Thank you for tuning in to the Editor’s Highlight Podcast for the August 2023 issue of the journal CHEST®. There is a great lineup of diverse content in this month’s issue.
Over the next 15 minutes, I will provide a brief overview of key manuscripts published in each of our content areas.
Starting with our Asthma content area, unlike bacterial microbiota, the role of the upper airway fungal microbiome in asthma control is poorly understood. In this issue, Yuan and colleagues investigated the upper airway mycobiome using internal transcribed spacer 1 sequencing of nasal blow samples collected from children with asthma when asthma was well controlled, and during early signs of loss of asthma control, to identify the upper airway fungal colonization patterns among children with asthma and their relationship with subsequent loss of asthma control. At baseline, 499 fungal genera were detected. The relative abundance of two commensal Malassezia species varied with age, BMI, and race. Higher relative abundance of Malassezia globosa at baseline was associated with lower risk of future loss of asthma control and lower risk of progression to severe asthma exacerbation at the time of loss of control. This study highlights the importance of the mycobiota in asthma control and the possible development of fungi-based markers to predict asthma exacerbation.
Next is our Chest Infections content area. Clinical parameters can predict mortality in COVID-19, and CT scan-derived low muscle and high adipose tissue cross-sectional areas (CSAs) have been associated with adverse outcomes in COVID-19. In this issue, van Bakel and colleagues report the results of a retrospective cohort analysis of 578 patients designed to determine if CT scan-derived muscle and adipose tissue CSAs are associated with 30-day in-hospital mortality independent of the 4C Mortality Score. Patients who died within 30 days had lower pectoralis CSA and higher visceral adipose tissue CSA than survivors. Lower pectoralis muscle CSA was associated with 30-day in-hospital mortality when adjusted for 4C Mortality Score. These findings identify CT scan-derived low pectoralis muscle CSA as an independent predictor of 30-day in-hospital mortality. Completing this section is a research letter exploring the relationship of low salivary secretory leukocyte protease inhibitor levels to airway Pseudomonas aeruginosa infection in bronchiectasis.
On to our COPD content area. Factors associated with longitudinal changes in diffusing capacity in patients with COPD are unclear. In this issue, Shiraishi and colleagues evaluated annual diffusing capacity changes over a 5-year period, and 10-year mortality, in a pooled analysis of 399 patients with COPD from two prospective observational COPD cohorts to determine if centrilobular and paraseptal emphysema are differently associated with longitudinal changes in diffusing capacity and mortality in patients with COPD. Moderate or more severe centrilobular, but not paraseptal, emphysema was associated with steeper declines in DLCO for GOLD stages 1 and 3 or higher, and additional FEV1 decline, and higher 10-year mortality among patients with GOLD stage 3 or higher. These results suggest CT findings of moderate or more severe centrilobular but not paraseptal emphysema are associated with accelerated impairment in DLCO and higher long-term mortality. Completing this section is a Special Features article, the second of a two-part series on imaging in COPD, that describes emerging concepts in imaging for COPD.
Next is our Critical Care content area. Evidence supporting the efficacy of epinephrine for out-of-hospital cardiac arrest (OHCA) is mixed. In this issue, Fernando and colleagues report findings from a systematic review and network meta-analysis of randomized controlled trials to assess the comparative efficacy and safety of standard-dose epinephrine, high-dose epinephrine, epinephrine plus vasopressin, and placebo or no treatment in improving outcome after OHCA. Eighteen trials, including 21,594 patients, were included. Compared with placebo or no treatment, high-dose epinephrine, standard-dose epinephrine, and epinephrine plus vasopressin increased survival to hospital admission and return of spontaneous circulation but not survival to discharge or survival with good functional outcome. Compared with placebo or no treatment, standard-dose epinephrine improved survival to discharge among patients with a nonshockable rhythm but not those with a shockable rhythm. These results help clarify the outcomes that are improved with each treatment for OHCA and clarify differences in the impact on survival to discharge for standard-dose epinephrine based on whether the underlying rhythm is shockable. Also in this section are two other original research articles—a large-scale, multicenter retrospective study on nephrotoxicity associated with empiric broad spectrum antibiotics in critically ill patients and a multicenter observational study of respiratory support techniques for COVID-19-related ARDS in a sub-Saharan African country. Completing this section is a research letter exploring the impact of delirium in patients receiving temporary mechanical circulatory support and an American College of Chest Physicians Clinical Practice Guideline and Expert Panel Report on respiratory management of patients with neuromuscular weakness.
On to our Diffuse Lung Disease content area. Patients with idiopathic pulmonary fibrosis (IPF) have many pulmonary and extrapulmonary comorbidities. In this issue, Zhu and colleagues aimed to determine whether comorbidities associated with IPF have causal relationships by performing a bidirectional Mendelian randomization using summary statistics from genome-wide association studies. Twenty-two comorbidities with genetic data available were included. Comorbidities associated causally with an increased risk of IPF included gastroesophageal reflux disease, venous thromboembolism, and hypothyroidism, whereas COPD was associated causally with a decreased risk of IPF. IPF showed causal associations with a higher risk of lung cancer and a reduced risk of hypertension. These results suggest causal associations between IPF and certain comorbidities from a genetic perspective. Also in this section are two original research articles—a description of the evolution of pulmonary involvement in idiopathic multicentric Castleman disease, not otherwise specified, and an evaluation of disparities in antifibrotic medication utilization among veterans with IPF.
On to our Education and Clinical Practice content area. Patents on inhalers contribute to the expense of inhaled medications. In this issue, Demkowicz and colleagues explored the duration of protection added by device patents to determine how manufacturers have relied on device patents to preserve market exclusivity on brand-name inhalers. Thirty-nine of 53 brand-name inhalers approved for asthma or COPD by the Food and Drug Administration from 1986 through 2020 had at least one device patent. Of 137 distinct device patents, 77% made no mention of active ingredients and 72% made no mention of any feature connecting the device patent to the drug product. Device patents extended the duration of market protection by a median of 5.5 years beyond the last-to-expire nondevice patent. These results suggest the use of device patents can impact the affordability of inhaled medications. Completing this section is an American College of Chest Physicians, American Association for Respiratory Care, American Thoracic Society, and Canadian Thoracic Society Evidence Review and Research Statement on the effect of race and ethnicity on pulmonary function testing interpretation.
Our Pulmonary Vascular content area is next. Lack of respiratory variation in right atrial pressure (RAP) may be a surrogate for severe pulmonary hypertension. In this issue, Al-Qadi and colleagues report the findings from a retrospective review of RAP tracings of patients with precapillary pulmonary hypertension designed to determine if a lack of respiratory variation in RAP is predictive of right ventricular (RV) dysfunction and worse clinical outcomes. Lack of respiratory variation in RAP was associated with a lower cardiac output, lower pulmonary artery saturation, higher pulmonary vascular resistance, RV dysfunction on echocardiography, higher proBNP, and more hospitalizations within 1 year for RV failure. These findings highlight an association between lack of respiratory variation in RAP and clinical outcomes, hemodynamic parameters, and RV dysfunction. Completing this section is a CHEST Review on the evaluation and management of chronic thromboembolic pulmonary hypertension.
Our Sleep Medicine content area is next. Alterations in sleep might stress biological systems that could influence malignancy risk. In this issue, Kendzerska and colleagues report findings from a retrospective multicenter cohort study using linked clinical and provincial health administrative data designed to evaluate the association between polysomnographic measures of sleep disturbances and incident cancer. Of 29,907 individuals, 8.4% were diagnosed with cancer over a median of 8.0 years. Five clusters were developed based on polysomnography findings—mildly abnormal, poor sleep, severe OSA, severe desaturations, and periodic limb movements of sleep (PLMS). When controlled for age and sex, PLMS and severe desaturations were associated with cancer development. These findings highlight potential roles for PLMS and oxygen desaturation in the development of cancer. Completing this section is an original research study evaluating the association between OSA with human gut microbiota composition and functional potential.
Next is our Thoracic Oncology content area. Few published studies have explored how to implement effective tobacco use treatment optimally during a lung cancer screening encounter. In this issue, Foley and colleagues report findings from the Optimizing Lung Screening intervention (OaSiS) study, an effectiveness-implementation hybrid type II cluster randomized trial designed to determine if a variety of strategies targeting the clinic and care team were effective at reducing tobacco use among patients undergoing lung cancer screening in community-based radiology facilities. Despite a significant increase in average smoking cessation rate over time (0% at baseline to 13% at 6 months), tobacco use did not differ by trial group at 14 days, 3 months, or 6 months. These results highlight a reduction in tobacco use over time but no influence of the trial intervention. Also in this section is an original research article reporting on invasive procedures performed for lung cancer screening findings in clinical practice and a research letter that reports on the association of communication quality with patient-centered outcomes among patients with incidental pulmonary nodules.
Finally, I encourage you to read our Humanities in Chest Medicine section, where you will find an Exhalations piece titled, “A Worse Doctor,” and an article from the Vantage series exploring a case study in artificial intelligence-generated manuscripts. Finally, please review our case series publications for the month, providing novel and educational cases to help improve your clinical skills.
I hope you enjoy reading all the high-quality content available in this month’s issue of the journal CHEST. As always, I am grateful to the authors of this work, to the reviewers who volunteered their time to improve the quality of these manuscripts, and to our editorial board for guiding everything that we do. Until next month, I hope you enjoy the August issue.