion, or heart failure, he said.

Dr. Good presented several cases that highlighted the importance of a thorough work-up, including that of a 70-year-old retired engineer with increasing air hunger dyspnea on exertion. Spirometry revealed a normal forced expiratory volume in 1 second of 2.74 L, or 84% of predicted volume, and forced expiratory vital capacity of 4.91 L, or 111% of predicted volume. The FEV₁/FVC ratio was 56%, which is low, but not enough to explain the amount of dyspnea the patient was experiencing. Cardiac evaluation proved uneventful, but pulmonary function tests revealed a diffusion capacity of 17.2, or just 53% of predicted value.

Dr. Good said that pulmonologists frequently rely on diffusion capacity when spirometry is normal, and when values are less than 50% of predicted, patients are frequently dyspneic.

"Once the dyspnea evaluation is complete, it is usually possible to determine all factors that are contributing to the patient’s breathlessness and direct specific therapy" to the underlying disease process, he said.

Other therapeutic approaches include conditioning, fitness, and weight loss in obese patients with dyspnea, as well as beta-agonists and anticholinergics, theophylline, opiates, anxiolytics, and selective serotonin reuptake inhibitors. Supplemental oxygen usually relieves dyspnea in hypoxemic patients, making vagal afferents unlikely contributors, he said.

Dr. Good disclosed serving as an investigator and speaker for Genentech and as a speaker for GlaxoSmithKline and Merck.

KEYSTONE, COLO. – Understanding the quality of a patient’s dyspnea provides insights into the underlying physiologic mechanism and can guide management, according to Dr. James T. Good Jr., a pulmonologist at National Jewish Health in Denver.

Complaints that may represent dyspnea can be as vague as fatigue, lack of energy, or simply getting old, but most commonly are a sensation of air hunger, of work or effort to breathe, or of chest tightness. All three sensations are the result of a mismatch or neuromechanical dissociation between ongoing motor signals to the respiratory muscles and incoming afferent information from the lungs, chest wall, and upper airways, Dr. Good said at a meeting on allergy and respiratory diseases.

For the patient who describes air hunger, the sensation can be equated to being held underwater and is often so distressing that patients say they would prefer pain to air hunger. The sensation is mediated primarily through central and peripheral chemoreceptors and stimulated by hypercapnia or hypoxia in the presence of decreased arterial carbon dioxide (CO₂) partial pressure and oxygen partial pressure, Dr. Good said.

In the patient who describes work or effort when breathing, the sensation is stimulated by respiratory motor muscle contraction and muscle fatigue and is mediated through a combination of central motor discharge, chest wall receptors, and metaboreceptors located within skeletal muscle, he said at the meeting, which was sponsored by National Jewish Health.

In patients with chest tightness, the sensation is stimulated by bronchoconstriction and tends to be mediated primary through rapidly adapting stretch receptors (RARs) and C-fiber receptors in the pulmonary and respiratory tract. Chest tightness can occur with other dyspneic sensations but is fairly specific to asthma and chronic obstructive pulmonary disease (COPD).

The first question to ask patients who present with complaints of an uncomfortable sensation associated with breathing is whether it occurs at rest or with exertion, Dr. Good suggested. Dyspnea at rest implies an acute illness or moderate to severe cardiopulmonary disease. It also is very common in patients with anxiety, with or without underlying disease, and in patients with alterations in the respiratory drive. Dyspnea with exertion is most common in patients with cardiac dysfunction, pulmonary diseases, metabolic disorders, deconditioning, obesity, and anemia.

The next important question to ask is whether the patient with dyspnea has normal oxygen saturation (SaO₂), he said. A normal SaO₂ implies a mild disorder such as exercise-induced bronchospasm, while an abnormal SaO₂ implies moderate to severe cardiopulmonary disease if dyspnea occurs at rest, mild to moderate cardiopulmonary disease if dyspnea occurs during exercise, or sleep-disordered breathing if it occurs with sleep.

Dr. Good observed that many of his cardiology colleagues routinely obtain an electrocardiogram in their patients who are short of breath, which is an important part of the work-up, but that they overlook spirometry.

"If a patient has dyspnea they need to have spirometry," he said. "You have to start with that. It is absolutely key."

Dyspneic patients with normal spirometry are unlikely to have significant underlying COPD or interstitial lung disease (ILD), but they could have exercise-induced bronchospasm, mild or persistent asthma, or vocal cord dysfunction.

If an obstructive pattern is observed on spirometry, this could be a clue to evaluate for COPD or asthma. A restrictive pattern on spirometry should raise suspicion for ILD, neuromuscular disease, chest wall abnormalities, pleural effusion, or heart failure, he said.

Dr. Good presented several cases that highlighted the importance of a thorough work-up, including that of a 70-year-old retired engineer with increasing air hunger dyspnea on exertion. Spirometry revealed a normal forced expiratory volume in 1 second of 2.74 L, or 84% of predicted volume, and forced expiratory vital capacity of 4.91 L, or 111% of predicted volume. The FEV₁/FVC ratio was 56%, which is low, but not enough to explain the amount of dyspnea the patient was experiencing. Cardiac evaluation proved uneventful, but pulmonary function tests revealed a diffusion capacity of 17.2, or just 53% of predicted value.

Dr. Good said that pulmonologists frequently rely on diffusion capacity when spirometry is normal, and when values are less than 50% of predicted, patients are frequently dyspneic.

"Once the dyspnea evaluation is complete, it is usually possible to determine all factors that are contributing to the patient’s breathlessness and direct specific therapy" to the underlying disease process, he said.

Other therapeutic approaches include conditioning, fitness, and weight loss in obese patients with dyspnea, as well as beta-agonists and anticholinergics, theophylline, opiates, anxiolytics, and selective serotonin reuptake inhibitors. Supplemental oxygen usually relieves dyspnea in hypoxemic patients, making vagal afferents unlikely contributors, he said.

Dr. Good disclosed serving as an investigator and speaker for Genentech and as a speaker for GlaxoSmithKline and Merck.