Hot in CHEST August 2017

By: Dr. Deep Ramachandran

August 9, 2017

Deep Ramachandran 2017Each month, we ask Drs. Chris Carroll and Deep Ramachandran, Social Media Co-Editors of CHEST, to weigh in on the hot topics in CHEST. It's August, so let's hear from Dr. Ramachandran as he outlines his highlights. After reviewing the issue, be sure to share your hot list on our Facebook wall, tweet with the hashtag #journalCHEST, or discuss in the CHEST LinkedIn group.

Here at CHEST, we have a tried and true format for presenting these blog pieces. We usually pick three or four “hot” articles to highlight each month that we think you may find interesting. But I gotta tell ya, this month, there’s too much--really way too much--to stick with the usual script. So I’m going off of it. That’s right people, this month the Deepster is going rogue and presenting as many as I like! Where to begin? Let’s start with inhaled corticosteroids. . .

When to use inhaled steroids in COPD, and when not to.

Once the belle of the ball, these drugs have been falling out of favor nearly as fast as a Kardashian vintage tee. In fact, this is not the first time we’ve talked about this (inhaled steroids, I mean. To my knowledge CHEST has never previously made reference to the Kardashians’ dubious understanding of copyright law).

The question now is, when should we still be using inhaled steroids? The answer may be in this study. The authors examined responsiveness to corticosteroids, as well as exacerbation risk stratified by peripheral eosinophilia. They found using inhaled corticosteroids only in those patients with COPD  with a peripheral eosiniphila of >4% significantly improved the risk-benefit profile. The authors estimate that there could be a dramatic improvement in the lives of patients with COPD by precisely targeting ICS toward these patients and discontinuing it in those patients who do not meet this parameter. By limiting the use of ICS in this way, they estimate an incredible reduction of 180,000 hospitalizations per year. Hard to believe, right? Check it out for yourself and see what you think.

For how long does the BCG vaccine cause positive PPD results?

Onwards, from one dicey issue to one that’s even moreso, TB skin tests. Common wisdom is that the BCG vaccine gives rise to false-positive TB skin testing. This effect lasts possibly 10 to 15 years after its administration, possibly more. In this study, researchers followed patients who had received the BCG vaccine for up to 55 years. They found that common wisdom may not be correct. Some people retained their false-positive TB test results for the entire 55-year study period.

This makes me wonder about the current CDC guidelines, which recommend that TB skin test results among those who have received the BCG vaccine be interpreted the same as those who have not received the vaccine. . . with the caveat that the BCG vaccine can give rise to false-positive test results. Clear as mud, right? Clearly, we need something better, and perhaps it’s on the way. As highlighted in this editorial, a new TB skin test is being developed that may have a lower risk of false-positives among those who have received the BCG vaccine.

Pulmonologists adherence to lung nodule guidelines.

What’s next? How about guidelines, specifically lung nodule guidelines. If you’re thinking “yeah lung nodule guidelines, I kinda follow those but not exactly,” then this study is for you. In evaluating lung nodules, researchers found that pulmonologist were actually better at estimating pretest probability of risk than validated prediction calculators. But before patting yourself on the back, read on. While their pretest prediction was good, their adherence to evidence-based guidelines was low—just under 40%. Why are pulmonary specialists not sticking to the guidelines? This editorial provides some insight as to why this might be.

It’s time to learn your ABCs again.

Most of us in the medical world relearned our ABCs as a mnemonic to help us learn about resuscitation. If you work in an ICU, you may have learned it again, as the ABCDE bundle. This coordinated bundle of evidence-based interventions helps reduce physical and mental complications of being on a ventilator. In this study, researchers performed an exhaustive review of the literature to identify the most common barriers to implementation of this bundle. They identified four common hurdles, what they termed as “a differential diagnosis checklist for clinicians planning ABCDE implementation to improve patient care and outcomes.”

Giving statins another run at helping lung disease.

Hey, remember that thing, when we thought statins could help in COPD? Yeah, I know, that didn’t turn out so well, but hey, nothing ventured, nothing gained, right? Well, anyway, we’re trying it in bronchiectasis now! In this small “proof of concept” study, the authors showed reduced levels of inflammatory markers in people with bronchiectasis who were infected with Pseudomonas. Where does this go? Let’s see!

Honk, Honk!

And finally, I don’t normally like to toot my own horn, but I think this merits a mention. If you haven’t joined a twitter chat, this study is a nice way to understand what a twitter chat is and how it works. In this study, we examined what worked, and what didn’t work, in our ongoing CHEST #PulmCC twitter chats. If your institution or organization is currently participating in or considering participating in twitter chats to increase its reach and message, take a look at this study. It provides a good roadmap on how to do this and what metrics you can use along the way.

Speaking of twitter chats, join us for our next CHEST #PulmCC Twitter Chat on Thursday, August 10, at 8:00 pm EST for a discussion around lung cancer.

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