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Novel Reference Equations for Pulmonary Artery Size and Pulsatility Using Echocardiography and Their Diagnostic Value in Pulmonary Hypertension. 利用超声心动图测量肺动脉大小和脉动性的新参考公式及其对肺动脉高压的诊断价值
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 Epub Date: 2024-07-25 DOI: 10.1016/j.chest.2024.06.3805
Shadi P Bagherzadeh, Bettia E Celestin, Everton J Santana, Michael Salerno, Kari C Nadeau, Andrew J Sweatt, Roham T Zamanian, Francois Haddad

Background: According to the most recent pulmonary hypertension (PH) guidelines, a main pulmonary artery (MPA) diameter > 25 mm on transthoracic echocardiography supports the diagnosis of PH. However, the size of the pulmonary artery (PA) may vary according to body size, age, and cardiac phases.

Research question: (1) What are the reference limits for PA size on transthoracic echocardiography, considering differences in body size, sex, and age? (2) What is the diagnostic value of the PA size for classifying PH? (3) How does the selection of different reference groups (healthy volunteers vs patients referred for right heart catheterization [RHC]) influence the diagnostic OR (DOR)?

Study design and methods: The study included a reference cohort of 248 healthy individuals as control patients, 693 patients with PH proven by RHC, and 156 patients without PH proven by RHC. In the PH cohort, 300 had group 1 PH, 207 had group 2 PH, and 186 had group 3 PH. MPA and right PA diameters and areas were measured in the upper sternal short-axis and suprasternal notch views. Reference limits (5th-95th percentile) were based on absolute values and height-indexed measures. Quantile regression analysis was used to derive median and 95th quantile reference equations for the PA measures. DORs and probability diagnostic plots for PH were then determined using healthy control and non-PH cohorts.

Results: The 95th percentile for indexed MPA diameter was 15 mm/m in diastole and 19 mm/m in systole in both sexes. Quantile regression analysis revealed a weak age effect (pseudo-R2 of 0.08-0.10 for MPA diameters). Among measures, the MPA size in diastole had the highest DOR (156.2; 95% CI, 68.3-357.5) for detection of group 1 PH. Similarly, the DORs were also high for groups 2 and 3 PH when compared with the control cohort but significantly lower compared with the non-PH cohort.

Interpretation: This study presents novel reference limits for MPA based on height indexing and quantile regression.

背景:根据最新的肺动脉高压(PH)指南,经胸超声心动图(TTE)显示主肺动脉(MPA)直径>25毫米可支持PH的诊断。然而,肺动脉(PA)的大小可能因体型、年龄和心脏阶段而异:1)考虑到体型、性别和年龄的差异,TTE 对肺动脉(PA)大小的参考界限是什么?2)PA 大小对肺动脉高压分类的诊断价值是什么?3)选择不同的参照组(健康志愿者与右心导管检查(RHC)转诊患者)对诊断几率(DOR)有什么影响?研究对象包括作为对照的 248 名健康人、693 名经右心导管检查确诊的 PH 患者和 156 名经右心导管检查确诊的非 PH 患者。在 PH 队列中,有 300 人患有第一组 PH,207 人患有第二组 PH,186 人患有第三组 PH。MPA和右PA(RPA)的直径和面积是在胸骨上短轴和胸骨上切迹切面上测量的。参考限值(第5-95百分位数)基于绝对值和身高指数测量值。量值回归分析用于得出 PA 测量的中位数和第 95 个量值参考方程。然后利用健康对照组和非PH队列确定PH的DOR和概率诊断图:结果:男女MPA直径指数的第95百分位数分别为舒张期15毫米/米和收缩期19毫米/米。量子回归分析显示年龄效应较弱(MPA直径的假R2为0.08至0.10)。在各种测量指标中,舒张期MPA尺寸的DOR最高,为156.2(68.3-357.5),用于检测1组PH。同样,与对照组相比,第2组和第3组PH的DOR也很高,但与非PH组相比则明显较低:该研究基于身高指数化和量子回归提出了新的 MPA 参考限值。
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引用次数: 0
A 52-Year-Old Woman With Persistent Back Pain and Multiple Pulmonary Nodules. 一名 52 岁女性,患有持续性背痛和多发性肺结节。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 DOI: 10.1016/j.chest.2024.06.3772
Moyan Sun, Abijha Boban, Schaza Rana, Hossny Alaws, Hisham F Qutob

Case presentation: A 52-year-old woman with a history of leiomyoma uteri and tobacco-use disorder in remission presented with 2 months of progressive back pain. Her pain was located between her shoulder blades and was described as constant with intermittent sharp, stabbing sensation. It was nonradiating and aggravated by inspiration. She denied fever, cough, shortness of breath, chest pain, or recent changes in weight or appetite. Two days prior, she was evaluated in the ED for similar symptoms and prescribed naproxen and cyclobenzaprine for suspected musculoskeletal pain. However, she received minimal relief, which prompted her visit. She underwent a total hysterectomy 13 years ago for benign uterine fibroid tumors. She had a 15-pack-year history but quit smoking 3 years ago. Family history was notable for colon and pancreatic cancer in her father and breast cancer in her maternal aunt.

病例介绍:一名 52 岁的妇女,曾患子宫良性肌瘤和烟草使用障碍,病情缓解后,出现持续性背部疼痛 2 个月。她的疼痛位于肩胛骨之间,被描述为持续性疼痛,间歇性尖锐刺痛感。疼痛无放射,吸气时加重。她否认发烧、咳嗽、气短、胸痛,也否认最近体重或食欲有变化。两天前,她因类似症状在急诊室接受了评估,并被开具了萘普生和环苯扎林治疗疑似肌肉骨骼疼痛。然而,她的症状得到的缓解微乎其微,这才导致了她的就诊。13 年前,她因良性子宫肌瘤接受了全子宫切除术。她有 15 年吸烟史,但 3 年前已经戒烟。家族史中,她的父亲患有结肠癌和胰腺癌,她的姨妈患有乳腺癌。
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引用次数: 0
Current Brain Death Clinical Criteria Are Adequate When Strictly Applied. 目前的脑死亡临床标准在严格应用时是充分的。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 DOI: 10.1016/j.chest.2024.05.049
Michael DePietro
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引用次数: 0
Prophylactic Minocycline for Delirium With Unexpected Death Benefits: What Was Treated Unexpectedly? 预防性米诺环素治疗谵妄可带来意外死亡收益:意外治疗了什么?
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 DOI: 10.1016/j.chest.2024.05.044
Sheng-Yuan Wang, James Cheng-Chung Wei
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引用次数: 0
Associations Between Air Pollution and the Onset of Acute Exacerbations of COPD: A Time-Stratified Case-Crossover Study in China. 空气污染与慢性阻塞性肺病急性加重发作之间的关系:中国的一项时间分层病例交叉研究。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 Epub Date: 2024-06-19 DOI: 10.1016/j.chest.2024.05.030
Yue Niu, Hongtao Niu, Xia Meng, Yixiang Zhu, Xiaoxia Ren, Ruoxi He, Hanna Wu, Tao Yu, Yushi Zhang, Haidong Kan, Renjie Chen, Ting Yang, Chen Wang

Background: Associations between air pollution and the acute exacerbations (AEs) of COPD have been established primarily in time-series studies in which exposure and health data were at the aggregate level, limiting the identification of susceptible populations.

Research question: Are air pollutants associated with the onset of AEs of COPD in China? Who is more susceptible to the effects of air pollutants?

Study design and methods: Data regarding AEs of COPD were obtained from the Acute Exacerbation of Chronic Obstructive Pulmonary Disease Registry (ACURE) study, and air pollution data were assigned to individuals based on their residential address. We adopted a time-stratified case-crossover study design combined with conditional logistic regression models to estimate the associations between six air pollutants and AEs of COPD. Stratified analyses were performed by individual characteristics, disease severity, COPD types, and the season of exacerbations.

Results: A total of 5,746 patients were included. At a 2-day lag, for each interquartile range increase in fine particulate matter and inhalable particulate matter concentrations, ORs for AEs of COPD were 1.054 (95% CI, 1.012-1.097) and 1.050 (95% CI, 1.009-1.092), respectively. The associations were more pronounced in participants who were younger than 65 years, who had experienced at least one severe AE of COPD in the past year, who had received a diagnosis of COPD between 20 and 50 years of age, and who had experienced AEs of COPD in the cool seasons. By contrast, significant associations for nitrogen dioxide, sulfur dioxide, and carbon monoxide lost significance when excluding patients collected before 2020 or with greater distance from the monitoring station, and no significant association was observed for ozone.

Interpretation: This study provides robust evidence that short-term exposure to fine particulate matter and inhalable particulate matter was associated with higher odds of AEs of COPD onset. Individuals who are young, have severe COPD, or whose first diagnosis of COPD was made when they were between 20 and 50 years of age and experience an exacerbation during the cooler seasons may be particularly susceptible.

Trial registry: ClinicalTrials.gov; No.: NCT2657525; URL: www.

Clinicaltrials: gov.

背景:空气污染与慢性阻塞性肺疾病(AECOPD)急性加重之间的关系主要是在时间序列研究中确定的,这些研究中的暴露和病例数据都是总体水平的,从而限制了对易感人群的识别:研究问题:在中国,空气污染物与 AECOPD 的发病是否相关?谁更容易受到空气污染物的影响?AECOPD数据来自慢性阻塞性肺疾病急性加重期登记研究,空气污染数据根据居住地址分配给个人。我们采用时间分层病例交叉研究设计,结合条件逻辑回归模型来估计六种空气污染物与 AECOPD 之间的关系。根据个人特征、疾病严重程度、慢性阻塞性肺病类型和恶化季节进行了分层分析:最终共纳入 5746 名患者。滞后2天后,PM2.5和PM10浓度每增加1个四分位数,慢性阻塞性肺疾病的几率比分别为1.054(95% CI:1.012,1.097)和1.050(95% CI:1.009,1.092)。年龄小于 65 岁、在过去一年中至少经历过一次严重的慢性阻塞性肺疾病、首次被诊断出患有慢性阻塞性肺疾病的年龄在 20 岁至 50 岁之间、在凉爽季节经历过慢性阻塞性肺疾病的参与者的相关性更为明显。相比之下,在排除 2020 年前收集的病例或与监测站距离较远的病例后,二氧化氮、二氧化硫和一氧化碳的显著相关性失去了意义,而臭氧则未观察到显著相关性:这项研究提供了强有力的证据,表明短期暴露于 PM2.5 和 PM10 与 AECOPD 发病几率较高有关。年龄较小、患有严重慢性阻塞性肺病或年轻慢性阻塞性肺病、在凉爽季节病情加重的人可能特别容易受到影响:临床试验注册号:NCT2657525(ClinicalTrials.gov)。
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引用次数: 0
Patient and Provider Perspectives Driving Inhaler Choice: Optimizing Sustainable Health Care. 从患者和医疗服务提供者的角度看吸入器的选择:优化可持续的医疗保健。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 Epub Date: 2024-07-02 DOI: 10.1016/j.chest.2024.06.3774
Graham Lough, Sinthia Bosnic-Anticevich, Nicolas Roche, Omar S Usmani
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引用次数: 0
Acute Pulmonary Edema Disguised as Pneumonia. 伪装成肺炎的急性肺水肿。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 DOI: 10.1016/j.chest.2024.05.045
Ali Naqvi, Mahmoud Abdallah, Ariel L Shiloh
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引用次数: 0
Enhancing Future Research and Clarifying the Role of Minocycline in Refining Delirium Prevention in Critical Care. 加强未来研究,明确米诺环素在完善重症监护中谵妄预防中的作用。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 DOI: 10.1016/j.chest.2024.06.3768
Shengshan Xu, Zhuming Lu
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引用次数: 0
Rethinking Blood Eosinophils for Assessing Inhaled Corticosteroids Response in COPD: A Post Hoc Analysis From the FLAME Trial. 重新思考用于评估慢性阻塞性肺病 ICS 反应的血液嗜酸性粒细胞:FLAME 的事后分析。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 Epub Date: 2024-07-09 DOI: 10.1016/j.chest.2024.06.3790
Alexander G Mathioudakis, Sebastian Bate, Pradeesh Sivapalan, Jens-Ulrik Stæhr Jensen, Dave Singh, Jørgen Vestbo

Background: The varied treatment response to inhaled corticosteroids (ICS) in patients with COPD and the associated increased risk of pneumonia necessitate a personalized ICS therapeutic approach. This is informed by blood eosinophil count (BEC), which predicts ICS treatment response. However, BEC appears to change in response to ICS treatment.

Research question: Does (1) BEC measured on ICS treatment (2) BEC measured off ICS treatment, or (3) the change in BEC during ICS treatment best predict treatment response to ICS in COPD?

Study design and methods: The Fluticasone Salmeterol on COPD Exacerbations Trial (FLAME), a 52-week, double-blind randomized controlled trial compared long-acting beta-2 agonists (LABAs)/long-acting muscarinic antagonists (LAMAs) with LABA/ICS. Corticosteroids were prohibited during a 4-week run-in period. We chose patients previously on ICS, thereby allowing BEC before and after the run-in period to represent BEC on and off ICS, respectively. In this post hoc analysis, we revisited outcome data, exploring how the three BEC biomarkers interacted with treatment response to the ICS-containing regimen.

Results: Our study showed that LABA/LAMA combination was superior, or at least noninferior, to LABA/ICS in curbing exacerbations for most FLAME participants. However, higher BEC off ICS, higher BEC on ICS, and significant BEC suppression during ICS treatment corresponded to superior response to LABA/ICS in terms of exacerbation rate, time to first exacerbation, and time to first pneumonia. In a subgroup, including 9% of participants, BEC changed significantly during ICS treatment (≥ 200 cells/μL), and higher BEC on ICS did not predict ICS treatment response. For these patients, BEC off ICS and BEC change proved more predictive. Excess pneumonia risk associated with ICS appeared to be confined to patients who do not benefit from this treatment. BEC was not predictive of treatment effects on lung function and health status.

Interpretation: This exploratory analysis advocates preferentially using BEC off ICS or BEC change during ICS treatment for guiding ICS treatment decisions. BEC measured on ICS is less predictive of treatment response.

Clinical trial registration: ClinicalTrials.gov; No.: NCT01782326; URL: www.

Clinicaltrials: gov.

背景:慢性阻塞性肺病(COPD)患者对吸入式皮质类固醇(ICS)的治疗反应各不相同,而且肺炎风险增加,因此有必要采用个性化的 ICS 治疗方法。血液嗜酸性粒细胞计数(BEC)可预测 ICS 的治疗反应。然而,嗜酸性粒细胞计数似乎会随着 ICS 治疗而发生变化:研究设计和方法:FLAME是一项为期52周的双盲RCT研究,比较了LABA/LAMA与LABA/ICS。在为期 4 周的磨合期内,禁止使用皮质类固醇。我们选择了之前服用过 ICS 的患者,从而使磨合期前和磨合期后的 BEC 分别代表服用和停用 ICS 时的 BEC。在这项事后分析中,我们重新研究了结果数据,探讨了三种 BEC 生物标志物如何与含 ICS 方案的治疗反应相互影响:结果:我们的研究证实,对于大多数 FLAME 参与者而言,LABA/LAMA 组合在遏制病情恶化方面优于或至少不劣于 LABA/ICS。然而,在ICS治疗期间,停用和使用ICS时的BEC值较高,且BEC值明显受到抑制,这与LABA/ICS在病情恶化率、首次病情恶化时间和首次肺炎时间方面的优越反应相对应。在包括 9% 的参与者在内的一个亚组中,BEC 在 ICS 治疗期间发生了显著变化(≥ 200 cells/μL),服用 ICS 时较高的 BEC 并不能预测 ICS 治疗反应。对这些患者来说,使用 ICS 后的 BEC 和 BEC 的变化更具预测性。与 ICS 相关的过高肺炎风险似乎仅限于不能从这种治疗中获益的患者。BEC不能预测治疗对肺功能和健康状况的影响:这项探索性分析主张优先使用ICS治疗后的BEC或ICS治疗期间的BEC变化来指导ICS治疗决策。临床试验注册:NCT01782326:临床试验注册:NCT01782326。
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引用次数: 0
Risk Assessment Tools in Pulmonary Arterial Hypertension: Why Can't We Be Friends? 肺动脉高压的风险评估工具:为什么我们不能成为朋友?
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 DOI: 10.1016/j.chest.2024.06.3819
Nicole F Ruopp, Harrison W Farber
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引用次数: 0
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