Chest最新文献

Background: Although infections play a role in the development of lung cancer, the longitudinal association between infection and the risk of lung cancer is disputed, and data relating to pathogen types and infection sites are sparse.

Research question: How do infections affect subsequent lung cancer risk, and is the impact limited to specific microbes rather than infection burden?

Study design and methods: Data on > 900 infectious diseases were gathered from the UK Biobank study. Short- and long-term effects of infections were assessed by using time-varying Cox proportional hazards models. The analysis was repeated, excluding patients with concurrent multi-pathogen infections or outcomes within the 10 years following the initial hospitalization for the index infection. A life table approach was used to estimate years of life lost from lung cancer. Infection burden was defined as the sum of the number of infection episodes over time and co-occurring infections. The genome-wide association studies used in two-sample Mendelian randomization were obtained from mostly European ancestry.

Results: Hospital-treated infectious disease was associated with a greater risk of lung cancer (adjusted hazard ratio [aHR], 1.79; 95% CI, 1.74-1.83). aHRs for lung cancer ranged from 1.39 to 2.82 across pathogen types. The impact of lower respiratory tract infections (LRTIs) on lung cancer was the strongest, with an aHR of 3.22 (95% CI, 2.64-3.92); the aHR for extra-LRTIs was 1.29 (95% CI, 1.16-1.44). A dose-response association was observed between infection burden and lung cancer risk across different FEV₁ percent predicted (P_trend < .001). Multiple infections led to significant life lost from lung cancer at the age of 50 years. Mendelian randomization analysis reaffirmed the causal association.

Interpretation: Both observational and genetic analyses suggest that infectious diseases could increase the risk of lung cancer. The dual perspective on the LRTIs and extra-LRTIs impacts may inform lung cancer prevention strategies.

Background: Obesity hypoventilation syndrome (OHS) is associated with high morbidity and mortality. There are few data on whether there are gender differences in outcomes.

Research question: Do women with OHS experience worse outcomes in ambulatory and hospitalized settings compared to men?

Study design and methods: Post hoc analyses were performed on two separate OHS cohorts: (1) stable ambulatory patients from the two Pickwick randomized controlled trials; and (2) hospitalized patients with acute-on-chronic hypercapnic respiratory failure from a retrospective international cohort. We first conducted bivariate analyses of baseline characteristics and therapeutics between genders. Variables of interest from these analyses were then grouped into linear mixed effects models, Cox proportional hazards models, or logistic regression models to assess the association of gender on various clinical outcomes.

Results: The ambulatory prospective cohort included 300 patients (64% self-identified as women), and the hospitalized retrospective cohort included 1,162 patients (58% self-identified as women). For both cohorts, women were significantly older and more obese than men. Compared with men, baseline Paco₂ was similar in ambulatory patients but higher in hospitalized women. In the ambulatory cohort, in unadjusted analysis, women had increased risk of emergency department visits. However, gender was not associated with the composite outcome of emergency department visit, hospitalization, or all-cause mortality in the fully adjusted model. In the hospitalized cohort, prescription of positive airway pressure was less prevalent in women at discharge. In unadjusted analysis, hospitalized women had a higher mortality at 3, 6, and 12 months following hospital discharge compared with men. However, after adjusting for age, gender was not associated with mortality.

Interpretation: Our findings indicate that although the diagnosis of OHS is established at a more advanced age in women, gender is not independently associated with worse clinical outcomes after adjusting for age. Future studies are needed to examine gender-related health disparities in diagnosis and treatment of OHS.

Background: The latest meta-analysis indicated potential survival benefits from ultra-short-acting β-blockers in patients with sepsis with persistent tachycardia. However, subsequent multicenter randomized controlled trials (RCTs) have reported conflicting findings, prompting the need for an updated meta-analysis to incorporate these newly published RCTs.

Research question: Does the use of ultra-short-acting β-blockers (esmolol or landiolol) in patients with sepsis with persistent tachycardia improve mortality?

Study design and methods: We conducted an updated systematic search through April 2, 2024, exploring the MEDLINE, Cochrane Central Register of Controlled Trials, and Embase databases for RCTs reporting mortality in adult patients with sepsis treated with esmolol or landiolol as compared with those treated with neither of these or receiving placebo and published in English. Meta-analyses were conducted with the random effects model. The primary outcome was mortality at the longest follow-up, with subgroup analysis separating single-center RCTS from large multicenter RCTs.

Results: Eight RCTs (885 patients) were included in the primary analysis. Ultra-short-acting β-blockers did not improve mortality significantly at the longest follow-up (risk ratio, 0.84; 95% CI, 0.68-1.02; P = .08; I² = 51%; very low certainty of the evidence) and 28-day mortality (risk ratio, 0.77; 95% CI, 0.59-1.00; P = .05; I² = 62%). Subgroup analyses of mortality outcomes pointed toward different results between single-center and multicenter RCTs. Trial sequence analyses showed that both mortality outcomes were not robust. The sensitivity analyses suggested a significant reduction in mortality by adding RCTs published in non-English languages.

Interpretation: In this updated meta-analysis, the use of esmolol or landiolol did not reduce mortality in patients with sepsis with persistent tachycardia. However, results were not robust and outcomes differed between single-center and multicenter RCTs. Moreover, sensitivity analyses showed the fragility of the primary outcome. Further studies regarding ultra-short-acting β-blockers with advanced cardiac monitoring or serial echocardiography are warranted.

Trial registry: International Prospective Register of Systematic Reviews; No.: CRD42024503570; URL: https://www.crd.york.ac.uk/prospero/.

Background: For decades, the incidence and clinical characteristics of Pneumocystis jirovecii colonization in patients with severe pneumonia was unclear.

Research question: What are the clinical features and outcomes associated with P jirovecii colonization in individuals diagnosed with severe pneumonia?

Study design and methods: In this multicenter, retrospective, matched study, patients with severe pneumonia who underwent bronchoalveolar lavage clinical metagenomics from 2019 to 2023 in the ICUs of 17 medical centers were enrolled. Patients were diagnosed based on clinical metagenomics, pulmonary CT scans, and clinical presentations. Clinical data were collected retrospectively, and according to propensity score matching and Cox multivariate regression analysis, the prognosis of patients with P jirovecii colonization was compared with that of patients who were P jirovecii-negative.

Results: A total of 40% of P jirovecii-positive patients are considered to have P jirovecii colonization. The P jirovecii colonization group had a higher proportion of patients with immunosuppression and a lower lymphocyte count than the P jirovecii-negative group. More frequent detection of cytomegalovirus, Epstein-Barr virus, human herpesvirus-6B, human herpesvirus-7, and torque teno virus in the lungs was associated with P jirovecii colonization than with P jirovecii negativity. By constructing two cohorts through propensity score matching, we incorporated codetected microorganisms and clinical features into a Cox proportional hazards model and revealed that P jirovecii colonization was an independent risk factor for mortality in patients with severe pneumonia. According to sensitivity analyses, which included or excluded codetected microorganisms, and patients not receiving trimethoprim-sulfamethoxazole treatment, similar conclusions were reached.

Interpretation: Immunosuppression and a reduced lymphocyte count were identified as risk factors for P jirovecii colonization in patients with non-Pneumocystis pneumonia. More frequent detection of various viruses was observed in patients colonized with P jirovecii, and P jirovecii colonization was associated with an increased 28-day mortality in patients with severe pneumonia.

Background: COPD primarily impairs expiratory flow due to progressive airflow obstruction and reduced lung elasticity. Increasing evidence underlines the importance of inspiratory flow as a biomarker for selecting inhaler devices and providing ancillary aerodynamic information.

Research question: Do the longitudinal changes in maximum forced inspiratory flow (FIFmax) influence acute exacerbations and lung function decline in patients with COPD?

Study design and methods: This longitudinal study evaluated FIFmax in patients with COPD over a 7-year period from 2004 to 2020. Eligible patients were categorized into two groups based on FIFmax trajectory: the increased FIFmax group and the decreased FIFmax group. The study assessed the annual rate of acute exacerbations and the annual decline rate of FEV₁. Subgroup analyses were conducted based on treatment status, with a focus on inhaled therapy and inhaler device usage.

Results: Among the eligible 956 patients with COPD, 56.5% belonged to the increased FIFmax group. After propensity score matching, the increased FIFmax group experienced lower rates of severe exacerbations (0.16 per year vs 0.25 per year, P = .017) and a slower decline in FEV₁ (0 [interquartile range, -51 to 71] mL/y vs -43 [interquartile range, -119 to 6] mL/y; P < .001) compared with the decreased FIFmax group. These associations were particularly prominent in patients using specific inhaler therapies such as dry powder inhalers.

Interpretation: This study showed that the longitudinal changes in FIFmax are associated with clinical outcomes in patients with COPD. Patients with increased FIFmax experienced a lower rate of severe exacerbations and a slower decline in lung function. These findings suggest the potential benefits of optimizing inspiratory flow in COPD management, although further studies are needed to confirm these observations due to potential confounding factors.

Background: Sarcoidosis is an idiopathic systemic granulomatosis whose evolution is self-limiting in most cases. However, it can progress to organ damage that menaces the vital or functional prognosis of patients. Sarcoidosis itself, but also its comorbidities, can pose a threat to the patient, require rapid initiation of treatment, and justify emergency hospitalization.

Research question: What are the reasons and prognosis of patients with sarcoidosis hospitalized in emergency?

Study design and methods: The objectives of our study were to describe the causes of admission for and to identify predictors of mortality in patients with sarcoidosis hospitalized in emergency. This is a retrospective monocentric study. We included patients hospitalized after a stay in the ED or ICU, or requiring an unscheduled hospitalization after telephone advice or a consultation, between January 1, 2017, and July 7, 2020.

Results: We identified 154 patients with sarcoidosis hospitalized in emergency, among which 14 (9%) required the ICU. There were 81 male patients, with a median age of 55.0 years (interquartile range, 44.0-67.0). Sarcoidosis was inaugural in 20 patients (14%). The primary reason for hospitalization was lower respiratory infections in 32 patients (21%), followed by acute pulmonary exacerbation of sarcoidosis in 17 (11%), suspected cardiac sarcoidosis in 13 (8.4%), and neurosarcoidosis in 12 (7.7%). The median length of stay was 6 days (interquartile range, 3.00-10.0). In-hospital mortality rate was 3.9%. The 2-year transplantation-free survival after hospitalization was 86.8% (95% CI, 81.4-92.5). The factors associated with a worse transplantation-free survival were Charlson Comorbidity Index score (hazard ratio [HR], 1.29; 95% CI, 1.04-1.61; P = .021), pulmonary hypertension (HR, 2.53; 95% CI, 1.10-5.83; P = .029), and oxygen therapy during hospitalization (HR, 4.18; 95% CI, 1.55-11.29; P = .005).

Interpretation: Our findings indicate that the overall mortality of patients with sarcoidosis hospitalized in emergency was high. The presence of comorbidities and the severity of respiratory failure, as reflected by oxygen requirement, are important prognostic determinants.

Case presentation: A 23-year-old man presented to the ED with a history of respiratory distress, cough, and fever for 10 days. He was evaluated in the ED, where he received a diagnosis of pulmonary edema, secondary to mitral regurgitation with mitral valve prolapse syndrome. He was treated with antibiotics and diuretics and discharged to home. Three months later, he returned to the ED with similar complaints, for which he was treated symptomatically and discharged. After 4 months, the patient once again appeared with worsening respiratory distress and cough with fever. The dyspnea was not accompanied by orthopnea, pedal edema, or palpitation. The patient was admitted to the medical ICU. He had no history of arthralgia, myalgia, skin rash, or other signs of autoimmune disease. He denied any history of smoking, work-related or occupational exposures, drug intake, or recent travel.