Hot in Journal CHEST® July 2018
By: Dr. Deep Ramachandran
July 5, 2018
Each 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 July, 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.
The Leadership Paradox in Health Care
Medical education places a great emphasis on individual achievement. Indeed, health-care training inculcates the idea that physicians are “lone heroic healers.” Modern health-care needs more from its doctors than skill. In this article by Dr. Stoller, he calls for a change in both how we select and train physicians. Principles of teamwork and leadership are teachable, he says, and should be incorporated into physician training to help cultivate the physician leadership that is desperately needed. In the article, he goes on to discuss interesting aspects of emotional intelligence as well as best practices for leadership development in health-care.
The Relationship Between COPD and Frailty
I learned a few things from this article, the first of which was the actual definition of frailty. I often use the terms “frailty,” “deconditioning,” and “debility” as clinical descriptors. In the article, the authors remind me of the definition, which requires three of five criteria, including unintentional weight loss, self-reported exhaustion, weakness, slow gait speed, or low energy expenditure. They found that the two conditions of COPD and frailty often cohabitate in the same patient. In addition, there was a bidirectional relationship, in that patients who had one condition (either frailty or COPD), were much more likely to develop the other. The accompanying editorial puts the article in perspective and suggests that we should be more diligent in identifying frailty and its impact on management decisions.
Aspirin Use and Progression of Emphysema on CT Imaging
My initial reaction to the idea that aspirin can slow the progression of emphysema was: “Huh?” My reaction upon reading that regular aspirin use was associated with a greater than 50% slower progression of emphysema-like lung on CT imaging over 10 years was: “No way!” Way. Results were similar with low- versus full-dose aspirin, and surprisingly, there was no change in FEV1. This was purely a radiological finding. Check out this editorial for further perspective. However, admittedly there is little perspective to be had here given that this is a new finding! This also raises another question. Should CT scanning now be considered as an endpoint for future research? Let the debate begin!
ICU Telemedicine Reduces Interhospital ICU Transfers
As I sat in my tele-ICU bunker the other night, I received a call from a nurse at one of the hospitalists that I cover. He was concerned that a patient with a pulmonary embolism needed to be transferred to a different hospital for higher level of care. We reviewed the case and ultimately decided that the patient could be well cared for where she was. Perhaps it’s these types of interactions that drove the results seen in this study in which implementation of a tele-ICU program significantly reduced interhospital ICU transfers, without a change in mortality. Given the significant challenges faced with critical care workforce shortages, programs like tele-ICU, will likely play a greater role in managing ICU patients.
Is a Routine Chest X-Ray After Ultrasound-Guided Central Venous Catheter Insertion Choosing Wisely?
There are some things that you just take as a given. The sun rises in the east, the United States is terrible at soccer, and you need to get a chest x-ray after placing a central line in the subclavian or internal jugular veins. This study calls at least one of those into question. The authors looked at complication rates of central venous catheter insertion and found that the overall incidence of pneumothorax and catheter misplacement were 0.33%, and 1.91% respectively. They also found that the cost related to routine post-procedural chest x-rays ranged from $105,000 to $183,000 per year. They concluded that the use of routine post-procedural chest x-rays in this setting does not provide adequate benefit to recommend its use.