Thank you for tuning in to the Editor’s Highlight Podcast for the October issue of the journal CHEST®. We have a great lineup of diverse content in this month’s issue.
Over the next 15 minutes, I will provide a brief overview of key original research manuscripts published in each of our content areas.
Starting with our Asthma content area, in this issue, Nanzer and Gupta describe the transition of asthma care from adolescents to adults. This How I Do It review focuses on the challenges of adolescent health care and provides guidance on how to take a planned, patient-centered approach to ensure each transition is effective and safe.
Next is our Chest Infections content area. The benefit of early antibiotics for sepsis have recently been questioned. In this issue, Schinkel and colleagues used machine learning to conduct exploratory partitioning cluster analysis to identify subgroups of patients with sepsis who may benefit from early antibiotics. Using data from the Prehospital Antibiotics Against Sepsis trial, a randomized trial of antibiotics in the ambulance vs in the emergency department in patients with sepsis, they found a significant interaction between age and the benefit of early antibiotics. Accounting for this, the models developed suggest that younger patients with sepsis benefit from early antibiotic administration. Validation of this finding could impact clinical practice. Other original research in this issue includes an evaluation of clinical and bronchoalveolar lavage profiles of children with bronchiectasis over two 5-year periods and the association of vitamin D deficiency and human T-lymphotropic virus type 1 infection with the severity of bronchiectasis, and a prospective multicenter study validating the Hospitalization or Outpatient Management of Patients With SARS-CoV-2 Infection rule for identifying patients who can safely be treated at home. Also in this section is a research letter evaluating how local SARS-CoV-2 prevalence has shaped pulmonary function testing laboratory protocols and a CHEST Review on the past, present, and future of pulmonary complications in the adult cystic fibrosis clinic.
On to our COPD content area. Uncertainty remains in the comparative effects of the multiple available long-acting beta agonist/long-acting muscarinic antagonist (LABA/LAMA) and long-acting beta agonist/inhaled corticosteroid (LABA/ICS) combination inhalers. In this issue, Wang and colleagues conducted a new user, propensity score-inverse probability of treatment weighting cohort study to compare the effectiveness of two LAMA/LABAs and three LABA/ICSs. They found that patients who initiated either of the LAMA/LABA combinations had a lower annual rate of moderate to severe exacerbations than those initiating salmeterol/fluticasone but a similar rate to those initiating formoterol/budesonide or formoterol/beclomethasone. The LAMA/LABAs were associated with a reduced pneumonia risk and similar cardiovascular risks. An intraclass difference in rates of COPD exacerbations and pneumonia was seen among the LABA/ICS combinations. These results suggest comparative effects may differ by individual components of the dual therapies, supporting future clinical trials. Also in this section is an original research article assessing the association between ACE-inhibitor and angiotensin receptor blocker use and the rate of progression of emphysema and lung function decline, and a CHEST Review describing the current state of stem cell therapy for COPD treatment.
Next is our Critical Care content area. The impact of variability in center management practices on ARDS mortality rates is unknown. In this issue, Qadir and colleagues conducted a 29-center, observational cohort study of 2,466 mechanically ventilated patients with ARDS to determine if there was an association between center variation in ventilator management and adjunctive therapy use with mortality. They found significant variability in adherence with lung protective ventilation, rates and methods of adjunctive therapy use, and mortality. Standardized mortality ratios ranged from 0.33 to 1.98, with center adherence to early lung protective ventilation being the only treatment level factor that correlated with the standardized mortality ratio. These findings suggest there are opportunities to improve the overall quality of care of patients with ARDS that will translate into improved outcomes. Other original research articles in this section include a randomized trial of Mycobacterium w in severe presumed gram-negative sepsis; a binational prospective cohort study assessing whether population-scale frailty screening is feasible and capable of identifying patients at risk of negative outcomes; and a prospective operational study assessing whether abdominal muscle thickening on ultrasound in mechanically ventilated patients provides clinically relevant information about abdominal muscle function and weaning outcomes. Finally, there is a case series published as a research letter that describes the paradoxical effect of chest wall compression on respiratory system compliance and a How I Do It review of the prevention and treatment of delirium in the ICU.
On to our Diffuse Lung Disease content area. It has previously been shown that nicotine normalizes immune responses to environmental antigens in patients with active pulmonary sarcoidosis. The effect of nicotine supplementation on the progression of pulmonary sarcoidosis is not known. In this issue, Crouser and colleagues report the results of a randomized, double-blind, controlled pilot trial of 24 weeks of daily nicotine transdermal patch treatment in patients with active pulmonary sarcoidosis. Nicotine treatment was well tolerated. There was a clinically significant improvement in forced vital capacity (FVC) in the treatment arm. No improvement in other physiology, symptom, and quality of life measures were noted. These results suggest the safety of nicotine treatment and the potential for treatment to reduce disease progression, supporting the conduct of larger trials. Also in this section is an original research article describing the pulmonary manifestations of GATA2 deficiency, research letters describing the impact of connective tissue disease-related interstitial lung disease on mortality and years of life lost in the United States, and the effect of pirfenidone on the prescription of antibiotics and antitussive drugs in patients with idiopathic pulmonary fibrosis. Finally, a CHEST Review explores sarcoidosis in the context of occupational lung disease.
Our Education and Clinical Practice content area is next. Infant pulmonary function tests (PFTs) have demonstrated expiratory airflow obstruction and air trapping in patients with neuroendocrine cell hyperplasia of infancy (NEHI). In this issue, Breuer and colleagues sought to determine whether indexes from infant pulmonary function tests could be useful in the diagnosis of neuroendocrine cell hyperplasia of infancy. In this observational case-control study, PFT data from 15 infants with neuroendocrine cell hyperplasia of infancy were compared with 292 wheezing infants, 128 premature infants, and 46 control infants. Increased trapped air volumes were seen in infants with NEHI compared with all other groups, while airflow limitation was similar to the disease control groups. The functional residual capacity measured by body plethysmography (FRCpleth) had the best discriminatory ability for NEHI, with an unvalidated receiver operating characteristic of 0.91. These results suggest markedly increased air trapping out of proportion to airflow limitation may be a sign of NEHI that warrants further validation. Other original research articles in this section include one characterizing aerosol generation during various intensities of exercise and another assessing the ability of a portable high efficiency particulate air filter with fume hood to mitigate aerosol generation during exercise testing. In addition, a CHEST Review on hypoglossal nerve stimulator treatment for obstructive sleep apnea; a How I Do It review on the delivery of a medical education escape room at a scientific conference; a Point/Counterpoint debate about whether fellowship interviews should remain exclusively virtual; and a guideline publication about the demographic and clinical considerations of the physiology and pathophysiology of cough all appear in this section.
Next is our Pulmonary Vascular content area. Preclinical evidence implicates neutrophil elastase in the pathogenesis of pulmonary arterial hypertension. The neutrophil elastase inhibitor elafin is being evaluated for its therapeutic potential. In this issue, Sweatt and colleagues evaluated whether circulating neutrophil elastase and elafin levels were abnormal in pulmonary arterial hypertension and whether they are associated with disease severity. They compared plasma levels of 249 patients with PAH and 106 healthy individuals. Prognostic relationships were validated using two external cohorts. They found higher levels of neutrophil elastase and lower levels of elafin in the disease group. Neutrophil elastase levels were associated with symptoms and signs of increased disease severity as well as increased mortality independent of known clinical risk predictors and prognostic cytokines. In vitro, elafin was able to rescue pulmonary artery endothelial cell homeostasis from the impact of exposure to neutrophil elastase. These results support the pathogenic role of neutrophil elastase and may facilitate the development of elafin as a therapeutic agent. Other original research published in this issue includes an evaluation of the incidence and clinical impact of right ventricular involvement in Takotsubo syndrome and an assessment of the risk of venous thromboembolism in an ethnically diverse population of patients with COVID-19. Finally, a CHEST Review on pulmonary thrombosis and thromboembolism in COVID-19 completes this section.
Our Sleep Medicine content area is next. Early identification of poor adherence to CPAP treatment is important to optimize treatment of patients with obstructive sleep apnea (OSA). In this issue, Palm and colleagues evaluated whether socioeconomic factors influence CPAP adherence. This was a nationwide population-based cohort study that cross-linked data from 20,521 patients with OSA receiving CPAP treatment in a Swedish quality registry to socioeconomic data from Statistics Sweden. They found CPAP adherence at 1.3 years of CPAP use was positively associated with being married, a higher education level, higher household income, and being born in Sweden. These results suggest that marital status, education level, and household income should be considered as predictors of CPAP adherence when treating OSA with CPAP.
Next is our Thoracic Oncology content area. A comprehensive epidemiologic understanding of adult pleural disease is not available. In this issue, Mummadi and colleagues report on a retrospective cohort study using Healthcare Cost and Utilization Project databases to describe the epidemiology of malignant and nonmalignant pleural effusions, pneumothoraces, and pleural tuberculous (TB). In 2016, more than 42,000 patients were treated and discharged from emergency departments and more than 361,000 hospitalizations related to pleural disease occurred. The sex distribution of primary spontaneous pneumothorax was 2.1:1 (men:women), substantially different from historic estimates. Comparing 2007 to 2016, there was a decrease in hospitalization rates for malignant mesothelioma, malignant pleural effusion, iatrogenic pneumothorax, and pleural TB, while there was an increase for empyema and nonmalignant pleural effusions. The proportion of readmissions attributed to a pleural cause varied by cause, ranging from 20% for iatrogenic pneumothorax to 49% for mesothelioma. These epidemiologic trends may help to identify opportunities for improvement in the management of pleural disease. Other original research published in this issue includes a description of CT findings and patterns of electronic cigarette or vaping product use-associated lung injury from a multicenter cohort; an evaluation of the safety and yield of transbronchial cryobiopsy for parenchymal lung lesions; and a comparison of two proposed changes to the nodal classification for non-small cell lung cancer based on the number and ratio of metastatic lymph nodes. In addition, a research letter evaluates the short- and long-term outcomes of patients with life threatening complications from lung cancer and another evaluates the risk of COVID-19 infection in bronchoscopy suite personnel in a setting without preprocedural outpatient testing. The section is completed by a How I Do It review describing mediastinal staging for lung cancer with examples from a tumor board.
Finally, I encourage you to take a look at our Humanities in Chest Medicine series, where the Exhalations series has an essay about the critical importance of medical humanities and the Vantage series includes a discussion about reserve systems for the allocation of scarce resources during the COVID-19 pandemic. Our case series publications for the month provide novel and educational cases to help improve your clinical skills.
I hope you enjoy reading all of 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 October issue.