Networks

Occupational and Environmental Health

Incident sarcoidosis

The history of sarcoidosis dates back to 1869, when Dr. Jonathan Hutchinson described symmetrical purple skin plaques on the legs and hands of a coal-wharf worker (James and Sharma. Curr Opin Pulm Med. 2002;8[5]:416). However, despite its distant beginning, much remains unknown. It has been hypothesized that environmental factors play a pivotal role in disease onset and course, as is evidenced by the notable exposure in the first historical case.

Research has shown environmental factors, such as wood smoke, tree pollen, insecticides, and mold; as well as occupational exposures, such as flight deck work on aircraft carriers, metalworking, construction, and firefighting, carry increased risk of sarcoidosis (Newman et al. Am J Respir Crit Care Med. 2004;170[12]:1324; Newman and Newman. Curr Opin Allergy Clin Immunol. 2012;12[2]:145). A significantly high annual incidence of sarcoidosis was first demonstrated in FDNY firefighters between 1985 and 1998; 12.9/100,000, as compared with 2.5 to 7.6/100,000 for U.S. white men (Prezant et al. Chest. 1999;116[5]:1183).

Following the attack of the World Trade Center (WTC) on September 11, 2001, a further increase in sarcoidosis incidence was found in FDNY firefighters exposed to WTC “dust” during the collapse and rescue/recovery effort (Izbicki et al. Chest. 2007;131[5]:1414). As of 2015, a total of 75 FDNY firefighters have been identified as having new post-9/11 sarcoidosis.

Since the WTC-exposed FDNY firefighters with new-onset sarcoidosis since September 11, 2001 can be considered to have had a WTC “trigger,” we have a unique opportunity to define the clinical patterns and outcomes of incident sarcoidosis following a distinct exposure. Members of the Occupational and Environmental NetWork Steering Committee are currently investigating this aim and others in a National Institute of Occupational Safety and Health (NIOSH)-granted cohort study. We hypothesize that the patterns of organ involvement, and time course of disease progression or resolution, may significantly differ in this group as compared with the general population. Preliminary results of our study of WTC-exposed FDNY firefighters will be presented at CHEST 2016 in Los Angeles.

Kerry Hena, MD

Physician-in-Training Member

Palliative and End-of-Life Care

Integrated palliative care for mechanical circulatory support

Patients with advanced heart failure (AHF) have well-documented needs for comprehensive supportive care services in the critical care setting. Notable symptom burden, high morbidity and mortality, prognostic uncertainty, and need for care coordination across hospital settings pave the way for palliative care (PC) teams to work symbiotically with advanced heart failure specialists and intensivists. Furthermore, the expanded availability of mechanical circulatory support (MCS) technology extends these clinical and ethical challenges to balancing longevity, quality of life, and resource utilization, most prominently in the ICU.

To date, collaborations between PC, AHF specialists, and critical care have tended to be reactive, not proactive – palliative consultation usually occurs after a medical or surgical crisis (for example, the massive stroke, MCS thrombus, sepsis, and multiorgan failure) or after a prolonged ICU stay without clear improvement in patient function or prognosis. This reactive consult may be misperceived by patient and family as “giving up.”

At our institution, we have worked to develop a model of seamless integration of interdisciplinary palliative care consultation upstream in advanced heart failure patient care that aims to preempt many dilemmas in the ICU around complex medical decision making and end-of-life care. Through development of therapeutic supportive care relationships, preparedness planning, and discussions of goals of care early in treatment pathways involving critical care resources – including MCS evaluation and cardiac transplantation – this model purports to strengthen appropriate critical care delivery for patients with advanced heart failure. This model has evolved to where PC consultation becomes a structured part of the preoperative evaluation of all candidates for left-ventricular assist device as destination therapy (LVAD-DT). The result is a collaborative approach where patients and families see PC as part of the continuum of whole-person AHF care, rather than a negative alternative.

MCS implantation is on the rise. While MCS technology continues to evolve, its recipients remain seriously ill. Normalizing and integrating PC consultation as part of high quality AHF and critical care sends an important message to patients and families: regardless of clinical outcome, relief from suffering matters throughout the trajectory of the illness experience.

Hunter Groninger, MD

Steering Committee Member

Respiratory Care NetWork

Professional relationships in RC

At the 2015 meeting of the American Association for Respiratory Care (AARC) in Tampa, there were more than 20 presentations given by FCCPs! Also, a majority of CHEST’s Respiratory Care NetWork’s steering committee was in attendance at the meeting. To other members of CHEST, that might seem rather unusual. However, many CHEST members have connections with the field of respiratory care. In addition, CHEST as an organization has a professional relationship with the respiratory care field. CHEST has more than 10 official liaisons to respiratory care professional organizations.