Annals of the American Thoracic Society最新文献

{"title":"Goals of Care Assessment during Hospitalization for Sepsis.","authors":"Leigh M Cagino, Emily Walzl, Jakob I McSparron, Megan Heath, Lakshmi Swaminathan, Douglas B White, Rania Esteitie, Elizabeth S McLaughlin, Jennifer K Horowitz, Patricia Posa, Stephanie Parks Taylor, Scott A Flanders, Hallie C Prescott","doi":"10.1513/AnnalsATS.202410-1041OC","DOIUrl":"10.1513/AnnalsATS.202410-1041OC","url":null,"abstract":"<p><p><b>Rationale:</b> Sepsis is a common cause of hospital mortality, as well as new morbidity among survivors. Clinical practice guidelines recommend assessing goals of care (GoCs) during sepsis hospitalization to ensure goal-concordant care is provided. <b>Objectives:</b> To determine how often GoCs are assessed during sepsis hospitalization in routine practice. <b>Methods:</b> We conducted a cohort study of adult patients hospitalized with community-onset sepsis at 66 hospitals (2020-2023) participating in the Michigan Hospital Medicine Safety Consortium's sepsis initiative. The primary outcomes were GoC discussion documented in the health record and GoC assessment inferred to have occurred on the basis of <i>1</i>) documented GoC discussion, <i>2</i>) treatment limitations on admission, <i>3</i>) treatment limitations initiated during hospitalization, <i>4</i>) palliative care consultation, or <i>5</i>) discharge to hospice. We examined the incidence of GoC discussion and GoC assessment among all sepsis hospitalizations, as well as in three subgroups defined by advanced age or health impairment; admission to intensive care; and presentation with shock or respiratory failure. We also evaluated factors associated with GoC discussion/assessment and quantified variation across hospitals using multilevel logistic regression. <b>Results:</b> Among 18,711 patients in the Michigan Hospital Medicine Safety Consortium sepsis initiative registry, 54.0% had advanced age or health impairment, 22.5% were admitted to intensive care, and 10.2% presented with shock or respiratory failure. GoC discussion and assessment occurred in 35.7% and 45.3% of patients, respectively, in the overall cohort. GoC discussion occurred within 3 days of presentation in 23.8%. Age, race, chronic conditions, preexisting cognitive impairment, preexisting functional limitation, admission to intensive care, and receipt of life support were each associated with GoC assessment. Median odds ratios for GoC discussion and assessment were 2.30 and 2.09, respectively, indicating substantial cross-hospital variation after accounting for patient characteristics. GoC discussion and assessment were more common among patients with advanced age or health impairment, admission to intensive care, or presentation with shock or respiratory failure, but cross-hospital variation was similar. <b>Conclusions:</b> GoC assessment did not occur consistently during sepsis hospitalization in this multihospital cohort, even among higher-risk patients, and there was marked variation in practice across hospitals. Future work is needed to better understand what drives high performance in assessing GoC.</p>","PeriodicalId":93876,"journal":{"name":"Annals of the American Thoracic Society","volume":" ","pages":"1035-1041"},"PeriodicalIF":0.0,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143788984","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Dermatological Emergencies in Critical Care.","authors":"Maya Haouili, Samantha H Seward, Anna C Eden, Jenny K Kim, Lauren E Pavlik, Sarah A Seyffert, Joseph P Smith, Muhammad A Rishi, Lawrence A Mark, Brent A Bagley, W Graham Carlos","doi":"10.1513/AnnalsATS.202409-987FR","DOIUrl":"10.1513/AnnalsATS.202409-987FR","url":null,"abstract":"<p><p>Non-burn dermatologic emergencies are associated with high morbidity and mortality, which can be lowered by multidisciplinary care at a burn center. However, because of the sparse distribution of these institutions, intensivists at non-burn centers typically provide the initial management and triage of these patients. This can be particularly challenging because of the absence of standardized guidelines for triaging these patients. This Focused Review provides triage criteria and a framework for the clinical management of common non-burn dermatologic emergencies. It includes guidance on airway management, fluid resuscitation, nutrition, thermoregulation, and wound care, as well as an overview of the most frequently encountered non-burn related skin emergencies.</p>","PeriodicalId":93876,"journal":{"name":"Annals of the American Thoracic Society","volume":" ","pages":"961-969"},"PeriodicalIF":0.0,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144037405","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Longitudinal Outcomes in Pi*MZ Alpha-1 Antitrypsin-Deficient Individuals with Tobacco Smoking History from the SPIROMICS Cohort.","authors":"Igor Barjaktarevic, Roxana Hixson, Zian Zhuang, Russell G Buhr, Vickram Tejwani, R Graham Barr, Lori A Bateman, Surya P Bhatt, Eugene R Bleecker, Christopher B Cooper, Jeffrey L Curtis, M Bradley Drummond, Spyridon Fortis, Auyon J Ghosh, MeiLan Han, Nadia N Hansel, Eric A Hoffman, Jill Ohar, Fernando J Martinez, Deborah A Meyers, Robert Paine, Cheryl S Pirozzi, Robert Sandhaus, Charlie Strange, Donald P Tashkin, J Michael Wells, Prescott Woodruff, Victor E Ortega","doi":"10.1513/AnnalsATS.202411-1209OC","DOIUrl":"10.1513/AnnalsATS.202411-1209OC","url":null,"abstract":"<p><p><b>Rationale:</b> Reliable data about the natural history of lung function decline in alpha-1 antitrypsin (AAT)-deficient Pi*MZ heterozygotes is largely missing. <b>Objectives:</b> We hypothesized that, in adults with a tobacco smoking history, lung function deteriorates faster in Pi*MZ compared with the Pi*MM genotype. <b>Methods:</b> We identified 1,856 Pi*MM and 79 Pi*MZ participants with ⩾20 pack-years tobacco smoking history from the SPIROMICS (Subpopulations and Intermediate Outcomes Measures in COPD Study) cohort by DNA sequencing and followed them over a median of 4.8 years, comparing radiographic and clinical characteristics between the two groups over time using regression models. <b>Results:</b> Adjusted for age, sex, race, smoking pack-year history, and smoking status, Pi*MZ participants had a lower baseline percent predicted forced expiratory volume in 1 second (FEV₁) (65.4% vs. 75.1%; difference 95% confidence interval [CI], -15.4% to -3.9%), more radiographic emphysema (<-950 Hounsfield units%, 12.9% vs. 7.8%; difference 95% CI, 2.8% to 7.5%), and nonsignificantly lower lung density. In the longitudinal analysis, the FEV₁ annual rate of decline was similar in both groups over the course of the study (-34.5 ml/yr vs. -34.6 ml/yr for Pi*MZ and Pi*MM; difference 95% CI, -16.9 to 17.1 ml/yr). There were no significant differences between Pi*MZ and Pi*MM individuals in the annualized change in lung density, emphysema, patient-reported outcomes, exacerbations, or survival. The proportion with faster FEV₁ decline (annual loss ⩾40 ml) was similar in Pi*MZ and Pi*MM groups. In both groups, faster FEV₁ decline was associated with more air trapping and small airway disease at baseline. In Pi*MZ only, faster decline was associated with higher blood eosinophil counts (310 vs. 220 cells/μl; difference 95% CI, 30 to 140 cells/μl). In the subgroup analysis limited to a small number of currently smoking participants, no significant differences in longitudinal outcomes were found. <b>Conclusions:</b> Despite a lower FEV₁ and more emphysema at enrollment, the longitudinal analysis did not demonstrate significantly greater lung function decline or lung density loss in Pi*MZ compared with Pi*MM participants with tobacco smoking history. Limited sample size and duration of longitudinal follow-up constrain generalizability of our findings, thus prohibiting the conclusion that longitudinal trajectories did not differ between these groups. However, our results may suggest that earlier life events could be responsible for more extensive lung disease at enrollment in Pi*MZ compared with Pi*MM tobacco-exposed individuals.</p>","PeriodicalId":93876,"journal":{"name":"Annals of the American Thoracic Society","volume":" ","pages":"998-1008"},"PeriodicalIF":0.0,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143607017","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Overlap Syndrome Paradox: COPD and OSA Care Doesn't Overlap.","authors":"Janna R Raphelson, Robert L Owens","doi":"10.1513/AnnalsATS.202506-617ED","DOIUrl":"https://doi.org/10.1513/AnnalsATS.202506-617ED","url":null,"abstract":"","PeriodicalId":93876,"journal":{"name":"Annals of the American Thoracic Society","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144546473","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"With Sadness and Resolve: Why I Resigned as Chief Medical Officer of a National Institutes of Health Institute and What Comes Next.","authors":"Joshua P Fessel","doi":"10.1513/AnnalsATS.202503-366IP","DOIUrl":"10.1513/AnnalsATS.202503-366IP","url":null,"abstract":"","PeriodicalId":93876,"journal":{"name":"Annals of the American Thoracic Society","volume":" ","pages":"970-972"},"PeriodicalIF":0.0,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144014818","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Further Insights into Emphysema Progression and Lung Function Decline in MZ Alpha-1 Antitrypsin Deficiency.","authors":"Oliver J McElvaney","doi":"10.1513/AnnalsATS.202505-519ED","DOIUrl":"10.1513/AnnalsATS.202505-519ED","url":null,"abstract":"","PeriodicalId":93876,"journal":{"name":"Annals of the American Thoracic Society","volume":" ","pages":"975-976"},"PeriodicalIF":0.0,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144227940","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effect of an Overnight Stay at 2,500 Meters on Nocturnal Hypoxemia and Sleep-disordered Breathing in Patients with Pulmonary Vascular Disease: A Randomized Clinical Trial.","authors":"Mona Lichtblau, Esther I Schwarz, Tanja Ulrich, Simon R Schneider, Meret Bauer, Michael Furian, Arcangelo Carta, Aglaia Forrer, Stéphanie Saxer, Julian Müller, Helga Preiss, Laura Mayer, Konrad E Bloch, Silvia Ulrich","doi":"10.1513/AnnalsATS.202412-1279OC","DOIUrl":"10.1513/AnnalsATS.202412-1279OC","url":null,"abstract":"<p><p><b>Rational:</b> Patients with pulmonary vascular disease often reveal nocturnal hypoxemia and sleep apnea. We investigated whether exposure to high altitude worsens those conditions. <b>Methods and Objectives:</b> In a randomized controlled crossover trial, stable patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension without resting hypoxemia (arterial oxygen pressure, >8 kPa at low altitude) underwent respiratory polygraphy at 470 meters and during an overnight stay at 2,500 meters. Patients with severe hypoxemia (oxygen saturation as measured by pulse oximetry [Sp_O₂], <80% for >30 min) at 2,500 meters received supplemental oxygen therapy (SOT) according to safety criteria. The main outcomes were the number of patients who did not require SOT, the effect of high altitude on nocturnal Sp_O₂, oxygen desaturation index (ΔSp_O₂, ⩾3%), apnea-hypopnea index, and the effect of SOT. <b>Results:</b> Of 27 patients (44% women; 20/7 pulmonary arterial hypertension/chronic thromboembolic pulmonary hypertension; mean ± standard deviation age, 62 ± 14 y), 10 (37%) required SOT during the course of the night (<i>P</i> = 0.008 vs. low altitude). At 2,500 meters versus 470 meters, mean nocturnal Sp_O₂ on ambient air decreased from 91 ± 2% to 83 ± 4% (mean change [95% confidence interval], -8% [-9 to -6]; <i>P</i> < 0.001), time with Sp_O₂ <90% increased from 29 ± 27% to 92 ± 15% (+63% [30 to 92]; <i>P</i> < 0.001), and the oxygen desaturation index increased from 17 ± 14 events/h to 42 ± 26 events/h (+24.8 events/h [12.8 to 36.5]; <i>P</i> < 0.001), but the apnea-hypopnea index remained unchanged. With SOT, Sp_O₂ was restored to values at 470 meters. <b>Conclusions:</b> In stable, low-risk patients with pulmonary vascular disease, altitude worsened nocturnal hypoxemia but not sleep-disordered breathing. The majority of patients did not require SOT according to predefined safety criteria. When needed, SOT restored low-altitude indices of oxygenation. Clinical trial registered with www.clinicaltrials.gov (NCT05089487).</p>","PeriodicalId":93876,"journal":{"name":"Annals of the American Thoracic Society","volume":" ","pages":"1053-1061"},"PeriodicalIF":0.0,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143627238","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Development of a Novel Shared Care Intervention to Address Obstructive Sleep Apnea in Rural West Virginia.","authors":"Robert Stansbury, Nicole Stout, Toni Rudisill, Judith Feinberg, Geri Dino, Sunil Sharma, Patrick J Strollo","doi":"10.1513/AnnalsATS.202410-1074OC","DOIUrl":"10.1513/AnnalsATS.202410-1074OC","url":null,"abstract":"&lt;p&gt;&lt;p&gt;&lt;b&gt;Rationale:&lt;/b&gt; There is a critical need to create sustainable interventions for the nearly 80% of patients with undiagnosed obstructive sleep apnea (OSA), particularly in rural communities where notable health disparities exist. &lt;b&gt;Objectives:&lt;/b&gt; The objective of this study is to use implementation science and community-engaged research methods to address OSA care disparity in West Virginia by designing an intervention to support primary care providers (PCPs) who treat patients in rural West Virginia. Our overall project is grounded in context-sensitive approaches to address the unique challenges of OSA management in the rural primary care setting. Here we describe the preimplementation work conducted to identify the determinants of implementation in rural settings and the selection of strategies that led to the initial program and will inform our prospective implementation effectiveness study. &lt;b&gt;Methods:&lt;/b&gt; The Veterans Affairs Quality Enhancement Research Initiative implementation roadmap considers all levels of a healthcare system and provides a pragmatic approach to program implementation, which is carried out through three phases: preimplementation, implementation, and sustainment. Barriers and facilitators were mapped to the domains of the Consolidated Framework for Implementation Research (CFIR) to inform our implementation plan. We derived Expert Recommendations for Implementing Change strategies from the CFIR mapping exercise to identify the strategies that would improve implementation outcomes in rural primary care. &lt;b&gt;Results:&lt;/b&gt; Themes identified from our previous mixed-methods community engagement study with PCPs were reviewed and mapped to CFIR domains and coded as implementation barriers or facilitators. Facilitators included provider recognition of the relative importance of OSA management, provider knowledge about OSA, and perceived patient receptivity to having a PCP evaluate and treat OSA. Predominant barriers included PCPs' relatively low self-reported confidence in their ability to identify or manage OSA, challenges with clinical process and workflow that facilitate program adoption, and a relative lack of community-based resources or networks to support patients in such a program. One major barrier mapped to the CFIR domain \"inner setting\" was lack of clinical processes to support OSA screening, testing, and referrals. The implementation strategy category that was identified to be most important for the OSA care program implementation was \"Develop stakeholder interrelationships.\" Other important strategy categories included \"Provide interactive assistance\" and \"Support for clinicians\" in the targeted rural communities. &lt;b&gt;Conclusions:&lt;/b&gt; Leveraging a community-engaged approach and using implementation science informed the development and implementation of a novel OSA program to educate and support PCPs in OSA diagnosis and management that is tailored to the realities of rural primary care. This program, the Wes","PeriodicalId":93876,"journal":{"name":"Annals of the American Thoracic Society","volume":" ","pages":"1062-1070"},"PeriodicalIF":0.0,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143694753","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Eliciting Patient Preferences for Pragmatic Critical Care Trials: A Qualitative Study.","authors":"Jessica A Palakshappa, Megan L Rischall, Ashley E Strahley, Alexa E Cecil, Matthew E Prekker, Brian E Driver, Brianna H Denny, Kevin W Gibbs","doi":"10.1513/AnnalsATS.202410-1122OC","DOIUrl":"10.1513/AnnalsATS.202410-1122OC","url":null,"abstract":"<p><p><b>Rationale:</b> Conducting pragmatic comparative effectiveness trials in critically ill populations poses distinct challenges. Knowledge gaps exist in how to best conduct pragmatic research while demonstrating respect for critically ill patients and their families. <b>Objectives:</b> To engage patients with lived critical care experience to elicit their perspectives on <i>1</i>) decisions related to the design and conduct of pragmatic comparative effectiveness trials in acute and critical care settings and <i>2</i>) subsequent notification of pragmatic trial participation. <b>Methods:</b> We conducted a qualitative research study using the principles of reflexive thematic analysis. An interview guide was developed by investigators with expertise in qualitative methodology, critical care, emergency medicine, and pragmatic comparative effectiveness trials; this guide used two research study examples to elicit feedback from participants. Using a purposive sampling technique to ensure the inclusion of diverse perspectives, we recruited a convenience sample of patients from two hospitals during a hospitalization for a critical illness or injury. Interviews with participants were conducted via telephone after discharge, audio recorded, and transcribed verbatim. A codebook was developed inductively, and coding was performed in duplicate. Emerging themes were reviewed and validated with the larger research team. <b>Results:</b> A total of 20 interviews were completed, and saturation was achieved. Findings were organized into four themes: <i>1</i>) trust and past care experiences influence patient receptivity to pragmatic comparative effectiveness research, <i>2</i>) familiarity with research influences patient comfort and willingness to participate, <i>3</i>) altruism and a desire to contribute to research knowledge motivate patient participation in research, and <i>4</i>) the experience of critical illness influences patient receptivity to the research process. <b>Conclusions:</b> Patients with a lived experience of critical illness are generally supportive of pragmatic comparativeness effectiveness trials in the emergency or critical care setting. The factors influencing patient receptivity identified in this study highlight opportunities for investigators, healthcare leaders, and regulators to better align with patients in the future design and conduct of pragmatic comparative effectiveness trials.</p>","PeriodicalId":93876,"journal":{"name":"Annals of the American Thoracic Society","volume":" ","pages":"1027-1034"},"PeriodicalIF":0.0,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143627239","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Family Experiences of Financial Hardship Following Critical Illness.","authors":"Deepshikha C Ashana","doi":"10.1513/AnnalsATS.202506-642ED","DOIUrl":"https://doi.org/10.1513/AnnalsATS.202506-642ED","url":null,"abstract":"","PeriodicalId":93876,"journal":{"name":"Annals of the American Thoracic Society","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144546471","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}