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Associations of socioeconomic status and phenotypic frailty with incident chronic obstructive pulmonary disease: findings from UK Biobank participants. 社会经济地位和表型虚弱与慢性阻塞性肺病发病率的关系:英国生物库参与者的研究结果。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-15 DOI: 10.1016/j.chest.2024.11.004
Zhaolong Feng, Guoxian Li, Qida He, Na Sun, Tongxing Li, Qiang Han, Hanqing Zhao, Ze Ma, Mengtong Sun, Boyan Liu, Yu Wang, Zexin Lou, Siqian Ma, Yujie Shi, Jianing Li, Ziqing Sun, Miao Jiang, Yueping Shen

Background: The independent, mediation, interaction, and joint effects of socioeconomic status (SES) and phenotypic frailty on the incidence of chronic obstructive pulmonary disease (COPD) are unclear.

Research question: Do SES and frailty increase the risk of COPD independently or jointly ? Is there an interaction between the two factors in incident COPD? Does frailty play a mediating role between SES and COPD?

Study design and methods: This study included 396,106 UK Biobank participants without COPD at baseline. Latent class analysis was used to define the SES of participants. Frailty was defined by the frailty phenotypes according to five factors. Cox regression models were employed to examine the associations and calculate hazard ratios (HRs) and 95% confidence intervals (CIs). Mediation and interaction analyses were used to explain the associations between SES and frailty on COPD risk.

Results: During a median follow-up period of 13.5 years, 12,626 individuals were diagnosed with COPD. Compared with individuals of high SES or robust, low SES (HR: 2.69, 95% CI: 2.48-2.92) or frailty (HR: 2.75, 95% CI: 2.58-2.93) increased the risk of COPD, respectively; 11.80% of the association between SES and COPD was mediated by frailty. In addition, there was a statistically significant additive interaction of low SES and frailty with COPD incidence (relative risk due to interaction: 3.591, 95% CI: 2.189-4.992; attributable proportion due to the interaction: 0.433, 95% CI: 0.276-0.589). Compared to robust individuals with high SES, frail individuals with low SES have the highest risk of COPD (HR: 7.85, 95% CI: 6.96-8.86).

Interpretation: Low SES and frailty are independent risk factors for COPD, and these two factors also have synergistic interaction in COPD. Frailty partially mediated the association between SES and COPD. Thus, the early identification and reversal of frailty may minimize the risk of COPD, especially in individuals with low SES.

背景:社会经济地位(SES)和表型虚弱对慢性阻塞性肺病(COPD)发病率的独立影响、中介影响、相互作用和联合影响尚不明确:研究问题:社会经济地位和体弱是否会单独或共同增加慢性阻塞性肺病的发病风险?这两个因素在慢性阻塞性肺病的发病中是否存在相互作用?虚弱在社会经济地位和慢性阻塞性肺病之间是否起着中介作用?本研究纳入了 396 106 名基线时未患有慢性阻塞性肺病的英国生物库参与者。采用潜类分析法对参与者的 SES 进行定义。根据五个因素对虚弱表型进行定义。采用 Cox 回归模型检验相关性,并计算出危险比 (HR) 和 95% 置信区间 (CI)。采用中介分析和交互分析来解释社会经济地位和虚弱与慢性阻塞性肺病风险之间的关系:中位随访期为 13.5 年,共有 12626 人被诊断为慢性阻塞性肺病。与社会经济地位高或体格健壮的人相比,社会经济地位低(HR:2.69,95% CI:2.48-2.92)或体弱(HR:2.75,95% CI:2.58-2.93)的人罹患慢性阻塞性肺病的风险分别增加了11.80%;社会经济地位与慢性阻塞性肺病之间的关联有11.80%是由体弱介导的。此外,低社会经济地位和体弱与慢性阻塞性肺病发病率之间存在统计学意义上显著的叠加交互作用(交互作用导致的相对风险为 3.591,95% CI:2.58-2.93):3.591,95% CI:2.189-4.992;相互作用导致的可归因比例为 0.433,95% CI:0.433:0.433,95% CI:0.276-0.589)。与社会经济地位高的体格健壮者相比,社会经济地位低的体弱者罹患慢性阻塞性肺病的风险最高(HR:7.85,95% CI:6.96-8.86):低社会经济地位和体弱是慢性阻塞性肺病的独立风险因素,这两个因素在慢性阻塞性肺病中还具有协同作用。虚弱在一定程度上介导了社会经济地位与慢性阻塞性肺病之间的关系。因此,及早识别和扭转虚弱可能会将慢性阻塞性肺病的风险降至最低,尤其是在社会经济地位较低的人群中。
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引用次数: 0
Effects of β-blockers on the Outcomes in Patients with Pulmonary Arterial Hypertension Stratified by the Presence of Comorbid Conditions: a Multicenter Prospective Cohort Study (BNP-PL). 多中心前瞻性队列研究(BNP-PL):β-受体阻滞剂对肺动脉高压患者疗效的影响(根据合并症情况进行分层
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-09 DOI: 10.1016/j.chest.2024.10.051
Marcin Waligóra, Marcin Kurzyna, Tatiana Mularek-Kubzdela, Ilona Skoczylas, Łukasz Chrzanowski, Piotr Błaszczak, Miłosz Jaguszewski, Beata Kuśmierczyk, Katarzyna Ptaszyńska, Grzegorz Grześk, Katarzyna Mizia-Stec, Ewa Malinowska, Małgorzata Peregud-Pogorzelska, Ewa Lewicka, Michał Tomaszewski, Wojciech Jacheć, Michał Florczyk, Ewa Mroczek, Zbigniew Gąsior, Agnieszka Pawlak, Katarzyna Betkier-Lipińska, Piotr Pruszczyk, Katarzyna Widejko, Wiesława Zabłocka, Grzegorz Kopeć

Background: The current guidelines do not recommend β-blockers in pulmonary arterial hypertension (PAH) unless indicated by comorbidities. However, the evidence regarding the role of β-blockers in PAH is contradictory.

Research question: What are the effects of β-blockers on clinical outcomes in patients newly diagnosed with pulmonary arterial hypertension (PAH), and how do these outcomes differ based on the presence of cardiovascular comorbidities that are standard indications for β-blocker use?

Study design and methods: We analyzed data from 806 patients newly diagnosed with PAH enrolled prospectively in the Database of Pulmonary Hypertension in the Polish Population (BNP-PL). The endpoints were all-cause mortality and a composite of hospitalization due to right heart failure, syncope or death. Indications for β-blocker included hypertension, significant arrhythmia, and coronary artery disease(CAD). Propensity score matching (PSM) was used to form a control group based on age, PAH mortality risk variables and initially introduced PAH specific therapy.

Results: Out of the 806 patients, 469 (58.2%) received β-blockers at the time of PAH diagnosis. In PSM, β-blocker treatment showed a higher incidence of the composite endpoint (HR:1.44; 95% CI: 1.04-1.99; P = .03) and had neutral impact on mortality (HR, 1.22; 95% CI, 0.87-1.72; P = .25). When stratified by the presence of comorbidities, β-blockers showed adverse effects on composite endpoint in patients without comorbidities and a neutral effect in patients with at least one comorbidity INTERPRETATION: β-blockers pose significant risks in patients with PAH, especially in patients without coexisting systemic hypertension, CAD and arrhythmia.

背景:现行指南不推荐使用β-受体阻滞剂治疗肺动脉高压(PAH),除非有合并症。然而,有关 β 受体阻滞剂在 PAH 中作用的证据却相互矛盾:研究问题:β-受体阻滞剂对新诊断的肺动脉高压(PAH)患者的临床疗效有何影响?我们分析了波兰人群肺动脉高压数据库(BNP-PL)中前瞻性登记的 806 名新诊断 PAH 患者的数据。研究终点为全因死亡率和因右心衰、晕厥或死亡住院的综合死亡率。β受体阻滞剂的适应症包括高血压、严重心律失常和冠状动脉疾病(CAD)。根据年龄、PAH 死亡风险变量和最初采用的 PAH 特定疗法,采用倾向得分匹配法(PSM)组成对照组:结果:在 806 名患者中,469 人(58.2%)在确诊 PAH 时接受了 β 受体阻滞剂治疗。在 PSM 中,β 受体阻滞剂治疗显示出更高的复合终点发生率(HR:1.44;95% CI:1.04-1.99;P = .03),对死亡率的影响为中性(HR,1.22;95% CI,0.87-1.72;P = .25)。当根据是否存在合并症进行分层时,β-受体阻滞剂对无合并症患者的复合终点有不利影响,而对至少有一种合并症的患者则无影响。
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引用次数: 0
Clinical accuracy and risk of harm in asthma related content on TikTok. TikTok 上哮喘相关内容的临床准确性和危害风险。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-09 DOI: 10.1016/j.chest.2024.09.047
John K Murray, Emma McNally, Brian D Kent
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引用次数: 0
Results of the SHARP Study: A Randomized, Placebo-Controlled, Double-Blind, Repeated-Measures, Crossover, Phase IV Clinical Trial of the Effect of the Wake-Promoting Agent Solriamfetol on Cognitive Function in Obstructive Sleep Apnea With Excessive Daytime Sleepiness and Cognitive Impairment. SHARP 研究结果:一项随机、安慰剂对照、双盲、重复测量、交叉的 IV 期临床试验,研究促醒剂 Solriamfetol 对伴有白天过度嗜睡和认知功能障碍的阻塞性睡眠呼吸暂停患者认知功能的影响。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-09 DOI: 10.1016/j.chest.2024.10.050
Hans P A Van Dongen, Eileen B Leary, Christopher Drake, Richard Bogan, Judith Jaeger, Russell Rosenberg, Caroline Streicher, Herriot Tabuteau

Background: Obstructive sleep apnea (OSA) causes episodes of fragmented sleep and intermittent hypoxia and leads to excessive daytime sleepiness (EDS). Deficits in cognitive function are a troublesome symptom in patients with OSA and EDS.

Research question: How does solriamfetol affect cognitive function in patients with cognitive impairment associated with OSA and EDS?

Study design and methods: SHARP was a phase 4, randomized, double-blind, placebo-controlled, crossover trial. Participants (N=59) were randomized to receive placebo or solriamfetol (75 mg/day for 3 days, then 150 mg/day) for 2 weeks, with crossover separated by a 1-week washout. Efficacy measures included the Coding subtest, comparable to the Digit Symbol Substitution Test, of the Repeatable Battery for the Assessment of Neuropsychological Status (DSST RBANS), the British Columbia Cognitive Complaints Inventory (BC-CCI), Patient Global Impression of Severity (PGI-S), and Epworth Sleepiness Scale (ESS). The primary endpoint was change from baseline in average post-dose DSST RBANS scores. Secondary endpoints were changes from baseline in BC-CCI, PGI-S, ESS, and DSST RBANS scores at 2, 4, 6, and 8 hours post-dose. Safety was monitored by treatment-emergent adverse events (TEAEs).

Results: Solriamfetol significantly improved post-dose average DSST RBANS scores compared with placebo (P=0.009; effect size [Cohen's d] 0.37). When evaluated at each 2-hour timepoint, cognitive function was significantly improved at 2, 6, and 8 hours after dosing (all P<0.05). During solriamfetol treatment, there were significant improvements in BC-CCI (P=0.002; d=0.45), PGI-S (P=0.0mixed; d=0.29), and ESS (P=0.004; d=0.40) compared with placebo. The most common TEAEs were nausea (7%) and anxiety (3%).

Interpretation: SHARP demonstrated that solriamfetol can improve objective and subjective measures of cognitive function in patients with cognitive impairment associated with OSA and EDS.

Clinical trial registration: NCT04789174; EudraCT: 2020-004243-92.

背景:阻塞性睡眠呼吸暂停(OSA)会导致睡眠碎片化和间歇性缺氧,并导致白天过度嗜睡(EDS)。认知功能缺陷是 OSA 和 EDS 患者的一个令人头疼的症状:研究问题:索利安非托对伴有 OSA 和 EDS 的认知功能障碍患者的认知功能有何影响?SHARP是一项第4期随机、双盲、安慰剂对照交叉试验。参试者(59 人)被随机分配接受安慰剂或索利安非托(75 毫克/天,连续 3 天,然后 150 毫克/天)治疗,为期 2 周,交叉治疗间隔 1 周。疗效测量包括神经心理状态评估可重复性电池(DSST RBANS)的编码子测试(与数字符号替换测试相当)、不列颠哥伦比亚认知抱怨量表(BC-CCI)、患者对严重程度的总体印象(PGI-S)和埃普沃斯嗜睡量表(ESS)。主要终点是用药后 DSST RBANS 平均得分与基线相比的变化。次要终点是用药后 2、4、6 和 8 小时 BC-CCI、PGI-S、ESS 和 DSST RBANS 评分与基线相比的变化。安全性通过治疗突发不良事件(TEAEs)进行监测:与安慰剂相比,索利安非妥能明显改善服药后的DSST RBANS平均得分(P=0.009;效应大小[Cohen's d] 0.37)。在每个 2 小时时间点进行评估时,用药后 2、6 和 8 小时的认知功能均有明显改善(所有 P 均为 0.009):SHARP表明,索利安非托尔能改善伴有OSA和EDS的认知功能障碍患者的客观和主观认知功能:临床试验注册:NCT04789174;EudraCT:2020-004243-92。
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引用次数: 0
Quantitative Computed Tomography Analysis in Rheumatoid Arthritis-Related Interstitial Lung Disease. 类风湿性关节炎相关间质性肺病的定量计算机断层扫描分析
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-09 DOI: 10.1016/j.chest.2024.10.052
Stephen M Humphries, Ayodeji Adegunsoye, M Kristen Demoruelle, Michelle Li Wei Kam, Isabelle Amigues, Tami J Bang, Shawn D Teague, David A Lynch, Jonathan H Chung, Mary E Strek, Jeffrey J Swigris, Joshua J Solomon

Background: Quantitative chest computed tomography (CT) may be a useful predictor of outcome in rheumatoid arthritis-related interstitial lung disease (RA-ILD).

Research question: What is the utility of deep learning-based lung fibrosis quantitation on CT in assessing disease severity, predicting mortality and identifying progression in RA-ILD?

Study design and methods: CT scans on a primary cohort of 289 and a validation cohort of 50 individuals with RA-ILD were assessed quantitatively by using the data-driven texture analysis (DTA) method. We examined associations between quantitative scores for extent of lung fibrosis and pulmonary function and survival.

Results: DTA fibrosis score at baseline showed moderate negative correlation with forced vital capacity (FVC) percentage predicted (primary cohort rho=-0.55, validation cohort rho= -0.50, p<0.001 for both), and diffusing capacity for carbon monoxide (DLCO) percentage predicted (primary cohort rho=-0.67, validation cohort rho=-0.65, p<0.001 for both). Longitudinal change in DTA fibrosis score was associated with changes in FVC and DLCO in the primary cohort (rho=-0.46 and rho=-0.43, respectively, p<0.001 for both). Cox multivariable models adjusted for potentially influential variables showed that the baseline DTA fibrosis score was significantly associated with mortality risk (primary cohort hazard ratio [HR] 1.04, 95% confidence interval [1.03, 1.05], p<0.001; validation cohort HR 1.06, 95% confidence interval [1.01, 1.11], p=0.026). In the primary cohort increase in DTA fibrosis score on sequential scans was associated with increased risk of mortality (HR 1.04, 95% confidence interval [1.01, 1.06], p=0.003) independent of baseline DTA extent.

Interpretation: In two cohorts of patients with RA-ILD, quantitative assessment of lung fibrosis on CT was associated with worse lung function at baseline and risk of mortality. Increase in DTA-derived lung fibrosis score on sequential scans was associated with subsequent risk of mortality. Quantitative CT should be considered for use as a clinical and research outcome assessment tool in RA-ILD.

背景:定量胸部计算机断层扫描(CT胸部计算机断层扫描(CT)定量可能是类风湿性关节炎相关间质性肺病(RA-ILD)预后的有效预测指标:研究问题:基于深度学习的CT肺纤维化定量在评估疾病严重程度、预测死亡率和识别RA-ILD进展方面有什么用处?采用数据驱动纹理分析(DTA)方法,对289名主要队列和50名验证队列的RA-ILD患者的CT扫描进行定量评估。我们研究了肺纤维化程度和肺功能的定量评分与生存之间的关系:基线时的 DTA 纤维化评分与肺活量(FVC)预测百分比呈中度负相关(主要队列 rho=-0.55,验证队列 rho=-0.50,p解释):在两组RA-ILD患者中,CT上肺纤维化的定量评估与基线肺功能恶化和死亡风险有关。连续扫描中DTA衍生肺纤维化评分的增加与随后的死亡风险有关。应考虑将定量 CT 用作 RA-ILD 的临床和研究结果评估工具。
{"title":"Quantitative Computed Tomography Analysis in Rheumatoid Arthritis-Related Interstitial Lung Disease.","authors":"Stephen M Humphries, Ayodeji Adegunsoye, M Kristen Demoruelle, Michelle Li Wei Kam, Isabelle Amigues, Tami J Bang, Shawn D Teague, David A Lynch, Jonathan H Chung, Mary E Strek, Jeffrey J Swigris, Joshua J Solomon","doi":"10.1016/j.chest.2024.10.052","DOIUrl":"https://doi.org/10.1016/j.chest.2024.10.052","url":null,"abstract":"<p><strong>Background: </strong>Quantitative chest computed tomography (CT) may be a useful predictor of outcome in rheumatoid arthritis-related interstitial lung disease (RA-ILD).</p><p><strong>Research question: </strong>What is the utility of deep learning-based lung fibrosis quantitation on CT in assessing disease severity, predicting mortality and identifying progression in RA-ILD?</p><p><strong>Study design and methods: </strong>CT scans on a primary cohort of 289 and a validation cohort of 50 individuals with RA-ILD were assessed quantitatively by using the data-driven texture analysis (DTA) method. We examined associations between quantitative scores for extent of lung fibrosis and pulmonary function and survival.</p><p><strong>Results: </strong>DTA fibrosis score at baseline showed moderate negative correlation with forced vital capacity (FVC) percentage predicted (primary cohort rho=-0.55, validation cohort rho= -0.50, p<0.001 for both), and diffusing capacity for carbon monoxide (DLCO) percentage predicted (primary cohort rho=-0.67, validation cohort rho=-0.65, p<0.001 for both). Longitudinal change in DTA fibrosis score was associated with changes in FVC and DLCO in the primary cohort (rho=-0.46 and rho=-0.43, respectively, p<0.001 for both). Cox multivariable models adjusted for potentially influential variables showed that the baseline DTA fibrosis score was significantly associated with mortality risk (primary cohort hazard ratio [HR] 1.04, 95% confidence interval [1.03, 1.05], p<0.001; validation cohort HR 1.06, 95% confidence interval [1.01, 1.11], p=0.026). In the primary cohort increase in DTA fibrosis score on sequential scans was associated with increased risk of mortality (HR 1.04, 95% confidence interval [1.01, 1.06], p=0.003) independent of baseline DTA extent.</p><p><strong>Interpretation: </strong>In two cohorts of patients with RA-ILD, quantitative assessment of lung fibrosis on CT was associated with worse lung function at baseline and risk of mortality. Increase in DTA-derived lung fibrosis score on sequential scans was associated with subsequent risk of mortality. Quantitative CT should be considered for use as a clinical and research outcome assessment tool in RA-ILD.</p>","PeriodicalId":9782,"journal":{"name":"Chest","volume":" ","pages":""},"PeriodicalIF":9.5,"publicationDate":"2024-11-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142615779","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}
引用次数: 0
Sarcoidosis Treatment Patterns in the United States: 2016-2022. 美国肉样瘤病治疗模式:2016-2022.
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-08 DOI: 10.1016/j.chest.2024.10.040
Ruchika Sangani, Nicholas A Bosch, Praveen Govender, Brittany Scarpato, Allan J Walkey, Julia Newman, Anica C Law, Kari R Gillmeyer, Divya A Shankar

Background: There are limited FDA-approved medications and real-world data on sarcoidosis treatment in the U.S. and concordance of practice patterns with guideline recommendations have not been well characterized.

Research question: What are the practice patterns and factors associated with treatment for patients with sarcoidosis in the year following diagnosis?

Study design and methods: We conducted a retrospective analysis of patients with sarcoidosis from 2016 - 2022 using a multicenter, all-payer, claims database (TriNetX). We ascertained treatments with corticosteroids and/or non-steroidal immunosuppressive medications (methotrexate, mycophenolate, leflunomide, hydroxychloroquine, cyclophosphamide, infliximab, adalimumab, azathioprine, rituximab, and janus kinase inhibitors) within one year of diagnosis. We summarized treatment rates, sequence of prescribed medications by mean rank, and used multivariable logistic regression analyses to identify factors associated with treatment.

Results: Out of 13,330 patients with sarcoidosis meeting inclusion, 5,671 (42.5%) received treatment within a year of diagnosis. Of those treated, 60% received steroids alone, 13% received non-steroidal immunosuppressives alone, and 27% received both. Further, 25% of treated patients received a non-steroidal immunosuppressive as their first medication. Corticosteroids had the lowest mean rank order, indicating they were, on average, the first medication initiated. Among those with pulmonary or cutaneous involvement, the second medication initiated on average was hydroxychloroquine, while in those with cardiac or neurologic involvement it was adalimumab and mycophenolate, respectively. Factors associated with higher odds of treatment were Black race, organ involvement at baseline (pulmonary, cardiac, and neurologic), and comorbid diagnoses (fatigue, hypercalcemia, and ILD).

Interpretation: Within the first year of diagnosis, 43% of patients with sarcoidosis were started on treatment. Non-steroidal immunosuppressives were used in 40% of treated patients. While factors associated with treatment initiation aligned with guideline recommendations, practice patterns of treatment were variable, particularly in choice and sequence of non-steroidal immunosuppressive therapy, underscoring the need for future trials and comparative effectiveness studies.

背景:在美国,FDA 批准的药物和有关肉样瘤病治疗的真实世界数据都很有限,而且实践模式与指南建议的一致性也没有得到很好的体现:研究设计和方法:我们利用多中心、全付费者、理赔数据库(TriNetX)对2016-2022年期间的肉样瘤病患者进行了回顾性分析。我们确定了确诊后一年内皮质类固醇和/或非类固醇免疫抑制剂(甲氨蝶呤、霉酚酸、来氟米特、羟氯喹、环磷酰胺、英夫利昔单抗、阿达木单抗、硫唑嘌呤、利妥昔单抗和janus激酶抑制剂)的治疗情况。我们总结了治疗率、按平均等级排列的处方药物顺序,并使用多变量逻辑回归分析来确定与治疗相关的因素:在 13,330 名符合纳入条件的肉样瘤病患者中,5,671 人(42.5%)在确诊后一年内接受了治疗。在接受治疗的患者中,60%只接受了类固醇治疗,13%只接受了非类固醇免疫抑制剂治疗,27%同时接受了这两种治疗。此外,25%接受治疗的患者首次用药是非类固醇免疫抑制剂。皮质类固醇的平均排序最低,这表明平均而言,皮质类固醇是最先开始使用的药物。在肺部或皮肤受累的患者中,第二种药物平均是羟氯喹,而在心脏或神经系统受累的患者中,第二种药物分别是阿达木单抗和霉酚酸酯。黑人种族、基线器官受累(肺部、心脏和神经系统)和合并诊断(疲劳、高钙血症和ILD)是导致更高的治疗几率的相关因素:在确诊后的第一年内,43%的肉样瘤病患者开始接受治疗。40%的患者使用了非类固醇免疫抑制剂。虽然与开始治疗相关的因素与指南建议一致,但治疗的实践模式却各不相同,尤其是在非类固醇免疫抑制剂治疗的选择和顺序方面,这说明今后需要进行试验和比较效果研究。
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引用次数: 0
Comparison of clinically meaningful improvements following center-based and home-based tele rehabilitation in people with COPD. 比较慢性阻塞性肺病患者在中心康复和家庭远程康复后取得的有临床意义的改善。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-08 DOI: 10.1016/j.chest.2024.11.001
Dr Narelle S Cox, Dr Christine McDonald, Dr Angela T Burge, Dr Catherine J Hill, Ms Janet Bondarenko, Prof Anne E Holland
<p><strong>Background: </strong>Response to pulmonary rehabilitation is not equal for all participants, and may vary across health outcomes for any one individual. Alternative modes of pulmonary rehabilitation delivery, e.g. telerehabilitation, may improve program access but could also affect response to rehabilitation.</p><p><strong>Research questions: </strong>What is the rate of clinical response to home-based telerehabilitation compared to center-based pulmonary rehabilitation? And, are there participant baseline characteristics associated with pulmonary rehabilitation response relative to model of delivery?</p><p><strong>Study design and methods: </strong>Secondary analysis of two randomized controlled trials. Participants were categorized as 'responders' or 'non-responders' according to achievement of the minimal important difference (MID) for each outcome of interest at end rehabilitation and after 12-month follow-up (change from baseline). Outcomes of interest were: functional exercise capacity (six-minute walk distance [6MWD], MID 30m); health-related quality of life (chronic respiratory questionnaire [CRQ], MID 2.5, 2, 3.5 and 2 points for the dyspnea, fatigue, emotion and mastery domains, respectively; CRQ total score MID 10 points); and symptoms (modified Medical Research Council [mMRC], MID -1 point).</p><p><strong>Results: </strong>266 individuals with COPD were included in the analysis. The proportion of responders was not different between center-based pulmonary rehabilitation and home-based telerehabilitation at either end rehabilitation or 12-month follow-up for any outcome (range 39% to 62%). In a binary logistic regression analysis, baseline outcome values, but not participant demographic characteristics, were most commonly associated with responder status. The relative risk of program non-completion in the center-based group was nearly four times greater than for telerehabilitation (PR completion: center-based PR n=79 (58%) versus home-based telerehabilitation n=116 (90%); RR 3.89, 95%CI 2.28 to 6.63).</p><p><strong>Interpretation: </strong>Responder status to pulmonary rehabilitation was not different between center-based and home-based telerehabilitation. The ability to identify patient characteristics that confer greater potential for rehabilitation response, or better suitability for a particular model of rehabilitation, remains a challenge. Take home points: STUDY QUESTION: What is the rate of clinical response to home-based telerehabilitation compared to center-based pulmonary rehabilitation? And, are participant baseline characteristics, program completion or program location associated with rehabilitation response?</p><p><strong>Results: </strong>The proportion of responders to rehabilitation is not different between center-based and home-based telerehabilitation programs; however the risk of program non-completion is 4 times higher for center-based rehabilitation.</p><p><strong>Interpretations: </strong>Responder sta
背景:并非所有参与者对肺康复的反应都是一样的,任何一个人的健康状况都可能不同。肺康复治疗的替代模式,如远程康复治疗,可能会提高项目的可及性,但也可能影响康复治疗的反应:研究问题:与中心肺康复相比,家庭远程康复的临床反应率如何?研究设计和方法:对两项随机对照试验进行二次分析。根据康复结束时和随访 12 个月后(与基线相比的变化)各相关结果的最小重要差异(MID),将参与者分为 "有反应者 "和 "无反应者"。相关结果包括:功能锻炼能力(六分钟步行距离[6MWD],MID 30米);健康相关生活质量(慢性呼吸系统问卷[CRQ],呼吸困难、疲劳、情绪和掌握领域的MID分别为2.5分、2分、3.5分和2分;CRQ总分MID 10分);以及症状(修改后的医学研究委员会[mMRC],MID-1分)。在康复结束或 12 个月的随访中,中心肺康复和家庭远程康复在任何结果上的应答者比例均无差异(范围为 39% 至 62%)。在二元逻辑回归分析中,基线结果值(而非参与者人口统计学特征)与应答者状态的关系最为密切。中心康复组未完成计划的相对风险是远程康复组的近四倍(完成肺康复计划:中心康复计划 n=79 (58%) 对家庭远程康复计划 n=116 (90%);RR 3.89,95%CI 2.28 至 6.63):中心远程康复与家庭远程康复的肺康复应答状态没有差异。要确定哪些患者特征更有可能对康复产生反应,或更适合某种特定的康复模式,仍然是一项挑战。归纳要点:研究问题:与中心肺康复相比,家庭远程康复的临床反应率如何?参与者的基线特征、项目完成情况或项目地点是否与康复反应有关?中心和家庭远程康复项目的康复反应者比例没有差异;但中心康复项目的未完成风险比家庭康复项目高 4 倍:解读:中心远程康复和家庭远程康复的肺康复应答率没有差异,但家庭远程康复的康复完成率更高。确定参与者的哪些特征更有可能对康复产生反应,或更适合某种特定的康复模式,仍然是一项挑战。
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引用次数: 0
Trends in All-cause Mortality among U.S. Veterans with Sarcoidosis, 2004-2022. 2004-2022 年患有肉样瘤病的美国退伍军人的全因死亡率趋势。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-07 DOI: 10.1016/j.chest.2024.10.043
Mohamed I Seedahmed, Mohamed T Albirair, Aaron D Baugh, Walid F Gellad, S Mehdi Nouraie, Kevin F Gibson, Mary A Whooley, Charles E McCulloch, Laura L Koth, Mehrdad Arjomandi

Background: Sarcoidosis is an idiopathic multiorgan disease with variable clinical outcomes. Comprehensive analysis of sarcoidosis mortality in U.S. Veterans is lacking.

Research questions: What are the trends in all-cause mortality among U.S. Veterans with sarcoidosis, and how are these trends influenced by demographics, Black vs. White racial disparities, and geographic variability in relation to mortality?

Study design and methods: Using Veterans Health Administration (VHA) electronic health records (EHR), we conducted a population-based, retrospective cohort study of adjusted all-cause mortality 2004-2022 among Veterans diagnosed with sarcoidosis who received care through the VHA. Demographics, region of residence, service branch, tobacco use, and comorbidities were extracted from EHR. Annual trends in all-cause mortality and patient-level characteristics associated with mortality were examined with multivariable ungrouped Poisson regression. We visualized trends and analyzed state-by-state mortality using the marginal means procedure. In subgroup analysis (2015-2022), we considered the impact of neighborhood-level socioeconomic disparities using the area deprivation index (ADI).

Results: In all, 23,745 Veterans were diagnosed with sarcoidosis between 2004 and 2019 and followed through 2022. After adjustment, including age and sex, all-cause mortality increased annually by 4.7% (P<0.0001) and was 6.4% higher in Black than White Veterans (mortality rate ratio=1.064, P=0.02). A subgroup analysis comparing models with and without ADI adjustment showed no meaningful change in mortality trends. Risk factors for increased all-cause mortality included older age, male sex, Black race, and Northeast residence, and lower risk with "Other" service branches. Despite distinct geographical variations in mortality rates, no clear patterns emerged.

Interpretation: Mortality among Veterans with sarcoidosis is rising. Differences identified by service branch and higher risk among male Veterans raise questions about differences in environmental exposures. The narrower racial disparities and smaller impact of ADI than in other studies may highlight the role of universal healthcare access in achieving equitable outcomes.

背景:肉样瘤病是一种特发性多器官疾病,临床结果各不相同。目前缺乏对美国退伍军人肉样瘤病死亡率的全面分析:研究问题:患有肉样瘤病的美国退伍军人的全因死亡率趋势如何,这些趋势如何受到人口统计学、黑人与白人种族差异以及与死亡率相关的地域差异的影响?我们利用退伍军人健康管理局 (VHA) 的电子健康记录 (EHR),对通过 VHA 接受治疗的被诊断患有肉样瘤病的退伍军人 2004-2022 年调整后的全因死亡率进行了一项基于人群的回顾性队列研究。研究人员从电子病历中提取了退伍军人的人口统计学特征、居住地区、服役部门、烟草使用情况和合并症。通过多变量非分组泊松回归分析了全因死亡率的年度趋势以及与死亡率相关的患者水平特征。我们使用边际均值程序对趋势进行了可视化,并对各州死亡率进行了分析。在分组分析(2015-2022 年)中,我们使用地区贫困指数(ADI)考虑了邻里层面社会经济差异的影响:2004年至2019年期间,共有23745名退伍军人被确诊为肉样瘤病,并随访至2022年。在对年龄和性别等因素进行调整后,全因死亡率每年增加 4.7%(P解释):患有肉样瘤病的退伍军人死亡率正在上升。根据服役部门确定的差异和男性退伍军人的较高风险提出了环境暴露差异的问题。与其他研究相比,ADI 的种族差异较小,影响也较小,这可能凸显了普及医疗保健在实现公平结果方面的作用。
{"title":"Trends in All-cause Mortality among U.S. Veterans with Sarcoidosis, 2004-2022.","authors":"Mohamed I Seedahmed, Mohamed T Albirair, Aaron D Baugh, Walid F Gellad, S Mehdi Nouraie, Kevin F Gibson, Mary A Whooley, Charles E McCulloch, Laura L Koth, Mehrdad Arjomandi","doi":"10.1016/j.chest.2024.10.043","DOIUrl":"https://doi.org/10.1016/j.chest.2024.10.043","url":null,"abstract":"<p><strong>Background: </strong>Sarcoidosis is an idiopathic multiorgan disease with variable clinical outcomes. Comprehensive analysis of sarcoidosis mortality in U.S. Veterans is lacking.</p><p><strong>Research questions: </strong>What are the trends in all-cause mortality among U.S. Veterans with sarcoidosis, and how are these trends influenced by demographics, Black vs. White racial disparities, and geographic variability in relation to mortality?</p><p><strong>Study design and methods: </strong>Using Veterans Health Administration (VHA) electronic health records (EHR), we conducted a population-based, retrospective cohort study of adjusted all-cause mortality 2004-2022 among Veterans diagnosed with sarcoidosis who received care through the VHA. Demographics, region of residence, service branch, tobacco use, and comorbidities were extracted from EHR. Annual trends in all-cause mortality and patient-level characteristics associated with mortality were examined with multivariable ungrouped Poisson regression. We visualized trends and analyzed state-by-state mortality using the marginal means procedure. In subgroup analysis (2015-2022), we considered the impact of neighborhood-level socioeconomic disparities using the area deprivation index (ADI).</p><p><strong>Results: </strong>In all, 23,745 Veterans were diagnosed with sarcoidosis between 2004 and 2019 and followed through 2022. After adjustment, including age and sex, all-cause mortality increased annually by 4.7% (P<0.0001) and was 6.4% higher in Black than White Veterans (mortality rate ratio=1.064, P=0.02). A subgroup analysis comparing models with and without ADI adjustment showed no meaningful change in mortality trends. Risk factors for increased all-cause mortality included older age, male sex, Black race, and Northeast residence, and lower risk with \"Other\" service branches. Despite distinct geographical variations in mortality rates, no clear patterns emerged.</p><p><strong>Interpretation: </strong>Mortality among Veterans with sarcoidosis is rising. Differences identified by service branch and higher risk among male Veterans raise questions about differences in environmental exposures. The narrower racial disparities and smaller impact of ADI than in other studies may highlight the role of universal healthcare access in achieving equitable outcomes.</p>","PeriodicalId":9782,"journal":{"name":"Chest","volume":" ","pages":""},"PeriodicalIF":9.5,"publicationDate":"2024-11-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142615785","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}
引用次数: 0
Parasitic Infections in Pulmonary and Intensive Care Unit Patients: Presentation, Diagnosis, and Treatment. 肺部和重症监护室病人的寄生虫感染:表现、诊断和治疗。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-07 DOI: 10.1016/j.chest.2024.10.046
Adam C Kley, A Clinton White

Parasitic infections in the United States are mostly seen in immigrants and travelers. In many cases, pulmonary and intensive care physicians fail to consider parasitic disease, which can result in delayed diagnosis and adverse outcomes. Almost 2,000 cases of imported malaria are diagnosed in the United States each year. Severe cases can be confused with bacterial sepsis (shock, lactic acidosis, pneumonia, renal failure, respiratory failure, and jaundice). In contrast to bacterial sepsis, survival is improved by restrictive fluid therapy. Parenteral artesunate is licensed to treat severe cases but may not be readily accessible. Strongyloidiasis is endemic in warm and most tropical regions. Chronic strongyloidiasis causes few symptoms and can persist for decades after the patient leaves the endemic region. Treatment with corticosteroids may lead to hyperinfection, which may present with bacteremia and meningitis due to enteric organisms, pulmonary hemorrhage, and gastrointestinal pain, bleeding or obstruction. Treatment with ivermectin can be curative if initiated early. Cystic echinococcosis can present as pulmonary mass. Paragonimus presents with hemoptysis, pulmonary nodules, and/or pleural effusions, and usually with eosinophilia. Endemic regions include not only East Asia, but also Southeast Asia, west Africa, the Pacific coast of Latin America, and even North America. Other parasitic infections can involve the lungs. This article aims to provide awareness of the most clinically relevant parasitic infections seen in pulmonary and critical care medicine.

在美国,寄生虫感染主要见于移民和旅行者。在许多情况下,肺部和重症监护医生没有考虑到寄生虫病,这可能导致诊断延误和不良后果。美国每年诊断出近 2000 例输入性疟疾病例。严重病例可能与细菌性败血症(休克、乳酸酸中毒、肺炎、肾衰竭、呼吸衰竭和黄疸)相混淆。与细菌性败血症不同的是,限制性液体疗法可提高存活率。肠外青蒿琥酯可用于治疗严重病例,但可能不易获得。强直丝虫病在温暖和大多数热带地区流行。慢性强直性脊柱炎很少引起症状,在患者离开流行地区后可持续数十年。使用皮质类固醇治疗可能会导致高感染,表现为肠道菌引起的菌血症和脑膜炎、肺出血以及胃肠道疼痛、出血或梗阻。如果及早使用伊维菌素治疗,可以治愈疾病。囊性棘球蚴病可表现为肺部肿块。副猪嗜血杆菌表现为咯血、肺结节和/或胸腔积液,通常伴有嗜酸性粒细胞增多。流行地区不仅包括东亚,还包括东南亚、西非、拉丁美洲太平洋沿岸甚至北美洲。其他寄生虫感染也会累及肺部。本文旨在介绍肺部和重症医学临床上最常见的寄生虫感染。
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引用次数: 0
Lessons learned: Risk factors and clinical impact of severe pneumothorax after endoscopic lung volume reduction with endobronchial valves. 经验教训:使用支气管内瓣膜进行内窥镜肺容积缩小术后出现严重气胸的风险因素和临床影响。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-07 DOI: 10.1016/j.chest.2024.10.045
Judith Maria Brock, Susanne Annemarie Dittrich, Florian Eichhorn, Kai Schlamp, Konstantina Kontogianni, Felix Jf Herth

Background: Pneumothorax is a major complication following endoscopic lung volume reduction with valves with a prevalence of up to 34%. While some patients benefit from valve implantation despite pneumothorax, others are significantly impaired after lung collapse.

Research question: What are the differences in the severity grades of pneumothorax and how does that affect our clinical practice?

Study design and methods: This single-center retrospective study analyzed patients undergoing endoscopic valve implantation with and without post-interventional pneumothorax. Emphysema characteristics, collateral ventilation, management, and outcome of patients with pneumothorax 3 months after valve implantation were assessed. Pneumothorax was categorized as "severe pneumothorax" (chest tube insertion, prolonged air leak requiring valve removal), "moderate pneumothorax" (chest tube, no valve removal), and "mild pneumothorax" (no chest tube).

Results: Pneumothorax occurred in 102/532 patients (19%) and was significantly more common after valve placement in the upper lobes (31.3%) compared to the lower lobes (11.3%, p < 0.001). Fissure integrity was significantly higher in patients with pneumothorax (mean 96.6 ± 6.3 % vs. 93.4 ± 10.3 %, p = 0.002). Of all pneumothoraces, 30.4% were mild, 30.4% moderate, 39.2% severe. Severe pneumothorax caused multiple complications and prolonged hospitalization. Valve placement in the left upper lobe and a larger size of the target lobe were identified as risk factors for severe pneumothorax. Patients with pneumothorax developed complete lobar atelectasis in >60% as a sign of therapeutic success, but obviously only when valves could be left in place or re-implanted. However, valve re-implantation resulted in re-pneumothorax in 42.9%.

Interpretation: Patients could be more individually informed about their risk of pneumothorax, which varies with target lobe location, fissure integrity and re-implantation. The poor outcome and high complication rate of severe pneumothorax calls for future research into the prediction of severe pneumothorax.

背景:气胸是使用瓣膜进行内窥镜肺容积缩小术后的主要并发症,发生率高达 34%。有些患者尽管存在气胸,但仍能从瓣膜植入术中获益,而另一些患者则在肺塌陷后严重受损:研究设计和方法:这项单中心回顾性研究分析了接受内窥镜瓣膜植入术并伴有和不伴有介入后气胸的患者。评估了气胸患者的肺气肿特征、辅助通气、处理方法以及瓣膜植入术后 3 个月的预后。气胸分为 "重度气胸"(插入胸管,长时间漏气需要移除瓣膜)、"中度气胸"(插入胸管,不移除瓣膜)和 "轻度气胸"(不插入胸管):102/532 例患者(19%)发生气胸,与下叶(11.3%,P < 0.001)相比,上叶(31.3%)置入瓣膜后发生气胸的比例明显更高。气胸患者的裂隙完整性明显更高(平均为 96.6 ± 6.3 % 对 93.4 ± 10.3 %,p = 0.002)。在所有气胸中,30.4% 为轻度,30.4% 为中度,39.2% 为重度。重度气胸会导致多种并发症和住院时间延长。瓣膜置入左上肺叶和目标肺叶面积较大被认为是导致严重气胸的危险因素。60%以上的气胸患者会出现完全性肺叶偏流,这是治疗成功的标志,但显然只有当瓣膜可以留在原位或再次植入时才会出现这种情况。然而,42.9%的患者在重新植入瓣膜后再次出现气胸:解释:患者应更多地了解其气胸风险,气胸风险因靶叶位置、裂隙完整性和再次植入而异。严重气胸的治疗效果差、并发症发生率高,因此今后需要对严重气胸的预测进行研究。
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引用次数: 0
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Chest
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