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Annual lung cancer screening using low-dose CT (LDCT) imaging effectively reduces mortality from lung cancer and is recommended for people who are at high risk of developing the disease. The utilization of lung cancer screening, however, has remained low. Due to significantly higher cigarette smoking rates, patients with behavioral health disorders (those living with mental illness and/or substance use disorders) are more likely to be diagnosed with and die of lung cancer; at the same time, they are less likely to undergo cancer screenings. There is an urgent need for targeted efforts to improve access to lung cancer screening among this population disproportionately affected by the disease. In this commentary, we propose integrating lung cancer screening facilitation into services provided by behavioral health professionals who are uniquely positioned to reach these patients and deliver interventions to increase uptake of cancer screenings. We suggest several measures that could improve lung health outcomes of patients with behavioral health disorders: (1) training behavioral health professionals in lung cancer screening eligibility assessment; (2) providing patients with educational materials; (3) integrating shared decision-making counseling for lung cancer screening into behavioral health care settings; (4) providing the practical support needed to access screening; and (5) establishing effective partnerships with community organizations. Regardless of the level of engagement, possibly ranging from brief training to the implementation of comprehensive programs, any involvement will benefit patients. This integrated approach will contribute to reducing lung cancer mortality among patients with behavioral health disorders who have long experienced systemic health inequities.

Asthma is a common multifaceted respiratory disease with a major impact on quality of life. Despite increased insights into mechanisms underlying various asthma phenotypes and endotypes and the availability of targeted biologic treatment options, the disease remains uncontrolled in a substantial proportion of patients with risk of exacerbations, requiring systemic corticosteroids, and with progressive disease. Current international guidelines advocate a personalized management approach to patients with uncontrolled severe asthma. The European Forum for Research and Education in Allergy and Airway Diseases asthma expert panel was convened to discuss strategies to optimize asthma care and to prevent systemic corticosteroid overuse and disease progression. In this meeting report, we summarize current concepts and recommendations and provide a rationale to implement personalized asthma management at earlier stages of the disease. The ultimate goal is to move away from the current one-size-fits-most concept, which focuses on a symptom-driven treatment strategy, and shift toward a phenotype- and endotype-targeted approach aimed at curbing the disease course by improving clinical outcomes and preserving health-related quality of life. Herein, we provide a consensus view on asthma care that advocates a holistic approach and highlight some unmet needs to be addressed in future clinical trials and population studies.

Background: Traditional approaches for learning anatomy for curvilinear endobronchial ultrasound (EBUS) require learners to mentally visualize structures relative to the position of the bronchoscope. Virtual reality (VR) can show anatomy from the perspective of bronchoscopic tools.

Research question: Does the use of a VR anatomy trainer for teaching EBUS-associated anatomy improve procedural performance compared with traditional methods?

Study design and methods: In this randomized, crossover study design, participants studied EBUS-related anatomy during two sequential sessions using a VR trainer and a traditional modality (two-dimensional pictures or a three-dimensional model). An EBUS simulator was used to test performance at baseline and following each training session. User experience and preferences were evaluated by using a mixed-methods approach of surveys and interviews. Spatial reasoning ability was measured by using the Mental Rotation Test.

Results: Sixty-eight fellows and residents at three institutions completed the study. All three learning methods improved EBUS performance significantly following the first, but not second, learning session. Learners spent more time (1.37 minutes) with VR, but no training method produced a greater improvement. Spatial reasoning ability was associated with improved EBUS performance. This impact was modified by training method: the VR approach leveled the impact of baseline spatial reasoning. The VR approach was preferred by 96% of learners. Qualitative data revealed a positive VR user experience with focused anatomy learning, ease of use, acceptable realism, and tolerance. This novel "inside-looking-out" perspective helped learners understand anatomy from the vantage of procedural tools and to create a mental map, but interpreting ultrasound remained challenging.

Interpretation: A VR anatomy trainer was preferred by learners because it provided visualization that aligned best with the procedural perspective. This approach helped learners of all spatial reasoning ability improve their procedural performance.

Lung cancer is the second most common and the deadliest cancer for men and women in the United States. Historical and current-day injustices, implicit and explicit bias, stigma, social determinants, and disparities contribute to inequitable lung cancer-related health outcomes for Black and African American people comparatively. Despite being a preventive health recommendation for more than a decade, the percentage of eligible individuals screened remains low. Burgeoning lung cancer screening programs have established capacity and opened access across the country, but screening rates remain exceedingly poor, especially among people of color. More intentional efforts must be made, and socially conscious and population-specific methods must be undertaken to ensure all eligible individuals realize the benefits of screening. Partnerships between advocacy for patients with lung cancer and faith-based organizations are a natural leverage point to educate, prepare, and empower Black health ministries to disseminate lung cancer-related health information to their faith communities. This How I Do It article shares an approach to community outreach and engagement in Black churches in the South, informed by established principles and best practices and the perspectives and skills only lived experiences can offer.

Background: The prevalence of nontuberculous mycobacteria (NTM) pulmonary disease is rising globally. Previously, we described a high prevalence of Mycobacterium simiae isolation in Israel.

Research question: What is the prevalence of NTM pulmonary disease and M simiae pulmonary disease in Northern Israel? Which factors are associated with mortality among people with NTM?

Study design and methods: We retrospectively recorded all samples from Clalit Health Services-Haifa District reference mycobacteria laboratory for growth of NTM between January 2010 and March 2021. We manually reviewed a random sample of corresponding patients' electronic medical files and extracted demographic, clinical, and radiologic data, and data on the course of the disease. Univariate and multivariate analyses were performed to assess factors associated with features of NTM pulmonary disease and mortality.

Results: A total of 2,968 clinical isolates from 1,501 people yielded NTM species. The relative abundance of M simiae, Mycobacterium avium complex (MAC), and other species increased over the study period. Among the 550 patients' files reviewed, clinical presentation, fulfilment of established criteria for NTM pulmonary disease, and mortality rates were not significantly different between patients with M simiae, MAC, and Mycobacterium kansasii/Mycobacterium szulgai, with 27.7%, 35.3%, and 27.8% of people fulfilling criteria for NTM pulmonary disease. Factors associated with mortality included age, male sex, and immunosuppression. Compared with MAC isolation, M simiae was associated with elevated mortality (hazard ratio, 1.84; 95% CI, 1.05-3.23). The extrapolated national annual incidence rate of NTM pulmonary disease was 1.7 to 2.0 per 100,000 population.

Interpretation: Infection with M simiae is prevalent in Israel, and although considered minimally pathogenic, demonstrated similar clinical and radiologic features to MAC pulmonary disease.

Topic importance: COPD is a complex, heterogeneous lung disease characterized by persistent airflow limitation secondary to airways and parenchymal abnormalities, and respiratory symptoms, including dyspnea, fatigue, chronic cough, and sputum production. Cigarette smoke exposure is a major contributor to COPD; however, inhalation of toxic particles and other environmental and host factors can contribute to its genesis. Over time, the clinical course is frequently punctuated by exacerbations that further accelerate lung function decline and increase exacerbation risk. Despite current optimal therapy, many patients remain symptomatic, have exacerbations, and have increased morbidity, mortality, and health care costs. This review focuses on current knowledge of COPD pathophysiology, the role of inflammatory mechanisms, and the potential use of biologics to modulate these mechanisms.

Review findings: The inflammatory response in COPD includes both type 1 and type 2 immune cells. Type 2 inflammation is suggested by eosinophilia in a significant proportion of patients with COPD. Studies targeting IL-5 in patients with COPD have failed to demonstrate significant reductions in exacerbations, suggesting that eosinophil modulation alone may be insufficient to treat COPD. Based on a better understanding of the disease and role of alarmins, with a broader role in the inflammatory cascade, it is likely that some biologics may benefit certain COPD endotypes. Ongoing trials will provide information about which groups can benefit from the blocking of specific pathways (eg, IL-5, IL-4/IL-13, IL-33, thymic stromal lymphopoietin).

Summary: Biologics targeting inflammatory pathways may be effective treatments for specific patients with COPD.

Case presentation: An 80-year-old man with no history of substance addiction presented with complaints of cough and breathlessness for 4 months. His cough was nonproductive, waxing and waning in nature with high symptom load during daytime, but not associated with chest pain or wheezing. He gives no history of nasal or sinus symptoms, aspiration, or reflux symptoms. Breathlessness was nonparoxysmal, independent of cough and progressing from modified medical research council Grade-I to Grade II. It was not accompanied by wheezing or stridor. He denied specific triggers and seasonal, diurnal, or postural variation of symptoms. His medical history was largely unremarkable, apart from hypertension diagnosed 2 decades earlier. Despite 6 months of treatment with dual antihypertensive medications, his BP remained uncontrolled. He did not receive angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for the treatment of hypertension as per his old medical records. He denies history of atopy, occupational or environmental dust exposure. He refused history of fever, significant loss of weight or appetite. He had been treated for asthma with a combination of a long-acting beta-2 agonist and an inhaled corticosteroid inhaler, which provided no relief.

Background: Vasopressor administration at an appropriate time is crucial, but the optimal timing remains controversial.

Research question: Does early vs late norepinephrine administration impact the prognosis of septic shock?

Study design and methods: Searches were conducted in PubMed, EMBASE, the Cochrane Library, and KMbase databases. We included studies of adults with sepsis and categorized patients into an early and late norepinephrine group according to specific time points or differences in norepinephrine use protocols. The primary outcome was overall mortality. The secondary outcomes included length of stay in the ICU, days free from ventilator use, days free from renal replacement therapy, days free from vasopressor use, adverse events, and total fluid volume.

Results: Twelve studies (four randomized controlled trials [RCTs] and eight observational studies) comprising 7,281 patients were analyzed. For overall mortality, no significant difference was found between the early norepinephrine group and late norepinephrine group in RCTs (OR, 0.70; 95% CI, 0.41-1.19) or observational studies (OR, 0.83; 95% CI, 0.54-1.29). In the two RCTs without a restrictive fluid strategy that prioritized vasopressors and lower IV fluid volumes, the early norepinephrine group showed significantly lower mortality than the late norepinephrine group (OR, 0.49; 95%, CI, 0.25-0.96). The early norepinephrine group demonstrated more mechanical ventilator-free days in observational studies (mean difference, 4.06; 95% CI, 2.82-5.30). The incidence of pulmonary edema was lower in the early norepinephrine group in the three RCTs that reported this outcome (OR, 0.43; 95% CI, 0.25-0.74). No differences were found in the other secondary outcomes.

Interpretation: Overall mortality did not differ significantly between early and late norepinephrine administration for septic shock. However, early norepinephrine administration seemed to reduce pulmonary edema incidence, and mortality improvement was observed in studies without fluid restriction interventions, favoring early norepinephrine use.