Chest最新文献

{"title":"How I do it. Choosing the right biologic for the right patient with severe asthma.","authors":"Simon Couillard, David J Jackson, Ian D Pavord, Michael E Wechsler","doi":"10.1016/j.chest.2024.08.045","DOIUrl":"https://doi.org/10.1016/j.chest.2024.08.045","url":null,"abstract":"<p><p>In this new instalment of the How I Do It: Severe Asthma series, we tackle the clinical conundrum of choosing the right biologic for the right patient with severe asthma. With 6 biologics now approved for use in this area comprising 4 different targeting strategies (anti-immunoglobulin E, omalizumab; anti-interleukin (IL)-5/5receptor, mepolizumab, reslizumab, and benralizumab; anti-IL-4receptor, dupilumab; anti-thymic stromal lymphopoietin, tezepelumab), this question is increasingly complex. Recognising that there is no head-to-head trial comparing biologics, we base our review on the expected effects of inhibiting different aspects of type-2 airway inflammation, supported whenever possible by clinical trial and real-world data. We use four variations of a case of severe uncontrolled asthma to develop concepts and considerations introduced in the previous Work-up of severe asthma installment and discuss pregnancy-, biomarker-, comorbidity-, and corticosteroid-dependency-related considerations when choosing a biologic. The related questions of deciding when, why, and how to switch from one biologic to another are also discussed. Overall, we consider that the choice between biologics should be based on the available clinical trial data for the desired efficacy outcomes; the biomarker profile of the patient; safety profiles (e.g., when pregnancy is considered); and opportunities to target two comorbidities with one biologic. Using systemic and airway biomarkers (blood eosinophils and exhaled nitric oxide (FeNO)) and other phenotypic characteristics, we suggest a framework to facilitate therapeutic decision-making. Post hoc studies and new comparative studies are urgently needed to test this framework and determine whether it allows us to make other clinically useful predictions.</p>","PeriodicalId":9782,"journal":{"name":"Chest","volume":null,"pages":null},"PeriodicalIF":9.5,"publicationDate":"2024-09-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142153220","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"DIAGNOSIS AND PREVENTION OF INVASIVE FUNGAL INFECTIONS IN THE IMMUNOCOMPROMISED HOST.","authors":"Abdul Wahab, David Sanborn, Paschalis Vergidis, Raymund Razonable, Hemang Yadav, Kelly M Pennington","doi":"10.1016/j.chest.2024.08.046","DOIUrl":"https://doi.org/10.1016/j.chest.2024.08.046","url":null,"abstract":"<p><strong>Topic importance: </strong>The prevalence of invasive fungal infections (IFI) has risen in the past three decades, attributed to advancements in immune-modulatory therapies employed in transplantation, rheumatology, and oncology.</p><p><strong>Review findings: </strong>Organisms that cause IFI evade the host's natural defenses or at opportunities of immunologic weakness. Infections occur from inhalation of potentially pathogenic organisms, translocation of commensal organisms, or reactivation of latent infection. Organisms that cause IFI in immunocompromised populations include Candida spp., Cryptococcus spp., environmental molds, and endemic fungi. Diagnosis of these infections is challenging due to slow organism growth and fastidious culture requirements. Moreover, fungal biomarkers tend to be non-specific and can be negatively impacted by prophylactic antifungals. Antibody-based tests are not sensitive in immunocompromised hosts making antigen-based testing necessary. Prevention of IFI is guided by pathogen avoidance, removal or minimization of immune-suppressing factors, and pharmacologic prophylaxis in select hosts.</p><p><strong>Summary: </strong>Understanding the complex interplay between the immune system and opportunistic fungal pathogens plays a key role in early diagnosis and prevention.</p>","PeriodicalId":9782,"journal":{"name":"Chest","volume":null,"pages":null},"PeriodicalIF":9.5,"publicationDate":"2024-09-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142153219","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Single Versus Double Lung Transplant in Older Adults: A Propensity-Matched Analysis.","authors":"Noah Weingarten, Atul C Mehta, Marie Budev, Usman Ahmad, James Yun, Kenneth McCurry, Haytham Elgharably","doi":"10.1016/j.chest.2024.08.044","DOIUrl":"https://doi.org/10.1016/j.chest.2024.08.044","url":null,"abstract":"<p><strong>Background: </strong>Single lung transplantation (SLT) is associated with worse long-term outcomes than bilateral lung transplantation (BLT) but is often performed for older adults at risk of not tolerating BLT.</p><p><strong>Research question: </strong>How do the outcomes of SLT and BLT compare among older adult recipients?</p><p><strong>Study design and methods: </strong>The Scientific Registry of Transplant Recipients database (2005-2022) was queried for lung transplant recipients aged ≥65 years. Patients were stratified by whether they underwent BLT or SLT, and propensity matched. Baseline characteristics and morbidity were compared with frequentist statistics. Survival was analyzed via Kaplan-Meier estimation. Risk factors for mortality were identified with Cox regression.</p><p><strong>Results: </strong>Of 9,904 included patients, 4,829 (48.8%) underwent SLT. SLT patients had lower lung allocation scores (39.6 v. 40.6, p<0.001), more interstitial lung disease (74.4% v. 64.6%, p<0.001) and lower rates of bridging (0.7% v. 2.4%, p<0.001). Groups did not differ significantly by sex, body mass index, or donor characteristics. Propensity matching resulted in 2,539 patients in each group. On matched analysis, SLT patients had shorter lengths of stay (14 v. 18 d), lower reintubation rates (14.7% v. 19.8%), and less postoperative dialysis use (4.2% v. 6.4%) (all p<0.001). SLT patients had comparable survival at 30-days (97.6% v. 97.3%, p=0.414) and 1-year (85.5% v. 86.3%, p=0.496), but lower survival at 5-years (45.4% v. 53.4%, p<0.001) on matched analysis. SLT was a risk factor for 5-year mortality (adjusted hazard ratio: 1.19, p<0.001).</p><p><strong>Interpretation: </strong>In older adults, SLT is associated with less morbidity and comparable early survival relative to BLT, but lower five-year survival. SLT is reasonable to perform in older adults at high risk for BLT.</p>","PeriodicalId":9782,"journal":{"name":"Chest","volume":null,"pages":null},"PeriodicalIF":9.5,"publicationDate":"2024-09-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142145289","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of Dyspnea on Adults with Respiratory Symptoms Without a Defined Diagnosis.","authors":"Jared Bierbrier, Emily Gerstein, G A Whitmore, Katherine L Vandemheen, Celine Bergeron, Louis-Philippe Boulet, Andreanne Cote, Stephen K Field, Erika Penz, R Andrew McIvor, Catherine Lemière, Samir Gupta, Paul Hernandez, Irvin Mayers, Mohit Bhutani, M Diane Lougheed, Christopher J Licskai, Tanweer Azher, Nicole Ezer, Martha Ainslie, Gonzalo G Alvarez, Sunita Mulpuru, Shawn D Aaron","doi":"10.1016/j.chest.2024.07.183","DOIUrl":"https://doi.org/10.1016/j.chest.2024.07.183","url":null,"abstract":"<p><strong>Background: </strong>We investigated dyspnea, its associated risk factors, and its impact on healthcare utilization, quality of life, and work productivity in adults with undiagnosed respiratory symptoms.</p><p><strong>Research question: </strong>What is the impact of dyspnea in adults with undiagnosed respiratory symptoms?</p><p><strong>Study design and methods: </strong>This population-based study included 2857 adults who were experiencing respiratory symptoms. These individuals had not been previously diagnosed with any lung conditions and were recruited from 17 Canadian centers using random digit-dialing. Each participant underwent spirometry testing both before and after using a bronchodilator to determine if they met the diagnostic criteria for COPD, asthma, Preserved Ratio Impaired Spirometry (PRISm), or if their spirometry results were normal. An age-matched control group (n= 231) was similarly recruited using random-digit dialing. A dyspnea impact assessment score from 0 to 100 was produced using questions from the COPD Assessment Test and St. George's Respiratory Questionnaire.</p><p><strong>Results: </strong>Individuals with PRISm (n=172) reported more impactful dyspnea (mean score 63.0, 95% CI: 59.5- 66.4) than those with undiagnosed asthma (n=265, mean score 56.6, 95% CI: 53.9-59.3) or undiagnosed COPD (n=330, mean score 57.5, 95% CI: 55.1-59.9). All groups reported significantly more impactful dyspnea compared to controls (mean score 13.8, 95% CI:11.8-15.7). Subject-specific risk factors including age, sex, BMI, smoking, and comorbidities explained 20.6% of the variation in dyspnea. An additional 12.4% of the variation was explained by disease classification and another 1.7% by the severity of lung function impairment assessed with spirometry. After adjusting for age, sex, and BMI, greater dyspnea impact was associated with increased healthcare utilization, lower quality of life, and reduced work productivity.</p><p><strong>Interpretation: </strong>In community-based adults with undiagnosed respiratory symptoms, those identified with PRISm experienced the greatest impact of dyspnea. Dyspnea imposes burdens on the healthcare system and is associated with impaired quality of life and work productivity.</p>","PeriodicalId":9782,"journal":{"name":"Chest","volume":null,"pages":null},"PeriodicalIF":9.5,"publicationDate":"2024-09-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142145288","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Noninvasive Arterial Pressure Measurements at the Lower Leg: Evaluation of the Influence of Patient Position (Semi-Recumbent or Horizontal). A prospective study.","authors":"Karim Lakhal, Alexia Audran, Gurvan Normand, Bertrand Rozec, Thierry Boulain, Jérôme E Dauvergne","doi":"10.1016/j.chest.2024.08.042","DOIUrl":"https://doi.org/10.1016/j.chest.2024.08.042","url":null,"abstract":"","PeriodicalId":9782,"journal":{"name":"Chest","volume":null,"pages":null},"PeriodicalIF":9.5,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142139444","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Post Pulmonary Embolism Phenotypes Described by Invasive Cardiopulmonary Exercise Testing.","authors":"Michael Insel, Tammer El Aini, Gregory Woodhead, Rebecca Wig, Saad Kubba, Guido Claessen, Erin Howden, Franz Rischard","doi":"10.1016/j.chest.2024.08.040","DOIUrl":"https://doi.org/10.1016/j.chest.2024.08.040","url":null,"abstract":"<p><strong>Background: </strong>Post pulmonary embolism (PE) dyspnea is common. Existing non-invasive studies have demonstrated that post PE dyspnea is associated with elevations in right ventricular afterload, dead space ventilation, and deconditioning. We aimed to use invasive cardiopulmonary exercise testing (iCPET) parameters in patients with post PE dyspnea to identify unique physiologic phenotypes.</p><p><strong>Research question: </strong>Are there distinct post pulmonary embolism dyspnea physiologic phenotypes described with iCPET?</p><p><strong>Study design and methods: </strong>Patients were enrolled at the time of acute PE and through our pulmonary hypertension and dyspnea clinic. ICPET was performed if there was high suspicion for pulmonary hypertension or if there was unexplained dyspnea. A hierarchical cluster analysis was performed to identify dyspnea phenotypes. ICPET parameters assessing pulmonary hemodynamics, ventilation, and peripheral oxygen utilization were then compared within and across each cluster and with iCPET controls against peak oxygen consumption (Peak VO2).</p><p><strong>Results: </strong>173 patients were enrolled. Sixty-seven patients underwent iCPET. All patients had reductions in Peak VO2 and peak cardiac index relative to controls. Three clusters were identified. Cluster one was defined by having elevated RV afterload and impaired ventilatory efficiency. Cluster two had elevated RV afterload with reductions in respiratory mechanics. Cluster three had mild derangement in RV afterload with mild reductions in peak cardiac output.</p><p><strong>Interpretation: </strong>iCPET reveals significant heterogeneity in post PE dyspnea. Three phenotypes are characterized by differences in RV afterload, ventilatory efficiency, respiratory mechanics, and peripheral oxygen utilization.</p>","PeriodicalId":9782,"journal":{"name":"Chest","volume":null,"pages":null},"PeriodicalIF":9.5,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142139445","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Performance of risk assessment models for venous thromboembolism in critically ill patients receiving pharmacologic thromboprophylaxis: a post hoc analysis of the PREVENT trial.","authors":"Hasan M Al-Dorzi, Hatim Arishi, Fahad M Al-Hameed, Karen Ea Burns, Sangeeta Mehta, Jesna Jose, Sami J Alsolamy, Sheryl Ann I Abdukahil, Lara Y Afesh, Mohammed S Alshahrani, Yasser Mandourah, Ghaleb A Almekhlafi, Mohammed Almaani, Ali Al Bshabshe, Simon Finfer, Zia Arshad, Imran Khalid, Yatin Mehta, Atul Gaur, Hassan Hawa, Hergen Buscher, Hani Lababidi, Abdulsalam Al Aithan, Abdulaziz Al-Dawood, Yaseen M Arabi","doi":"10.1016/j.chest.2024.07.182","DOIUrl":"https://doi.org/10.1016/j.chest.2024.07.182","url":null,"abstract":"<p><strong>Background: </strong>The diagnostic performance of the available risk assessment models for venous thromboembolism in critically ill patients receiving pharmacologic thromboprophylaxis is unclear.</p><p><strong>Research question: </strong>For critically ill patients receiving pharmacologic thromboprophylaxis, do risk assessment models predict who would develop venous thromboembolism or who could benefit from adjunctive pneumatic compression for thromboprophylaxis?</p><p><strong>Study design and methods: </strong>In this post hoc analysis of the PREVENT trial, we evaluated different risk assessment models for venous thromboembolism (ICU-VTE, Kucher, Intermountain, Caprini, Padua, and IMPROVE models). We constructed receiving operator characteristic curves and calculated the sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios. Additionally, we conducted subgroup analyses evaluating the effect of adjunctive pneumatic compression versus none on the study primary outcome.</p><p><strong>Results: </strong>Among 2003 patients receiving pharmacologic thromboprophylaxis, 198 (9.9%) developed venous thromboembolism. With multivariable logistic regression analysis, the independent predictors of venous thromboembolism were APACHE II score, prior immobilization, femoral central venous catheter, and invasive mechanical ventilation. All risk assessment models had areas under the curve <0.60 except for the Caprini model (0.64, 95% confidence interval 0.60, 0.68). The Caprini, Padua and Intermountain models had high sensitivity (>85%) but low specificity (<20%) for predicting venous thromboembolism, whereas ICU-VTE, Kucher, and IMPROVE models had low sensitivities (<15%), but high specificities (>85%). The positive predictive value was low (<20%) for all studied cutoff scores, whereas the negative predictive value was mostly >90%. Using the risk assessment models to stratify patients into high- versus low-risk subgroups, the effect of adjunctive pneumatic compression versus pharmacologic prophylaxis alone was not different across the subgroups (p for interaction >0.05).</p><p><strong>Interpretation: </strong>The risk assessment models for venous thromboembolism performed poorly in critically ill patients receiving pharmacologic thromboprophylaxis. None of the models identified a subgroup of patients who might benefit from adjunctive pneumatic compression.</p>","PeriodicalId":9782,"journal":{"name":"Chest","volume":null,"pages":null},"PeriodicalIF":9.5,"publicationDate":"2024-09-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142131933","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Peeling Back the Onion: Kidney Disease Across Clinical Sepsis Phenotypes.","authors":"Alexander H Flannery,Javier A Neyra","doi":"10.1016/j.chest.2024.04.018","DOIUrl":"https://doi.org/10.1016/j.chest.2024.04.018","url":null,"abstract":"","PeriodicalId":9782,"journal":{"name":"Chest","volume":null,"pages":null},"PeriodicalIF":9.6,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142202454","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Behind Bars at the Bedside: Navigating the Space Between Care and Criminalization as a Trainee.","authors":"Gwenyth L Day,Matthew F Griffith,Erin S DeMartino","doi":"10.1016/j.chest.2024.04.003","DOIUrl":"https://doi.org/10.1016/j.chest.2024.04.003","url":null,"abstract":"","PeriodicalId":9782,"journal":{"name":"Chest","volume":null,"pages":null},"PeriodicalIF":9.6,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142174811","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"No Set Rules: Variations in Decision-Making for Venovenous Extracorporeal Membrane Oxygenation Candidacy.","authors":"Catherine L Auriemma,Jacob Gutsche","doi":"10.1016/j.chest.2024.04.020","DOIUrl":"https://doi.org/10.1016/j.chest.2024.04.020","url":null,"abstract":"","PeriodicalId":9782,"journal":{"name":"Chest","volume":null,"pages":null},"PeriodicalIF":9.6,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142202455","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}