Home CHEST Thought Leaders Hot in Journal CHEST® February 2019

Hot in Journal CHEST® February 2019

By: Dr. Viren Kaul

Viren KaulEach month, we ask our Social Media Co-Editors of CHEST, to weigh in on the hot topics in CHEST. It's February, so let's hear from one of our co-editors, Dr. Viren Kaul, 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.

I have learned more about life, making judicious choices, and why (also how) important funding is to understand diseases. Maybe, we just need to make a Super Bowl commercial of our own! “For your future, for the future of our children, join us in making tomorrow healthier for everyone!” Why do I say this? Please read on about my number one pick this month: the analysis from the NHLBI LAM Registry.

The NHLBI LAM Registry: Prognostic Physiologic and Radiologic Biomarkers Emerge From a 15-Year Prospective Longitudinal Analysis

Funding for medical research is hard to secure, and federal or government funding is susceptible to vagrancies of economy, political climate, and ongoing interest in a particular field. The National Heart, Lung, and Blood Institute (NHLBI) Lymphangioleiomyomatosis (LAM) Registry prospectively recruited 246 women with LAM from 1998 to 2001. However, due to lack of funding 5 years into the follow-up, further research was halted. The study data and biomaterials were stored at the National Disease Research Interchange (NDRI).

The authors retrieved this benched data to study the natural progression of LAM. This is the last set of LAM patients to be studied from prior to sirolimus becoming the standard of care in treatment of LAM (the MILES trial in 2011 followed by the FDA approval for this indication in 2015). This study describes spirometric, clinical, disease state, and biomarker factors that influenced the natural progression of LAM to death or transplantation.

My summary of this trial follows in the old school “notes” format. There is so much to learn from this registry and the patients, due to the fact that the data were revived, retrieved, and analyzed decades later to help us understand this rare disease. The persistence of the authors to improve our understanding of LAM made this the study to highlight in the CHEST® February 2019 issue! Kudos to the authors, NHLBI, and NDRI! Here’s hoping for stronger funding and grant cycles for my researcher colleagues in 2019. 

HIC Feb19

Let’s talk about the other study to look out for in this issue of CHEST®.

Indwelling Pleural Catheters in Hepatic Hydrothorax: A Single-Center Series of Outcomes and Complications

Traditionally, management of hepatic hydrothorax (HH) involves addressing the underlying portal hypertension and sodium restriction. Placement of indwelling pleural catheters (IPCs) is strongly advised against for the fear of complications, as well as nutritional loss. Kniese and team conducted this 10-year retrospective review to evaluate outcomes of IPC placement in 62 patients with HH. The IPCs were placed as a bridge to transplant or for palliation.

The study reports an overall 36% complication rate that is higher than the 17% rate reported with IPCs for other indications. The authors postulate that this could be a representation of their patients having end-stage liver disease with mean MELD-Na scores of 24. This leads to the debate around the value of placing IPCs, given the high 3-month mortality in such patients. Ten patients developed empyema. Three of these ten patients developed septic shock leading to death. Two of these three patients were actively listed for liver transplant and were not able to receive one due to the complications secondary to IPCs. A modest reduction in BMI and albumin levels was noted. The authors highlight the risk of complications secondary to an IPC leading to patients becoming ineligible for a liver transplant, thus offsetting the benefit profile of the procedure.

How will this study change my practice? Given the retrospective, observational, and EMR search query-based limitations of this study, and lack of a control arm, it is difficult to make drastic practice-changing decisions; however, I will consider IPCs for patients with HH for palliation if they aren’t responding to conservative treatment and are ineligible for TIPS or liver transplant. For patients eligible or listed for liver transplant, I’ll be more cautious and will use a multidisciplinary decision-making approach to arrive at the decision.

With that, hope your Super Bowl team takes the win. Go Rams!