Thank you for tuning in to the Editor’s Highlight Podcast for the July issue of the journal CHEST®. We have a great lineup of original research and review articles in this month’s issue.
Over the next 10-15 minutes, I will provide a brief overview of key original research manuscripts published in each of our content areas.
Starting with our Asthma content area, hormone replacement therapy has previously been reported to have both protective and harmful effects in asthma. In this month’s issue, Hansen and colleagues asked the question of whether hormone replacement therapy in menopause is associated with the development of new onset asthma. Using a nested, case-control study design that included more than 34,500 women with asthma and 345,000 women without asthma between 40 and 65 years of age, active hormone replacement therapy resulted in a hazard ratio of 1.63 for the development of a new asthma diagnosis. Women with asthma who terminated hormone replacement therapy were more likely to discontinue their asthma treatment. These results highlight an association between hormone replacement therapy and the development of asthma that should be considered if airway symptoms develop after its initiation. Also in this section is an original research paper evaluating medication adherence in patients with severe asthma who were prescribed oral corticosteroids in the U-BIOPRED cohort.
Next is our Chest Infections content area. There have been few studies describing the lung function trajectories of individuals with cystic fibrosis (CF) who were diagnosed as adults. In this issue, Desai and colleagues used the Canadian CF Registry to assess the trajectory of lung function, and clinical characteristics associated with lung function decline, in those who receive a diagnosis of CF as an adult. Lung function was found to be stable in early adulthood, decline from ages 30-50, and have a greater decline after age 50. Being diagnosed after age 50 and having pulmonary symptoms was associated with a faster rate of lung function decline. These findings advance our understanding of the evolution of CF in this subgroup and identify individuals who should be more closely monitored. Also in this section is a pilot randomized controlled trial of progesterone in addition to standard of care in men with moderate to severe COVID-19; a research letter assessing the effect of prone positioning on respiratory support of nonintubated patients with acute hypoxic respiratory failure; and a second Research Letter that assesses the relationship between dihydropyridine calcium channel blockers and the risk of severe COVID-19.
On to our COPD content area. It has been recognized that mild expiratory flow limitation may not be uncovered with traditional spirometric criteria. In this issue, Fortis and colleagues asked whether the use of a slow vital capacity (SVC) measure instead of forced vital capacity (FVC) could increase the sensitivity of spirometry to identify those with early obstructive lung disease. They assessed 854 current and former smokers with postbronchodilator FEV1/FVC >0.7 and FEV1 % predicted >80%. Of the 854 evaluated, 120 had a postbronchodilator FEV1/SVC <0.7. These individuals showed a greater percentage of emphysema, percentage of gas trapping, and percentage of functional small airways disease at baseline. An FEV1/SVC <0.7 was associated with severe exacerbations and progression to COPD over a 3-year follow-up period. This work can help us to identify those with normal spirometry whose clinical features and course are likely to mirror that of someone with COPD. Also in this section is a Research Letter describing the clinical consequence of the COVID-19 lockdown on patients with COPD; a CHEST Review on sex and gender omic biomarkers in men and women; and a Special Feature discussion of the seven pillars of small airways disease in asthma and COPD and how this understanding can support the development of novel therapies.
Next is our Critical Care content area. The impact of resting the respiratory musculature after undergoing a spontaneous breathing trial on the success of extubation is not well established. In this issue, Dadam and colleagues sought to determine if reconnection to mechanical ventilation for 1 hour after a successful spontaneous breathing trial could reduce the risk of reintubation. This randomized clinical trial, conducted in four ICUs, randomized individuals to direct extubation or extubation after reconnection to mechanical ventilation for 1 hour. Reintubation at 48 hours was the primary outcome. In the group of 336 enrolled, the differences in reintubation rates were not statistically significant, nor were differences in mortality or length of stay. In a prespecified exploratory analysis of those who were ventilated for more than 72 hours, the incidence of reintubation in the group who received respiratory muscle rest was lower than those who did not (12.7% vs 22.6%). These results suggest the added support strategy may benefit those who were ventilated for more than 72 hours and should prompt further exploration of this group. Also in this section are original research manuscripts assessing the prediction of brain death after out-of-hospital cardiac arrest; the burden of mental illness among survivors of critical care; outcomes and resource use associated with acute respiratory failure in safety net hospitals; the impact of approaches to minimize aerosol dispersion of SARS-CoV-2 during noninvasive ventilator support on ventilator performance; and the pulmonary function and radiological features of survivors of critical COVID-19 at 3 months.
On to our Diffuse Lung Disease content area. Inhalational exposures are recognized as contributing factors to the development of interstitial lung disease (ILD), but the characteristics of both the exposures and the exposed individuals are not well understood. In this issue, Lee and colleagues assessed the prevalence of inhalational exposures across all ILD diagnoses and sought to determine their clinical impact. One hundred fifty-six patients from a tertiary ILD clinic were interviewed for exposures, of whom 65% had a potentially relevant exposure. Being male and white race were associated with having an exposure. Those with exposures had worse transplant-free survival, though the difference was not statistically significant after adjustment for confounders. These results support steps to identify and avoid exposures as a routine part of ILD management. Also in this section is an original research article assessing the impact of ultra-small lung cysts on lung function in patients with lymphangioleiomyomatosis and a Point/Counterpoint debate about whether isolated cardiac sarcoidosis should be considered a significant manifestation of sarcoidosis.
Our Education and Clinical Practice content area is next. Little is known about barriers for fellows-in-training to develop competence in ultrasonography. In this issue, Brady and colleagues conducted a national survey of pulmonary and critical care medicine (PCCM) fellowship programs to assess how fellows acquire experience with ultrasonography and identify barriers to acquiring expertise. From 475 responses, independent performance of ultrasonography at bedside was the most common method of learning. The greatest barriers were the lack of trained faculty experts and the lack of a formal curriculum. Fellows were most comfortable with thoracic ultrasound and least with advanced cardiac ultrasound. These results may help focus future educational efforts to address barriers at the level of the program and institution. Also in this section are original research articles assessing portable chest radiography as an exclusionary test for adverse clinical outcomes during the COVID-19 pandemic and the impact of long-term air pollution exposure on adolescent lung function. You will also find a Research Letter addressing pulmonary function and the risk of Alzheimer dementia; a How I Do It review from our leadership in CHEST medicine series describing the creation of an organizational culture for the chest clinician; and a CHEST Review on advanced diagnostic and therapeutic bronchoscopy technology and reimbursement.
Next is our Pulmonary and Cardiovascular content area. Early initiation of pulmonary arterial hypertension therapies is felt to be associated with improved outcomes, though the evidence in support of this is limited. In this issue, Gaine and colleagues performed a post-hoc analysis of the GRIPHON study to assess whether time from diagnosis impacts morbidity and mortality events and response to selexipag treatment. Time from diagnosis was <6 months in 34.9% of the study subjects. These individuals had a poorer long-term outcome than those who had been diagnosed for longer. Treatment reduced the risk of morbidity and mortality in both those with a recent and distant diagnosis, with a more pronounced effect in those who were newly diagnosed. These results highlight differences in the disease prognosis and response to therapy based on time from diagnosis that should be considered in practice. Also in this section are original research articles assessing the association of bronchopulmonary dysplasia and right ventricle systolic function in young adults born preterm, and ST2 as a biomarker of pediatric pulmonary arterial hypertension severity and clinical worsening.
Our Sleep Medicine content area is next. Solriamfetol is approved to improve wakefulness in adults with excessive daytime sleepiness associated with OSA. In this issue, Schweitzer and colleagues assessed whether solriamfetol had differential effects of excessive daytime sleepiness based on adherence to primary OSA therapy and whether solriamfetol affects primary OSA therapy use. Four hundred fifty-nine patients were randomized to 12 weeks of placebo or solriamfetol. At baseline, 70.6% adhered to OSA primary therapy. Improvements in the Maintenance of Wakefulness Test and Epworth Sleepiness Scale in those receiving solriamfetol were similar between those who were and those who were not compliant with primary therapy. Use of solriamfetol did not influence compliance with primary therapy. These results suggest the effectiveness and safety of solriamfetol therapy regardless of compliance with primary therapy.
Next is our Thoracic Oncology content area. Lung cancer screening eligibility criteria vary across guidelines. Knowing the eligible pool across demographic groups may help with policy and programmatic decisions for affected populations. In this issue, Pinsky and colleagues sought to determine eligibility rates according to sex and race or ethnicity and relate these to lung cancer incidence rates. Eligibility to incidence ratios were calculated using data from the 2015 National Health Interview Survey. These were compared to guidelines and a risk model. Eligibility rates were 10 percentage points higher for men than women. Among both men and women, non-Hispanic Whites had the highest eligibility to incidence ratios across all guidelines. Non-Hispanic Black men had a higher lung cancer incidence but 30%-50% lower eligibility to incidence ratio. These results highlight the need for screening guidelines to consider potential disparities in care. Also in this section are original research articles assessing the quality of shared decision-making for lung cancer screening; breathlessness as a predictor of survival in patients with malignant pleural effusions; and whether the geographic distribution of lung cancer screening programs matches the need in the Veterans Health Administration population. A Research Letter addresses the impact of the COVID-19 pandemic on volumes and disparities in lung cancer screening, and a Special Feature describes the development of quality metrics for lung cancer screening programs.
Finally, I encourage you to take a look at our Humanities in Chest Medicine series, where a publication in the Exhalations series, titled With You In Time, is a worthy read. Our case series publications for the month provide novel and educational cases to test your clinical skills.
I hope you enjoy reading all of the high-quality content available in this month’s issue of the journal CHEST. As always, I am grateful to the authors of this work, to the reviewers who volunteered their time to improve the quality of these submissions, and to our editorial board for guiding everything that we do. Until next month, I hope you enjoy the July issue.