Thank you for tuning in to the Editor’s Highlight Podcast for the November 2023 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, studies examining agreement between home and clinic spirometry in patients with asthma have had conflicting results. In this issue, Oppenheimer and colleagues report findings of a post hoc analysis of two prior randomized controlled treatment trials in patients with uncontrolled asthma in which trough FEV1 measurements were collected via home spirometry and supervised in-person spirometry to determine how well home and clinic measurements of trough FEV1 agree in patients with uncontrolled asthma. Data from 2,436 and 421 patients were analyzed. Improvements in FEV1 were of lower magnitude and less consistent when measured by home spirometry. There was poor agreement between home and clinic trough FEV1 at baseline and week 24. These results suggest that unsupervised home FEV1 readings are not interchangeable with clinic measurements.
Next is our Chest Infections content area. Microbiological outcomes of treatment of Mycobacterium avium complex (MAC) are often used as the primary endpoint of antimicrobial treatment, but their long-term impact on prognosis is uncertain. In this issue, Kim and colleagues report findings from a retrospective evaluation of adult patients treated for MAC designed to determine if patients who achieve microbiological cure at the end of treatment have longer survival than those who do not. Of 382 patients, 236 achieved microbiological cure at the completion of treatment. Microbiological cure was significantly associated with reduced mortality after adjustment for major clinical factors (aHR 0.52). These results suggest that microbiological cure at completion of treatment of MAC pulmonary disease is associated with longer survival. Also in this section are original research articles that include a case series of patients with pulmonary mucormycosis, a systematic review and meta-analysis of risk factors for nontuberculous mycobacterial pulmonary disease, and a living systematic review and network meta-analysis of conservative and surgical modalities in the management of pediatric parapneumonic effusion and empyema.
On to our COPD content area. Identifying individuals at risk of progressing to COPD may allow for initiation of treatment to slow the progression. In this issue, Makimoto and colleagues evaluated whether the addition of CT imaging features, texture-based radiomic features, and established quantitative CT scan features to conventional risk factors improves the performance for predicting progression to COPD. Two hundred ninety-four participants who were at-risk were evaluated, and 52 (23.7%) participants in the training dataset and 17 (23.0%) in the testing dataset had disease progression to spirometric COPD at follow-up. Compared with demographics alone, the addition of CT imaging features or CT imaging features and spirometry significantly improved the performance for predicting progression to COPD. These results suggest that the quantification of structural changes on CT imaging improves the ability to predict progression to COPD when compared with conventional risk factors alone. Completing this section is a CHEST Review of quantitative CT airway imaging for diagnosis and management of lung disease and the 2023 Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD.
Next is our Critical Care content area. Persistent inflammation, immunosuppression, and catabolism syndrome (PICS) is linked to delayed mortality in sepsis. Limited information is available on PICS in pediatric patients with sepsis. In this issue, Patterson and colleagues report findings from a retrospective study of pediatric patients who died of culture-positive sepsis to determine the prevalence and characteristics of pediatric PICS (pPICS) in patients who died of sepsis-related causes. Of 557 patients with culture-positive sepsis, 262 (47%) had pPICS. Those with pPICS were more likely to have underlying hematologic, oncologic, or cardiac disease and increased odds of associated fungal infections. Having a sustained absolute lymphocyte count of <1,000/uL was most closely associated with having pPICS compared with other laboratory parameters. These findings show the high prevalence of pPICS in pediatric patients who die of a sepsis-related cause and focus attention on those in cardiac ICUs and with associated fungal infections. Also in this section is a scoping review on liberation from venovenous extracorporeal membrane oxygenation for respiratory failure, a research letter that explores variation in arterial pressure response to increased norepinephrine by baseline dose in patients with septic shock, and a CHEST Review on optimizing vasopressin use, and initiation timing, in septic shock.
On to our Diffuse Lung Disease content area. OSA and nocturnal hypoxemia are common in patients with fibrotic interstitial lung disease (F-ILD), but their relationship with disease outcomes is unclear. In this issue, Myall and colleagues report findings of a prospective observational cohort study of patients with F-ILD without daytime hypoxemia designed to determine the relationship between nocturnal hypoxemia, OSA, and clinical outcomes. Twenty of 102 patients (19.6%) showed prolonged nocturnal hypoxemia, and 32 (31.4%) showed OSA. Nocturnal hypoxemia was associated with a more rapid decline in both quality of life and higher all-cause mortality at 1 year. There was no significant difference in annualized change in measures of pulmonary function testing. These results suggest that nocturnal hypoxemia, but not OSA, is associated with worsening disease-related quality of life and increased mortality in patients with F-ILD. Also in this section is an original research article evaluating high-definition videobronchoscopy for the diagnosis of airway involvement in sarcoidosis and a research letter that reports on screening for exposure to beryllium among US Veterans with a diagnosis of sarcoidosis.
On to our Education and Clinical Practice content area. The association of preserved ratio impaired spirometry (PRISm) with new-onset macrovascular and microvascular complications and mortality among individuals with type 2 diabetes (T2D) remains unknown. In this issue, Li and colleagues report findings from 20,047 participants in the UK Biobank cohort who had T2D and complete spirometry data to determine if PRISm is a predictor of poor prognosis. At baseline, 4,521 (22.6%) of participants had PRISm. Over a median follow-up of nearly 12 years, patients with T2D and PRISm at baseline had higher risks of T2D complications and mortality, such as a hazard ratio of 1.4 for stroke, 1.4 for ischemic stroke, 1.3 for myocardial infarction, 1.4 for diabetic kidney disease, 1.3 for all-cause mortality, and 1.6 for cardiovascular and respiratory mortality. Adding PRISm to an office-based risk score improved its accuracy. These results show that patients with T2D and PRISm have increased risks for macrovascular and microvascular complications and mortality compared with those with normal spirometry. Also in this section is an original research article reporting symptom duration, recurrence, and long-term effects of swimming-induced pulmonary edema; a research letter on the diagnostic impact of a race-composite pulmonary function test interpretation strategy; and a Special Feature article on methodological issues specific to prediction model development and evaluation.
Our Pulmonary Vascular content area this month contains a research letter on predictors of thrombus resolution among patients on anticoagulation for a right heart thrombus.
Our Sleep Medicine content area contains a research letter on the association of the nocturnal blood pressure profile on the CPAP effect on blood pressure in patients with OSA and resistant hypertension.
Next is our Thoracic Oncology content area. Many lung nodule risk prediction models have been developed in populations with lower cancer prevalence than is seen in specialty clinics and are limited when there are missing data elements. In this issue, Godfrey and colleagues update a previously developed risk prediction model, the Thoracic Research Evaluation and Treatment (TREAT) model, into a more generalized approach for specialty evaluation. A total of 1,401 patients with indeterminate pulmonary nodules were divided into groups by clinical setting: those from a pulmonary nodule clinic with a lung cancer prevalence of 42%, those from an outpatient thoracic surgery clinic with a lung cancer prevalence of 73%, and those from inpatient surgical resection with a lung cancer prevalence of 90%. Two-thirds of patients had missing data, with nodule growth and fluorodeoxyglucose-PET scan avidity missing most frequently. The model developed had an AUC across missingness patterns of 0.85 compared with 0.8 for the original TREAT model, 0.73 for the Herder model, 0.72 for the Mayo model, and 0.69 for the Brock model. The bias-corrected net reclassification index was 0.23. These results suggest that the TREAT 2.0 model is more accurate and better calibrated for predicting lung cancer in high-risk indeterminate pulmonary nodules seen in specialty nodule evaluation clinics. Completing this section are two original research articles. The first explores the accuracy of exhaled breath analysis with an electronic nose to detect early lung cancer in people with COPD, and the second is a pragmatic clinical trial of an electronic health record-integrated everyday shared decision-making tool and clinician-facing prompts for the implementation of lung cancer screening in primary care and pulmonary clinics.
I encourage you to read our Humanities in Chest Medicine section, where you will find an Exhalations piece titled, “A Kind of Faith,” and an editorial related to the CHEST After Hours series at the CHEST Annual Meeting titled, “The Whole Story.” 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 November issue.