Thank you for tuning in to the Editor’s Highlight Podcast for the May 2024 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.
In our Asthma content area this month, a CHEST Review by Wu and colleagues provides an update on patient-reported outcomes in asthma.
Next is our Chest Infections content area. Results of retrospective studies have suggested clofazimine could be an alternative to rifampicin in the treatment of Mycobacterium avium complex pulmonary disease (MAC-PD). In this issue, Zweijpfenning and colleagues report findings from a single-center, nonblinded, clinical noninferiority trial of 40 adult patients with MAC-PD randomly assigned to receive rifampicin or clofazimine as adjuncts to an ethambutol-macrolide regimen, with the primary outcome of sputum culture conversion after 6 months of treatment. Similar sputum culture conversion rates were noted, 58% for rifampicin and 62% for clofazimine. Study discontinuation for adverse events was equal in both arms. Diarrhea was more prevalent in the clofazimine arm and arthralgia was more frequent in the rifampicin arm. These findings suggest that a clofazimine-ethambutol-macrolide regimen could be considered in the treatment of MAC-PD, with the choice of therapy individualized to patient characteristics and medication use. Also in this section is an original research article exploring the tolerability of guideline-recommended multidrug antibiotic treatment for MAC-PD in Medicare beneficiaries with bronchiectasis and another that describes an association between situs ambiguous and adverse clinical outcomes in children with primary ciliary dyskinesia.
On to our COPD content area. There is a lack of up-to-date information quantifying COPD burden and costs and providing long-term projections to various stakeholders. In this issue, Mannino and colleagues report findings of a cross-sectional, retrospective study using data from 4,135 people with COPD and 86,021 people without COPD from three large surveys designed to determine state-specific and nationwide estimates of the COPD disease burden and direct costs in 2019 with projections through 2029. Those with COPD had a higher proportion of concurrent conditions than those without. In 2019, COPD-attributable medical costs were estimated at $31.3 billion with a wide variation in state-specific costs. Projections of national medical costs attributable to COPD in 2029 are $60.5 billion. These findings help to highlight unmet needs and gaps in care that help inform health care decision-makers in planning future actions to alleviate disease burden.
Next is our Critical Care content area. Minocycline has neuroprotective effects in animal models of neurologic diseases. In this issue, Dal-Pizzol and colleagues report findings from a randomized, placebo-controlled, double-blind trial conducted in four ICUs designed to determine if the neuroprotective effect of minocycline prevents delirium occurrence in critically ill patients. One hundred fifty-nine patients were randomized and analyzed. A small but significant decrease in delirium incidence was noted, 20% in the minocycline arm and 35% in the placebo arm. No other delirium-related secondary outcomes were modified by minocycline treatment. A significant decrease in hospital mortality (39% vs 23%) was noted. Plasma levels of C-reactive protein decreased after minocycline treatment. These findings signal a possible positive effect of minocycline on delirium incidence, supporting the conduct of definitive confirmatory trials. Other original research published in this section includes an evaluation of the effect of atypical sleep EEG patterns on weaning from prolonged mechanical ventilation, a description of the epidemiology of intensive care patients classified as third sex in Australia and New Zealand, and a study reporting the application of machine learning models to biomedical and information system signals from critically ill adults. Completing this section is a CHEST Review on outcomes and management following COVID-19 critical illness.
On to our Diffuse Lung Disease content area. It is unclear whether there are significant differences in FVC decline in idiopathic pulmonary fibrosis (IPF) between the antifibrotic agents pirfenidone and nintedanib. In this issue, Kim and colleagues report findings from a post hoc analysis of 513 participants in the CleanUP-IPF trial, 407 of whom were being treated with pirfenidone or nintedanib, designed to determine if there are differences in 12-month FVC decline between the two antifibrotics. Those treated with nintedanib had a higher 12-month FVC than those treated with pirfenidone (mean difference of 106 mL). This was attenuated at 24 months of follow-up. There were no differences in overall survival or nonelective respiratory hospitalization. These findings identify a potential difference in FVC rate of decline between the antifibrotics, supporting further evaluation of their differential efficacy. Completing this section is an original research article that evaluates the association between circulating mitochondrial DNA with high levels of fatigue in those with sarcoidosis.
On to our Education and Clinical Practice content area. There are no studies of postinterview communication (PIC) practices in fellowship recruitment for pulmonary and critical care medicine and critical care medicine. In this issue, John and colleagues report findings from thematic content analysis of surveys of applicants and program directors after the 2022 to 2023 National Resident Matching Program Specialty Match. Survey responses were received from 33% of those eligible. PIC was initiated by 66% of applicants and 49% of program directors. PIC did not impact program rank order list decisions for 73% of applicants or 83% of program directors. Of the applicants, 23% strongly agreed or agreed that PIC helped in creating their program rank order list. Challenges that were identified included time, lack of uniformity, peer pressure, misleading language, and uncertainty about motives, rules, and response protocols. These findings highlight the frequent occurrence of PIC, with a modest influence on applicants’ and program directors’ program ranking, and the need for guidance about the proper content of this communication. Also in this section is a point-counterpoint debate about whether intensivists should be compensated by productivity or salary and a How I Do It review that provides guidance about how to discuss and teach about race and health inequities.
Our Pulmonary Vascular content area is next. The association between epicardial adipose tissue (EAT) and right-sided heart failure caused by pulmonary arterial hypertension (PAH) is unknown. In this issue, Chen and colleagues evaluate the potential impact of EAT volume on right ventricular (RV) function, biomarkers of myocardial injury, and long-term prognosis in 135 age- and BMI-matched patients with PAH and 49 control subjects. Patients with PAH had a lower EAT volume. The association of EAT volume with RV end-diastolic volume, RV end-diastolic volume index, RV cardiac output, N-terminal pro-brain natriuretic peptide, and the risk of clinical worsening was U-shaped. The hazard ratio for clinical worsening was 6.0 for individuals with low-level EAT volume and 6.8 for high-level EAT volume in patients with PAH. These findings identify and characterize a new association between EAT volume and RV function and clinical worsening in patients with PAH, prompting further assessment of the clinical impact of the association. Completing this section is a research letter presenting results from a survey of patients and clinicians about the role of genetic testing in PAH in the US.
Now our Sleep Medicine content area. Medicare claims-based data have been used as a proxy for positive airway pressure (PAP) adherence. This approach has not been validated in a US commercially insured population where coverage rules are not standardized. In this issue, Alpert and colleagues used deidentified administrative claims data of more than 230,000 commercially insured patients with OSA, linked to PAP therapy usage from cloud-connected devices, to determine how well claims-based algorithms for defining PAP adherence correspond with objective PAP device usage. Based on device usage, 48% of patients were adherent in the first year, whereas claims-based algorithms labeled 10% to 84% as adherent. Those who were device-adherent had consistently higher usage across all metrics. Consistent users of PAP were frequently identified as nonadherent by claims-based algorithms, while many users who were inconsistent were classified as adherent. These results suggest caution when applying existing claims-based algorithms to commercial populations given the low concordance between claims-based definitions of adherence and objective PAP usage. Completing this section is a CHEST Review on sleep education—the barriers and opportunities to grow a diverse sleep team.
Next is our Thoracic Oncology content area. A summary estimate for postsurgical recurrence-free survival (RFS) in patients with non-small cell lung cancer (NSCLC) treated with surgery is lacking. In this issue, Rajaram and colleagues report findings from a systematic review with meta-regressions performed to determine the RFS after surgery in patients with stage I through III NSCLC at different time points and the factors associated with RFS. Data from 471 studies including 1,060 surgical study arms and 60,695 patients were extracted. RFS was 96% at 1 year and 82% at 5 years for stage I, as well as 68% at 1 year and 34% at 5 years for stage III. Slightly higher estimates in those using eighth edition staging criteria were noted. Older age, male sex, advancing stage, larger tumor size, and geographic location (North America and Europe) were associated with worse RFS. These findings may help to inform treatment decisions, trial designs, and future research to improve outcomes. Completing this section is an original research article comparing outcomes from sublobar resection, stereotactic body radiation therapy, and percutaneous ablation for lung metastasis-directed therapy.
I encourage you to read our Humanities in Chest Medicine section, where you will find Exhalations pieces titled, “A Prayer for My Children,” and “The Ones We Left Alone.” In our Commentary series, you will find a thoughtful discussion on the implication of supine vs upright exercise for invasive cardiopulmonary exercise testing interpretation. 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 May issue.