Chest最新文献

{"title":"Response.","authors":"Daniel P Sulmasy, Christopher A DeCock, Carlo S Tornatore, Allen H Roberts, James Giordano, G Kevin Donovan","doi":"10.1016/j.chest.2024.06.3796","DOIUrl":"https://doi.org/10.1016/j.chest.2024.06.3796","url":null,"abstract":"","PeriodicalId":9782,"journal":{"name":"Chest","volume":"166 5","pages":"e171-e172"},"PeriodicalIF":9.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142615835","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":"\"Against Medical Advice\" Discharges After Respiratory-Related Hospitalizations: Strategies for Respectful Care.","authors":"J Henry Brems, Judith Vick, Deepshikha Ashana, Mary Catherine Beach","doi":"10.1016/j.chest.2024.05.035","DOIUrl":"10.1016/j.chest.2024.05.035","url":null,"abstract":"<p><p>Against medical advice (AMA) discharges are practically and emotionally challenging for both patients and clinicians. Moreover, they are common after admissions for respiratory conditions such as COPD and asthma, and they are associated with poor outcomes. Despite the challenges presented by AMA discharges, clinicians rarely receive formal education and have limited guidance on how to approach these discharges. Often, the approach to AMA discharges prioritizes designating the discharge as \"AMA,\" whereas effective coordination of discharge care receives less attention. Such an approach can lead to stigmatization of patients and low-quality care. Although evidence for best practices in AMA discharges remains lacking, we propose a set of strategies to improve care in AMA discharges by focusing on respect, in which clinicians treat patients as equals and honor differing values. We describe five strategies, including (1) preventing an AMA discharge; (2) conducting a patient-centered and truthful discussion of risk; (3) providing harm-reducing discharge care; (4) minimizing stigma and bias; and (5) educating trainees. Through a case of a patient discharging AMA after a COPD exacerbation, we highlight how these strategies can be applied to common issues in respiratory-related hospitalizations, such as prescribing inhalers and managing oxygen requirements. We argue that, by using these strategies, clinicians can deliver more respectful and higher quality care to an often-marginalized population of patients with respiratory disease.</p>","PeriodicalId":9782,"journal":{"name":"Chest","volume":" ","pages":"1155-1161"},"PeriodicalIF":9.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11562651/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141436365","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Pulmonologists' Attitudes and Role in Precision Medicine Biomarker Testing for Non-Small Cell Lung Cancer.","authors":"Adam H Fox, Mark A Rudzinski, Paul J Nietert, Gerard A Silvestri","doi":"10.1016/j.chest.2024.06.001","DOIUrl":"10.1016/j.chest.2024.06.001","url":null,"abstract":"<p><strong>Background: </strong>Despite advances in precision medicine for non-small cell lung cancer (NSCLC), biomarker testing for these therapies remains frequently underused, delayed, and inequitable. Pulmonologists often play a critical role in the initial diagnostic steps for patients with lung cancer, and previous data show variability in their knowledge and practices regarding biomarker testing. The purpose of this study is to better understand how pulmonologists view their role in lung cancer care.</p><p><strong>Research question: </strong>With the increasing importance of biomarker testing and precision medicine, how do pulmonologists view their role in lung cancer care?</p><p><strong>Study design: </strong>An electronic survey consisting of 31 items focused on attitudes and practices regarding diagnostic steps for NSCLC was randomly distributed to a sample of practicing pulmonologists in the American College of Chest Physicians (CHEST) analytics database. Inferential statistics were performed using χ² tests and multivariable logistic regression models.</p><p><strong>Results: </strong>A total of 401 pulmonologists responded to the survey. Most (92%) were general pulmonologists, and more than one-half (62%) indicated they order biomarker testing. Longer practice tenure, higher case volumes, and participation in a multidisciplinary tumor board were associated with ordering biomarkers (P < .05). Pulmonology was identified to have the leading responsibility for the initial diagnostic biopsy by most respondents (83%) and less often for staging (45%), leading discussions about biomarker testing with patients (28%), and for ordering biomarkers (22%). The most common reasons for not ordering biomarkers included the following: oncology was responsible (84%), it was not within their scope of practice (46%), or lack of the necessary knowledge (51%).</p><p><strong>Interpretation: </strong>This study shows that pulmonologists vary in their practices for ordering biomarkers, and many defer this responsibility to oncology. Despite the role of bronchoscopy and pulmonology societal guidelines for staging, many defer leadership of this process. Many pulmonologists lack the necessary resources and multidisciplinary infrastructure likely required to efficiently accomplish biomarker testing.</p>","PeriodicalId":9782,"journal":{"name":"Chest","volume":" ","pages":"1229-1238"},"PeriodicalIF":9.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141436367","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":"Clinical Impact of Telomere Length Testing for Interstitial Lung Disease.","authors":"David Zhang, Christina M Eckhardt, Claire McGroder, Shannon Benesh, Julie Porcelli, Christopher Depender, Kelsie Bogyo, Joseph Westrich, Amanda Thomas-Wilson, Vaidehi Jobanputra, Christine K Garcia","doi":"10.1016/j.chest.2024.06.006","DOIUrl":"10.1016/j.chest.2024.06.006","url":null,"abstract":"<p><strong>Background: </strong>Shortened telomere length (TL) is a genomic risk factor for fibrotic interstitial lung disease (ILD), but its role in clinical management is unknown.</p><p><strong>Research question: </strong>What is the clinical impact of TL testing on the management of ILD?</p><p><strong>Study design and methods: </strong>Patients were evaluated in the Columbia University ILD clinic and underwent Clinical Laboratory Improvement Amendments-certified TL testing by flow cytometry and fluorescence in situ hybridization (FlowFISH) as part of clinical treatment. Short TL was defined as below the 10th age-adjusted percentile for either granulocytes or lymphocytes by FlowFISH. Patients were offered genetic counseling and testing if they had short TL or a family history of ILD. FlowFISH TL was compared with research quantitative polymerase chain reaction (qPCR) TL measurement.</p><p><strong>Results: </strong>A total of 108 patients underwent TL testing, including those with clinical features of short telomere syndrome such as familial pulmonary fibrosis (50%) or extrapulmonary manifestations in the patient (25%) or a relative (41%). The overall prevalence of short TL was 46% and was similar across clinical ILD diagnoses. The number of short telomere clinical features was independently associated with detecting short TL (OR, 2.00; 95% CI, 1.27-3.32). TL testing led to clinical treatment changes for 35 patients (32%), most commonly resulting in reduction or avoidance of immunosuppression. Of the patients who underwent genetic testing (n = 34), a positive or candidate diagnostic finding in telomere-related genes was identified in 10 patients (29%). Inclusion of TL testing below the 1st percentile helped reclassify eight of nine variants of uncertain significance into actionable findings. The quantitative polymerase chain reaction test correlated with FlowFISH, but age-adjusted percentile cutoffs may not be equivalent between the two assays.</p><p><strong>Interpretation: </strong>Incorporating TL testing in ILD impacted clinical management and led to the discovery of new actionable genetic variants.</p>","PeriodicalId":9782,"journal":{"name":"Chest","volume":" ","pages":"1071-1081"},"PeriodicalIF":9.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11562654/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141476031","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Development and Validation of the Hospital Medicine Safety Sepsis Initiative Mortality Model.","authors":"Hallie C Prescott, Megan Heath, Elizabeth S Munroe, John Blamoun, Paul Bozyk, Rachel K Hechtman, Jennifer K Horowitz, Namita Jayaprakash, Keith E Kocher, Mariam Younas, Stephanie P Taylor, Patricia J Posa, Elizabeth McLaughlin, Scott A Flanders","doi":"10.1016/j.chest.2024.06.3769","DOIUrl":"10.1016/j.chest.2024.06.3769","url":null,"abstract":"<p><strong>Background: </strong>When comparing outcomes after sepsis, it is essential to account for patient case mix to make fair comparisons. We developed a model to assess risk-adjusted 30-day mortality in the Michigan Hospital Medicine Safety sepsis initiative (HMS-Sepsis).</p><p><strong>Research question: </strong>Can HMS-Sepsis registry data adequately predict risk of 30-day mortality? Do performance assessments using adjusted vs unadjusted data differ?</p><p><strong>Study design and methods: </strong>Retrospective cohort of community-onset sepsis hospitalizations in the HMS-Sepsis registry (April 2022-September 2023), with split derivation (70%) and validation (30%) cohorts. We fit a risk-adjustment model (HMS-Sepsis mortality model) incorporating acute physiologic, demographic, and baseline health data and assessed model performance using concordance (C) statistics, Brier scores, and comparisons of predicted vs observed mortality by deciles of risk. We compared hospital performance (first quintile, middle quintiles, fifth quintile) using observed vs adjusted mortality to understand the extent to which risk adjustment impacted hospital performance assessment.</p><p><strong>Results: </strong>Among 17,514 hospitalizations from 66 hospitals during the study period, 12,260 hospitalizations (70%) were used for model derivation and 5,254 hospitalizations (30%) were used for model validation. Thirty-day mortality for the total cohort was 19.4%. The final model included 13 physiologic variables, two physiologic interactions, and 16 demographic and chronic health variables. The most significant variables were age, metastatic solid tumor, temperature, altered mental status, and platelet count. The model C statistic was 0.82 for the derivation cohort, 0.81 for the validation cohort, and ≥ 0.78 for all subgroups assessed. Overall calibration error was 0.0%, and mean calibration error across deciles of risk was 1.5%. Standardized mortality ratios yielded different assessments than observed mortality for 33.9% of hospitals.</p><p><strong>Interpretation: </strong>The HMS-Sepsis mortality model showed strong discrimination and adequate calibration and reclassified one-third of hospitals to a different performance category from unadjusted mortality. Based on its strong performance, the HMS-Sepsis mortality model may aid in fair hospital benchmarking, assessment of temporal changes, and observational causal inference analysis.</p>","PeriodicalId":9782,"journal":{"name":"Chest","volume":" ","pages":"1035-1045"},"PeriodicalIF":9.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141533720","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":"A 53-Year-Old Man With Recurrent Cough, Expectoration, and Fever.","authors":"Linfan Su, Feng Luo, Zhenguo Zhai, Teng Han","doi":"10.1016/j.chest.2024.05.022","DOIUrl":"https://doi.org/10.1016/j.chest.2024.05.022","url":null,"abstract":"<p><strong>Case presentation: </strong>A 53-year-old man was admitted with complaints of recurrent cough, mucopurulent phlegm, and fever for 10 days. These symptoms started in his youth, and he had experienced three or more acute attacks per year in the past 3 years. Persistent nasal obstruction was noticed. When asked for symptoms, the patient denied heartburn, wheezing, aspiration, night sweats, and weight loss. The patient was married for 30 years and had a son. He had never used tobacco products or alcohol. A family history indicated that his parents were consanguineously married, and one of his sisters died of bronchiectasis coinfection.</p>","PeriodicalId":9782,"journal":{"name":"Chest","volume":"166 5","pages":"e147-e150"},"PeriodicalIF":9.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142615787","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":"P2X3 Receptor Antagonists in Chronic Cough: \"De Gustibus Non Disputandum Est\" (There Is No Arguing About Tastes).","authors":"Ahmad Kantar","doi":"10.1016/j.chest.2024.06.3793","DOIUrl":"https://doi.org/10.1016/j.chest.2024.06.3793","url":null,"abstract":"","PeriodicalId":9782,"journal":{"name":"Chest","volume":"166 5","pages":"911-912"},"PeriodicalIF":9.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142615825","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":"Sepsis Order Set Use Associated With Increased Care Value.","authors":"Christopher R Dale, Shih-Ting Chiu, Shelley Schoepflin Sanders, Caleb J Stowell, Tessa L Steel, Joshua M Liao, James I Barnes","doi":"10.1016/j.chest.2024.05.032","DOIUrl":"10.1016/j.chest.2024.05.032","url":null,"abstract":"<p><strong>Background: </strong>Sepsis is common and expensive, and evidence suggests that sepsis order sets may help to improve care. Very incomplete evidence exists regarding the effects of sepsis order sets on the value of care produced by hospitals or the societal costs of sepsis care.</p><p><strong>Research question: </strong>In patients hospitalized for sepsis, is the receipt a of a sepsis order set vs no order set associated with improved value of care, defined as decreased hospital mortality, decreased hospital direct variable costs, and decreased societal spending on hospitalizations?</p><p><strong>Study design and methods: </strong>This retrospective cohort study included patients discharged with sepsis International Classification of Diseases, Tenth Revision, codes over 2 years from a large integrated delivery system. Using a propensity score, sepsis order set users were matched to nonusers to study the association between sepsis order set use and the value of care from the hospital and societal perspective. The association between order set receipt and hospital mortality, direct variable cost, and hospital revenue also were examined in a priori defined subgroups of sepsis severity and hospital mortality.</p><p><strong>Results: </strong>The study included 97,249 patients, with 52,793 patients (54%) receiving the sepsis order set. The propensity score match analysis included 55,542 patients, with 27,771 patients in each group. Recipients of the sepsis order set showed a 3.3% lower hospital mortality rate and a $1,487 lower median direct variable total cost (P < .01 for both). Median payer-neutral reimbursement (ie, PNR), a proxy for hospital revenue and thus societal costs, was $465 lower for sepsis order set users (P < .01). Receipt of the sepsis order set was associated with a $1,022 increase in contribution margin, the difference between direct variable costs and PNR per patient.</p><p><strong>Interpretation: </strong>Receipt of the sepsis order set was associated with improved value of care, from both a hospital and societal perspective.</p>","PeriodicalId":9782,"journal":{"name":"Chest","volume":" ","pages":"1046-1055"},"PeriodicalIF":9.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141436368","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":"\"My Mom Is a Fighter\": A Qualitative Analysis of the Use of Combat Metaphors in ICU Clinician Notes.","authors":"Shannen Kim, Hunter Mills, Teva Brender, Samuel McGowan, Eric Widera, Allyson C Chapman, Krista L Harrison, Sei Lee, Alex K Smith, David Bamman, Oksana Gologorskaya, Julien Cobert","doi":"10.1016/j.chest.2024.07.178","DOIUrl":"10.1016/j.chest.2024.07.178","url":null,"abstract":"<p><strong>Background: </strong>A metaphor conceptualizes one, typically abstract, experience in terms of another, more concrete, experience with the goal of making it easier to understand. Although combat metaphors have been well described in some health contexts, they have not been well characterized in the setting of critical illness.</p><p><strong>Research question: </strong>How do clinicians use combat metaphors when describing critically ill patients and families in the electronic health record?</p><p><strong>Study design and methods: </strong>We included notes written about patients aged 18 years or older admitted to ICUs within a large hospital system from 2012 through 2020. We developed a lexicon of combat words and isolated note segments that contained any combat mentions. Combat mentions were defined systematically as a metaphor or not across two coders. Among combat metaphors, we used a grounded theory approach to construct a conceptual framework around their use.</p><p><strong>Results: </strong>Across 6,404 combat-related mentions, 5,970 were defined as metaphors (Cohen κ, 0.84). The most common metaphors were \"bout\" (26.2% of isolated segments), \"combat\" (18.5%), \"confront\" (17.8%), and \"struggle\" (17.5%). We present a conceptual framework highlighting how combat metaphors can present as identity (\"mom is a fighter\") and process constructs (\"struggling to breathe\"). Identity constructs usually were framed around: (1) hope, (2) internal strength, (3) contextualization of current illness based on prior experiences, or (4) a combination thereof. Process constructs were used to describe: (1) \"fighting for\" (eg, working toward) a goal, (2) \"fighting against\" an unwanted force, or (3) experiencing internal turmoil.</p><p><strong>Interpretation: </strong>We provide a novel conceptual framework around the use of combat metaphors in the ICU. Further studies are needed to understand intentionality behind their use and how they impact clinician behaviors and patient and caregiver emotional responses.</p>","PeriodicalId":9782,"journal":{"name":"Chest","volume":" ","pages":"1162-1172"},"PeriodicalIF":9.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142092457","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":"Two Birds With One Stone: Cross-Registry Analysis of Women Undergoing Lung Cancer and Breast Cancer Screening.","authors":"John Michael Sweetnam, Lenka Goldman, Lars Grimm, Gerard A Silvestri, Nichole T Tanner","doi":"10.1016/j.chest.2024.06.3798","DOIUrl":"10.1016/j.chest.2024.06.3798","url":null,"abstract":"","PeriodicalId":9782,"journal":{"name":"Chest","volume":" ","pages":"1250-1253"},"PeriodicalIF":9.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141598703","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}