Current Opinion in Pulmonary Medicine最新文献

Purpose of review: This review aims to summarize the current state of the art and future directions in optimal long-term anticoagulation following acute pulmonary embolism (PE).

Recent findings: Actual studies and guidelines underscore the preference for direct oral anticoagulants (DOAC) in standard therapeutic doses for maintenance therapy post-PE, while considering patient-specific factors and dose-reduction criteria. Risk stratification should always include the assessment of concomitant trigger- or risk factors regarding their strength and persistence. The use of tools like specific scores can facilitate the identification of optimal candidates for long-term therapy, emphasizing once more personalized approaches and strategies. Special patient groups, such as cancer associated thrombosis, chronic thromboembolic pulmonary hypertension or antiphospholipid syndrome require even more tailored therapy approaches.

Summary: Optimal long-term anticoagulation post-PE should be guided by straightforward and individual risk assessment strategies. The array of indications for DOACs has gotten wider in last years, also within special patient groups. Still, chronic thromboembolic pulmonary hypertension and antiphospholipid syndrome remains domain of vitamin K agonists.

Purpose of review: The impact of healthcare disparities in the treatment, care, and outcomes of patients with sarcoidosis has been described. There is paucity of literature on ways to address these disparities with a goal to improving health outcomes for patients with sarcoidosis.

Recent findings: Recent findings in other respiratory and systemic diseases suggest that multifaceted interventions directed at improving care at various levels including individual, family, and larger societal levels have been successful in dismantling some of the social and structural barriers to care and consequently have resulted in a reduction in disparate disease outcomes. We explore what some of these interventions would look like in sarcoidosis.

Summary: The impact of healthcare disparities in the treatment, care, and outcomes of patients with sarcoidosis has been described. We outline various steps and approaches aimed at addressing these health disparities with a goal to improving outcomes for those most impacted by disease.

Purpose of review: Obstructive sleep apnea (OSA) is common in children. Phenotyping pediatric OSA has a crucial role in personalized diagnosis and treatment to improve outcomes for this population. This review sets forth a clinical approach that allows for phenotyping pediatric OSA.

Recent findings: The emerging concept of phenotyping pediatric OSA is based on identifying a primary cause, which leads to a more precise understanding of the pathogenesis in any individual patient. Phenotyping enables treatment focusing on the primary cause, but does not exclude the need for supplemental management strategies based on other recognizable traits. The identification of pediatric OSA phenotypes (POP) relies on observable characteristics with significant prevalence. This review will concentrate on the most important phenotypes seen in clinical practice: pediatric OSA with craniofacial abnormalities (POPCA); OSA with upper airway disease (POPUAD); OSA with obesity (POPO), and OSA associated with neuromuscular disease (POPNED).

Summary: Phenotyping pediatric OSA is a form of personalized medicine. By identifying clinical subtypes, individualized treatment plans can be devised in order to choose therapies that are associated with predictable responses. Moreover, it is rare that a therapeutic modality is devoid of possible complications; knowledge of the phenotype being treated can enable early intervention should those occur. Finally, all of the aforementioned phenotypes require personalized support incorporating individualized care plans so as to optimize the quality of life and overall sleep health of children with OSA.

Purpose of review: The purpose of this review is to summarize available data on fertility, fertility preservation, pregnancy and parenthood following lung transplantation for people with cystic fibrosis (pwCF).

Recent findings: In the era of cystic fibrosis transmembrane conductance regulator (CFTR) modulator use, oral therapies that positively impact fundamental CFTR protein abnormalities, the number of pregnancies has increased dramatically with a concomitant decrease in lung transplantation. Nonetheless, some pwCF still require lung transplantation as a life-saving measure, and a fraction of those individuals desires parenthood. Cystic fibrosis (CF) providers infrequently discuss fertility preservation with pwCF, and pwCF feel uneducated about their fertility options posttransplant. However, because the immunosuppression required to successfully maintain lung allografts may impact future fertility, pwCF should receive genetic and reproductive counseling prior to lung transplantation. While pregnancies posttransplantation are high-risk, selected females with CF may be able to pursue this path to parenthood.

Summary: Although there is a paucity of data specific to pwCF who have undergone lung transplantation, recently developed general guidelines should inform discussions regarding fertility, pregnancy and parenthood in pwCF who desire parenthood following lung transplantation for optimal shared decision-making.

Purpose of review: There is increasing evidence for relevant sex differences in pathophysiology, symptom presentation and outcomes in obstructive sleep apnoea (OSA). However, research on sex differences and sex-specific phenotypes in sleep-disordered breathing (SDB) is still in its infancy and data on sex differences in other SDB is still very scarce.

Recent findings: While OSA is more common in men than in premenopausal women, the prevalence of OSA doubles postmenopausally and becomes comparable to that of men. Women have a lower collapsibility of the upper airway and a lower arousal threshold. In addition, the rapid eye movement (REM)-apnoea-hypopnoea index (AHI) is typically higher in women than in men, but the non-REM-AHI and thus the total AHI is often lower. Women are often symptomatic at lower AHI and present more frequently with symptoms of sleep fragmentation and poor sleep quality. Both certain forms of OSA (e.g. REM-OSA) and certain phenotypes (e.g. COMISA) are more common in women. Men have a higher risk of high loop gain central sleep apnoea.

Summary: For a better understanding of sex-typical phenotypes with the aim of a more targeted treatment approach of SDB, adequately powered studies on sex differences in SDB should be conducted.

Purpose of review: Obstructive sleep apnoea (OSA) is the most common form of sleep-disordered breathing and has been linked to cardiovascular health. However, some of the findings supporting this are controversial. These discrepancies might be a result of heterogeneity among OSA patients, and thus, additional information would be required to better stratify OSA patients according to cardiovascular risk. In this review, we aim to discuss the potential of biomarkers to fulfil this role.

Recent findings: Randomized controlled trials have been unable to confirm whether OSA treatment with continuous positive airway pressure (CPAP) has a positive effect on cardiovascular outcomes. Emerging physiology-based metrics of OSA seem to be more suitable for identifying patients at higher risk of cardiovascular disease and predicting the effects of CPAP outcomes on cardiovascular health. Similarly, blood-based molecular markers have gained attention in this context over the last few years.

Summary: Accurate cardiovascular risk stratification and appropriate treatment allocation for OSA patients remain challenging. However, significant efforts are being made to develop novel tools to address these important issues.

Purpose of review: Advanced cystic fibrosis lung disease remains the main cause of death in people with cystic fibrosis (pwCF). Cystic fibrosis transmembrane regulator (CFTR) modulators have changed the disease burden for eligible pwCF with access to this therapy.

Recent findings: Real-world data show that there are no safety concerns for patients with advanced cystic fibrosis lung disease treated with highly effective triple CFTR modulator therapy. The improvements are comparable to those in other people with cystic fibrosis and in part even better. Mortality and rates of lung transplantation have decreased since the approval of CFTR modulator therapy and, especially, highly effective triple CFTR modulator therapy. Nevertheless, at least 10% of people with cystic fibrosis are not eligible for highly effective CFTR modulator therapy, and the development of alternative treatments remains important.

Summary: The approval of highly effective CFTR modulator therapies has been a breakthrough in treatment for most people with cystic fibrosis, especially those with advanced lung disease, improving survival and reducing the burden of the disease.

Purpose of review: The cystic fibrosis (CF) Foundation issued guidelines to promote timely lung transplant referral for people with cystic fibrosis (pwCF) in 2019. Since then more has been published to help refine this complex decision. The goal of this review is to summarize the recent literature informing disease severity in CF, barriers to referral for pwCF and guide timely and appropriate lung transplant referrals.

Recent findings: Existing guidelines utilize the degree of airflow limitation as the primary criteria to refer for lung transplant, yet this variable has some prognostic uncertainty. Novel prognostic tools may provide more reliable metrics for predicting who with CF is at greatest risk of dying from their lung disease and could be used as an indicator for when to refer. In addition, updated analyses of national registry data have highlighted the significance of hemoptysis, low body mass index, and extra-pulmonary organ failure, as important prognostic markers. PwCF with these complications have historically been under-referred for lung transplant despite data suggesting lung transplant can be safe for some in these populations. Early referral should be considered in the presence of these complications.

Summary: This review builds on existing guidelines by incorporating novel data to better determine when lung transplant referral is most appropriate. Improved prognostic tools are still needed to decrease the chances of pwCF dying without consideration of lung transplant. It is still unclear how novel therapies for CF may change the need and timing for lung transplant referral.

Purpose of review: The gold standard for diagnosis and treatment of obstructive sleep apnea (OSA) is attended overnight polysomnography (PSG) in a sleep laboratory. Alternative diagnostic techniques are urgently needed for both diagnosis and treatment control when initiating positive airway pressure (PAP) in the home setting. Current PAP devices compute data such as residual AHI (apnea-hypopnea index) using their proprietary algorithms to provide an automatic event detection (AED). It was suggested that these should be labeled AHIFLOW.

Recent findings: The current study situation shows an acceptable agreement with the tendency of mildly overestimating the AHI by the PAP devices. But, the literature is still limited in terms of accuracy, especially when considering the lack of standardization and different detection algorithms.

Summary: A validation of PAP devices regarding the agreement of AHIFLOW compared to AHIPSG is extremely important, given that the device analysis is exclusively based on the measured flow. There are considerable concerns about assessing the PAP effectiveness in higher risk groups based on the AED function alone. Given these reservations, the use of PAP event detection can be an important addition to the diagnostic spectrum and, in combination with telemonitoring, offers promising potential.

Purpose of review: Dreaming has only recently become a topic of scientific research. This review updates current findings on dream studies, emphasizing recent research on the neural mechanisms of dreaming. Additionally, it summarizes new evidence on the functional role of dreams, including insights from studies on dreams and nightmares during the coronavirus disease 2019 (COVID-19) pandemic.

Recent findings: Recent advances on the neural basis of mental activity during sleep have shifted towards dream-related phenomena, such as dream experiences in relation to parasomnias and hypnagogic hallucinations. Although some findings are consistent with the main models explaining dream recall (i.e., continuity hypothesis; activation hypothesis), some results contrast with the role of parieto-occipital region in dream experience. Moreover, recent findings - related to COVID-19 pandemic - underlined that dream experiences could express emotion regulation processes as well as provide a simulation of reality to prepare for future dangerous or social interactions.

Summary: Overall, we highlighted the intricate interplay between brain regions in dreaming and suggest that dreams serve multiple functions, from reflecting waking-life experiences to simulating adaptive responses to threats. Understanding the neural bases and functions of dreaming can provide valuable insights into human mental health, nevertheless, further research is needed.