Thank you for tuning in to the Editor’s Highlight Podcast for the November issue of the journal CHEST®. We have a great lineup of diverse content in this month’s issue.
Over the next 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,These results may prompt future work to determine the mechanisms involved and whether impairments in mucociliary clearance drive worsen clinical outcomes. Also in this section is a How I Do It review that discusses the management of corticosteroid-related comorbidities in severe asthma.
Next is our chest infections content area. The relative impact of prenatal and postnatal household air pollution exposure on early childhood pneumonia is unknown. In this issue, Kinney and colleagues evaluated data from the Ghana Randomized Air Pollution and Health Study, which enrolled 1,414 nonsmoking pregnant women before 24 weeks’ gestation with prospective follow-up until the child’s age of 1 year. Seventy-two-hour household air pollution exposures were measured four times prenatally and three times postnatally. Weekly assessment identified ill-appearing children for pneumonia assessment. In total, 1,141 infants were followed. The risk for pneumonia and severe pneumonia in the first year of life increased by 10% and 15% respectively per 1-part per million (ppm) increase in average prenatal carbon monoxide (CO) exposure and by 6% per 1-ppm increase in average postnatal CO exposure. These results suggest that clean-burning interventions may be most effective when begun prenatally in areas where household air pollution is present. Other original research in this section explores the association between elastase activity from Pseudomonas respiratory isolates and ICU mortality and characterizes parapneumonic effusions by elevated levels of neutrophil extracellular traps. A research letter assessing IL-33 depletion in COVID-19 lungs completes this section.
On to our COPD content area. Systemic corticosteroids improve outcomes when used to treat COPD exacerbations. The optimal dosing is unclear. In this issue, Li and colleagues report a prospective, randomized open-label trial designed to determine if 5 days of personalized-dose corticosteroid administered according to a dosing scale is more effective than fixed-dose corticosteroid administration (the equivalent of 40 mg of prednisolone) in hospitalized patients with COPD exacerbations. Two hundred forty-eight patients were randomized between the groups. In-hospital failure of therapy was significantly lower in the personalized-dose group, 10.6% vs 24.4%. Post-discharge failure, adverse events, length of stay, and costs were similar between the groups. After-treatment failure, a lower dose, and shorter duration of corticosteroids were needed in the personalized-dose group. In the personalized therapy group, those receiving more than 40 mg had a lower failure rate than those receiving less than 40 mg, 22.9% v. 44.4%. These results suggest that when treating a COPD exacerbation in the hospital, personalized dosing, particularly when dosing more than 40 mg of a prednisolone-equivalent corticosteroid, may decrease the risk of in-hospital failure. Also in this section is an original research article assessing factors associated with nonreceipt of recommended COPD medications and two Special Feature articles from a Technical Expert Panel guiding optimal noninvasive Medicare Access promotion for individuals with COPD and with hypoventilation syndromes.
Next is our Critical Care content area. Survivors of critical illness have poor long-term outcomes. The interplay between multimorbidity and long-term outcomes is not known. In this issue, McPeake and colleagues used data from a prospectively collected cohort of 3,112 participants to determine whether baseline patient demographics impact mortality and health care utilization in the year after hospital discharge. Differences in outcome between patients with a critical care encounter and patients admitted to the hospital without requiring critical care were assessed. Differences in long-term mortality between the critical care and hospital cohorts were not present. Older age, male sex, the presence of comorbidities including depression, current and previous smoking status, and socioeconomic deprivation were associated with long-term mortality. Mortality was more than double in those with two or more comorbidities compared with those without comorbidity. The critical care cohort had a 29% increased risk of hospital readmission. Those currently smoking and those with comorbidities had a higher risk of hospital readmission. These results suggest that multimorbidity, lifestyle factors, and socioeconomic factors influence long-term outcomes and should be the focus of future research and post-ICU support. Other original research in this section includes an assessment of the safety and feasibility of a protocolized daily assessment of readiness for liberation from venovenous extracorporeal membrane oxygenation (VV-ECMO); an assessment of the role of tidal volume and inspiratory effort in achieving safe liberation from VV-ECMO; and a qualitative study assessing the influence of the COVID-19 pandemic on ICU organization, care processes, and frontline clinician experiences. A research letter that reports on paradoxically improved respiratory compliance with abdominal compression in COVID-19 ARDS and a CHEST Review on precision medicine and heterogeneity of treatment effect in therapies for ARDS complete this section.
On to our Diffuse Lung Disease content area. Antifibrotic medications are approved for slowing the rate of lung function decline in idiopathic pulmonary fibrosis (IPF). Little is known about the treatment effect on mortality and risk of acute exacerbation. In this issue, Petnak and colleagues performed a systematic review with meta-analysis including 26 studies to determine if antifibrotic treatment decreases the risk of mortality and acute exacerbations in IPF. In their analysis, antifibrotic treatment was associated with a decreased risk of all-cause mortality with a respiratory rate (RR) of 0.55 that was consistent across subgroup analysis, including duration of follow-up and antifibrotic used. Antifibrotic treatment also reduced the risk of acute exacerbations with a RR of 0.63. These findings add further support to the use of antifibrotic therapy in patients with IPF. Also in this section is a research article describing the clinical features and outcomes of combined pulmonary fibrosis and emphysema after lung transplant and a research letter describing pulmonary alveolar proteinosis after allogeneic hematopoietic stem cell transplantation in adults. Completing this section is a CHEST Review on the genetic features and clinical implications of familial pulmonary fibrosis and a How I Do It Review on managing cough in idiopathic pulmonary fibrosis.
Our Education and Clinical Practice content area is next. Large population-based studies identifying the incidence of swimming-induced pulmonary edema are not available. In this issue, Hardstedt and colleagues assessed the incidence of swimming-induced pulmonary edema in a mixed group of competitive and recreational swimmers during a large open water swimming event. From 47,573 swimming distances, 211 patients (0.44%) received a diagnosis of swimming-induced pulmonary edema. Ninety percent of all diagnoses occurred in women with an adjusted odds of 8.6. The incidence increased with age with an adjusted odds of 12.7 for the oldest age group compared with the youngest age group. These results provide novel information about the incidence of swimming-induced pulmonary edema and its relationship to sex and age. Also in this section is an original research article about bronchoscopy teaching describing variability in learner assessment and supervisory style. Two Special Feature articles from a Technical Expert Panel (TEP) guiding optimal noninvasive Medicare Access promotion complete this section, one for individuals with thoracic restrictive disease and the other an executive summary of the series of TEP reports.
Next is our Pulmonary Vascular content area. Improved prediction of the risk of early major bleeding in pulmonary embolism is needed. In this issue, Chopard and colleagues used data from 3,754 patients in a multicenter prospective registry to perform a multivariable logistic regression analysis to build a risk score to predict major bleeding events up until the time of hospital discharge. The model was internally validated and its performance was compared with other available models. Three predictors of the 82 major bleeding episodes were identified: Syncope, anemia, and renal dysfunction. Patients were divided into low-, intermediate-, and high-bleed risk groups, with observed bleeding rates of 0.97% in the low-risk group and 8.93% in the high-risk group. This model, termed the PE-SARD score, outperformed existing models. These results suggest that the PE-SARD score may be a useful tool to predict early major bleeding risk in those with a pulmonary embolism, warranting external validation of the findings. Also in this section is an original research report on the enrollment characteristics and 1-year follow-up from the United States Chronic Thromboembolic Pulmonary Hypertension Registry; a Special Feature describing challenges and opportunities of interhospital transfer of patients with acute pulmonary embolism; and a How I Do It describing the use of point-of-care ultrasound for bedside diagnosis of lower extremity deep venous thrombosis.
Our Sleep Medicine content area is next. There is limited information about the association between obstructive sleep apnea (OSA) and coronary plaque assessed by quantitative coronary CT angiography. In this issue, Lu and colleagues report on a cross-sectional study of 692 patients who underwent sleep monitoring and coronary CT angiography. Patients with moderate to severe OSA were more likely to have coronary plaques, plaques with a noncalcified component, and a low-density noncalcified component. The apnea hypopnea index and oxygen desaturation index were associated with the presence of plaque. Measures of the severity of OSA were associated with higher total plaque volume. These results show an association between OSA and the burden of coronary plaque, suggesting an increased risk of coronary events. Completing this section is a Special Feature article from the Technical Expert Panel guiding optimal noninvasive Medicare Access promotion for individuals with OSA.
Next is our Thoracic Oncology content area. Identified pulmonary nodules may not be noted by the provider responsible for following them. In this issue, Zheng and colleagues asked whether it is possible to identify pulmonary nodules and associated characteristics using an automated method. The authors revised and refined a natural language processing (NLP) algorithm, expanding its functionality to identify the characteristics of the largest nodule. They compared the NLP results with a reference standard and applied the final automated method to a large cohort of patients. The NLP algorithm was 98.6% sensitive and 100% specific for identifying nodules and edge, attenuation, and calcification characteristics. It was 95.7% accurate at identifying the diameter of the nodule. The NLP tool identified nearly 218,000 reports with nodules among 717,000 chest CT reports (30.4%). Laterality and lobe were documented more often than attenuation, calcification, and edge characteristics. These results suggest the NLP algorithm can be used in population-based studies to identify pulmonary nodules. Other original research published in this section includes a systematic review and meta-analysis of the safety of thoracentesis and tube thoracostomy in patients with uncorrected coagulopathy; an observational study assessing diagnostic outcomes and safety of cryobiopsy added to conventional sampling methods; an analysis of the impact of systemic anticancer therapy on malignant pleural effusion control; and an evaluation of the association between pleural fluid exposure duration and survival in pleural mesothelioma. Completing this section is a CHEST Review on the impact of delays in lung cancer treatment on survival and an update to the CHEST Lung Cancer Screening Guidelines.
Finally, I encourage you to take a look at our Humanities in Chest Medicine section, where you will find two manuscripts in the Exhalations series, the first exploring how rare diseases can inform us about disparities in disease registries—clinical trial and treatment algorithms using pulmonary arterial hypertension as an example—and the second titled “Finding my belonging in critical care.” An article about resilience in health care describing the intersection of a pandemic, major deadly disaster, and economic collapse appears in the Vantage series, and letters exploring the ethics of partial codes in cardiac arrest complete this section.
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 November issue.