Annals of the American Thoracic Society最新文献

Rationale: People with cystic fibrosis (pwCF) are living longer with increasing comorbidities. Objectives: To estimate the rate of emerging nonpulmonary comorbidities in adults with cystic fibrosis (CF) and to compare these rates with the non-CF population. Methods: This is a population-based cohort study of adults using Canadian Cystic Fibrosis Registry data linked with health administrative databases in Ontario. Cases of cardiovascular disease (CVD) and symptomatic kidney stones were identified using diagnostic and procedural codes. Chronic kidney disease (CKD) was defined as estimated glomerular filtration rate  <60 ml/min/1.73 m². Cancer cases were obtained using the Ontario Cancer Registry. Poisson regression was used to estimate the rates per 1,000 person-years of follow-up. Results: The age- and sex-adjusted rates of CVD, CKD, kidney stones, and cancer per 1,000 person-years in the non-lung transplantation cohort were 24.5 (95% confidence interval [CI], 21.5-28.0), 3.7 (95% CI, 2.7-5.2), 7.4 (95% CI, 6.1-9.0), and 5.8 (95% CI, 4.5-7.6) respectively. pwCF who underwent lung transplantation had higher rates of all four conditions, and cancer and CKD occurred earlier compared with the nontransplantation cohort. When comparing the CF and non-CF populations, pwCF without lung transplantation had higher age- and sex-adjusted rates of CVD (relative risk [RR], 2.9 [95% CI, 2.6-3.4]), CKD (RR, 2.1 [95% CI, 1.5-2.9]), kidney stones (RR, 2.9 [95% CI, 2.4-3.6]), and cancer (RR, 1.9 [95% CI, 1.5-2.5]). These events occurred at a median age of at least 20 years earlier in the CF cohort. In the post-transplantation population, there were no significant differences in the rates of CVD, kidney stones, and cancers between pwCF and the non-CF population, but events occurred earlier in pwCF. Conclusions: Nonpulmonary complications occur at a high rate and at a younger age in pwCF compared with the non-CF population, which highlights the importance of incorporating these issues in CF care models.

Rationale: In patients with lung cancer, the impact of chronic obstructive pulmonary disease (COPD) diagnosis and subsequent management on mortality remains uncertain, because evidence supporting the efficacy of inhaled therapies in improving clinical outcomes in this population is limited. Objectives: This aim of this study was to assess whether COPD worsens outcomes in patients with lung cancer and to investigate whether inhaled treatments for COPD can improve these outcomes. Methods: This retrospective cohort study used the Korea Central Cancer Registry database from 2012 to 2019. Patients with lung cancer aged 40 years and older with health screening records were included. Patients were classified into COPD and non-COPD groups, and within the COPD group, they were further classified on the basis of inhaled therapy status. The primary outcome was all-cause mortality, and secondary outcomes included healthcare resource use. Subgroup analyses were conducted on the basis of lung cancer stage, histologic subtypes, and treatment modalities. Results: Among 113,071 patients with lung cancer, 38,145 (33.7%) had COPD. COPD was associated with higher all-cause mortality (adjusted hazard ratio, 1.327; 95% confidence interval, 1.305-1.350; P < 0.001), increased use of steroids and antibiotics, higher rates of hospital admissions, and more frequent emergency department visits. Patients with COPD receiving inhaled treatment had lower mortality rates at the 3-month landmark (adjusted hazard ratio, 0.934; 95% confidence interval, 0.895-0.975; P = 0.002). Notably, the dual bronchodilator combination (long-acting β-agonist/long-acting muscarinic antagonist) was associated with a significant mortality reduction, as observed across multiple landmark time points. Conclusions: COPD is linked to worse clinical outcomes in patients with lung cancer. Among the inhaled treatments, the long-acting β-agonist/long-acting muscarinic antagonist dual therapy showed a beneficial effect on mortality, whereas adding inhaled corticosteroids as part of triple therapy did not provide an additional survival benefit. This study suggests the importance of early COPD detection and timely initiation of inhaled therapy in patients with lung cancer.

Rationale: Exposure to violence has been associated with asthma and worse asthma outcomes in youth, but no study has tested for an association between exposure to violence and specific asthma endotypes, including T helper (T)2-low endotypes. Objectives: We sought to determine if exposures to violence are associated with T2-high, T17-high, and T2-low/T17-low endotypes. Methods: We analyzed data from Puerto Rican youth aged 9-20 years with (cases) and without (controls) asthma in the EVA-PR (Epigenetic Variation and Childhood Asthma in Puerto Ricans) study. Using nasal (airway) epithelial transcriptomic profiles, participants with asthma were categorized into T2-high, T17-high, or T2-low/T17-low endotypes. Lifetime exposure to violence (ETV), past year ETV, and gun violence exposure (assessed using the validated ETV Scale questionnaire) and violence-related distress, assessed using the validated Checklist of Children's Distress Symptoms questionnaire, were our exposures of interest, and asthma endotype was our outcome of interest. Results: There were 236 cases (69 [29%] T2-high, 82 [35%] T17-high, and 85 [36%] T2-low/T17-low) and 243 controls. In multivariable analyses, ETV was associated with T17-high asthma (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.002-1.274), gun violence exposure was associated with both T2-high asthma (OR, 2.49; 95% CI, 1.22-5.08) and T17-high asthma (OR, 1.99; 95% CI, 1.05-3.74), and violence-related distress was associated with T2-high asthma (OR, 1.69; 95% CI, 1.11-2.59). Neither exposure to violence nor related distress was associated with T2-low/T17-low asthma. Conclusions: Exposure to violence or related distress was associated with T2-high asthma and T17-high asthma but not T2-low/T17-low asthma in Puerto Rican youth, a minoritized population with high asthma burden.

Rationale: Lifetime trauma is common and may affect interactions with the healthcare system. Objectives: To measure the prevalence of lifetime trauma and its association with family-clinician interpersonal outcomes in the intensive care unit (ICU). Methods: A cross-sectional study was conducted in nine ICUs in one urban and one suburban-rural health system. Participants were Black or White surrogate decision makers for mechanically ventilated patients. Independent variables were the number of lifetime traumatic events measured using the Life Stressor Checklist-Revised (LSC-R) and, secondarily and separately, discrimination-related traumatic stress symptoms. The primary outcome was family-reported conflict with ICU clinicians about treatment decisions. Secondary outcomes were family-reported quality of clinician communication and therapeutic alliance. Results: Among 141 family members (median age, 52.7 yr [interquartile range, 41.9-62.0 yr]; n = 100 women [70.9%]; n = 85 White [60.3%]; n = 56 Black [39.7%]), the median number of lifetime traumatic events was 6.0 (interquartile range, 4.0-9.0). Lifetime trauma was significantly but nonlinearly associated with family-clinician conflict (odds ratio [OR], 1.44 [95% confidence interval (CI), 1.09-1.90] for LSC-R scores of 0-7.5; OR, 0.75 [95% CI, 0.55-1.02] for LSC-R scores of 7.5-16; P = 0.03). Discrimination-related stress symptoms were also associated with conflict (OR, 1.04 [95% CI, 1.003-1.07]; P = 0.03). Interactions between the independent variables and family member race were not significant, suggesting the effects of lifetime trauma and discrimination-related traumatic stress on family-clinician conflict were similar for Black and White caregivers. Conclusions: Lifetime trauma is common among families of critically ill patients and is associated with negative experiences of critical care. Trauma-informed care may reduce family- clinician conflict and improve other measures of family experience.

Rationale: Physical limb restraints are commonly used in intensive care units (ICUs) to protect patients and staff but are associated with increased morbidity and disparities in care, particularly in intubated patients. Whether disparities in restraint use persist for nonintubated patients remains less clear. Objectives: We sought to identify whether patient race, ethnicity, and preferred language are associated with restraint use in nonintubated patients across multiple ICUs in a large U.S. hospital system. Methods: We performed a retrospective cohort study using electronic health record data across five ICUs within the University of California, San Francisco, from 2013 to 2022. We included adults who were 18 years of age and older. We excluded patients who received mechanical ventilation during their ICU stay. Our primary independent variables were primary language, race, and ethnicity. The outcome of interest was restraint use, defined as at least one restraint order placed during the patient's ICU stay. We modeled any restraint use using a multivariable logistic regression adjusted for sociodemographic and clinical covariates and explored interactions of our primary exposures using sensitivity analyses and Wald testing. Results: Across 22,259 unique ICU admissions, we identified 11,676 nonintubated patients. Of these, 2,411 (20%) received an order for physical restraints. In a multivariable regression model, compared with English, Chinese (all dialects) (odds ratio [OR], 1.57; 95% confidence interval [CI], 1.31-1.87) and a language other than Chinese, English, or Spanish (OR, 1.60; 95% CI, 1.36-1.89) were associated with increased use of restraints. Patients identifying as Black or African American were also more likely to be restrained at least once during the encounter (OR, 1.51; 95% CI, 1.27-1.79) compared with non-Hispanic White patients. Conclusions: Patients preferring Chinese or any language other than English or Spanish and those who identify as Black are more likely to be restrained in the ICU when not intubated. Interventions to minimize the use of unnecessary physical restraints could improve an inequity known to be associated with downstream harms.