Thank you for tuning in to the Editor’s Highlight Podcast for the December 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 Chest Infections content area, the clinical significance of respiratory virus detection in the nasopharynx of patients who are immunocompromised with acute respiratory failure (ARF) is uncertain. In this issue, Maillard and colleagues report the findings of a preplanned post hoc analysis of a randomized controlled trial of patients who are immunocompromised admitted to 32 ICUs for ARF designed to determine if viral detection in nasopharyngeal swabs is associated with causes and outcomes. Of 510 sampled patients, 103 had positive results of the viral polymerase chain reaction (PCR) assay. The cause of ARF varied according to the assay results. The proportion of viral pneumonia diagnoses was 50.0% with flu-like viruses, 14.0% with other viruses, and 3.6% when no virus was detected. There was no difference in 28-day mortality, the need for invasive mechanical ventilation (IMV), or both based on positive assay findings. Whereas, flu-like virus detection was associated with a higher rate of day 28 mortality, IMV, or both. These results suggest a positive result on a nasopharyngeal multiplex PCR assay in patients who are immunocompromised with ARF is only associated with IMV or mortality for flu-like viruses. Three additional original research articles can be found in this section. The first evaluates phenotypic features of pediatric bronchiectasis exacerbations that are associated with symptom resolution after 14 days of oral antibiotic treatment. The second explores CT scan differences of pulmonary tuberculosis according to the presence of a pleural effusion. The third is a systematic review of the economic burden of bronchiectasis.
On to our COPD content area. It is unclear if the updated Rome proposed definition of exacerbation of COPD has clinical relevance. In this issue, Crisafulli and colleagues report findings from an observational retrospective study designed to assess the association between the Rome severity classification and short-term and intermediate-term clinical outcomes. Three hundred forty-seven hospitalized patients were categorized, 39% as mild, 31% as moderate, and 30% as severe. Those with severe exacerbations had an extended length of hospital stay and worse prognosis at follow-up points, including a higher risk of death at 1 year (HR 1.99). Those with moderate grade exacerbations also had a higher risk of death at 1 year (HR 1.47). Age over 80, long-term oxygen therapy requirement, and having prior exacerbations were also associated with higher mortality. These results suggest that the Rome classification can help to identify poor prognosis after a COPD exacerbation over time.
Next is our Critical Care content area. The safety and efficacy of bone marrow mesenchymal stem cell (BM-MSC)-derived extracellular vesicles, which have immunomodulatory and regenerative properties, as treatment for moderate to severe ARDS in patients with severe COVID-19 are not known. In this issue, Lightner and colleagues report findings of a prospective phase II, multicenter, double-blind, randomized, placebo-controlled dosing trial designed to assess the safety and efficacy of BM-MSC-derived extracellular vesicles in 102 patients in this patient population. They did not find any treatment-related adverse events from two doses. Sixty-day mortality was not significantly reduced overall, while mortality reduction and ventilation-free days were noted in subgroup analysis in participants aged 18 to 65. These results show promise for the safety and potential efficacy of BM-MSC-derived extracellular vesicle therapy for severe ARDS. Also in this section is an original research article exploring indicators of neighborhood-level socioeconomic position and pediatric critical illness, a research letter evaluating restrictive visitation policies and related posttraumatic stress among families of patients who are critically ill with COVID-19, and a How I Do It review on the identification and management of acute neuromuscular respiratory failure in the ICU.
On to our Diffuse Lung Disease content area. It is unclear how to apply guideline-described radiologic patterns of usual interstitial pneumonia (UIP) and fibrotic hypersensitivity pneumonitis (fHP) concurrently within a single patient. In this issue, Marinescu and colleagues assigned guideline-defined patterns to patients from the Canadian Registry for Pulmonary Fibrosis in a standardized multidisciplinary discussion to determine how to integrate radiologic patterns to diagnose interstitial lung disease (ILD) and identify potential pitfalls. In 1,593 patients, 26% with idiopathic pulmonary fibrosis (IPF) and 12% with fHP, typical and probable UIP patterns corresponded to a diagnosis of IPF in 66% and 57% of patients, respectively, while a typical fHP pattern corresponded to an fHP diagnosis in 65% of patients. Compatible fHP pattern was nonspecific, and no pattern ruled out connective tissue disease-related ILD. Gas trapping affecting >5% on lung parenchyma on expiratory imaging helped to separate compatible and typical fHP from other patterns. These results suggest that an integrated approach to guideline-defined UIP and fHP is feasible, with typical or probable UIP and typical fHP patterns having moderate predictive values, and support >5% gas trapping as an important feature. Completing this section is a research letter evaluating intrafamilial correlation and variability in the clinical evolution of pulmonary fibrosis.
On to our Education and Clinical Practice content area. It is unclear whether race-specific spirometry reference equations improve the ability of predicted FEV1 to explain quantitative CT scan abnormalities, dyspnea, or Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification. In this issue, Non and colleagues explored this question using data from healthy adults who never smoked in the National Health and Nutrition Survey and COPDGene study cohorts to generate race-neutral, race-free, and race-specific prediction equations, then applied these equations in a cross-sectional analysis of individuals who currently or previously smoked. They found that the race-specific equations did not have an advantage in models of quantitative chest CT scan phenotypes or dyspnea. Race-neutral equations reclassified up to 19% of Black participants into more severe GOLD classes, and race-neutral/race-free equations improved model fit for dyspnea symptoms. These results suggest race-specific equations offered no advantage over race-neutral/race-free percent predicted FEV1 in models of dyspnea and chest CT scan abnormalities. Also in this section is an original research article describing the acute effects of water-pipe smoking on central and peripheral hemodynamics, a research letter that describes the validation of a quantitative lung ultrasound protocol in patients with COVID-19, and a How I Do It review describing mechanical insufflation-exsufflation implementation and management aided by graphics analysis.
Our Pulmonary Vascular content area is next. There is conflicting data about whether adopting upfront combination therapy for patients who are treatment-naïve with low-risk pulmonary arterial hypertension (PAH) is beneficial or well tolerated. In this issue, Fauvel and colleagues use data from the original Ambrisentan and Tadalafil in Patients with Pulmonary Arterial Hypertension (AMBITION) trial with patients’ risk classified by the REVEAL 2.0 score and the Pulmonary Hypertension Outcomes and Risk Assessment (PHORA) tool to assess the benefit of upfront combination therapy in patients with low-risk PAH. Patients categorized as low risk by these measures had reduced HRs for clinical worsening at 1 and 3 years post-enrollment that did not achieve statistical significance. Patients with low-risk PAH had a nonsignificantly higher incidence of side effects. These results suggest that some patients with low-risk PAH may benefit from further stratification of risk when deciding on the use of upfront combination therapy. Completing this section is the American College of Chest Physicians Expert Panel Report on antithrombotic therapy in arterial thrombosis and thromboembolism.
Now on to our Sleep Medicine content area. OSA has been associated with increased incidence and aggressiveness of melanoma, but the long-term impact of OSA and CPAP treatment on melanoma prognosis is not known. In this issue, Gómez-Olivas and colleagues report findings from a retrospective cohort study of 443 patients with cutaneous melanoma who underwent a sleep study within 6 months of diagnosis to determine if OSA and CPAP treatment are independently associated with a poor prognosis for cutaneous melanoma. After adjustment for age, sex, sentinel lymph node involvement, BMI, diabetes, nighttime hypoxia, Breslow index, Epworth sleepiness scale score, and melanoma treatment, moderate (HR 2.45) and severe (HR 2.96) OSA were associated with poorer melanoma prognosis. This excess risk was mitigated by good adherence to CPAP (HR 1.66). These results identify moderate to severe untreated OSA as an independent risk factor for poor prognosis of melanoma, with CPAP treatment improving outcomes.
Next is our Thoracic Oncology content area. Anxiety and emotional distress have not been studied in large, diverse samples of patients with pulmonary nodules. In this issue, Gould and colleagues report the findings of surveys of participants in a large, pragmatic clinical trial of more vs less intensive strategies for radiographic surveillance of patients with small pulmonary nodules to determine how common anxiety and distress are and what factors are associated with these outcomes. Two thousand forty-nine individuals completed the baseline survey. The Impact of Event Scale-Revised scores indicated mild, moderate, or severe distress in 32.2%, 9.4%, and 7.2% of respondents, respectively. Greater emotional distress was associated with larger nodule size, lack of timely notification by a clinician, younger age, female sex, ever smoking, Black race, and Hispanic ethnicity. Anxiety was associated with lack of timely notification, ever smoking, and female sex. These results suggest almost one-half of those with small pulmonary nodules have emotional distress 6 to 8 weeks following pulmonary nodule identification. Subgroups where strategies to mitigate the burden of distress could be targeted were noted. Completing this section is a research letter that describes the use of a blood biomarker to distinguish benign from malignant pulmonary nodules among subgroups of sex, smoking history, nodule size, and nodule detection setting.
I encourage you to read our Humanities in Chest Medicine section, where you will find an Exhalations piece titled, “Making anger count.” 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 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 December issue.