Thank you for tuning in to the Editor’s Highlight Podcast for the September issue of the journal CHEST®. We have a great lineup of diverse content 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, phenotypic characteristics of patients with eosinophilic and noneosinophilic asthma are not well described in real-world severe asthma cohorts. In this issue, Heaney and colleagues attempted to define the prevalence of eosinophilic and noneosinophilic severe asthma phenotypes and evaluate if they can be differentiated by clinical and biomarker variables. Using data from 1,716 patients from the International Severe Asthma Registry, they found that approximately 92% of patients were likely or very likely to have eosinophilic asthma, while 1.6% showed a noneosinophilic phenotype. Those with eosinophilic phenotypes had later-onset asthma and worse lung function. Those with noneosinophilic phenotypes were more likely to be women, have eczema, and use anti-IgE and leukotriene receptor antagonist therapies. These results could improve our ability to identify traits across phenotypes, leading to the potential to improve treatment precision.
Next is our Chest Infections content area. An understanding of how health outcomes differ for patients with advanced cystic fibrosis (CF), cared for in different health systems, may influence health policy. In this issue, Ramos and colleagues assessed the rates of lung transplant and death without lung transplant in the United States and Canada among individuals with cystic fibrosis and an FEV1 <40% predicted. Using data from 2005 to 2016 from the US CF Foundation, United Network for Organ Sharing, and the Canadian CF registry, 5,899 patients from the United States and 905 from Canada who met these criteria were identified. Those from the United States had an increased risk of death without lung transplant and a decreased rate of lung transplant. Those with Medicaid/Medicare insurance and patients of nonwhite race were most disadvantaged. These results may be used to focus policy to improve the care of disadvantaged patient groups with advanced cystic fibrosis. Also in this section is an original research article assessing the sustainability and durability of culture conversion and safety of long-term exposure of amikacin liposome inhalation suspension for refractory Mycobacterium avium complex lung disease, and a Research Letter that assesses eosinophil extracellular traps in the casts of plastic bronchitis associated with influenza virus infection.
On to our COPD content area. In patients with GOLD spirometric stage I COPD, the clinical and prognostic impact of a low diffusing capacity is not known. In this issue, de Torres and colleagues evaluated whether a diffusing capacity threshold could help define an increased risk of death and different presentation in this patient group. Three hundred sixty patients with GOLD stage I COPD were followed over 109 months. A diffusing capacity cutoff of <60% predicted was associated with all-cause mortality. Patients with a diffusing capacity <60% predicted had a lower BMI, more dyspnea, lower inspiratory capacity to total lung capacity ratio, lower 6-minute walk distance, and a higher BODE index. Identifying this threshold may further work to identify the causes of this association and the personalization of treatments for those in this cohort. Also in this section is original research assessing the association between lung hyperinflation and coronary artery disease in smokers and a CHEST Review article exploring impaired respiratory health and life course transitions from health to chronic lung disease.
Next is our Critical Care content area. Long-term cognitive impairment frequently occurs after critical illness. No treatments are known to improve long-term cognition. In this issue, Han and colleagues explored whether a single high-dose enteral treatment of vitamin D3, given shortly after hospital admission in critically ill patients who are vitamin D deficient, could improve long-term global cognition or executive function. They conducted a multicenter, blinded, randomized clinical trial with 95 patients randomized. The repeatable battery for the assessment of neuropsychological status, a measure of global cognition, and subscales of the Delis-Kaplan Executive Function System, a measure of executive function, did not differ between the groups at a median of 443 days after randomization. These results suggest that a large dose of enteral vitamin D3 does not improve long-term global cognition or executive function in critically ill adults who are vitamin D deficient. Other original research articles published in this section include an evaluation of the role of inter-ICU transfer on psychological outcomes in family members of patients with acute respiratory failure; the effect of a quality improvement intervention on sleep and delirium in critically ill patients in a surgical intensive care unit; the performance of an electronic decision support system for insulin titration as a therapeutic intervention in pediatric patients with heart and lung failure; modeling to identify distinct clinical subphenotypes of critically ill patients with COVID-19; and a look at symptoms of mental health disorders in critical care clinicians during the second wave of the COVID-19 pandemic. A Research Letter describing media portrayals of the acute respiratory distress syndrome and a CHEST Review on the epidemiology, mechanisms, and clinical management of multiorgan dysfunction following severe traumatic brain injury complete this section.
On to our Diffuse Lung Disease content area. Regulatory T cells are believed to be functionally impaired in pulmonary sarcoidosis. OX40 is a costimulatory molecule essential for T-cell functions and memory development. In this issue, Kumari and colleagues asked whether the OX40 pathway influences the suppressive functions of regulatory T cells in pulmonary sarcoidosis. OX40 expression was observed on both effector and regulatory T cells in the BAL fluid of patients with pulmonary sarcoidosis. OX40 enhanced effector T-cell functions while inhibiting regulatory T-cell functions. Silencing or blocking OX40 on regulatory T cells restored their function. These findings suggest inhibition of the OX40 pathway could be explored as a therapeutic strategy in patients with pulmonary sarcoidosis. Other original research manuscripts in this issue include an evaluation of tobacco smoking as a risk for pulmonary fibrosis and the results of an international cohort study assessing the incidence and prognostic significance of hypoxemia in fibrotic interstitial lung disease.
Our Education and Clinical Practice content area is next. The metabolic syndrome and insulin resistance are associated with poorer outcomes in those with chronic lung disease. The relationship of lung health to a measure of metabolic dysfunction, the triglyceride-glucose index, is unknown. In this issue, Wu and colleagues aimed to determine if a relationship between the triglyceride-glucose index and lung function exists using data from the National Health and Nutrition Examination Survey on nearly 6,900 adults over age 40, with lung function measurements in nearly 3,400. They found that an increase in the triglyceride-glucose index was associated with higher odds of cough, phlegm production, exertional dyspnea, chronic bronchitis, and a restrictive spirometry pattern. These results suggest further study of the association of the triglyceride-glucose index with impaired lung health could lead to clinically impactful insights. Other original research published in this section includes a prospective multicenter study evaluating the predictive value of lung ultrasound scores for the development of bronchopulmonary dysplasia and the association of posttraumatic stress disorder with decreased maximal oxygen uptake, anaerobic threshold, and oxygen pulse. A guideline on demographic considerations of the global physiology and pathophysiology of cough and a How I Do It review on strategic planning for the chest clinician complete this section.
Next is our Pulmonary Vascular content area. Supervised exercise training improves outcomes in patients with pulmonary arterial hypertension (PAH). The effect of an unsupervised activity intervention is not known. In this issue, Hemnes and colleagues report the results of a randomized trial of 42 participants, with the aim of determining if a text-based mobile health intervention could increase step counts in patients with PAH. They found that the change in steps over 12 weeks was approximately 1,400 steps higher in those who received the intervention. The week 12 6-minute walk distance was not different between the groups, while the intervention group showed an improvement in the emPHasis-10 score and a reduction in visceral fat volume. These findings support a text message-based intervention to increase physical activity in patients with PAH and warrant further evaluation of the effect of this intervention on clinical outcomes.
Our Sleep Medicine content area is next. The evidence of an association between habitual snoring and cardiovascular disease (CVD) is incomplete. In this issue, Wei and colleagues used data from nearly 500,000 individuals ages 30 to 79 from 10 regions in China as part of the Kadoorie Biobank study to determine if there is an association between habitual snoring and cardiovascular disease. Over a median follow-up of 9.6 years, nearly 131,000 participants developed cardiovascular disease. For those younger than 50 years at baseline, habitual snoring was associated with an increased risk of total CVD, ischemic heart disease, ischemic stroke, and hemorrhagic stroke. The association was weaker in those ages 50-64 and was not present in those 65 or older. These results suggest that habitual snoring in those younger than 50 could be considered a risk factor for cardiovascular disease. Completing this section is a CHEST Review about sleep in the hospitalized child.
Next is our Thoracic Oncology content area. The usefulness of circulating tumor DNA (ctDNA) in detecting mutations and monitoring treatment response has not been completely evaluated. In this issue, Roosan and colleagues aimed to determine the usefulness of ctDNA analysis compared with that of solid tumor biopsy analysis in patients with non-small cell lung cancer (NSCLC). In a retrospective analysis of 370 patients with NSCLC, a total of 1,688 somatic mutations were detected, with 177 of 473 samples showing at least one actionable mutation with a currently approved therapy available. Gene-level concordance between ctDNA samples and biopsy samples was 93.8%, whereas the positive concordance rate was 41.6%, with more mutations in targetable genes present in ctDNA than tissue biopsy samples. Treatment response and tumor evolution were detected in repeated ctDNA samples. These results suggest that additional study evaluating outcomes when ctDNA is used in conjunction with tissue biopsy samples is warranted. Other original research published in this issue includes an article that evaluated the BLESS model’s ability to predict survival in patients with malignant pleural effusions; another that prospectively validated the HAL and HOMER models for lymph node metastasis prediction in non-small cell lung cancer; and a third that assessed molecular biomarker and programmed death-ligand 1 expression testing in patients with advanced stage non-small cell lung cancer in community hospitals. Also in this section is a Research Letter describing the effect of a basic training nicotine-free policy on soldiers in the United States Army; a Point/Counterpoint debate on the use of e-cigarettes for harm reduction in those with tobacco use disorder; and a CHEST Review about the causes, common presentations, preventative strategies, and recommendations for clinical care for the nonexpanding lung.
Finally, I encourage you to take a look at our Humanities in Chest Medicine series, where three thoughtful essays describing physician and patient experiences appear in our Exhalations 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 September issue.