Thank you for tuning in to the Editor’s Highlight Podcast for the June 2022 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.
Starting with our Asthma content area, the beneficial effect of azithromycin has been demonstrated in asthmatic adults, but data on its role in treating children are limited. In this issue, Ghimire and colleagues report the results of an open-label, randomized controlled trial of azithromycin taken three times weekly in children 5 to 15 years of age with poorly controlled asthma with a primary outcome of asthma control. One hundred twenty children were randomized. At 3 months, the Asthma Control Test and Childhood Asthma Control Test were higher in the treated groups, 21.7 vs 18.3. The number of children with well-controlled asthma was 41 of 56 in the azithromycin group and 10 of 56 in the control group, and the median number of exacerbations was reduced. There was no difference in adverse effects between the groups. These results suggest the use of azithromycin in children with poorly controlled asthma can improve asthma control and reduce exacerbations. Also in this section is an original research article that evaluated the relationship between insurance status and the Affordable Care Act on asthma outcomes among low-income US adults.
Next is our Chest Infections content area. The characteristics and outcomes of adult patients with respiratory syncytial virus (RSV) infection who require ICU admission are poorly defined. In this issue, Coussement and colleagues report the findings of a retrospective study that included 17 sites in France and Belgium designed to determine the characteristics and outcomes of adult patients in the ICU with RSV infection compared with those with influenza infection. Six hundred eighteen patients, 309 with RSV and 309 with influenza, were analyzed. Those with RSV were more likely to have a chronic respiratory condition and to be immunocompromised. Differences in clinical signs were noted, while in-hospital mortality, approaching 25%, was not significantly different between the two groups. These results help identify the patient phenotype most likely to present with RSV infection and confirm a high in-hospital mortality. Also in this section are two research letters, the first describing the organization of outpatient care after COVID-19 hospitalization and the second describing an impaired antibody response to SARS-CoV-2 mRNA vaccination in those with chronic medical conditions.
On to our COPD content area. The impact of physical capacity and physical activity on all-cause mortality in patients with COPD is unclear. In this issue, Vaes and colleagues report the findings of a retrospective study of 829 patients with COPD designed to determine the impact of four quadrants of physical capacity (“can do”) and physical activity (“do do”) on 6-year all-cause mortality. Physical capacity was assessed with a 6-minute walk, and physical activity was assessed as steps per day. Patients in the “can do, don’t do” and “can do, do do” quadrants showed significantly lower mortality risk than those in the “can’t do, don’t do” quadrant, with a heart rate of 0.36 beats/min and 0.24 beats/min respectively. These results suggest physical capacity, regardless of physical activity level, is a major determinant of 6-year mortality risk in those with COPD. Completing this section is a How I Do It review that describes the use of cardiopulmonary exercise testing to understand dyspnea and exercise intolerance in respiratory disease.
Next is our Critical Care content area. Older adults with disabilities, dementia, frailty, and multimorbidity are vulnerable to adverse outcomes. Little is known about how preexisting geriatric conditions have changed over time. In this issue, Cobert and colleagues identified measures of disability, dementia, frailty, and multimorbidity from responses to the Medicare-linked Health and Retirement Survey from individuals more than 65 years old who were admitted to the ICU between 1998 and 2015. Among 6,084 ICU patients, the proportion of ICU admissions with preexisting disability rose from 15.5% to 24.0%, frailty increased from 36.6% to 45.0%, and multimorbidity increased from 54.4% to 71.8%. Rates for dementia did not change. These results suggest that preexisting disability, frailty, and multimorbidity rates have increased over time, highlighting the importance of integrating geriatric principles into the ICU setting. Other original research appearing in this section includes a report on mechanical ventilator liberation of patients with COVID-19 in long-term acute care facilities; a survey of health care providers in Brazil evaluating perceptions of critical care shortages, resource utilization, and provider well-being during the COVID-19 pandemic; and a cross-sectional study estimating the prevalence and outcomes of sepsis in adult ICUs in India. Completing this section is a How I Do It review of how to set and titrate positive end-expiratory pressure.
On to our Diffuse Lung Disease content area. As many pathophysiologic mechanisms have been described in idiopathic pulmonary fibrosis (IPF), the mechanisms driving fibrosis may differ from one patient to another. In this issue, De Sadeleer and colleagues clustered samples based on a dimension reduction algorithm using data from a publicly available gene expression data set of BAL samples from 176 patients with IPF from three centers to determine if IPF endotypes exist and are associated with outcomes. Their findings were validated in three independent, publicly available blood gene expression data sets. Samples were clustered into six clusters. Clinical characteristics did not differ between clusters. One cluster—enriched for increased epithelial, innate, and adaptive immunity signatures—had worse survival, and another—showing important telomere and mitochondrial dysfunction, loss of proteostasis, and increased myofibroblast signatures—approached worse survival. These results suggest that gene expression-based endotyping in IPF is feasible, can inform clinical evolution, and may open the possibility of endotype-tailored therapy. Completing this section are two research letters, the first describing the outcomes and impact of mTOR inhibition of COVID-19 in lymphangioleiomyomatosis and the second evaluating the malignancy risk associated with mycophenolate mofetil or azathioprine in patients with fibrotic interstitial lung disease.
Our Education and Clinical Practice content area is next. Airborne personal protective equipment is important in protecting health care workers from airborne viral transmission. A modified fast quantitative fit-test protocol was recently approved by the Occupational Safety and Health Administration. In a research letter appearing in this issue, Regli and colleagues compared the consistency of results between the standard quantitative fit-test protocol and the modified fast protocol in 19 health care workers who had both tests performed using the same N95 mask. The fit pass rate was 74% for the modified protocol and 47% for the standard protocol. These results suggest the need for larger, methodologically rigorous studies to evaluate the utility of the modified fast quantitative fit-test protocol. Also in this section is a How I Do It review of echocardiographic-based stroke volume and cardiac output determination.
Next is our Pulmonary Vascular content area. Pulmonary arterial hypertension (PAH) is a range of illnesses, partly divided into idiopathic PAH and heritable PAH. It is unknown whether the broad proinflammatory phenotype of idiopathic PAH is different than heritable PAH. In this issue, Schwiening and colleagues report a comparison of inflammatory and pathogenic analytes, previously connected to PAH development or progression, between 54 patients with idiopathic PAH and 54 with heritable PAH. Those with heritable PAH were younger and had worse hemodynamic indexes at presentation. Those with idiopathic PAH had higher VEGF-A levels. IL-6 was a more significant predictor of death in heritable PAH than in idiopathic PAH, while TNF-alpha and IL-8 were more significant predictors of death in idiopathic PAH. NT-proBNP levels did not predict death in heritable PAH. These results suggest different driving inflammatory components in heritable and idiopathic PAH, which may lead to genotype-specific prognostic biomarkers and treatment. Also in this section is a cost-effectiveness analysis of societal guidelines for diagnosis of pulmonary embolism in pregnancy, a CHEST Review of pulmonary artery tumors mimicking pulmonary embolism, and a Point/Counterpoint debate about whether therapeutic heparin should be administered to acutely ill hospitalized patients with COVID-19.
Our Sleep Medicine content area is next. Limitations in trials, such as low CPAP adherence, may contribute to their failure to demonstrate an effect of CPAP therapy on mortality in patients with OSA. In this issue, Pepin and colleagues used data from the French national health insurance reimbursement system for all new CPAP users, and propensity matching, to determine the effects of CPAP therapy termination in the first year on all-cause mortality in patients with OSA. Each matched group included 88,007 patients. Continuation of CPAP therapy was associated with a significantly lower risk of all-cause mortality (heart rate 0.61 beats/min) and incident heart failure (heart rate 0.77 beats/min). These results suggest the potential for ongoing use of CPAP treatment to reduce all-cause mortality in patients with OSA.
Next is our Thoracic Oncology content area. The prevalence of persistent smoking in the postoperative period and its association with long-term oncologic outcomes are poorly described. In this issue, Heiden and colleagues report the findings from a retrospective cohort study using a Veterans Health Administration data set to determine the relationship between persistent smoking and long-term outcomes in early-stage lung cancer after surgical treatment. Of 7,489 patients included, 4,652 were smoking at the time of surgery. Fifty-eight percent of those smoking at the time of surgery continued to smoke 1 year later, while 19.6% of those who were not smoking at the time of surgery had relapsed in the first year after surgery. Persistent smoking at 1 year post surgery was associated with shorter overall survival (heart rate 1.29 beats/min) but not disease-free survival. These results suggest that persistent smoking after surgery for stage I lung cancer is common and should be considered an important aspect of postoperative care. Other research in this section includes an evaluation of the risk of cardiovascular toxicity according to tumor laterality among older patients with lung cancer treated with radiation therapy and a systematic review and meta-analysis of the clinical outcomes of immune checkpoint inhibitor therapy in patients with non-small cell lung cancer and preexisting interstitial lung disease. This section also includes a How I Do It review of standardized reporting of incidental, non-lung cancer findings identified on lung cancer screening low-dose CT scans.
Finally, I encourage you to take a look at our Humanities in Chest Medicine section, where you will find a research article describing perceptions of life support and advanced care planning during the COVID-19 pandemic, a case-based discussion providing a framework for integrating equity into machine learning models, and an Exhalations piece titled “Ghosts.”
Our case series publications for the month 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 June issue.