Thank you for tuning in to the Editor’s Highlight Podcast for the July 2024 issue of the journal CHEST®. There is a great lineup of diverse content in this month’s issue.
Over the next 15 minutes, I will provide a brief overview of key manuscripts published in each of our content areas.
First is our Asthma content area. Asthma exacerbation frequency influences treatment choices in patients with severe asthma. The variability of asthma exacerbation rates is not known. In this issue, Lee and colleagues reviewed data from an international observational cohort of patients diagnosed with severe asthma to determine the extent of variability of exacerbation rates across countries and the implication for disease management. The cohort included 7,510 patients from 17 countries, with 1,939 severe exacerbations. The severe exacerbation rate ranged from a minimum of 0.04 per person-year to 0.88 per person-year, with an IQR of 0.13 to 0.54 per person-year. These findings suggest that unknown patient factors or system-level variations are influencing severe asthma exacerbation rates.
Next is our Chest Infections content area. Results of individual studies assessing inhaled antibiotics for the treatment of patients with bronchiectasis are inconsistent. In this issue, Cordeiro and colleagues present results of an updated systematic review and meta-analysis of randomized controlled trials designed to determine the efficacy and safety of inhaled antibiotics in the treatment of adults with bronchiectasis. Twenty studies involving 3,468 patients were included. Inhaled antibiotics were associated with a reduced number of exacerbations, exacerbation frequency, and frequency of severe exacerbations. There was an increase in time to first exacerbation and in the Quality of Life-Bronchiectasis respiratory symptom score. Bacterial load was reduced while FEV1 was unchanged. There was no difference in adverse effects, but antibiotic-resistant organisms were increased. These findings identify benefits from inhaled antibiotics for the treatment of patients with bronchiectasis. Also in this section is a retrospective cohort study assessing the benefits and harms of anaerobic antibiotic coverage in aspiration pneumonia and another evaluating disparities in influenza, pneumococcal, and COVID-19 vaccine coverage in high-risk adults.
On to our COPD content area. It is unclear how breathlessness relates to self-reported and physiologic responses in people with chronic airflow obstruction. In this issue, Ekstrom and colleagues report on associations between both participant-reported and physiologic outcomes and breathlessness. The study included 330 people with chronic airflow obstruction who had breathlessness graded during cardiopulmonary exercise testing (CPET). Relative to peak power output, rate of oxygen uptake, and minute ventilation, abnormally high exertional breathlessness was associated with worse lung function, exercise capacity, self-reported symptom burden, physical activity, and health-related quality of life, as well as greater physiologic abnormalities during CPET. These findings support the construct validity of abnormal exertional breathlessness, identifying associations with clinical, physiologic, and functional outcomes. Completing this section is a Point/Counterpoint debate on the use of triple inhaled therapy in all patients with grade E COPD.
Next is our Critical Care content area. Little is currently known about the goals of care decision-making process in patients with chronic critical illness. In this issue, Andersen and colleagues report findings from semistructured interviews with a purposeful sample of intensivists using a mental models approach, designed to identify how intensivists facilitate decision-making and the barriers and facilitators of the decision-making process. Twenty-nine intensivists from six institutions were interviewed. Many intensivists identified the process as being complex, longitudinal, and iterative, stressing the importance of multiple family meetings to build trust. Barriers included 1-week staffing models, limited time and cognitive bandwidth, difficulty eliciting patient values, and interpersonal challenges with care team members and families. Regular family meetings, consistent messaging, and interprofessional involvement were identified as facilitators. A complex, time- and labor-intensive group process to achieve goals of care decision-making was described. Other original research in this section includes a study of clinician- and patient-identified solutions to reduce the fragmentation of post-ICU care and a retrospective cohort study of early deep sedation practices during the pandemic among adult patients without COVID-19. Completing this section is a CHEST Review of caring for patients, and the family of patients, dying in the ICU.
On to our Diffuse Lung Disease content area. Data on the risk of venous thromboembolism (VTE) in patients with sarcoidosis are sparse. In this issue, Yafasova and colleagues used data from Danish nationwide registries to perform a nested case-control study that included 14,742 patients with newly diagnosed sarcoidosis without prior VTE and 58,968 matched individuals to determine if patients with sarcoidosis have a higher long-term risk of VTE. Absolute 10-year risks of outcomes for those with sarcoidosis vs the background population were 2.9% vs 1.6% for VTE, 1.5% vs 0.7% for pulmonary embolism, and 1.6% vs 1.0% for deep vein thrombosis. Sarcoidosis was associated with an increased rate of all outcomes in the first year after diagnosis with an HR of 4.94 and after the first year with an HR of 1.65. These findings identify an association between sarcoidosis and higher long-term risk of VTE. Completing this section is an original research article on the costs of end-of-life hospitalizations for individuals with pulmonary diseases in the US.
On to our Education and Clinical Practice content area. The interpretation of chest radiographs (CXRs) can be difficult in an emergency unit setting. In this issue, Rudolph and colleagues aimed to determine if a convolutional neural network-based artificial intelligence (AI) system that interprets CXRs improves the accuracy for diagnosis of four pathologies in an emergency unit setting (pleural effusion, pneumothorax, pneumonia, and lung nodules). Nonradiology residents’ sensitivity and accuracy improved for all four pathologies. A 30% gain in sensitivity and 2% gain in accuracy were noted for pneumothorax and a 53% gain in sensitivity and 7% gain in accuracy were seen for lung nodules. Smaller, mostly nonsignificant gains were noted in radiology residents. These findings suggest the potential benefit to the AI solution in an emergency unit setting without 24/7 radiology coverage. Completing this section is a CHEST Review of laryngeal dysfunction manifesting as chronic refractory cough and dyspnea.
Our Pulmonary Vascular content area is next. It is not clear if subgroups of patients with idiopathic pulmonary arterial hypertension (IPAH) have different vascular phenotypes. In this issue, Nossent and colleagues report findings from a cross-sectional registry study of 50 patients with IPAH and a lung histologic examination, designed to determine the histologic patterns and their clinical correlates in patients with IPAH or hereditary PAH. A plexiform vasculopathy was noted in 52% of patients. Nonplexiform vasculopathy was characterized by prominent pulmonary microvascular remodeling and vascular rarefaction. Those with nonplexiform vasculopathy were older, were more often male, had stronger cigarette smoking histories, and had lower diffusing capacity at diagnosis despite comparable hemodynamic parameters. No mutations in established PAH genes were found in the nonplexiform group. These findings highlight possible differences in the underlying pathobiology of patients with plexiform and nonplexiform microvascular disease. Completing this section is a CHEST Review on atrial arrhythmias in patients with pulmonary hypertension.
Our Sleep Medicine content area is next. The basis for distinct endotypic characteristics of patients with positional OSA (POSA) is poorly understood. In this issue, Wang and colleagues evaluated endotypes of 1,036 individuals with POSA and nonpositional OSA (NPOSA) within the Shanghai Sleep Health Study cohort to determine if the endotypes differ and which endotypic characteristics are important in determining severity. Those with POSA had lower loop gain, lower arousal threshold, higher pharyngeal collapsibility, and higher muscle compensation in all sleep stages and all sleep positions. In NPOSA, VpassiveAll was the most critical predictor of the apnea-hypopnea index. Nonanatomic characteristics were more significant predictors of severity of POSA, with loop gain being the most crucial factor. These findings highlight differences in endotypes between NPOSA and POSA, with anatomic factors related to the severity of NPOSA and nonanatomic traits related to the severity of POSA.
Next is our Thoracic Oncology content area. The relationship between female-specific reproductive factors and lung cancer risk is uncertain. In this issue, Zhang and colleagues evaluate the association between multiple reproductive factors and the risk of lung cancer developing in a prospective cohort study of 273,190 female individuals from the UK Biobank, including 1,182 who developed lung cancer. Early menarche, early menopause, a shorter reproductive span, and early age at first birth were associated with a higher risk of lung cancer. Early age at menopause, shortened reproductive span, and early age at first birth had a stronger relationship with an elevated risk of lung cancer in populations with high genetic risk and more detrimental behaviors. These findings suggest reproductive factors could be considered as risk factors for the development of lung cancer.
I encourage you to read our Humanities in Chest Medicine section, where you will find an Exhalations piece titled, “The Mountain,” and our Commentary series where you will find a perspective comparing the Global Initiative for Chronic Obstructive Lung Disease and Canadian Thoracic Society COPD guidelines. Finally, please review our case series publications for the month, which provide novel and educational cases to help improve 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 manuscripts, and to our editorial board for guiding everything that we do. Until next month, I hope you enjoy the July issue.