Thank you for tuning in to the Editor’s Highlight Podcast for the November 2022 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 Chest Infections content area, most clinical trial data have not supported the efficacy of convalescent plasma treatment for COVID-19. In this issue, Self and colleagues report the results of a multicenter, blinded, placebo-controlled randomized clinical trial designed to determine if selected COVID-19 convalescent plasma with neutralizing anti-SARS-CoV-2 antibodies improve clinical status in adults hospitalized with COVID-19. In the primary analysis, 960 randomized patients were included. Clinical status at 14 days did not differ between the convalescent plasma treatment and placebo groups in the overall population or in those without endogenous antibodies. No secondary outcome differed between the groups. The results suggest that convalescent plasma does not improve clinical outcomes in adults hospitalized with COVID-19, including those seronegative for anti-SARS-CoV-2 antibodies. Also in this section is an original research article exploring the use of a deep learning-based prediction model using chest radiograph for nontuberculous mycobacterial pulmonary disease and another evaluating neutrophil extracellular traps, local IL-8 expression, and cytotoxic T-lymphocyte response in the lungs of fatal COVID-19.
On to our COPD content area. There is little evidence comparing the impact of single-inhaler triple therapy with multiple-inhaler triple therapy on treatment compliance, exacerbations, and other outcomes. In this issue, Alcazar-Navarrete and colleagues report the results of an observational, retrospective cohort study that identified 4,625 patients who initiated single- or multiple-inhaler triple therapy in the Spanish National Healthcare System designed to determine if patients with COPD initiating single-inhaler triple therapy have improved compliance, fewer exacerbations, and lower health care resource utilization. At 12 month follow-up, those initiating single-inhaler triple therapy had higher compliance (HR 1.37), reduced risk of exacerbations (HR 0.68), lower all-cause mortality risk (HR 0.67), and reduced health care resource use. These results suggest there is improved compliance and improved health care outcomes with the initiation of single-inhaler triple therapy. Also in this section is a CHEST Review of ventilation-perfusion mismatching as a pharmacologic target for COPD treatment and a Point/Counterpoint debate about the clinical relevance of chronic bacterial infection in COPD.
Next is our Critical Care content area. Little has been reported about the outcomes of patients with solid tumors who present with septic shock. In this issue, Cuenca and colleagues report the findings of a retrospective cohort study of 271 patients to evaluate independent predictors of 28-day mortality in critically ill adults with solid tumors and septic shock. They found that 84.5% had metastatic disease, and the 28-day mortality was 69.4%. Nonsurvival was associated with metastatic disease, respiratory failure, elevated lactate levels, and ECOG performance scores of 3 or 4. Only 14% were discharged home without medical assistance. These findings highlight the need for early goals-of-care discussions for patients with septic shock and metastatic cancer, while identifying predictors of mortality that can inform these discussions. Also in this section is a systematic review and meta-analysis that assesses the impact of sample size misestimations on the interpretation of ARDS trials and an original research study that performed a global comparison of communication of end-of-life decisions in the ICU.
On to our Diffuse Lung Disease content area. The association of BMI and OSA with the development of sarcoidosis is not known. In this issue, Judson and colleagues evaluated 10,512 patients with sarcoidosis and a BMI value recorded in the 12 months before the sarcoidosis diagnosis and 2,709,884 patients without sarcoidosis. They did not find an association between BMI and the rate of sarcoidosis developing. A diagnosis of OSA was protective against sarcoidosis developing with a 49.0% lower odds. These findings suggest an increased BMI is not associated with developing sarcoidosis and that the presence of OSA lowers the odds of sarcoidosis developing. Completing this section is a CHEST Review outlining pregnancy considerations for patients with interstitial lung disease.
Our Education and Clinical Practice content area is next. The pathophysiology of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is poorly understood. In this issue, Joseph and colleagues explored whether neurovascular dysregulation contributes to exercise intolerance in ME/CFS and whether its treatment can improve exercise capacity. In a single center, randomized, double-blind, placebo-controlled trial, subjects were randomized to receive oral pyridostigmine or placebo after an invasive cardiopulmonary exercise test (iCPET). A second iCPET was performed 50 minutes later with the primary endpoint being the difference in peak oxygen uptake (VO2). They found that the peak VO2 increased after pyridostigmine but decreased after placebo. Cardiac output and right atrial pressure were greater in the treatment group. These results suggest treatment of patients with ME/CFS with pyridostigmine can improve peak VO2, supporting the premise that neurovascular dysregulation contributes to acute exercise intolerance. Also in this section is an original research article that compares different methods of anaerobic threshold evaluation in heart failure prognostic assessment and an official ACCP Clinical Practice Guideline on the perioperative management of antithrombotic therapy.
Next is our Pulmonary Vascular content area. Patients who develop venous thromboembolism (VTE) are at increased risk of major adverse cardiovascular events (MACE). It is not known whether anticoagulation for VTE influences the risk of a MACE. In this issue, Noumegni and colleagues evaluated findings of 3,790 patients included in a prospective cohort receiving one family of anticoagulant treatment after the acute phase of VTE to determine if anticoagulant treatment for VTE affects the risk of subsequent MACE. Patients treated for 3 to 12 months and those treated >12 months had a significantly reduced risk of MACE compared with those treated for 0 to 3 months, with HRs of 0.64 and 0.47, respectively. The risk of a MACE was lower in those treated with direct oral anticoagulants (DOACs) than with vitamin-K antagonists (HR 0.48). These findings suggest treatment of VTE for >3 months, particularly with DOACs, is associated with a reduced risk of MACE. Completing this section is a CHEST Review about considerations when selecting patient-reported outcome measures for the assessment of health-related quality of life in patients with pulmonary hypertension.
Our Sleep Medicine content area is next. Ambient air pollution can affect the severity of untreated OSA. It is unknown whether air pollution adversely impacts the effectiveness of positive airway pressure (PAP) therapy. In this issue, Kendzerska and colleagues report the findings of a retrospective, community-based, repeated measures, longitudinal study of adults with OSA using data from the daily device-derived residual apnea hypopnea index (AHI) linked to data from air pollution databases to determine if short-term changes in outdoor air pollution adversely impact adults with OSA using PAP therapy. Eight thousand four hundred forty-eight adults were analyzed with a median of 89 days of observation. An increase in air pollution was found to be associated with a statistically significant increase in the AHI, with the largest effect, seen for the Air Quality Health Index, being just 0.07/hour. The findings suggest a small but statistically significant increase in residual respiratory events with PAP therapy is associated with an increase in air pollution concentrations.
Next is our Thoracic Oncology content area. Real-world data about the risk of drug-related pneumonitis (DRP) from treatment of epidermal growth factor receptor (EGFR) mutation-positive lung cancer with osimertinib are not available. In this issue, Sato and colleagues report the findings of a retrospective, multicenter cohort study of patients treated with osimertinib for advanced EGFR mutation-positive non-small cell lung cancer (NSCLC) designed to determine the prevalence, characteristics, clinical impact, and risk factors for osimertinib-induced DRP. Four hundred fifty-two patients from 18 institutions were included, 80 of whom (18%) had a diagnosis of DRP. Forty-six percent of these had a transient asymptomatic pulmonary opacity. CT patterns included organizing pneumonia (38%), pulmonary eosinophilia (26%), hypersensitivity pneumonitis (23%), diffuse alveolar damage (11%), and nonspecific interstitial pneumonia (3%). Smoking history was an independent risk factor for developing DRP, and DRP was associated with poor treatment efficacy. These results suggest a considerable frequency of DRP with osimertinib treatment in first-line settings. Also in this section is an original research article that evaluates the impact of preoperative diagnostic biopsy on spread through air spaces and related outcomes in resected stage I NSCLC and another that describes the natural history of contralateral bullae/blebs after video-assisted thoracoscopic surgery for primary spontaneous pneumothorax.
Finally, I encourage you to take a look at our Humanities in Chest Medicine section, where you will find a case-based discussion about balancing the rights and responsibilities of key stakeholders in addressing reports of disrespect experienced by patients and an Exhalations piece titled, “Breathing Under Water.”
Our case series publications for the month provide novel and educational cases to help improve your clinical skills.
I hope you enjoy reading all of the high-quality content available in this month’s issue of the journal CHEST. As always, I am grateful to the authors of this work, to the reviewers who volunteered their time to improve the quality of these manuscripts, and to our editorial board for guiding everything that we do. Until next month, I hope you enjoy the November issue.