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  • A systematically derived exposure assessment instrument for Chronic Hypersensitivity Pneumonitis
    Chest (IF 9.657) Pub Date : 2020-01-17
    Hayley Barnes; Julie Morisset; Philip Molyneaux; Glen Westall; Ian Glaspole; Harold R. Collard

    Background Chronic hypersensitivity pneumonitis (CHP) is an immune mediated interstitial lung disease, caused by inhalational exposure to environmental antigens, resulting in parenchymal fibrosis. By definition, a diagnosis of CHP assumes a history of antigen exposure, but only half of all patients eventually diagnosed with CHP will have a causative antigen identified. Individual clinician variation in eliciting a history of antigen exposure may affect the frequency and confidence of CHP diagnosis. Methods A list of potential causative exposures were derived from a systematic review of the literature. A Delphi method was applied to an international panel of ILD experts, to obtain consensus regarding technique for the elicitation of exposure to antigens relevant to a diagnosis of CHP. The consensus threshold was set at 80% agreement, and median ≤ 2, IQR = 0 on a five-point Likert scale (1: strongly agree, 2: tend to agree, 3: neither agree nor disagree, 4: disagree, 5: strongly disagree). Results In two rounds, 36/40 experts participated. Experts agreed on 18 exposure items to ask every patient with suspected CHP. Themes included CHP inducing exposures, features that contribute to an exposure’s relevance, and quantification of a relevant exposure. Based on the results from the literature review and Delphi process, a CHP exposure assessment instrument was derived. Using cognitive interviews, the instrument was revised by ILD patients for readability and usability. Conclusions This Delphi survey provides items that ILD experts agree are important to ask in all patients presenting with suspected CHP and provides basis for a systematically derived CHP exposure assessment instrument. Clinical utility of this exposure assessment instrument may be affected by different local prevalence patterns of exposures. Ongoing research is required to clinically validate these items and consider their impact in more geographically diverse settings.

    更新日期:2020-01-17
  • Eosinophilic Granulomatosis with Polyangiitis: clinical predictors of long-term asthma severity.
    Chest (IF 9.657) Pub Date : 2020-01-17
    Alvise Berti; Divi Cornec; Marta Casal Moura; Robert J. Smyth; Lorenzo Dagna; Ulrich Specks; Karina A. Keogh

    Background The long-term clinical course of asthma in patients with Eosinophilic Granulomatosis with Polyangiitis (EGPA) remains unclear. We aimed to characterize long-term asthma in EGPA and to identify baseline predictors of long-term asthma severity. Methods Retrospective cohort study of patients who fulfilled standardized criteria for EGPA that were followed in a single referral center between 1990-2017. Baseline and 3 (±1) years of follow-up clinical, laboratory and pulmonary function data were analyzed. Results Eighty-nine patients with EGPA, and a documented asthma assessment at baseline and at 3 years from diagnosis were included. Severe/uncontrolled asthma was observed in 42.7% of patients at diagnosis and was associated with previous history of respiratory allergy (p<0.01), elevated serum total IgE levels (p<0.05), increased use of high dose inhaled (ICS; p<0.05) and oral corticosteroids (OCS; p<0.001) for respiratory symptoms the year before the diagnosis of EGPA. During follow-up, an improvement or worsening in asthma severity was noted in 12.3% and 10.1% of patients, respectively. Severe/uncontrolled asthma was present in 40.5% of patients at 3 years, and was associated with increased airway resistance on pulmonary function testing (p<0.05). Long-term PFTs did not improve during long-term follow-up regardless of ICS or OCS therapy. Using multivariate binary logistic regressions, severe rhinosinusitis (p=0.038), pulmonary infiltrates (p=0.011), overweight (BMI>25kg/m2; p=0.041) and severe/uncontrolled asthma at vasculitis diagnosis (p<0.001) independently predicted severe/uncontrolled asthma at the 3-year endpoint. Conclusion In asthmatic patients with EGPA, long-term severe/uncontrolled asthma is associated with baseline pulmonary and ENT manifestations, but not with clear-cut vasculitic features.

    更新日期:2020-01-17
  • A geographic analysis of racial disparities in use of pulmonary rehabilitation after hospitalization for COPD exacerbation
    Chest (IF 9.657) Pub Date : 2020-01-17
    Kerry A. Spitzer; Mihaela S. Stefan; Aruna Priya; Quinn R. Pack; Penelope S. Pekow; Tara Lagu; Kathy Mazor; Victor M. Pinto-Plata; Richard L. ZuWallack; Peter K. Lindenauer

    Rationale Guidelines recommend pulmonary rehabilitation (PR) after hospitalization for an exacerbation of COPD, but few patients enroll in PR. We explored whether density of PR programs explained regional variation and racial disparities in receipt of PR. Methods We used CMS data from 223,832 Medicare beneficiaries hospitalized for COPD during 2012 who were eligible for PR post-discharge. We used Hospital-Referral Regions (HRR) as the unit of analysis. For each HRR, we calculated the density of PR programs as a measure of program access, and estimated risk-standardized rates of PR within 6 months of discharge overall, and for non-Hispanic, white and black beneficiaries. We used linear regression to examine the relationship between access to PR and HRR PR rates. We tested for racial disparity in PR rates among non-Hispanic white and black beneficiaries living in the same HRRs. Results Across 306 HRRs the median number of PR programs per 1,000 Medicare beneficiaries was 0.06 (IQR: 0.04-0.10). Risk-standardized rates of PR ranged from 0.53% to 6.67% (median 1.93%). Density of PR programs was positively associated with PR rates overall and among non-Hispanic white beneficiaries (p <0.001), but this relationship was not observed among black beneficiaries. Rates were higher among non-Hispanic white beneficiaries (median 2.08%: IQR 1.54%-2.87%) compared to black beneficiaries (median 1.19%: IQR 1.15%-1.20%). Conclusions Greater PR program density was associated with higher rates of PR for non-Hispanic white but not black beneficiaries. Further research is needed to identify reasons for this discrepancy and strategies to increase receipt of PR for black patients.

    更新日期:2020-01-17
  • Update on Apneas of Heart Failure with Reduced Ejection Fraction: Emphasis on the Physiology of Treatment Part 2: Central Sleep Apnea
    Chest (IF 9.657) Pub Date : 2020-01-17
    Shahrokh Javaheri; Lee K. Brown; Rami N. Khayat

    Central sleep apnea/Hunter-Cheyne-Stokes Breathing (CSA/HCSB), is prevalent in patients with heart failure with reduced ejection fraction (HFrEF). The acute pathobiological consequences of CSA/HSCB eventually lead to sustained sympathetic over-activity, repeated hospitalization, and premature mortality. Few small randomized controlled trials (RCTs) have shown statistically significant and clinically important reduction in sympathetic activity when CSA/HCSB is attenuated by oxygen or positive airway pressure (PAP) therapy, both continuous PAP (CPAP) and Adaptive servo ventilation (ASV) devices. Yet, the two largest PAP trials in patients with HFrEF, one with CPAP and the other with an ASV, were negative with respect to their primary outcomes, and both associated with excess mortality. However, both trials suffered from significant deficiencies casting doubt on their results. A second RCT evaluating an ASV device with advanced algorithm is ongoing. A new modality of therapy, unilateral phrenic nerve stimulation, has undergone an RCT that demonstrated an improvement in CSA that was associated with a reduction in arousals, improvement in sleepiness and quality of life. However, a long-term mortality trial has not been performed with this modality. Most recently, the NIH funded a long-term, phase-III RCT of low flow oxygen vs. sham for the treatment of CSA/HCSB in HFrEF. The composite primary outcome includes all-cause mortality and hospitalization for worsening HF. In this article, we focus on various therapeutic options for the treatment of CSA/HCSB and, when appropriate, emphasize the importance of identifying CSA/HCSB phenotypes to tailor treatment.

    更新日期:2020-01-17
  • Associations between 25-hydroxy-vitamin D levels, lung function, and exacerbation outcomes in COPD: An analysis of the SPIROMICS cohort
    Chest (IF 9.657) Pub Date : 2020-01-17
    Robert M. Burkes; Agathe S. Ceppe; Claire M. Doerschuk; David Couper; Eric A. Hoffman; Alejandro P. Comellas; R. Graham Barr; Jerry A. Krishnan; Christopher Cooper; Wassim W. Labaki; Victor E. Ortega; J. Michael Wells; Gerard J. Criner; Prescott G. Woodruff; Russell P. Bowler; Cheryl S. Pirozzi; Nadia N. Hansel; Robert Wise; M. Bradley Drummond

    Introduction The relationship between 25-hydroxy-vitamin D (25-OH-vitamin D) and COPD outcomes remains unclear. Using the Subpopulations and Intermediate Outcome Measures in COPD Study (SPIROMICS), we determined associations between baseline 25-OH-vitamin D and cross-sectional and longitudinal lung function and COPD exacerbations. Methods Serum 25-OH-vitamin D level was measured in stored samples from 1609 SPIROMICS participants with COPD. 25-OH-vitamin D levels were modeled continuously and dichotomized as deficient (<20 ng/ml) vs. not deficient (≥20 ng/ml). Outcomes of interest included %-predicted FEV1 (current and one-year longitudinal decline) and COPD exacerbations (separately any and severe, occurring in prior year and first year of follow-up). Results Vitamin D deficiency was present in 21% of the cohort and was more prevalent in the younger-aged, active smokers, and African-Americans. Vitamin D deficiency was independently associated with 4.11 lower FEV1 %-predicted at enrollment (95% CI -6.90 to -1.34 %-predicted, P=0.004), 1.27 %-predicted greater rate-of-FEV1-decline after one year (95% CI -2.32 to -0.22 %-predicted/yr; P=0.02), and higher odds of any COPD exacerbation in the prior year (OR 1.32; 95% CI 1.00-1.74; P=0.049). Each 10 ng/ml decrease in 25-OH-vitamin D was associated with lower baseline lung function [-1.27 %-predicted (95% CI -2.32 to -0.22 %-predicted); P=0.02] and increased odds of any exacerbation in the year prior to enrollment [OR 1.11 (95% CI 1.01-1.22); P=0.04]. Interpretation Vitamin D deficiency is associated with worse cross-sectional and longitudinal lung function and increased odds of prior COPD exacerbations. These findings identify 25-OH-vitamin D levels as a potentially useful marker of adverse COPD-related outcomes.

    更新日期:2020-01-17
  • Genetic risk factors for spontaneous pneumothorax in Birt-Hogg-Dubé syndrome
    Chest (IF 9.657) Pub Date : 2020-01-17
    Elke C. Sattler; Zulfiya Syunyaeva; Ulrich Mansmann; Ortrud K. Steinlein

    Background Birt-Hogg-Dubé syndrome (BHDS) is a genetic tumor syndrome characterized by lung cysts, spontaneous pneumothorax, fibrofolliculoma and renal cell cancer. Due to its rarity and clinical heterogeneity, much is still unknown regarding the course of the disease and individual risk assessment. Therefore, we studied non-environmental risk factors for pneumothorax in a large sample of BHDS patients. Methods Clinical data were available from 197 BHDS patients (male 103, female 94) belonging to 63 unrelated families. The FLCN coding region including adjacent intronic sequences was analysed by PCR and subsequent Sanger sequencing as well as MLPA. Statistical analyses were performed using adequate methods to account for familial clustering. Results Patients who had only a single spontaneous pneumothorax were significantly older at the time of occurrence than those with multiple ones (mean 38.93 versus 29.74 years, p-value 0.010). The risk for three or more pneumothoraces drastically increased after the second event. Significantly increased pneumothorax risks were found for mutations c.1300G>C (59%) and c.250-2A>G (77%), compared to FLCN hotspot mutation c.1285dup (37% risk) (p-value 0.02). Conclusions We observed significant differences for the spontaneous pneumothorax risk regarding both age and gender in BHDS patients. Furthermore, two FLCN mutations were identified that are associated with significantly increased pneumothorax risk. Thus, formerly unknown individual predictors have been identified that provide improved risk stratification for BHDS patients.

    更新日期:2020-01-17
  • UNDERWEIGHT PATIENTS WITH CYSTIC FIBROSIS HAVE ACCEPTABLE SURVIVAL AFTER LUNG TRANSPLANTATION: A UNOS REGISTRY STUDY
    Chest (IF 9.657) Pub Date : 2020-01-17
    Kathleen J. Ramos; Siddhartha G. Kapnadak; Miranda C. Bradford; Ranjani Somayaji; Eric D. Morrell; Joseph M. Pilewski; Erika D. Lease; Michael S. Mulligan; Moira L. Aitken; Cynthia J. Gries; Christopher H. Goss

    Background Reduced body mass index (BMI) is an absolute contraindication for lung transplantation (LTx) at most centers in the United States (US). Our objective was to quantify post-LTx survival of moderate-to-severely underweight cystic fibrosis (CF) patients (BMI <17 kg/m2) in the US relative to normal-weight CF recipients and other frequently transplanted patient cohorts. Methods Using United Network for Organ Sharing (UNOS) data (transplanted June 2005-November 2015), Kaplan-Meier estimates of median post-transplant survival were calculated for all CF, chronic obstructive pulmonary disease (COPD), and idiopathic pulmonary fibrosis (IPF) patients, as well as low and normal-weight CF subgroups. Cox regression modeling stratified by transplant center assessed risk of post-transplant mortality in CF recipients with BMI <17 kg/m2 compared to COPD recipients (reference). Results Median post-transplant survival [95% CI] for CF, COPD, and IPF was 7.9 [7.2, 8.6], 5.9 [5.6, 6.2], and 5.5 [5.2, 5.8] years, respectively. While an absolute decrease was noted in post-transplant survival for CF recipients with BMI < 17 kg/m2, compared to those with BMI ≥17 kg/m2 (7.0 years [4.5, 7.9] vs. 8.2 years [7.3, 9.0]), Cox modeling found no increased mortality risk (adjusted HR 1.09 [0.90, 1.32], p=0.38). There was no difference in post-transplant mortality between CF with BMI <17 kg/m2 and COPD recipients of all BMIs (adjusted HR 1.04 [0.86, 1.25], p=0.71). Conclusions CF recipients with BMI <17 kg/m2 had post-transplant survival comparable to other frequently transplanted groups. BMI <17 kg/m2 as a single risk factor in the CF population should not be treated as an absolute contraindication to LTx.

    更新日期:2020-01-17
  • Impact of preoperative right heart chambers measurement in the evaluation of pulmonary hypertension after aortic valve replacement.
    Chest (IF 9.657) Pub Date : 2020-01-17
    Mercè Cladellas; Cora Garcia-Ribas; Mirea Ble; Miquel Gómez; Núria Farré; Aleksandra Mas-Stachurska; Consol Ivern; Joan Vila; Julio Martí-Almor

    Background Severe pulmonary hypertension (PH) in patients with aortic stenosis is related to poor prognosis after aortic valve replacement (AVR). Current European PH guidelines recommend adding two different echocardiographic signs to tricuspid regurgitation velocity (TRV) in PH estimation, classifying its probability as “low” (TRV≤2.8m/s), “intermediate” (TRV 2.9-3.4m/s) and “high” (TRV>3.4m/s). Right ventricle (RV) is an important determinant of prognosis in PH. Our aim was to analyze the value of right atrial area>18cm2 and RV/left ventricle ratio>1 in the long-term prognosis after AVR, mainly in the “intermediate” group. Methods We included 429 consecutive patients (mean age 73±8 years, 55% males) with median follow-up of 4.25 years (completed in 98%). Patients were divided into “low” (n=247), “intermediate” (n=117) and “high” groups (n=65). The “intermediate” group was divided into 2 subgroups: “subgroup 2a” (n=27, TRV non-measurable or ≤2.8m/s and two signs present) and “subgroup 2b” (n=90, TRV 2.9-3.4m/s and none or only one sign present). Results Overall mortality rates during follow-up of the “low”, “intermediate” and “high” were 24%, 32% and 42%, respectively. “High” PH probability was an independent predictor of all-cause mortality (HR 1.82; 95% CI:1.11-3.00), but the "intermediate" group did not reach significance after multivariate analysis (HR 1.40; 95% CI: 0.91-2.16). When the "intermediate" group was divided into subgroups, “subgroup 2a” mortality rate (56%) was higher than that of both “subgroup 2b” (24%, p=0.002) and the "low" group (24%, p<0.001). After multivariate analysis, “subgroup 2a” showed a significantly higher mortality (HR 2.13; 95% CI: 1.11-4.10) in contrast to “subgroup 2b” (HR 1.24, 95% CI: 0.75-2.05), both compared to the low group. Conclusions Incorporating right cavities measures to the PH probability model in the assessment of long-term prognosis after AVR, allows better risk discrimination, especially in the “intermediate” group.

    更新日期:2020-01-17
  • A Systematic Review of Digital Versus Analog Drainage for Air Leak Following Surgical Resection or Spontaneous Pneumothorax
    Chest (IF 9.657) Pub Date : 2020-01-17
    Fadi Aldaghlawi; Jonathan S. Kurman; Jason A. Lilly; D. Kyle Hogarth; Jessica Donington; Mark K. Ferguson; Septimiu D. Murgu

    Background The concerns regarding air leak following lung surgery or spontaneous pneumothorax include detection and duration. Prior studies have suggested that digital drainage systems permit a shorter chest tube duration and hospital length of stay (LOS) by earlier detection of air leak cessation. We conducted a systematic review to assess the impact of digital drainage on chest tube duration and hospital LOS following pulmonary surgery and spontaneous pneumothorax. Methods Ovid MEDLINE, PubMed, Embase, the Cochrane Library, Scopus, and Google Scholar were searched from inception through January 2019. We included randomized controlled trials, cohort studies, and case series of adult patients using digital or traditional drainage devices for air leaks of either post-surgical or spontaneous pneumothorax origin. Results Of 1,272 references reviewed, 23 articles were included. Nineteen articles addressed post-operative air leak, while 4 articles pertained to air leak after spontaneous pneumothorax. Thirteen studies were randomized controlled trials. Digital drainage resulted in significantly shorter chest tube duration in 8 of 18 studies and shorter hospital LOS in 6 of 14 studies for post-operative air leak. For post-pneumothorax air leak, digital drainage resulted in a significantly shorter chest tube duration in 2 of 3 studies and hospital LOS in 1 of 2 studies with an analog control group. Conclusions Most studies show no significant differences in chest tube duration and hospital LOS with digital versus analog drainage systems for patients with air leak after pulmonary resection. For post spontaneous pneumothorax air leak, the limited published evidence suggests a shorter chest tube duration and hospital LOS with analog drainage systems.

    更新日期:2020-01-17
  • Disease Severity and Quality of Life in Patients with Idiopathic Pulmonary Fibrosis: A Cross-Sectional Analysis of the IPF-PRO Registry
    Chest (IF 9.657) Pub Date : 2020-01-15
    Emily C. O’Brien; Anne S. Hellkamp; Megan L. Neely; Aparna Swaminathan; Shaun Bender; Laurie D. Snyder; Daniel A. Culver; Craig S. Conoscenti; Jamie L. Todd; Scott M. Palmer; Thomas B. Leonard

    Background Limited data are available on the association between clinically measured disease severity markers and quality of life (QOL) in idiopathic pulmonary fibrosis (IPF). We examined the associations between objective disease severity metrics and QOL in a contemporary IPF population. Methods We evaluated baseline data from patients enrolled in the multicenter, US-based IPF-PRO Registry between June 2014 and July 2018. Disease severity metrics included forced vital capacity [FVC] % predicted, diffusing capacity for carbon monoxide [DLCO] % predicted, supplemental oxygen use with activity, supplemental oxygen use at rest, and two summary scores: the Gender-Age-Lung Physiology (GAP) Index (based on gender, age, and % predicted values for DLCO and FVC) and the Composite Physiologic Index (CPI) (based on % predicted values for DLCO, FVC, and forced expiratory volume in 1 second). We used multivariable adjusted regression models to examine cross-sectional associations between each severity measure and St. George’s Respiratory Questionnaire (SGRQ) total score. Results Among 829 patients with complete SGRQ data, the median SGRQ score at enrollment was 40 (IQR=26-53; higher scores indicate worse QOL). Modest SGRQ impairments were observed with increasing GAP score [2.9 (1.8-4.0) per 1-point increase] and with increasing CPI [3.0 (2.4-3.6) per 5-point increase]. Substantial SGRQ impairments were observed for oxygen use with activity [15.6 (12.9-18.2)], oxygen use at rest [16.2 (13.0-19.4)], and decreasing DLCO [5.0 (4.0-6.1) per 10% decrease in % predicted]. Conclusions Objective measures of disease severity, including severity scores, physiologic parameters, and supplemental oxygen use, are associated with worse QOL in patients with IPF.

    更新日期:2020-01-15
  • Respiratory disease and lower pulmonary function as risk factors for dementia: a systematic review with meta-analysis
    Chest (IF 9.657) Pub Date : 2020-01-15
    Tom C. Russ; Mika Kivimäki; G. David Batty

    Background In addition to affecting the oxygen supply to the brain, pulmonary function is a marker of multiple insults throughout life (including smoking, illness, and socioeconomic deprivation). In this meta-analysis of existing longitudinal studies, we tested the hypothesis that lower pulmonary function and respiratory illness are linked to an elevated risk of dementia. Method We conducted a systematic review of longitudinal studies using PubMed until April 1st, 2019 and, where possible, pooled results in random-effects meta-analyses. Results We identified eleven studies relating pulmonary function to later dementia risk, and eleven studies of respiratory illness and dementia (including one which assessed both). The lowest quartile of Forced Expiratory Volume in one second (FEV1) compared with the highest was associated with a 1.4-fold (1.46, 95%CI 0.77-2.75) increased dementia risk (Ntotal=62,209, two studies). An decrease of one standard deviation in FEV1 was associated with a 28% increase in dementia risk (1.28, 95%CI 1.03-1.60; Ntotal=67,505; six studies). Respiratory illness was also associated with increased dementia risk to a similar degree (1.54, 1.30-1.81, Ntotal=288,641, 11 studies). Conclusions Individuals with poor pulmonary function experience increased risk of dementia. The extent to which the association between poor pulmonary function and dementia is causal remains unclear and requires examination.

    更新日期:2020-01-15
  • Arnold Nerve Reflex: Vagal Hypersensitivity in Chronic Cough with Various Causes
    Chest (IF 9.657) Pub Date : 2020-01-13
    Yonglin Mai; Chen Zhan; Shengfang Zhang; Jiaxing Liu; Wanqin Liang; Jiawei Cai; Kefang Lai; Nanshan Zhong; Ruchong Chen

    Background A higher incidence of Arnold Nerve Reflex (ANR) has been observed in patients with chronic cough. However, the different ANR response in various causes of chronic cough remains unclear. Furthermore, it is unknown whether ANR will change after effective treatment. Methods Patients with chronic cough were enrolled in the Guangzhou Institute of Respiratory Health. The causes of chronic cough were diagnosed via a validated management algorithm. Patients underwent an assessment of ANR response before and after one-month etiological treatment. Result A total of 127 patients with chronic cough and 55 healthy controls were enrolled. The positive response, defined as cough-only ANR or urge-to-cough (UTC), was present in 14.8% of cough variant asthma (CVA), 11.1% of upper airway cough syndrome (UACS), 15.4% of gastroesophageal reflex related cough (GERC), 4.8% of eosinophilic bronchitis (EB), 26.9% of unexplained cough (UC), respectively. No ANR or UTC was found in the healthy controls. The incidence of the positive response was higher in subjects with CVA, GERC and UC compared with healthy controls (all P<0.05). No difference was observed among the different causes of chronic cough (all P>0.05). After one-month treatment, 87.5% of patients identified with a positive response changed to a negative response. In a subgroup analysis, an increased cough sensitivity to capsaicin was found in the patients with a positive response compared with the patients with a negative response (P<0.05). Conclusion A positive ANR appears to be a sign of vagal hypersensitivity and can be reversed after effective treatment of chronic cough. However, while various causes of chronic cough share a similar feature of an elevated ANR response in a minority of patients, there appears to be limited usefulness in assessing the ANR because it does not appear to be a valid predictor of etiology of chronic cough or outcome of treatment.

    更新日期:2020-01-13
  • Subtyping COPD by Using Visual and Quantitative CT Imaging Features
    Chest (IF 9.657) Pub Date : 2019-07-05
    Jinkyeong Park; Brian D. Hobbs; James D. Crapo; Barry J. Make; Elizabeth A. Regan; Stephen Humphries; Vincent J. Carey; David A. Lynch; Edwin K. Silverman

    Background Multiple studies have identified COPD subtypes by using visual or quantitative evaluation of CT images. However, there has been no systematic assessment of a combined visual and quantitative CT imaging classification. We integrated visually defined patterns of emphysema with quantitative imaging features and spirometry data to produce a set of 10 nonoverlapping CT imaging subtypes, and we assessed differences between subtypes in demographic features, physiological characteristics, longitudinal disease progression, and mortality. Methods We evaluated 9,080 current and former smokers in the COPDGene study who had available volumetric inspiratory and expiratory CT images obtained using a standardized imaging protocol. We defined 10 discrete, nonoverlapping CT imaging subtypes: no CT imaging abnormality, paraseptal emphysema (PSE), bronchial disease, small airway disease, mild emphysema, upper lobe predominant centrilobular emphysema (CLE), lower lobe predominant CLE, diffuse CLE, visual without quantitative emphysema, and quantitative without visual emphysema. Baseline and 5-year longitudinal characteristics and mortality were compared across these CT imaging subtypes. Results The overall mortality differed significantly between groups (P < .01) and was highest in the 3 moderate to severe CLE groups. Subjects having quantitative but not visual emphysema and subjects with visual but not quantitative emphysema were unique groups with mild COPD, at risk for progression, and with likely different underlying mechanisms. Subjects with PSE and/or moderate to severe CLE had substantial progression of emphysema over 5 years compared with findings in subjects with no CT imaging abnormality (P < .01). Conclusions The combination of visual and quantitative CT imaging features reflects different underlying pathological processes in the heterogeneous COPD syndrome and provides a useful approach to reclassify types of COPD. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00608764; URL: www.clinicaltrials.gov;

    更新日期:2020-01-06
  • Managing Massive Hemoptysis
    Chest (IF 9.657) Pub Date : 2019-07-30
    Kevin Davidson; Samira Shojaee

    Massive hemoptysis is a medical emergency with high mortality presenting several difficult diagnostic and therapeutic challenges. The origin of bleeding and underlying etiology often is not immediately apparent, and techniques for management of this dangerous condition necessitate an expedient response. Unlike hemorrhage in other circumstances, a small amount of blood can rapidly flood the airways, thereby impairing oxygenation and ventilation, leading to asphyxia and consequent cardiovascular collapse. Of paramount importance is early control of the patient’s airway and immediate isolation of hemorrhage in an attempt to localize and control bleeding. A coordinated team response is essential to guarantee the best chances of patient survival. Prompt control of the airway and steps to limit the spread of hemorrhage take precedence. Bronchial artery embolization, rigid and flexible bronchoscopy, and surgery all serve as potential treatment options to provide definitive control of hemorrhage. Several adjunctive therapies described in recent years may also assist in the control of bleeding; however, their role is less defined in life-threatening hemoptysis and warrants additional studies. In this concise review, we emphasize the steps necessary for a systematic approach in the management of life-threatening hemoptysis.

    更新日期:2020-01-06
  • Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung Disease
    Chest (IF 9.657) Pub Date : 2019-07-24
    Simon Bax; Joseph Jacob; Riaz Ahmed; Charlene Bredy; Konstantinos Dimopoulos; Aleksander Kempny; Maria Kokosi; Gregory Kier; Elisabetta Renzoni; Philip L. Molyneaux; Felix Chua; Vasilis Kouranos; Peter George; Colm McCabe; Michael Wilde; Anand Devaraj; Athol Wells; S. John Wort; Laura C. Price

    Background Patients with interstitial lung disease (ILD) may develop pulmonary hypertension (PH), often disproportionate to the severity of the ILD. The right ventricular to left ventricular diameter (RV:LV) ratio measured at CT pulmonary angiogram (CTPA) has been shown to provide valuable information in patients with pulmonary arterial hypertension and to predict death or deterioration in acute pulmonary embolism. Methods Demographic characteristics, ILD subtype, echocardiography, and detailed CTPA measurements were collected in consecutive patients undergoing both CTPA and right heart catheterization at the Royal Brompton Hospital between 2005 and 2015. Fibrosis severity was formally scored according to CT criteria. The RV:LV ratio at CTPA was evaluated by using three different methods. Cox proportional hazards analysis was used to assess the relation of CTPA-derived parameters to predict death or lung transplantation. Results A total of 92 patients were included (64% male; mean age 65 ± 11 years) with an FVC 57 ± 20% predicted, corrected transfer factor of the lung for carbon monoxide 22 ± 8% predicted, and corrected transfer coefficient of the lung for carbon monoxide 51 ± 17% predicted. PH was confirmed at right heart catheterization in 78%. Of all the CTPA-derived measures, an RV:LV ratio ≥ 1.0 strongly predicted mortality or transplantation at univariate analysis (hazard ratio, 3.26; 95% CI, 1.49-7.13; P = .003), whereas invasive hemodynamic data did not. The RV:LV ratio remained an independent predictor at multivariate analysis (hazard ratio, 3.19; 95% CI, 1.44-7.10; P = .004), adjusting for an ILD diagnosis of idiopathic pulmonary fibrosis and CT imaging-derived ILD severity. Conclusions An increased RV:LV ratio measured at CTPA provides a simple, noninvasive method of risk stratification in patients with suspected ILD-PH. This should prompt closer follow-up, more aggressive treatment, and consideration of lung transplantation.

    更新日期:2020-01-06
  • Lung Hyperlucency
    Chest (IF 9.657) Pub Date : 2019-07-26
    Sujith V. Cherian; Francis Girvin; David P. Naidich; Stephen Machnicki; Kevin K. Brown; Jay H. Ryu; Nishant Gupta; Vishisht Mehta; Rosa M. Estrada -Y- Martin; Mangala Narasimhan; Margarita Oks; Suhail Raoof

    Areas of diminished lung density are frequently identified both on routine chest radiographs and chest CT examinations. Colloquially referred to as hyperlucent foci of lung, a broad range of underlying pathophysiologic mechanisms and differential diagnoses account for these changes. Despite this, the spectrum of etiologies can be categorized into underlying parenchymal, airway, and vascular-related entities. The purpose of this review is to provide a practical diagnostic algorithmic approach to pulmonary hyperlucencies incorporating clinical history and characteristic imaging patterns to narrow the differential.

    更新日期:2020-01-06
  • Upper Airway Stimulation vs Positive Airway Pressure Impact on BP and Sleepiness Symptoms in OSA
    Chest (IF 9.657) Pub Date : 2019-07-09
    Harneet K. Walia; Nicolas R. Thompson; Kingman P. Strohl; Michael D. Faulx; Tina Waters; Alan Kominsky; Nancy Foldvary-Schaefer; Reena Mehra

    Background Positive airway pressure (PAP) and upper airway stimulation (UAS) are approved OSA treatment options. Although the effect of PAP on improvement in BP and daytime sleepiness (defined according to the Epworth Sleepiness Scale [ESS]) has been established, the impact of UAS on BP remains unclear. This study hypothesized that PAP and UAS will confer improvements in BP and daytime sleepiness. Methods Clinic-based BP and ESS scores were compared between 517 patients with OSA (apnea-hypopnea index, 15-65) and BMI ≤ 35 kg/m2 initiating PAP therapy (2010-2014) at the Cleveland Clinic and 320 patients with UAS implantation (2015-2017) via an international registry with 2- to 6-month follow-up. Mixed effect models were used to compare outcomes in 201 patients in each arm following propensity matching. Results PAP showed greater improvement in diastolic BP (mean difference of change between groups, 3.7 mm Hg; P < .001) and mean arterial pressure (mean difference of change between groups, 2.8 mm Hg; P = .008) compared with UAS. UAS showed greater improvement in ESS scores vs PAP (mean difference of change between PAP and UAS groups, –0.8; P = .046). UAS therapy usage was 6.2 h/week greater than PAP-treated patients (95% CI, 3.3-9.0). Results were consistent following adjustment for therapy adherence. Conclusions PAP showed greater improvement in BP, potentially reflecting an enhanced ability of PAP to exert beneficial mechanical intrathoracic cardiac and vascular influences. BP measurement error in the UAS group may also have accounted for findings. Greater improvement in sleepiness symptoms was noted with UAS compared with PAP.

    更新日期:2020-01-06
  • A Randomized Trial of Nebulized Lignocaine, Lignocaine Spray, or Their Combination for Topical Anesthesia During Diagnostic Flexible Bronchoscopy
    Chest (IF 9.657) Pub Date : 2019-07-09
    Sahajal Dhooria; Shivani Chaudhary; Babu Ram; Inderpaul Singh Sehgal; Valliappan Muthu; Kuruswamy Thurai Prasad; Ashutosh N. Aggarwal; Ritesh Agarwal

    Background The optimal mode of delivering topical anesthesia during flexible bronchoscopy remains unknown. This article compares the efficacy and safety of nebulized lignocaine, lignocaine oropharyngeal spray, or their combination. Methods Consecutive subjects were randomized 1:1:1 to receive nebulized lignocaine (2.5 mL of 4% solution, group A), oropharyngeal spray (10 actuations of 10% lignocaine, group B), or nebulization (2.5 mL, 4% lignocaine) and two actuations of 10% lignocaine spray (group C). The primary outcome was the subject-rated severity of cough according to a visual analog scale. The secondary outcomes included bronchoscopist-rated severity of cough and overall procedural satisfaction on a visual analog scale, total lignocaine dose, subject’s willingness to undergo a repeat procedure, adverse reactions to lignocaine, and others. Results A total of 1,050 subjects (median age, 51 years; 64.8% men) were included. The median (interquartile range) score for subject-rated cough severity was significantly lower in group B compared to group C or group A (4 [1-10] vs 11 [4-24] vs 13 [5-30], respectively; P < .001). The bronchoscopist-rated severity of cough was also the least (P < .001), and the overall satisfaction was highest in group B (P < .001). The cumulative lignocaine dose administered was the least in group B (P < .001). A significantly higher proportion of subjects (P < .001) were willing to undergo a repeat bronchoscopy in group B (73.7%) than in groups A (49.1%) and C (59.4%). No lignocaine-related adverse events were observed. Conclusions Ten actuations of 10% lignocaine oropharyngeal spray were superior to nebulized lignocaine or their combination for topical anesthesia during diagnostic flexible bronchoscopy. Trial Registry ClinicalTrials.gov; No.: NCT03109392; URL: www.clinicaltrials.gov.

    更新日期:2020-01-06
  • A 38-Year-Old Man With Well Treated OSA on CPAP With Persistent Nocturnal Hypoxemia
    Chest (IF 9.657) Pub Date : 2020-01-06
    David J. Culpepper; Deborah Hong; Armand Ryden; Jesse Currier; Jonathan M. Tobis; Sharon De Cruz; Michelle R. Zeidler

    Case Presentation A 38-year-old male with a prior diagnosis of severe OSA (apnea-hypopnea index [AHI] 99/h) presented for transfer of care. He was successfully titrated to CPAP of 10 cm H2O at an outside laboratory and was compliant with therapy with residual AHI 1.9/h. On presentation, he was polycythemic, with negative evaluation for primary polycythemia, and evaluation for hypoxemia was initiated.

    更新日期:2020-01-06
  • A 64-Year-Old Man With Rapidly Progressive Respiratory Failure and Pneumomediastinum
    Chest (IF 9.657) Pub Date : 2020-01-06
    Minkyung Kwon; Isabel Mira-Avendano; Andras Khoor; Jorge Mallea

    Case Presentation A 64-year-old man presented for consideration for lung transplant. He had a history of previous tobacco use, OSA on CPAP therapy, and gastroesophageal reflux disease. He worked as a design engineer. The patient had a 4-year history of dyspnea on exertion, followed with periodic CT scan of the chest. Nine months prior to his evaluation for lung transplant, the patient developed worsening of dyspnea, dry cough, poor appetite, and weight loss. At times, the cough was violent and associated with chest pressure. He was prescribed systemic corticosteroids and antibiotics without improvement. Four months later, the patient noted sudden onset of severe chest pain and worsening dyspnea. A CT scan of the chest demonstrated extensive pneumomediastinum in addition to changes consistent with pulmonary fibrosis. An esophagogram showed thickening of the distal esophagus, but no signs of perforation. He was prescribed supplemental oxygen and advised to stop the use of CPAP. The patient sought a second opinion. A CT scan of the chest showed improvement of the pneumomediastinum and extensive fibrotic lung disease. Pulmonary function tests (PFTs) were consistent with a restrictive pattern, decreased diffusing capacity (Dlco), and a preserved residual volume over total lung capacity ratio. The patient was prescribed systemic corticosteroids with no improvement of his symptoms. Repeat PFTs showed further decline of Dlco, and he was referred for lung transplant evaluation.

    更新日期:2020-01-06
  • A 59-Year-Old Man With Chronic Kidney Disease After Kidney Transplantation Presents With Chronic Dyspnea
    Chest (IF 9.657) Pub Date : 2020-01-06
    Patrick Duncan; Stephanie Cull; Palmi Shah; Amie Gamino

    Case Presentation A 59-year-old man presented to the ED with a chief complaint of shortness of breath. His past medical history was significant for end-stage renal disease secondary to lithium toxicity, immunosuppression subsequent to cadaveric renal transplantation, bipolar disorder, and hypertension. His shortness of breath had begun 6 months previously and was initially intermittent; it then progressed to constant shortness of breath over the few weeks before presentation. He had no fever, hemoptysis, or chest pain. The patient was admitted to hospital for further evaluation.

    更新日期:2020-01-06
  • A Woman With Dyspnea, Weight Loss, and Splenic Lesions
    Chest (IF 9.657) Pub Date : 2020-01-06
    Jennifer S. Hanberg; Dana Dunne

    Case Presentation The patient is a 37-year-old hospital employee and current smoker with a 10 pack-year smoking history, who presented with dyspnea, chest pain, and weight loss. She was in her usual state of health until 4 months prior to admission when she developed intermittent left-sided chest pain, cough productive of scant yellow sputum, fevers, and anorexia. Initial chest radiograph was normal and her outpatient physician prescribed azithromycin, which she took without improvement. One month prior to admission, a follow-up chest radiograph revealed a left-sided upper lobe consolidation; she received a course of levofloxacin without improvement. At follow-up, given her occupation, 13.6-kg unintentional weight loss, and persistent pulmonary symptoms and infiltrate despite treatment for pneumonia, her provider referred her for admission with particular concern for exclusion of active TB. As a hospital employee with clinical exposure, she underwent annual TB screening, which was always negative. She had no known exposure to patients with TB. Her most recent travel was to the Midwestern United States, without significant outdoors exposure. Review of systems was positive for wheezing, anorexia, and arthralgias of both knees and the left ankle and wrist. There was no hemoptysis, leg swelling, visual changes, palpitations, or muscle weakness.

    更新日期:2020-01-06
  • A 78-Year-Old Man With Repeated Dyspnea and Neutrophilia in Peripheral Blood and BAL
    Chest (IF 9.657) Pub Date : 2020-01-06
    Erika Nakamatsu; Takayoshi Morita; Atsuyoshi Morishima; Hiroshi Tagawa; Mitsugi Furukawa; Masato Matsushita; Hiroyuki Yamane

    Case Presentation A 78-year-old man with asthma and COPD presented with shortness of breath, cough, and severe malaise for 4 days. Upon arrival, the patient was conscious and body temperature was 37.5°C. Arterial oxygen saturation (Spo2) was 80% on room air. Laboratory data demonstrated a WBC count of 17,400/μL (89.5% neutrophils) and C-reactive protein of 5.00 mg/dL. CT scan of chest revealed scattered ground-glass in the upper right lobe and thickening of the bronchial wall. Based on these findings, acute bronchopneumonia was diagnosed and antibacterial therapy was started. The day after admission, the patient’s general condition and shortness of breath had gradually improved. We treated and observed him carefully for 10 days in the hospital on antibacterial therapy because of his underlying comorbidities (asthma and COPD) and his ongoing hypoxemia. Three days after discharge, the patient re-presented with shortness of breath, hypoxemia, and loss of appetite. The patient was hospitalized for a second time.

    更新日期:2020-01-06
  • Machine Learning Characterization of COPD Subtypes: Insights from the COPDGene Study
    Chest (IF 9.657) Pub Date : 2019-12-28
    Peter J. Castaldi; Adel Boueiz; Jeong Yun; Raul San Jose Estepar; James C. Ross; George Washko; Michael H. Cho; Craig P. Hersh; Gregory L. Kinney; Kendra A. Young; Elizabeth A. Regan; David A. Lynch; Gerald J. Criner; Jennifer G. Dy; Stephen I. Rennard; Richard Casaburi; Barry J. Make; James Crapo; John E. Hokanson

    COPD is a heterogeneous syndrome. Many COPD subtypes have been proposed, but there is not yet consensus on how many COPD subtypes there are and how they should be defined. The COPDGene study, which has generated ten-year longitudinal chest imaging, spirometry, and molecular data, is a rich resource for relating COPD phenotypes to underlying genetic and molecular mechanisms. In this article, we place COPDGene clustering studies in context with other highly cited COPD clustering studies, and we summarize the main COPD subtype findings from COPDGene. First, most manifestations of COPD occur along a continuum, which explains why continuous aspects of COPD or disease axes may be more accurate and reproducible than subtypes identified through clustering methods. Second, continuous COPD-related measures can be used to create subgroups through the use of predictive models to define cutpoints, and we review COPDGene research on blood eosinophil counts thresholds as a specific example. Third, COPD phenotypes identified or prioritized through machine learning methods have led to novel biological discoveries, including novel emphysema genetic risk variants and systemic inflammatory subtypes of COPD. Fourth, trajectory-based COPD subtyping captures differences in the longitudinal evolution of COPD, addressing a major limitation of clustering analyses that are confounded by disease severity. Ongoing longitudinal characterization of subjects in COPDGene will provide useful insights about the relationship between lung imaging parameters, molecular markers, and COPD progression that will enable the identification of subtypes based on underlying disease processes and distinct patterns of disease progression, with the potential to improve the clinical relevance and reproducibility of COPD subtypes.

    更新日期:2019-12-29
  • Comparative Safety and Effectiveness of Inhaled Corticosteroids and Long-Acting β2 Agonist Combinations in Patients with Chronic Obstructive Pulmonary Disease
    Chest (IF 9.657) Pub Date : 2019-12-28
    Ting-Yu Chang; Jung-Yien Chien; Chung-Hsuen Wu; Yaa-Hui Dong; Fang-Ju Lin

    Introduction The differential risk of pneumonia among inhaled corticosteroids (ICSs) in patients with chronic obstructive pulmonary disease (COPD) requires more investigation, especially for beclomethasone-containing inhalers. This study aimed to compare the risk and benefit profile of different ICS/long-acting β2 agonist (LABA) combinations in COPD patients. Methods We conducted a retrospective cohort study using national health insurance claims data from the years 2009-2015 in Taiwan and included COPD patients with new ICS/LABA use. Propensity score matching and Cox regression models were used to estimate the hazard ratios of severe pneumonia and acute exacerbation (AE) for different ICS/LABA users. Results Both budesonide/formoterol (BUD/FOR) dry-powder inhalers (DPIs) and beclomethasone/formoterol (BEC/FOR) metered-dose inhaler (MDIs), compared with fluticasone propionate/salmeterol (FLU/SAL) delivered via the same device type, were associated with a lower risk of severe pneumonia (BUD/FOR HR 0.83 [95% CI 0.70-0.98], BEC/FOR 0.69 [0.58-0.81]) and severe AE (BUD/FOR HR 0.88 [0.78-0.99], BEC/FOR 0.90 [0.84-0.96]). After additionally adjusting for the average daily ICS dose, BUD/FOR DPI users continued to have a significantly decreased risk of severe pneumonia (18%) but not BEC/FOR MDI users. The results were consistent in most of the prespecified subgroups and across all the sensitivity analyses. Conclusion This study augments the existing evidence concerning the different safety and effectiveness outcomes of ICS/LABA combinations in COPD patients, which may be considered when making clinical treatment decisions.

    更新日期:2019-12-29
  • IgA Antibodies Directed Against Citrullinated Protein Antigens Are Elevated in Patients with Idiopathic Pulmonary Fibrosis
    Chest (IF 9.657) Pub Date : 2019-12-23
    Joshua J. Solomon; Scott Matson; Lindsay B. Kelmenson; Jonathan H. Chung; Stephen B. Hobbs; Ivan O. Rosas; Paul F. Dellaripa; Tracy J. Doyle; Sergio Poli; Anthony J. Esposito; Ashley Visser; A. Itzam Marin; Isabelle Amigues; Evans R. Fernández Pérez; Kevin K. Brown; Michael Mahler; David Heinz; Carlyne Cool; M. Kristen Demoruelle

    Objectives The etiology of idiopathic pulmonary fibrosis (IPF) is unknown. Because it shares genetic, histopathologic and radiographic features with the fibrosing interstitial lung disease seen in rheumatoid arthritis (RA), we sought to investigate RA-related autoantibodies in IPF. Methods We included IPF subjects from two separate cohorts at National Jewish Health and Brigham Women’s Hospital (N=181), general population controls (N=160) and disease controls (N=86, 40 with RA-UIP and 46 with hypersensitivity pneumonitis). Serum was tested for RA-associated antibodies including immunoglobulin-G (IgG) and IgA to citrullinated protein antigens (ACPA). Lung tissue in 11 IPF subjects was examined for ectopic lymphoid aggregates. Results An increased prevalence of ACPA positivity was found in two separate IPF cohorts. In particular, positivity for IgA-ACPA was increased in these two IPF cohorts compared to general population controls (21.3% and 24.8% vs. 5.6%, p<0.01). IPF subjects were more likely to be IgA-ACPA than IgG-ACPA positive (23.2% vs. 8.3%, p<0.01), whereas RA subjects were more likely to be IgG-ACPA than IgA-ACPA positive (72.5% vs. 52.5%, p=0.04). There was a strong correlation between IgA-ACPA level and the number of ectopic lymphoid aggregates on lung histology in IPF (r=0.72, p=0.01). Conclusions In our study, IgA-ACPA is elevated in IPF subjects and correlates with lymphoid aggregates in the lung supporting that IgA-ACPA may play a role in lung disease pathogenesis in a subset of individuals with IPF. Future studies are needed to determine whether this subset of ACPA positive IPF subjects is distinct from IPF subjects without antibodies.

    更新日期:2019-12-23
  • Sleep and Delirium in Critically Ill Adults: A Contemporary Review Chest
    Chest (IF 9.657) Pub Date : 2019-12-23
    Margaret A. Pisani; Carolyn D’Ambrosio

    Sleep is important to health and well-being and studies in healthy adults have demonstrated that sleep deprivation impacts respiratory, immune and cognitive function. Historically, due to the nature of critical illness, sleep has not been considered a priority for patient care in the intensive care unit. More recently, research has demonstrated that sleep is markedly abnormal in critically ill patients. In addition, there is often disruption of circadian rhythms. Delirium is a syndrome of acute alteration in mental status that occurs in the setting of contributing factors such as serious illness, medication, drug or alcohol intoxication or withdrawal. Delirium is a frequent occurrence in critical illness and research has demonstrated several adverse outcomes associated with delirium including persistent cognitive impairment and increased mortality. Sleep deprivation and delirium share many common symptoms. The similarity in symptoms between sleep disruption and delirium have prompted experts to draw links between the two and question both the relationship and its direction. In addition, the inclusion of sleep disturbance to the Diagnostic and Statistical Manual V in its constellation of symptoms used in diagnosing delirium has increased awareness of the link between sleep and delirium. This article will review the literature on sleep in critical illness and the potential mechanisms and pathways that may connect sleep and delirium.

    更新日期:2019-12-23
  • CHEST Submission: Contemporary Reviews in Sleep Medicine The Physical and Social Environment Relationship with Sleep Health and Disorders
    Chest (IF 9.657) Pub Date : 2019-12-21
    Martha E. Billings; Lauren Hale; Dayna A. Johnson

    Sleep health is a multidimensional construct that includes adequate duration, quality and appropriately timed sleep, that may be influenced by environmental factors. In this review, we focus on how an individual’s living and sleeping environment, both the surrounding neighborhood physical and social features and the atmosphere around them, may impact their sleep health. We explore the associations of the physical environment (urban density, recreational facilities, green space, mixed land use, healthy food stores), neighborhood deprivation (disadvantage, disorder), and the social environment (social cohesion, safety, stigma) with sleep in both adult and pediatric populations. We investigate how physical and social environmental features may lead to alterations in the timing, duration and quality of sleep and contribute to the most prevalent sleep disorders: insomnia, sleep apnea and circadian rhythm disorders. We also review how ambient factors such as artificial light, environmental noise, and air pollution may contribute to sleep pathology. We have included key studies and recent emerging data regarding how the differential distribution of environmental factors that may affect sleep health may contribute to sleep health disparities.

    更新日期:2019-12-21
  • Intratracheal delivery of nano- and microparticles and hyperpolarized gases: a promising strategy for imaging and treatment of respiratory disease
    Chest (IF 9.657) Pub Date : 2019-12-20
    Hongbin Wang; Lina Wu; Xilin Sun

    Accurate diagnosis is crucial for improving treatment and prognosis of respiratory disease, especially lung cancer. Tumors and lesions located deep in the lung are directly accessible via dendritic tracheal bronchus, thereby opening a new way to tackle respiratory disease. Intratracheal delivery is an innovative noninvasive approach for imaging and treating respiratory disease efficiently, when compared to other delivery methods. Intratracheal delivery of nano- and microparticles and hyperpolarized gases offers valuable clinical advantages, such as assessing lung function, monitoring ventilation and perfusion, controlling disease progression and inhibiting tumor growth. Especially, versatile nano-sized particles have enormous potential to benefit precision imaging and therapy at molecular level. Here we discuss the recent advances in intratracheal delivery of nano- and microparticle approaches and hyperpolarized gases for respiratory disease imaging and treatment, with an emphasis on intratracheal nanoparticles delivery of pulmonary imaging, which has extremely valuable clinical applications in precise theranostic for respiratory disease.

    更新日期:2019-12-20
  • Neurological Pupil Index for Early Prognostication Following Veno-Arterial Extracorporeal Membrane Oxygenation
    Chest (IF 9.657) Pub Date : 2019-12-20
    John-Paul Miroz; Nawfel Ben-Hamouda; Adriano Bernini; Federico Romagnosi; Filippo Bongiovanni; Aurélien Roumy; Matthias Kirsch; Lucas Liaudet; Philippe Eckert; Mauro Oddo

    Background Veno-arterial extra-corporeal membrane oxygenation therapy (VA-ECMO) following refractory cardiogenic shock (r-CS) or cardiac arrest (r-CA) has significant morbidity and mortality. Early outcome prediction is crucial in this setting, but data on neuro-prognostication are limited. We examined the prognostic value of clinical neurological examination, using an automated device for the quantitative measurement of pupillary light reactivity. Methods An observational cohort of sedated mechanically ventilated VA-ECMO patients was analyzed at the early phase following ECMO insertion (first 72 hours). Using the NPi®-200 automated infrared pupillometer, pupillary light reactivity was assessed repeatedly (every 12 hours) by calculating the Neurological Pupil index (NPi). Trends of NPi over time were correlated to 90-day mortality, and the prognostic performance of the NPi, alone and in combination with the 12-h PREDICT VA-ECMO score, was evaluated. Results A total 100 consecutives patients were studied (51 r-CS/49 r-CA; 12-h PREDICT VA-ECMO 40%; observed 90-day survival 43%). Non-survivors (n=57) had significantly lower NPi than survivors at all time-points (all p<0.01). Abnormal NPi (<3, at any time from 24 to 72 hours) was 100% specific for 90-day mortality, with 0% false positives. Adding 12-h PREDICT VA-ECMO score to the NPi provided the best prognostic performance (specificity 100% [95% confidence interval 91-100%], sensitivity 60% [46-72%], area under the ROC curve 0.82). Conclusions Quantitative NPi alone had excellent ability to predict a poor outcome from day 1 after VA-ECMO insertion, with no false positives. Combining NPi and 12-h PREDICT-VA ECMO score increased sensitivity of outcome prediction, while maintaining 100% specificity.

    更新日期:2019-12-20
  • Neighborhood Disadvantage and Lung Cancer Incidence in Ever-Smokers at a Safety-Net Healthcare System: A Retrospective Study
    Chest (IF 9.657) Pub Date : 2019-12-17
    Yosra Adie; Daniel J. Kats; Abdulhakim Tlimat; Adam Perzynski; Jarrod Dalton; Douglas Gunzler; Yasir Tarabichi

    Background Neighborhood circumstances have an influence on multiple health outcomes, but the association between neighborhood conditions and lung cancer incidence has not been studied in sufficient detail. We sought to understand whether neighborhood conditions are independently associated with lung cancer incidence in ever-smokers after adjusting for individual smoking exposure and other risk factors. Methods A cohort of ever-smokers 55 years and older was assembled from 19 years of electronic health record data from our academic community healthcare system. Patient demographics and other measures known to be associated with lung cancer were ascertained. Patient addresses at their index visit were geocoded to the census block group level to determine the area deprivation index (ADI), drawn from 5-year estimates from the American Community Survey. A multivariate Cox-proportional hazard model was fit to assess the association between ADI and time to lung cancer diagnosis. Tests of statistical significance were two-sided. Results The study included 19,867 males and 21,748 females. 53% of the patients were White, 38% were Black and 5% were Hispanic. Of these, 1,149 developed lung cancer. After adjusting for known risk factors, patients residing in the most disadvantaged areas had a significantly increased incidence of lung cancer as compared to those in the least disadvantaged areas (HR 1.29, 95% CI 1.07-1.55). Conclusions Census-derived estimates of neighborhood conditions have a powerful association with lung cancer incidence, even when adjusting for individual variables. Further work investigating the mechanisms that link neighborhood conditions to lung cancer is warranted.

    更新日期:2019-12-18
  • Ultrashort Echo-time MRI for the Assessment of Tracheomalacia in Neonates
    Chest (IF 9.657) Pub Date : 2019-12-17
    Erik B. Hysinger; Alister J. Bates; Nara S. Higano; Dan Benscoter; Robert J. Fleck; Catherine Hart; Gregory Burg; Alessandro De Alarcon; Paul S. Kingma; Jason C. Woods

    Background Bronchoscopy is the gold standard for evaluating tracheomalacia; however, reliance on an invasive procedure limits understanding of normal airway dynamics. Self-gated ultrashort echo-time magnetic resonance imaging (UTE MRI) can assess tracheal dynamics; but has not been rigorously evaluated. Methods This is a validation of UTE MRI diagnosis of tracheomalacia in neonates using bronchoscopy as the gold standard. Bronchoscopies were reviewed for the severity and location of tracheomalacia based on standardized criteria. The percentage change in cross-sectional area (CSA) of the trachea between end-inspiration and end-expiration was determined by UTE MRI, and receiver operating curves were utilized to determine the optimal cut-off values to predict TM and determine positive and negative predictive value. Results Airway segments with tracheomalacia based on bronchoscopy had more than 3-fold change in CSA measured from MRI (54.4±56.1% vs 14.8±19.5%, p<0.0001). MRI correlated moderately with bronchoscopy for tracheomalacia severity (ρ=0.39, p=0.0001). Receiver operating curves, however, demonstrated very good ability of MRI to identify tracheomalacia (AUC=0.78). A “loose” definition (>20% change in CSA) of tracheomalacia had good sensitivity (80%) but low specificity (64%) for identifying tracheomalacia based on MRI, while a “strict” definition (>40% change in CSA) was poorly sensitive (48%) but highly specific (93%). Conclusions Self-gated UTE MRI can non-invasively assess tracheomalacia in neonates without sedation, ionizing radiation, or increased risk. This technique overcomes major limitations of other diagnostic modalities and may be suitable for longitudinal population studies of tracheal dynamics.

    更新日期:2019-12-18
  • Multidisciplinary Team Based Management of Incidentally Detected Lung Nodules
    Chest (IF 9.657) Pub Date : 2019-12-17
    Francys C. Verdial; David K. Madtes; Guang-Shing Cheng; Sudhakar Pipavath; Richard Kim; Jesse J. Hubbard; Megan Zadworny; Douglas E. Wood; Farhood Farjah

    Background Each year, over 1.5 million Americans are diagnosed with an incidentally-detected lung nodule. Practice guidelines attempt to balance the benefit of early detection of lung cancer with the risks of diagnostic testing, but adherence to guidelines is low. We sought to determine guideline-adherence rates in the setting of a multidisciplinary nodule clinic and describe reasons for non-adherence as well as associated outcomes. Methods We performed a cohort study with 3 years of follow-up on patients ≥35 years of age with an incidentally-detected lung nodule evaluated in a multidisciplinary clinic that used the 2005 Fleischner Society Guidelines. Results Among 113 patients, 67% (95% confidence interval [CI] 58-76%) were recommended a guideline-concordant nodule evaluation whereas 7.1% (95% CI 3.1-13%) and 26% (95% CI 18-25) were recommended less or more intense evaluation, respectively. In contrast, 58% (95% CI 48-67%), 22% (95% CI 18-25%), and 23% (95% CI 16-32%) received a guideline-concordant, less intense, or more intense evaluation, respectively. The most common reason for recommending guideline-discordant care was concern for two different diagnoses that would each benefit from early detection and treatment. A majority of lung cancer diagnoses (88%) occurred in patients who received guideline-concordant care. There were no lung cancer cases in those who received less intense nodule care. Conclusions A multidisciplinary nodule clinic may serve as a system-level intervention to promote guideline-concordant care, while also providing a multidisciplinary basis by which to deviate from guidelines in order to address the needs of a heterogeneous patient population.

    更新日期:2019-12-18
  • International Severe Asthma Registry: Mission Statement
    Chest (IF 9.657) Pub Date : 2019-12-12

    Regional and/or national severe asthma registries provide valuable country-specific information. However, they are often limited in scope within the broader definitions of severe asthma, have insufficient statistical power to answer many research questions, lack intra-operability to share lessons learned, and have fundamental differences in data collected, making cross comparisons difficult. What is missing is a worldwide registry which brings all severe asthma data together in a cohesive way, under a single umbrella, based on standardized data collection protocols, permitting data to be shared seamlessly. The International Severe Asthma Registry (ISAR; http://isaregistries.org/) is the first global adult severe asthma registry. It is a joint initiative where national registries (both newly created and pre-existing) retain ownership of their own data but open their borders and share data with ISAR for ethically approved research purposes. Its strength comes from collection of patient level, anonymous, longitudinal, real-life, standardized, high-quality data (using a core set of variables) from countries across the world, combined with organizational structure, database experience, inclusivity/openness, and clinical, academic, and database expertise. This gives ISAR sufficient statistical power to answer important research questions, sufficient data standardization to compare across countries and regions, and the structure and expertise necessary to ensure its continuance as well as the scientific integrity and clinical applicability of its research. ISAR offers a unique opportunity to implement existing knowledge, generate new knowledge, and identify the unknown, therefore promoting new research. The aim of this commentary is to fully describe how ISAR may improve our understanding of severe asthma.

    更新日期:2019-12-13
  • County-Level Variations in Receipt of Surgery for Early-Stage Non-small Cell Lung Cancer in the United States
    Chest (IF 9.657) Pub Date : 2019-12-05
    Helmneh M. Sineshaw, Liora Sahar, Raymond U. Osarogiagbon, W. Dana Flanders, K. Robin Yabroff, Ahmedin Jemal

    Background Although counties are the smallest geographic level for comprehensive health-care delivery analysis, little is known about county-level variations in receipt of curative-intent surgery for early-stage non-small cell lung cancer (NSCLC) and factors contributing to such variations in the United States. Methods A total of 179,189 patients aged ≥ 35 years who were diagnosed with stage I to II NSCLC between 2007 and 2014 in 2,263 counties were identified from 39 states, the District of Columbia, and Detroit population-based cancer registries; the data were compiled by the North American Association of Central Cancer Registries. The percentage of patients who underwent surgery was calculated for each county with ≥ 20 cases. Adjusted risk ratios were generated by using generalized estimating equation models with modified Poisson regression. Results Receipt of surgery for early-stage NSCLC during 2007 to 2014 according to county ranged from 12.8% to 48.6% in the lowest decile of counties, to 74.3% to 91.7% in the highest decile of counties. There were pockets of low surgery receipt rate counties within each state. For example, there was a 25% absolute difference between the lowest and highest surgery receipt rate counties in Massachusetts. Counties in the lowest quartile for receipt of surgery were those with a high proportion of non-Hispanic black subjects, high poverty and uninsured rates, low surgeon-to-population ratio, and nonmetropolitan status. Conclusions Receipt of curative-intent surgery for early-stage NSCLC varied substantially across counties in the United States, with pockets of low receipt counties in each state. Low surgery receipt counties were characterized by unfavorable area-level socioeconomic and health-care delivery factors.

    更新日期:2019-12-05
  • Prevalence and Risk Factors for Osteoporosis in Individuals With COPD
    Chest (IF 9.657) Pub Date : 2019-07-25
    Yi-Wen Chen, Andrew H. Ramsook, Harvey O. Coxson, Jessica Bon, W. Darlene Reid

    Background Osteoporosis is prevalent in individuals with COPD. Updated evidence is required to complement the previous systematic review on this topic to provide best practice. The aim of this systematic review and meta-analysis was to quantitatively synthesize data from studies with respect to the prevalence and risk factors for osteoporosis among individuals with COPD. Methods EMBASE, CINAHL, MEDLINE, and PubMed databases were searched for articles containing the key words “COPD,” “osteoporosis,” “prevalence,” and “risk factor.” Eligibility screening, data extraction, and quality assessment of the retrieved articles were conducted independently by two reviewers. Meta-analyses were performed to determine osteoporosis prevalence and risk factors in individuals with COPD. Meta-regression analyses were conducted to explore the sources of heterogeneity. Results The pooled global prevalence from 58 studies was 38% (95% CI, 34-43). The presence of COPD increased the likelihood of having osteoporosis (OR, 2.83). Other significant risk factors for osteoporosis in COPD patients were BMI < 18.5 kg/m2 (OR, 4.26) and the presence of sarcopenia (OR, 3.65). Conclusions Osteoporosis is prevalent in individuals with COPD, and the prevalence seems to be high and similar in many countries. Patients with COPD should be screened for osteoporosis and contributing risk factors.

    更新日期:2019-12-04
  • Diffusing Capacity of Carbon Monoxide in Assessment of COPD
    Chest (IF 9.657) Pub Date : 2019-07-25
    Aparna Balasubramanian, Neil R. MacIntyre, Robert J. Henderson, Robert L. Jensen, Gregory Kinney, William W. Stringer, Craig P. Hersh, Russell P. Bowler, Richard Casaburi, MeiLan K. Han, Janos Porszasz, R. Graham Barr, Barry J. Make, Robert A. Wise, Meredith C. McCormack

    Background Diffusing capacity of the lung for carbon monoxide (Dlco) is inconsistently obtained in patients with COPD, and the added benefit of Dlco testing beyond that of more common tools is unknown. Objective The goal of this study was to determine whether lower Dlco is associated with increased COPD morbidity independent of emphysema assessed via spirometry and CT imaging. Methods Data for 1,806 participants with COPD from the Genetic Epidemiology of COPD (COPDGene) study 5-year visit were analyzed, including pulmonary function testing, quality of life, symptoms, exercise performance, and exacerbation rates. Dlco percent predicted was primarily analyzed as a continuous variable and additionally categorized into four groups: (1) Dlco and FEV1 > 50% (reference); (2) only Dlco ≤ 50%; (3) only FEV1 ≤ 50%; and (4) both ≤ 50% predicted. Outcomes were modeled by using multivariable linear and negative binomial regression, including emphysema and FEV1 percent predicted among other confounders. Results In multivariable analyses, every 10% predicted decrease in Dlco was associated with symptoms and quality of life (COPD Assessment Test, 0.53 [P < .001]; St. George’s Respiratory Questionnaire, 1.67 [P < .001]; Medical Outcomes Study Short Form 36 Physical Function, –0.89 [P < .001]), exercise performance (6-min walk distance, –45.35 feet; P < .001), and severe exacerbation rate (rate ratio, 1.14; P < .001). When categorized, severe impairment in Dlco alone, FEV1 alone, or both Dlco and FEV1 were associated with significantly worse morbidity compared with the reference group (P < .05 for all outcomes). Conclusions Impairment in Dlco was associated with increased COPD symptoms, reduced exercise performance, and severe exacerbation risk even after accounting for spirometry and CT evidence of emphysema. These findings suggest that Dlco should be considered for inclusion in future multidimensional tools assessing COPD.

    更新日期:2019-12-04
  • Alterations in Polyamine Metabolism in Patients With Lymphangioleiomyomatosis and Tuberous Sclerosis Complex 2-Deficient Cells
    Chest (IF 9.657) Pub Date : 2019-07-09
    Yan Tang, Souheil El-Chemaly, Angelo Taveira-Dasilva, Hilary J. Goldberg, Shefali Bagwe, Ivan O. Rosas, Joel Moss, Carmen Priolo, Elizabeth P. Henske

    Background Lymphangioleiomyomatosis (LAM), a destructive lung disease that affects primarily women, is caused by loss-of-function mutations in TSC1 or TSC2, leading to hyperactivation of mechanistic/mammalian target of rapamycin complex 1 (mTORC1). Rapamycin (sirolimus) treatment suppresses mTORC1 but also induces autophagy, which promotes the survival of TSC2-deficient cells. Based on the hypothesis that simultaneous inhibition of mTORC1 and autophagy would limit the availability of critical nutrients and inhibit LAM cells, we conducted a phase 1 clinical trial of sirolimus and hydroxychloroquine for LAM. Here, we report the analyses of plasma metabolomic profiles from the clinical trial. Methods We analyzed the plasma metabolome in samples obtained before, during, and after 6 months of treatment with sirolimus and hydroxychloroquine, using univariate statistical models and machine learning approaches. Metabolites and metabolic pathways were validated in TSC2-deficient cells derived from patients with LAM. Single-cell RNA-Seq was employed to assess metabolic enzymes in an early-passage culture from an LAM lung. Results Metabolomic profiling revealed changes in polyamine metabolism during treatment, with 5′-methylthioadenosine and arginine among the most highly upregulated metabolites. Similar findings were observed in TSC2-deficient cells derived from patients with LAM. Single-cell transcriptomic profiling of primary LAM cultured cells revealed that mTORC1 inhibition upregulated key enzymes in the polyamine metabolism pathway, including adenosylmethionine decarboxylase 1. Conclusions Our data demonstrate that polyamine metabolic pathways are targeted by the combination of rapamycin and hydroxychloroquine, leading to upregulation of 5′-methylthioadenosine and arginine in the plasma of patients with LAM and in TSC2-deficient cells derived from a patient with LAM upon treatment with this drug combination. Trial Registry ClinicalTrials.gov; No.: NCT01687179; URL: www.clinicaltrials.gov. Partners Human Research Committee, protocol No. 2012P000669.

    更新日期:2019-12-04
  • Objectively Measured Chronic Lung Injury on Chest CT
    Chest (IF 9.657) Pub Date : 2019-06-22
    Rola Harmouche, Samuel Y. Ash, Rachel K. Putman, Gary M. Hunninghake, Ruben San Jose Estepar, Fernando J. Martinez, Augustine M. Choi, David A. Lynch, Hiroto Hatabu, MeiLan K. Han, Russell P. Bowler, Ravi Kalhan, Ivan O. Rosas, George R. Washko, Raul San Jose Estepar

    Background Tobacco smoke exposure is associated with emphysema and pulmonary fibrosis, both of which are irreversible. We have developed a new objective CT analysis tool that combines densitometry with machine learning to detect high attenuation changes in visually normal appearing lung (NormHA) that may precede these diseases. Methods We trained the classification tool by placing 34,528 training points in chest CT scans from 297 COPDGene participants. The tool was then used to classify lung tissue in 9,038 participants as normal, emphysema, fibrotic/interstitial, or NormHA. Associations between the quartile of NormHA and plasma-based biomarkers, clinical severity, and mortality were evaluated using Jonckheere-Terpstra, pairwise Wilcoxon rank-sum tests, and multivariable linear and Cox regression. Results A higher percentage of lung occupied by NormHA was associated with higher C-reactive protein and intercellular adhesion molecule 1 (P for trend for both < .001). In analyses adjusted for multiple covariates, including high and low attenuation area, compared with those in the lowest quartile of NormHA, those in the highest quartile had a 6.50 absolute percent lower percent predicted lower FEV1 (P < .001), an 8.48 absolute percent lower percent predicted forced expiratory volume, a 10.78-meter shorter 6-min walk distance (P = .011), and a 56% higher risk of death (P = .003). These findings were present even in those individuals without visually defined interstitial lung abnormalities. Conclusions A new class of NormHA on CT may represent a unique tissue class associated with adverse outcomes, independent of emphysema and fibrosis.

    更新日期:2019-12-04
  • Monitoring Pulmonary Arterial Hypertension Using an Implantable Hemodynamic Sensor
    Chest (IF 9.657) Pub Date : 2019-06-29
    Raymond L. Benza, Mark Doyle, David Lasorda, Kishan S. Parikh, Priscilla Correa-Jaque, Nima Badie, Greg Ginn, Sophia Airhart, Veronica Franco, Manreet K. Kanwar, Srinivas Murali, Amresh Raina, Rahul Agarwal, Sudarshan Rajagopal, Jason White, Robert Biederman

    Background Pulmonary arterial hypertension (PAH) is a chronic disease that ultimately progresses to right-sided heart failure (HF) and death. Close monitoring of pulmonary artery pressure (PAP) and right ventricular (RV) function allows clinicians to appropriately guide therapy. However, the burden of commonly used methods to assess RV hemodynamics, such as right heart catheterization, precludes frequent monitoring. The CardioMEMS HF System (Abbott) is an ambulatory implantable hemodynamic monitor, previously only used in patients with New York Heart Association (NYHA) class III HF. In this study, we evaluate the feasibility and early safety of monitoring patients with PAH and right-sided HF using the CardioMEMS HF System. Methods The CardioMEMS HF sensors were implanted in 26 patients with PAH with NYHA class III or IV right-sided HF (51.3 ± 18.3 years of age, 92% women, 81% NYHA class III). PAH therapy was tracked using a minimum of weekly reviews of CardioMEMS HF daily hemodynamic measurements. Safety, functional response, and hemodynamic response were tracked up to 4 years with in-clinic follow-ups. Results The CardioMEMS HF System was safely used to monitor PAH therapy, with no device-related serious adverse events observed and a single preimplant serious adverse event. Significant PAP reduction and cardiac output elevation were observed as early as 1 month postimplant using trends of CardioMEMS HF data, coupled with significant NYHA class and quality of life improvements within 1 year. Conclusions The CardioMEMS HF System provided useful information to monitor PAH therapy, and demonstrated short- and long-term safety. Larger clinical trials are needed before its widespread use to guide therapy in patients with severe PAH with right-sided HF.

    更新日期:2019-12-04
  • Transmission of Oral Pressure Compromises Oronasal CPAP Efficacy in the Treatment of OSA
    Chest (IF 9.657) Pub Date : 2019-06-22
    Fernanda Madeiro, Rafaela G.S. Andrade, Vivien S. Piccin, George do Lago Pinheiro, Henrique T. Moriya, Pedro R. Genta, Geraldo Lorenzi-Filho

    Background An oronasal mask is frequently used to treat OSA. In contrast to nasal CPAP, the effectiveness of oronasal CPAP varies by unknown mechanisms. We hypothesized that oral breathing and pressure transmission through the mouth compromises oronasal CPAP efficacy. Methods Thirteen patients with OSA, well adapted to oronasal CPAP, were monitored by full polysomnography, pharyngeal pressure catheter, and nasoendoscope. Patients slept with low doses of midazolam, using an oronasal mask with sealed nasal and oral compartments. CPAP was titrated during administration by the oronasal and nasal routes, and was then reduced to induce stable flow limitation and abruptly switched to the alternate route. In addition, tape sealing the mouth was used to block pressure transmission to the oral cavity. Results Best titrated CPAP was significantly higher by the oronasal route rather than the nasal route (P = .005), and patients with > 25% oral breathing (n = 5) failed to achieve stable breathing during oronasal CPAP. During stable flow limitation, inspiratory peak flow was lower, driving pressure was higher, upper airway inspiratory resistance was higher, and retropalatal and retroglossal area were smaller by the oronasal rather than nasal route (P < .05 for all comparisons). Differences were observed even among patients with no oral flow and were abolished when tape sealing the mouth was used (n = 6). Conclusions Oral breathing and transmission of positive pressure through the mouth compromise oronasal CPAP.

    更新日期:2019-12-04
  • Pre-EDIT
    Chest (IF 9.657) Pub Date : 2019-07-30
    Geoffrey A. Martin, Selina Tsim, Andrew C. Kidd, John E. Foster, Philip McLoone, Anthony Chalmers, Kevin G. Blyth

    Background Talc slurry pleurodesis (TSP) prevents recurrence of symptomatic malignant pleural effusion (MPE) in 71% to 78% patients. Nonexpansile lung (NEL) frequently accounts for TSP failure but is often occult predrainage, impairing selection of patients. NEL is associated with high pleural elastance (PEL), but technical limitations have hampered the development of PEL as a predictive NEL marker. We performed a single-center, randomized, controlled, open-label feasibility trial of EDIT (elastance-directed indwelling pleural catheter or TSP) management, using a novel digital manometer and a new definition of high PEL. Methods Patients with symptomatic MPE were randomized 1:1 between EDIT and standard care (TSP). EDIT involved PEL assessment during large-volume thoracentesis; patients with high PEL (maximum PEL sustained over 250 mL [MaxPEL250] ≥ 14.5 cm H2O/L) were allocated to immediately receive an indwelling pleural catheter; the remainder underwent immediate drain placement for TSP. The primary outcome measure was recruitment feasibility, defined a priori as 30 patients over 12 months. Secondary outcomes included safety, technical reliability, and the aspiration volume required to detect high PEL. The accuracy of the PEL definition for NEL was analyzed post hoc. Results Thirty-one patients were randomized (one allocation failure) over 12 months. PEL assessment (mean duration, 33 minutes) was successful in 13 of 15 patients (87%). No directly attributable serious adverse events occurred. High PEL was detected in seven of 13 patients (54%), associated with 100% sensitivity and 67% specificity for NEL, and was first detected at a median volume of 325 mL (range, 250-800 mL). Conclusions A phase 3 trial testing the effect of EDIT management on symptomatic MPE recurrence following TSP is feasible. Trial Registry ClinicalTrials.gov; No.: NCT03319186; URL: www.clinicaltrials.gov.

    更新日期:2019-12-04
  • Simulation Training in the ICU
    Chest (IF 9.657) Pub Date : 2019-07-30
    Nitin Seam, Ai Jin Lee, Megan Vennero, Lillian Emlet

    Because of an emphasis on patient safety and recognition of the effectiveness of simulation as an educational modality across multiple medical specialties, use of health-care simulation (HCS) for medical education has become more prevalent. In this article, the effectiveness of simulation for areas important to the practice of critical care is reviewed. We examine the evidence base related to domains of procedural mastery, development of communication skills, and interprofessional team performance, with specific examples from the literature in which simulation has been used successfully in these domains in critical care training. We also review the data assessing the value of simulation in other areas highly relevant to critical care practice, including assessment of performance, integration of HCS in decision science, and critical care quality improvement, with attention to the areas of system support and high-risk, low-volume events in contemporary health-care systems. When possible, we report data evaluating effectiveness of HCS in critical care training based on high-level learning outcomes resulting from the training, rather than lower level outcomes such as learner confidence or posttest score immediately after training. Finally, obstacles to the implementation of HCS, such as cost and logistics, are examined and current and future strategies to evaluate best use of simulation in critical care training are discussed.

    更新日期:2019-12-04
  • Leading Change and Negotiation Strategies for Division Leaders in Clinical Medicine
    Chest (IF 9.657) Pub Date : 2019-07-09
    Hung Bryant Nguyen, Carey Thomson, Nizar N. Jarjour, Anne E. Dixon, Timothy N. Liesching, Lynn M. Schnapp, John Mark Madison, Susan Murin, Robb Glenny, Naftali Kaminski

    Most physician leaders assume their administrative role based on past achievements but with very little leadership training. In this article, leaders of the Association of Pulmonary, Critical Care, and Sleep Division Directors describe two leadership skills that are often required to effectively lead in a clinical division at an academic or community hospital setting: leading change and negotiation strategy. We adopted our discussion from the business sector and refined the approaches through our own experiences to help division leaders in leading a successful team, whether as a division chief, residency or fellowship program director, or a clinical service director. Leading any change project may include an eight-step process, starting with creating a sense of urgency and completing with anchoring the change to the organizational culture. We then review negotiation strategies, comparing positional bargaining vs principled negotiation, to create more changes and continuing growth for the division. Finally, we discuss the importance of emotional intelligence, exemplary leadership practices, and self-development that the division leader should embrace.

    更新日期:2019-12-04
  • Nonidentical Twins With Asthma
    Chest (IF 9.657) Pub Date : 2019-12-04
    Rachel L. Eddy, Alexander M. Matheson, Sarah Svenningsen, Danielle Knipping, Christopher Licskai, David G. McCormack, Grace Parraga

    Recent pulmonary functional MRI findings of spatially and temporally persistent ventilation abnormalities in patients with asthma contrast with previous in silico modeling studies that suggest that in asthma, ventilation defects may be randomly distributed. In a case study that used pulmonary MRI, CT imaging, and pulmonary function tests, we prospectively evaluated over the course of 7 years, nonidentical female adult twins, each with a lifelong history of asthma. We evaluated pulmonary function and MRI ventilation heterogeneity at baseline and follow-up after 7 years. In both twins, there was a spatially identical MRI ventilation defect and an abnormal subsegmental left-sided upper lobe airway that persisted in the same spatial location after 7 years. If ventilation defects are randomly distributed, this bears a probability of approximately one per 130,000 people. Our MRI observations in related patients with asthma suggest that ventilation abnormalities may not be randomly distributed in patients with asthma and persist distal to airway abnormalities for long periods of time.

    更新日期:2019-12-04
  • A 65-Year-Old Man with Pulmonary Opacities and Worsening Cough
    Chest (IF 9.657) Pub Date : 2019-12-04
    Wesley Pidcock, Florence Chau-Etchapare, Susan Murin

    Case Presentation A 65-year-old man was referred for evaluation of several years of chest congestion and cough productive of yellow sputum as well as recently noted abnormalities on chest imaging. He denied dyspnea, weight loss, fevers, chills, or hemoptysis. He had no history of systemic illness, pneumonia, other respiratory illness, gastroesophageal reflux, or sinusitis. He had a remote smoking history. He worked as a railroad conductor and had occupational exposure to asbestos, as well as to other uncharacterized dusts and fumes. The patient spent most of his life in Washington and California and regularly traveled through the California Central Valley. Other travel history included trips to Southeast Asia, Iceland, and Europe in the remote past. The patient had one dog but no exposure to other animals. His only medication was loratadine, taken daily for allergic rhinitis. He applied petroleum jelly to his nares nightly to moisturize his nasal passages.

    更新日期:2019-12-04
  • A Man in His 20s With Cough, Unilateral Pleural Effusion, and Nodular Pleural Thickening
    Chest (IF 9.657) Pub Date : 2019-12-04
    Mark A. Sonnick, Stacey Weisman, Alain C. Borczuk, Meredith L. Turetz

    Case Presentation A man in his 20s presented to the ED after several months of progressive dyspnea, dry cough, and night sweats. He had no chest pain, fevers, weight loss, or sick contacts. He was previously healthy and took no medications. Social history was notable for 5 pack-years of tobacco use. The patient was sexually active with male partners and had a recent partner infected with human T-lymphotropic virus. The patient worked in set design and window installations, and wore a respirator when working around solvents and resins. From ages 2 to 7 years, he frequently visited buildings at his parents’ workplace that were undergoing asbestos abatement. From ages 7 to 24 years, he frequently visited pottery studios where talc-containing products were used. He frequently visited northern Massachusetts, and infections with Borrelia burgdorferi and Bartonella henselae were common in family members. His stepfather had recently been infected with Anaplasma. There was no family history of cancer.

    更新日期:2019-12-04
  • An 80-Year-Old Man With a 24-Hour History of Epigastric Pain
    Chest (IF 9.657) Pub Date : 2019-12-04
    Corey R. O’Brien, Muyi Li, Christopher Morton

    Case Presentation An 80-year-old man was admitted to our hospital with 24 hours of epigastric pain. The pain was described as sharp, episodic, nonradiating, and without an identifiable provoking factor. Associated symptoms included nausea and nonbloody vomiting. He denied dyspnea, angina, fevers, chills, dysphagia, diarrhea, melena, or hematochezia. He had taken less than 2 g of acetaminophen earlier in the day without symptomatic relief. He had a 30-pack-year smoking history but quit over 25 years ago. He did not drink alcohol or use illicit drugs. He had a medical history of end-stage renal disease, for which he had undergone hemodialysis; hypertension; metastatic prostate cancer, for which he had received androgen deprivation therapy; and abdominal aortic aneurysm. His surgical history included a remote endovascular repair of the abdominal aortic aneurysm. His medications included amlodipine, losartan, carvedilol, sevelamer, and leuprolide.

    更新日期:2019-12-04
  • A 38-Year-Old Man With An Ataxic Gait, Night Sweats, and Weight Loss
    Chest (IF 9.657) Pub Date : 2019-12-04
    Elyana Matayeva, Theresa Henson, Artur Alaverdian

    Case Presentation A 38-year-old Jamaican man with no medical history presented with worsening right-sided weakness. He developed an ascending hemiparesis that began in the right lower extremity 3 months ago and progressed to the right upper extremity this past month. Over the past 3 months, the patient has had unintentional weight loss and an ataxic gait, and for the past month he has had night sweats. He denied headache, vision changes, numbness, tingling, cough, or chest pain. Social history was significant for 20 smoking pack-years and daily use of marijuana.

    更新日期:2019-12-04
  • A 60-Year-Old Man With Right Lung Mass Presents With Cough
    Chest (IF 9.657) Pub Date : 2019-12-04
    Yanbin Tan, Jie Min, Fan Yang, Bin Zhang, Jinfan Li

    Case Presentation A 60-year-old Chinese man was admitted to our hospital with chronic cough for > 2 months. His cough was paroxysmal and nonirritating, occasionally productive with some small amounts of white phlegm. He had had a low-grade fever for half a month. There were no night sweats, joint swelling on limbs, pain, rash, or any other discomfort. The patient denied weight loss and decreased appetite.

    更新日期:2019-12-04
  • Comparing the Effectiveness and Safety of Non-Vitamin K Antagonist Oral Anticoagulants and Warfarin in the Elderly Asian Patients with Atrial Fibrillation: A Nationwide Cohort Study
    Chest (IF 9.657) Pub Date : 2019-12-03
    Tze-Fan Chao, Chern-En Chiang, Jo-Nan Liao, Tzeng-Ji Chen, Gregory Y.H. Lip, Shih-Ann Chen

    Background Stroke prevention in elderly patients with atrial fibrillation (AF) can be challenging, requiring a balance between thromboembolism prevention and serious bleeding. Comparisons of non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in the elderly, at different age strata (age 65-74, 75-89, ≥90) in the daily practice have not been well described, particularly in Asians. We aimed to assess the clinical outcomes of NOACs compared to warfarin for stroke prevention in elderly patients with AF. Methods From 2012 to 2015, 64,169 AF patients aged ≥ 65 years who received at least 1 NOAC (dabigatran, rivaroxaban, or apixaban) or warfarin prescription were identified from the Taiwan National Health Insurance Research Database. The risks of ischemic stroke, intra-cranial hemorrhage (ICH), major bleeding, mortality and composite adverse events were compared between NOACs and warfarin in all patients age ≥65 and specifically, with different age strata; that is 65-74 years, 75-89 years and >90 years. Results Overall NOACs were associated with a significantly lower risk of ischemic stroke (adjusted hazard ratio [aHR] 0.869, 95% confidence interval [CI] 0.812-0.931), ICH (aHR 0.524, 95%CI 0.456-0.601), major bleeding (aHR 0.824, 95%CI 0.776-0.875), mortality (aHR 0.511, 95%CI 0.491-0.532) and composite adverse events (aHR 0.646, 95%CI 0.625-0.667) compared to warfarin. There was heterogeneity in treatment effect for NOACs versus warfarin in different age strata, but the results still favored NOACs even among the very elderly (> 90 years). The results were generally consistent with propensity matching analysis. The absolute risk difference and reductions in ICH and composite adverse events with NOAC use were even greater among the elderly compared to warfarin. Conclusions Compared to warfarin, NOACs were associated with a significantly lower risk of adverse events, with heterogeneity in treatment effects among different age strata. Overall, the clear safety signal in favor of NOACs over warfarin was evident irrespective of age strata, being most marked in the most elderly.

    更新日期:2019-12-04
  • Post-embolotherapy pulmonary arteriovenous malformation follow-up: a role for graded transthoracic contrast echocardiography prior to high-resolution chest CT
    Chest (IF 9.657) Pub Date : 2019-11-30
    Daniel M. DePietro, Nicole R. Curnes, Jesse Chittams, Victor A. Ferrari, Reed E. Pyeritz, Scott O. Trerotola

    Background High-resolution chest CT (HRCT) is recommended after PAVM embolotherapy to assess for PAVM persistence and untreated PAVM growth. Graded transthoracic contrast echocardiography (TTCE) predicts need for embolotherapy in PAVM screening. This study sought to determine whether post-embolotherapy graded TTCE can similarly predict need for repeat embolotherapy. Methods Thirty-two patients (8M:24F, mean age 51.1 ± 12.6 years) with prior PAVM embolotherapy and follow-up HRCT were prospectively enrolled. Patients underwent graded TTCE using a validated 3-point quantitative grading scale. TTCE grade and HRCT findings were compared. Results Median time between most recent HRCT and TTCE was 7 days (interquartile range 0-272 days). Thirty patients (94%) had no PAVMs requiring repeat embolotherapy on HRCT. Two patients (6%) had PAVMs requiring repeat embolotherapy (FA ≥ 3 mm), 1 with untreated PAVM growth and 1 with treated PAVM persistence. TTCE was positive in 88% (n=28) of patients. All patients (n=4, 12%) with negative TTCE had no visible PAVMs on HRCT. Nine patients (32%) had grade 1 shunt, ten (35%) had grade 2 shunt, and nine (32%) had grade 3 shunt. No patients with grade 1 shunt had PAVMs amenable to repeat embolotherapy on HRCT. All patients (n=2) with PAVMs requiring repeat embolotherapy (FA ≥ 3 mm) had grade 3 shunt. TTCE grade was significantly associated PAVM feeding artery diameter (P < 0.001). Conclusions Post-embolotherapy graded TTCE can predict need for repeat embolotherapy on HRCT. Patients with negative TTCE and grade 1 shunt may not require HRCT follow-up and can potentially be followed with serial graded TTCE.

    更新日期:2019-11-30
  • Reference Standards for Ventilatory Threshold Measured with Cardiopulmonary Exercise Testing: The Fitness Registry and the Importance of Exercise National Database (FRIEND)
    Chest (IF 9.657) Pub Date : 2019-11-30
    Baruch Vainshelboim, Ross Arena, Leonard A. Kaminsky, Jonathan Myers

    Background Established reference standards for the ventilatory threshold (VT) are lacking. The aim of this study was to develop reference standards for the VT derived from cardiopulmonary exercise testing (CPX) using treadmill and cycle ergometry. Methods Seven laboratories experienced in CPX administration with established quality control procedures contributed to the “Fitness Registry and the Importance of Exercise: A National Database” (FRIEND) from April 2014 through February 2019. VT data from 27 states in the US and Ontario Province of Canada, comprising 9,350 tests [treadmill (n=1,195), cycle ergometer (n=8,155)] in men (n=7,540) and women (n=1,810) aged 20-79 years who were free from smoking and known cardiovascular, pulmonary, metabolic and/or neoplastic disease were used to develop the reference standards. Comparisons of VT values were made between exercise testing modes, sex, and age groups. Results VT values on the treadmill were higher compared to cycle ergometry; men had higher VTs compared to women on both test modalities and the highest VT values achieved were in the 20-29 year age group compared to all other age groups (all p<.001). The rates of decline in VT from age groups 20-29 to 70-79 years were 23% and 35% in men and 47% and 30% in women for treadmill and cycle ergometry tests, respectively. Conclusions In addition to previous reference standards from FRIEND for cardiorespiratory fitness, the VT reference standards reported herein provide valuebale information on functional metric. These data have important implications for CPX interpretation and aerobic exercise prescription in the clinical and fitness settings.

    更新日期:2019-11-30
  • Is mortality a useful primary endpoint for critical care trials?
    Chest (IF 9.657) Pub Date : 2019-11-29
    Richard A. Veldhoen, Daniel Howes, David M. Maslove

    Mortality has long been used as a primary endpoint for randomized controlled trials in critical care. Recently, a plurality of trials targeting mortality endpoints as their primary outcome have failed to detect a difference between study arms. While there are a number of reasons for the preponderance of such neutral trials, the use of mortality as an outcome is one important consideration. We explore some of the reasons why such trials may be biased towards a neutral result, as well as reasons to consider alternative endpoints that are better coupled to the expected therapeutic effect. We also discuss to what extent mortality as a binary outcome is patient-important in the intensive care unit.

    更新日期:2019-11-30
  • The association of nicotine replacement therapy with outcomes among smokers hospitalized for a major surgical procedure
    Chest (IF 9.657) Pub Date : 2019-11-29
    Mihaela S. Stefan, Quinn Pack, Meng-Shiou Shieh, Penelope S. Pekow, Steven L. Bernstein, Karthik Raghunathan, Katie S. Nason, Peter K. Lindenauer

    Introduction There are concerns that starting nicotine replacement therapy (NRT) in the immediate perioperative period may negatively impact wound healing. We investigated the association of NRT with postoperative outcomes among smokers hospitalized for a surgical procedure. Methods This was a retrospective study in 552 hospitals of active smokers hospitalized between 1/1/2015 and 12/31/2016 for a major surgical procedure (Medicare Severity Diagnosis-Related Group expected length of stay of ≥ 2 days). We analyzed the association of receipt of NRT within 2 days of admission with a composite outcome of inpatient complications and with other outcomes. We developed a propensity score for receipt of NRT and examined differences in outcomes in a propensity- matched cohort. Results Of 147,506 active smokers, 25,651 (17.4%) were prescribed NRT within 2 days of admission. Patients treated with NRT were younger, less likely to be Black or Hispanic, more likely to have Medicaid or have a diagnosis of alcohol, substance abuse disorder, or COPD compared to those who were not treated. In the propensity matched analysis, there was no association between receipt of NRT and in-hospital complications (OR: 0.99, 95% CI: 0.93-1.05), mortality (OR: 0.84, 95% CI: 0.68-1.04), all-cause 30-day readmissions (OR: 1.02, 95% CI: 0.97-1.07), or 30-day readmission for wound complications (OR: 0.96, 95% CI: 0.86-1.07). Conclusions This is the first large observational study of surgical patients to demonstrate that perioperative NRT is not associated with adverse outcomes following surgery. These results strengthen the evidence that NRT should be prescribed routinely in the perioperative period.

    更新日期:2019-11-30
  • Characterization of severe asthma worldwide: data from the International Severe Asthma Registry (ISAR)
    Chest (IF 9.657) Pub Date : 2019-11-27
    Wang Eileen, Michael E. Wechsler, Trung N. Tran, Liam G. Heaney, Rupert C. Jones, Andrew N. Menzies-Gow, John Busby, David J. Jackson, Paul E. Pfeffer, Chin Kook Rhee, You Sook Cho, G. Walter Canonica, Enrico Heffler, Peter G. Gibson, Mark Hew, Matthew Peters, Erin S. Harvey, Mariana Alacqua, David B. Price

    Background To date, clinical characteristics of the international severe asthma population are unknown. Inter-country comparisons are hindered by variable data collection within regional/national severe asthma registries. Our aim was to describe demographic and clinical characteristics of patients managed in severe asthma services in the USA, Europe, and Asia/Pacific region. Methods The International Severe Asthma Registry (ISAR) retrospectively and prospectively collected data on severe asthma patients (≥18 years old), receiving GINA Step 5 treatment or remaining uncontrolled on GINA Step 4. Baseline demographic and clinical data were collected from the U.S., UK, South Korea, Italy, and the SAWD registry (including Australia, Singapore and New Zealand) from December 2014-December 2017. Results 4,990 patients were included. Average age was 55.0 (SD: 15.9) years, and age at asthma onset 30.7 (SD: 17.7) years. Patients were predominantly female (59.3%), white (72.6%), had never smoked (60.5%) and were over-weight/obese (70.4%). 34.9% were on GINA Step 5. 57.2% had poorly controlled disease. 51.1% of patients were on regular intermittent OCS and 25.4% were on biologics (72.6% for those on GINA Step 5). Mean exacerbation rate was 1.7 (SD: 2.7) per year. Inter-country variation was observed in clinical characteristics, prescribed treatments and biomarker profiles. Conclusions Using a common dataset and definitions, this study is the first to describe severe asthma characteristics of a large cohort of patients included in multiple severe asthma registries, and to identify country differences. Whether these are related to underlying epidemiological, environmental factors, phenotype, asthma management systems, treatment access and/or cultural factors requires further study.

    更新日期:2019-11-28
  • The role of house calls in the care of patients with pulmonary disease
    Chest (IF 9.657) Pub Date : 2019-11-27
    Elizabeth T. McCormick, Christian Escobar, Ania Wajnberg, Elizabeth T. McCormick

    As the population ages, and more patients with chronic pulmonary diseases become frail and functionally impaired, the prevalence of homebound patients grows. Homebound patients have higher disease burden, inpatient utilization rates, and mortality than non- homebound patients. Vulnerable homebound patients with pulmonary disease benefit from pulmonary expertise to evaluate and optimize their complex medication regimens, evaluate equipment such as nebulizers, home oxygen, ventilators and suction machines, and coordinate services. We review the need and benefits of house calls for these patients, and illustrate these needs with cases. We also explore the logistics of making house calls part of pulmonary practice, including supplies needed, safety in the home, and reimbursement. Reimbursement has grown for house calls, we review how to bill for visits, for advance care planning, and for the care management that is often required when caring for patients with advanced illness. In addition, house calls can often be beneficial for patients who may be identified as high risk and are part of value based agreements with payers.

    更新日期:2019-11-28
  • Effect of different probes and expertise on the interpretation reliability of point-of-care lung ultrasound
    Chest (IF 9.657) Pub Date : 2019-11-27
    Clotilde Gomond-Le Goff, Laura Vivalda, Silvia Foligno, Barbara Loi, Nadya Yousef, Daniele De Luca

    Background The effect of different probes and operators’ experience on reliability of lung ultrasound (LU) interpretation has not been investigated.We aim to study the effect of probes and operators’ experience on the interpretation reliability of LU in critically ill neonates Methods Prospective, blind, cohort study enrolling patients with basic patterns (“B”;“severe B”;consolidation).Patients were scanned with micro-linear (15 MHz;L15), phased-array sectorial (6-12 MHz;S7) and micro-convex (8 MHz;C8) probes, in random order.Static images were acquired in high resolution, anonymized and included in a pictorial database in random sequences.Seventeen clinicians with different LU experience were asked to blindly assess the pictorial database. Inter-rater agreement and interpretation reliability were analyzed.Sub-analyses according to expertise and probe, and multivariate linear regression (including an “expertise*probe” interaction factor) were also performed Results The agreement tends to be lower and more heterogeneous for residents (ICC:0.82 (95%CI:0.74-0.9),p<0.001; I2:67%,p=0.04),and for fellows (ICC:0.93 (95%CI:0.9-0.97),p<0.001; I2:69%,p=0.04),especially when using non-linear probes,compared to senior physicians (ICC:0.95 (95%CI:0.93-0.96),p<0.001; I2:0%,p=0.433).AUC values were high for all probes (L15:0.96 (95%CI:0.93-0.99); C8:0.91 (95%CI:0.85-0.98); S7:0.86 (95%CI:0.82-0.91)) and physicians (senior:0.95 (95%CI:0.83-0.99);fellows:0.95 (95%CI:0.75-0.99);residents:0.86 (95%CI:0.5-0.99)).Worse reliability and a higher heterogeneity were found when the evaluation was performed by residents (AUC:0.9 (95%CI:0.85-0.94),p<0.01; I2:93.6%,p<0.001), than by fellows (AUC:0.99 (95%CI:0.9-0.999),p<0.001; I2:34.3%,p=0.09) and/or by senior physicians (AUC:0.99 (95%CI:0.9-0.999),p<0.001; I2:18%,p=0.236).The “expertise*probe” interaction factor was associated with lower ICC (St.β:-0.69;p<0.0001;adjusted R2:0.99) and AUC (St.β:-0.76;p<0.0001;adjusted R2:0.98) Conclusions LU interpretation in neonates shows good inter-rater agreement and reliability,irrespective of the probe and raters’ expertise.The use of non-linear probes by novice operators is associated with lowest agreement and reliability.

    更新日期:2019-11-28
  • Responsiveness of Patient Reported Outcomes to Treatment among Patients with Type 2 Diabetes Mellitus and Obstructive Sleep Apnea
    Chest (IF 9.657) Pub Date : 2019-11-27
    Lucas M. Donovan, Lan Yu, Suzanne M. Bertisch, Daniel J. Buysse, Michael Rueschman, Sanjay R. Patel.

    Introduction The Patient Reported Outcomes Information System (PROMIS) includes two instruments to quantify sleep symptoms (sleep disturbance, SDA; sleep-related impairment, SRI) in diverse populations across a wide symptom spectrum. However, the responsiveness of PROMIS measures to treatment of sleep disorders is unknown. We examined the responsiveness of the PROMIS sleep scales to the treatment of obstructive sleep apnea (OSA). Methods We collected SDA, SRI and Epworth Sleepiness Scale (ESS) before and after initiation of positive airway pressure (PAP) in patients with type 2 diabetes newly diagnosed with OSA. To compare responsiveness, we compared effect sizes and classifications of symptom improvement using both the reliable change method and thresholds of minimum important difference (MID). Results 103 patients completed assessments pre- and post-PAP. SDA, SRI, and ESS scores all declined significantly with PAP therapy. We observed the largest effect size for SDA (-0.64, 95%CI -0.86 to -0.42), followed by SRI (-0.43, 95%CI -0.63 to -0.23), and ESS (-0.28, 95%CI -0.42 to -0.15). More patients experienced the reliable change category of ‘symptom remission’ categorized by the PROMIS measures (SDA: 23.3%; SRI: 31.1%) relative to ESS (5.8%, p<0.001 for both). Using MID, SDA and SRI also classified more patients as improved (SDA 54.4%; SRI 49.5%) relative to ESS (35.0%, p<0.001 for both pairwise comparisons). Conclusions PROMIS sleep measures were more likely than ESS to detect an improvement with PAP therapy. Incorporating PROMIS measures into research and clinical care may provide a more sensitive assessment of symptomatic response to OSA treatment.

    更新日期:2019-11-28
  • Transbronchial Cryobiopsy for the Diagnosis of Interstitial Lung Diseases: CHEST Guideline and Expert Panel Report
    Chest (IF 9.657) Pub Date : 2019-11-27
    Fabien Maldonado, Sonye K. Danoff, Athol U. Wells, Thomas V. Colby, Jay H. Ryu, Moishe Liberman, Momen M. Wahidi, Lindsy Frazer, Juergen Hetzel, Otis Rickman, Felix J.F. Herth, Venerino Poletti, Lonny Yarmus

    Background Transbronchial cryobiopsy (TBC) is increasingly recognized as a potential alternative to surgical lung biopsy (SLB) for the diagnosis of interstitial lung disease (ILD). The goal of this analysis was to examine the literature on TBC as it relates to diagnostic utility and safety to provide evidence-based and expert guidance to clinicians. Methods Approved panelists developed key questions regarding the diagnostic utility and safety of TBC for the evaluation of ILD using the PICO (population, intervention, comparator, and outcome) format. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion and vetted evaluation tools were used to assess the quality of included studies, to extract data, and to grade the level of evidence supporting each recommendation or statement. Graded recommendations and ungraded consensus-based statements were drafted and voted on using a modified Delphi technique to achieve consensus. Results The systematic review and critical analysis of the literature based on 4 PICO questions resulted in 6 statements: 2 evidence-based graded recommendations and 4 ungraded consensus-based statements. Conclusions Evidence of the utility and safety of TBC for the diagnosis of ILD is limited but suggests TBC is safer than SLB and its contribution to the diagnosis obtained via multidisciplinary discussion is comparable to that of SLB, although the histologic diagnostic yield appears higher with SLB (approximately 80% for TBC VS. 95% for SLB). Additional research is needed to enhance knowledge regarding utility and safety of TBC, its role in the diagnostic algorithm of ILD, and the impact of technical aspects of the procedure on diagnostic yield and safety.

    更新日期:2019-11-27
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