Annals of the American Thoracic Society最新文献

Rationale: Positive airway pressure therapy modalities in obesity hypoventilation syndrome (OHS) are still debated. Objectives: To describe health trajectories before and after starting noninvasive ventilation (NIV) and compare post-NIV outcomes between groups with different pre-NIV trajectories. Methods: Data came from the French national health insurance reimbursement database for individuals with OHS and one or more NIV prescriptions between January 1, 2015, and December 31, 2019. Health trajectory clusters were determined using mixture models that were graphically represented by time sequence analysis. Results: Data from 8,842 individuals were analyzed (59.7% had coexisting obstructive sleep apnea, 64% had one or more comorbidities). Median follow-up was 3.1 years. Cluster 1 (n = 5,853; 66.2%) started NIV while stable after pulmonary function testing, arterial blood gas (ABG) analysis, and sleep studies; 23.7% underwent bariatric surgery around NIV initiation. One-year therapy termination and mortality rates were 51.8% and 5.5%, respectively. Cluster 2 (n = 757; 8.6%) started NIV during or immediately after one or more acute intensive care unit hospitalizations in the previous year; 1-year NIV termination and mortality rates were 34.3% and 9.1%, respectively. Cluster 3 (n = 526; 5.9%) had NIV initiation after a sleep study, pulmonary function testing/arterial blood gas analysis, and approximately 3 months of continuous positive airway pressure; 1-year therapy termination and mortality rates were 23.0% and 2.1%, respectively. In cluster 4 (n = 1,706; 19.3%), long-term continuous positive airway pressure preceded the switch to NIV after reassessment in ambulatory care; 1-year therapy termination and mortality rates were 18.4% and 4.5%, respectively. Conclusions: These novel data highlight marked heterogeneity in OHS and use of positive airway pressure therapies, which significantly impacts outcomes.

Rationale: Tobacco use disorder begins in adolescence. In December 2019, the Tobacco 21 federal law restricted sales of tobacco products to persons ⩾21 years old in the United States. It is unclear how underaged tobacco sales changed after passage of Tobacco 21. Objectives: To compare underaged sales violations in Iowa before and after Tobacco 21, identify retailers with frequent violations, and measure assessed federal penalties. Methods: We analyzed 2017-2023 retail inspections in Iowa from U.S. Food and Drug Administration (FDA) tobacco compliance checks. We classified retailers by store type and used binary logistic regression to model underaged sales by retailer type, location, and time. We tabulated monetary penalties from FDA letters to retailers. Results: The FDA recorded 16,530 inspections at 3,789 locations. A total of 1,148 inspections (6.9%) resulted in sales violations. Twenty-four percent of locations had one or more violations. Tobacco/vape shops proliferated 3.8-fold in 7 years. Retailers with the highest violation rates included tobacco/vape shops, liquor stores, and some gas station chains. Violations trended higher in urban counties. Inspections and violations varied because of the COVID-19 pandemic. After inspections paused in 2020, violations grew to 10.6% in 2021. Federal penalties to retailers totaled $152,903 in 7 years. By contrast, tobacco marketing in Iowa exceeds $100 million annually. Conclusions: Underaged sales remained prevalent after passage of Tobacco 21. Tobacco specialty retailers proliferated in Iowa and frequently violated underaged sales restrictions. Violations rose after decreased inspections from the COVID-19 pandemic, emphasizing the importance of continued surveillance. Penalties for underaged sales were small relative to tobacco revenues. Higher penalties are needed to deter illegal sales.

Rationale: The most common lung function abnormality in people with human immunodeficiency virus (HIV) (PWH) is a low diffusing capacity of the lung for carbon monoxide (Dl_CO), which is associated with distinct plasma biomarker patterns, increased symptom burden, and increased mortality. In PWH undergoing spirometry and Dl_CO measurement, the most common abnormality is an abnormal Dl_CO with normal spirometry (iso↓Dl_CO), which is associated with distinct biomarkers and increased symptom burden but whose association with mortality is unknown. Objectives: To investigate the relationship between abnormal Dl_CO, including iso↓Dl_CO, and mortality in PWH. Methods: Adult PWH underwent pre and postbronchodilator spirometry and single-breath Dl_CO measurements from April 2013 to January 2023. Dl_CO was categorized as normal (Dl_CO greater than or equal to the lower limit of normal [LLN]), mildly abnormal (60% predicted < Dl_CO < LLN), or moderately to severely abnormal (Dl_CO ≤60% predicted). Iso↓Dl_CO was defined as abnormal Dl_CO with normal spirometry (forced expiratory volume in 1 second/forced vital capacity ⩾ LLN, forced expiratory volume in 1 second ⩾ LLN, forced vital capacity ⩾ LLN). Participants' present vital status was assessed through electronic health record review and the National Death Index. Multivariable Cox proportional hazards models adjusted for age, smoking status, history of bacterial pneumonia, and CD4 count were used to estimate associations between Dl_CO and all-cause mortality. Results: Among 241 participants, 205 (85%) were male and 26 (11%) died during follow-up of 1,055 person-years. Among 178 participants with normal spirometry, 16 (9%) died over 770 person-years. Both moderate to severe Dl_CO impairment (adjusted hazard ratio, 4.67; 95% confidence interval, 1.69-12.9; P = 0.003) and moderate to severe iso↓Dl_CO (adjusted hazard ratio, 11.0; 95% confidence interval, 2.20-55.1; P = 0.004) were significantly associated with increased mortality. Conclusions: Moderate to severe impairment of Dl_CO and iso↓Dl_CO are associated with all-cause mortality in PWH. Further studies evaluating mechanistic pathways and cause-specific mortality are warranted.

Rationale: Undertreatment of tuberculosis (TB) is common in resource-limited settings where same-day microbiological diagnosis is unavailable. Objectives: We evaluated if a simple clinical risk score for predicting active TB could facilitate treatment initiation among individuals at high risk for TB. Methods: We conducted a pragmatic, implementation-effectiveness study in periurban primary health clinics in Uganda. Four intervention clinics were paired with standard-of-care comparison clinics. Providers in intervention clinics were trained to use the score and set a threshold score for considering same-day treatment initiation; treatment decisions were at the providers' discretion. Our primary effectiveness outcome was the change in the proportion of individuals with confirmed TB who started on treatment within 7 days of presentation, comparing preintervention and postintervention periods. Results: Among intervention clinics, 594 (83%) of 720 people diagnosed with TB started treatment within 7 days during the preintervention period versus 264 (84%) of 316 after implementation (pre-post difference, 1%; 95% confidence interval [95% CI], -6%, 8%). In comparison clinics, 7-day treatment initiation changed from 312 (86%) of 363 preintervention to 153 (73%) of 211 postintervention (pre-post difference, -13%; 95% CI, -22, -5%). A difference-in-differences estimate was 14% (95% CI, 10%, 19%). In intervention clinics, 1,206 (66%) of 1,826 people presenting with TB symptoms were administered the risk score. Two hundred twenty-nine (19%) had a score above the treatment threshold, and 105 (46%) initiated treatment on the same day. Conclusions: An easy-to-use clinical risk score did not increase 7-day empiric treatment initiation in intervention clinics. However, it improved rapid treatment initiation relative to clinics using the prevailing standard of care. The score was also highly acceptable to clinical providers. Clinical trial registered with www.clinicaltrials.gov (NCT05122624).

Rationale: Few studies have identified risk sets for perinatal factors and airflow obstruction into middle adulthood. Objectives: To investigate associations between gestational age (GA), GA-adjusted birthweight, and mode of delivery and persistent airflow obstruction among patients 7-49 years old with obstructive lung diseases. Methods: The study population encompassed 44,778 individuals with asthma or chronic obstructive pulmonary disease (COPD) and one or more registration of post-bronchodilator values of forced expiratory volume in 1 second (FEV₁) and forced vital capacity (FVC) recorded in the Swedish National Airway Register in 2014-2022 and with both GA and birthweight data in the Medical Birth Register between 1973-2015. Persistent airflow obstruction was defined as a FEV₁/FVC z-score below the lower limit of normal. Analyses were done separately for children, young adults, and middle-aged adults. Results: Subjects who were extremely, very, moderate, and late preterm-born all had increased odds ratios (ORs) of persistent airflow obstruction up to age 49 years compared with those term-born. Middle-aged adults born small for GA had increased OR of persistent airflow obstruction compared with those appropriate for GA (OR, 1.49; 95% confidence interval, 1.23-1.81). In the risk sets, GA was the most significant covariate for persistent airflow obstruction. GA-adjusted birthweight was an additional covariate for those born late preterm, term, or postterm. Mode of delivery did not contribute. Conclusions: GA was an independent covariate of persistent airflow obstruction and, in the risk sets, proved to be the most important covariate in patients of all ages with either asthma or COPD. GA-adjusted birthweight further improved the prediction.

Rationale: Lung cancer is the leading cause of cancer death, with most cases attributable to cigarette smoking. People who identify as lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) are more likely to smoke; however, there are limited interventions to support lung cancer prevention in this community. Through prior community-engaged work, we developed a patient navigation intervention to support smoking cessation and lung cancer screening (LCS) for LGBTQ+ adults. Objectives: To conduct a prospective pilot study of the patient navigation intervention to evaluate patient satisfaction, acceptability, and knowledge change as well as LCS care completion and smoking cessation. Methods: We enrolled participants who currently smoked, identified as LGBTQ+, and were eligible for LCS in a patient navigation intervention and assessed outcomes over a 90-day period. We administered pre- and postintervention surveys, tracked navigation and LCS activities in the electronic health record, and verified tobacco cessation with exhaled carbon monoxide (CO) measurements. Primary outcomes included postintervention Acceptability of Intervention Measure scores, the Patient Satisfaction with Navigator Interpersonal Relationship score, and knowledge change on two validated measures. Secondary outcomes included being appropriately up-to-date on LCS and smoking cessation, measured as reported >7-day floating abstinence and end-of-study CO-confirmed [Formula: see text]30-day cessation. Results: Forty-one participants enrolled in the study and participated in the navigation program, with 34 completing postintervention surveys at Day 90. Acceptability (mean Acceptability of Intervention Measure score, 4.5) and patient satisfaction (mean Patient Satisfaction with Navigator Interpersonal Relationship score, 40.8) were both high. Fifty-nine percent of individuals were appropriately up-to-date on LCS at Day 90, as compared with 22% at baseline. Of postsurvey respondents, 41% reported a period of >7-day smoking abstinence during the study, with 18% reporting CO-confirmed abstinence of [Formula: see text]30 days at study end. Conclusions: Tailored patient navigation is a promising approach to enhance LCS uptake and smoking cessation in LCS-eligible LGBTQ+ individuals. Clinical trial registered with www.clinicaltrials.gov (NCT05304390).