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Current Issue

Editorials

Chest. 2014;146(1):1-4. doi:10.1378/chest.14-1038
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Welcome to the new look of CHEST. With this issue, the design of the Journal comes into harmony with the new brand of CHEST (American College of Chest Physicians).

Chest. 2014;146(1):4-6. doi:10.1378/chest.14-0163

The evaluation, maintenance, and ultimate transplant of donor lungs remain one of the most challenging areas in transplantation. Donor lungs are often concomitantly injured at the time of donor death through infection, trauma, aspiration, and/or excessive smoking history. Although some progress has been made in terms of placing more organs over the past decade, lung use remains well below 50% of donors.1,2 There are a number of barriers to improving organ recovery in lung transplantation, including (1) the limited ability to accurately assess donor quality based on currently available preprocurement testing and (2) the limited evidence-based guidance regarding best practice in the ventilator management of potential donors.

Chest. 2014;146(1):6-8. doi:10.1378/chest.14-0171

Articles on pneumococcal pneumonia (PP) over the past 2 decades have frequently commented that reported mortality has shown very little, if any, improvement since the 1960s. Making true comparisons across the decades is difficult, however, due to the increasing numbers of elderly patients, the increasing frequency of chronic organ failure in the community, and the large variety of immunocompromised hosts from conditions such as HIV infection, chronic dialysis, and autoimmune diseases and their therapy. Acknowledging the problems of comparing outcomes in different populations, significant attention over the past 2 decades has been given to measuring how “sick” a patient is at entry to the ICU. It is, therefore, now possible to look at outcomes between units or across time intervals and be reasonably sure that you are comparing “apples with apples.”

Chest. 2014;146(1):8-10. doi:10.1378/chest.14-0030

Rheumatoid arthritis (RA) is the most common of the connective tissue diseases, affecting approximately 1% of the adult population.1,2 RA is a result of a complex interplay of autoimmune phenomena that ultimately results in a symmetric, inflammatory, and destructive arthropathy, and the majority of patients with the disease have evidence of circulating autoantibodies to rheumatoid factor (RF) or anticyclic citrullinated peptide antibodies (ACPAs).1,2

Chest. 2014;146(1):10-12. doi:10.1378/chest.13-2817

We are in the midst of a revolution in human biology, with our understanding of the evolution of transition from health to disease being decoded daily. Proteomics to genomics beckon as harbingers of a nirvana-like state where our maladies will be analyzed to such a degree that prognosis and treatment options will be available on an individualized level. As newer diagnostic and imaging technologies emerge, the art of history taking and clinical examination risks becoming redundant. Despite the undoubted promise of the new technologies, fundamental behavioral issues will still need to be addressed. It is unlikely that we will discover a gene that identifies those more at risk for nonadherence or that provides a marker for the presence of a low level of health literacy. Likewise, as transglobal migration creates multicultural and ethnic communities, behavioral and cultural issues will also require a different lens in creating models of care, especially those affected by the emerging global burden of chronic disease. This perspective argues the hypothesis that despite the promise of new technology, there will remain a need for an acknowledgment of behavioral perspective best described as a humanomics perspective.

Giants in Chest Medicine

Chest. 2014;146(1):13-15. doi:10.1378/chest.14-0014

Speaking for the remarkable number of mentees of Lawrence D. H. Wood, MD, PhD, who are productive and creative contributors to the field of critical care medicine, of which Dr Wood is a primary founder, I feel both delighted and humbled to offer some thoughts about this extraordinary man. Many others could and should add their own reflections on knowledge and inspiration received from him, and I acknowledge this as but a single step in that process. I believe that all of us regard Dr Wood as a leader in applying rigorous science to test hypotheses or answer questions arising at the bedside of critically ill patients.

Second Opinion

Chest. 2014;146(1):16. doi:10.1378/chest.146.1.16
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Commentary

Chest. 2014;146(1):17-21. doi:10.1378/chest.14-0536

Bronchial thermoplasty (BT) involves the application of radiofrequency energy to visible proximal airways to selectively ablate airway smooth muscle. BT is the first nonpharmacologic interventional therapy approved by the US Food and Drug Administration (FDA) for severe asthma. This approval was based on the results of the pivotal Asthma Intervention Research (AIR)-2 trial, which is the only randomized, double-blind, sham-controlled trial of BT. The primary end point of the AIR-2 trial was improvement in the Asthma Quality of Life Questionnaire (AQLQ). The results of the AIR-2 trial have generated enormous interest, controversy, and confusion regarding the true efficacy of BT for severe asthma. Current marketing of BT highlights its use for patients with “severe” asthma, which is interpreted by most practicing clinicians as meaning oral corticosteroid dependence, frequent exacerbations, or a significantly reduced FEV1 with a poor quality of life. Did the AIR-2 trial include patients with a low FEV1, oral steroid dependence, or frequent exacerbations? Did the trial show efficacy for any of the primary or secondary end points? The FDA approved the device based on the reduction in severe asthma exacerbations. However, were the rates of asthma exacerbations, ED visits, or hospitalizations truly different between the two groups, and was this type of analysis even justified given the original study design? This commentary is designed to specifically answer these questions and help the practicing clinician navigate the thermoplasty literature with confidence and clarity. We carefully dissect the design, conduct, and results of the AIR-2 trial and raise serious questions about the efficacy of bronchial thermoplasty.

Original Research: Chest Infections

Chest. 2014;146(1):22-31. doi:10.1378/chest.13-1531

OBJECTIVE:  The objective of the present study was to compare antibiotic prescribing practices and survival in the ICU for patients with pneumococcal severe community-acquired pneumonia (SCAP) between 2000 and 2013.

METHODS:  This was a matched case-control study of two prospectively recorded cohorts in Europe. Eighty patients from the Community-Acquired Pneumonia en la Unidad de Cuidados Intensivos (CAPUCI) II study (case group) were matched with 80 patients from CAPUCI I (control group) based on the following: shock at admission, need of mechanical ventilation, COPD, immunosuppression, and age.

RESULTS:  Demographic data were comparable in the two groups. Combined antibiotic therapy increased from 66.2% to 87.5% (P < .01), and the percentage of patients receiving the first dose of antibiotic within 3 h increased from 27.5% to 70.0% (P < .01). ICU mortality was significantly lower (OR, 0.82; 95% CI, 0.68-0.98) in cases, both in the whole population and in the subgroups of patients with shock (OR, 0.67; 95% CI, 0.50-0.89) or receiving mechanical ventilation (OR, 0.73; 95% CI, 0.55-0.96). In the multivariate analysis, ICU mortality increased in patients requiring mechanical ventilation (OR, 5.23; 95% CI, 1.60-17.17) and decreased in patients receiving early antibiotic treatment (OR, 0.36; 95% CI, 0.15-0.87) and combined therapy (OR, 0.19; 95% CI, 0.07-0.51).

CONCLUSIONS:  In pneumococcal SCAP, early antibiotic prescription and use of combination therapy increased. Both were associated with improved survival.

Chest. 2014;146(1):32-40. doi:10.1378/chest.13-2247

BACKGROUND:  Surface major histocompatibility complex class I-related chain (MIC) A and B molecules are increased by IL-15 and have a role in the activation of natural killer group 2 member D-positive natural killer and CD8 T cells. MICA and MICB also exist in soluble forms (sMICA and sMICB). Rhinoviruses (RVs) are the major cause of asthma exacerbations, and IL-15 levels are decreased in the airways of subjects with asthma. The role of MIC molecules in immune responses in the lung has not been studied. Here, we determine the relationship between MICA and MICB and RV infection in vitro in respiratory epithelial cells and in vivo in healthy subjects and subjects with asthma.

METHODS:  Surface MICA and MICB, as well as sMICA and sMICB, in respiratory epithelial cells were measured in vitro in response to RV infection and exposure to IL-15. Levels of sMICA and sMICB in serum, sputum, and BAL were measured and correlated with blood and bronchoalveolar immune cells in healthy subjects and subjects with asthma before and during RV infection.

RESULTS:  RV increased MICA and MICB in vitro in epithelial cells. Exogenous IL-15 upregulated sMICB levels in RV-infected epithelial cells. Levels of sMICB molecules in serum were increased in healthy subjects compared with subjects with stable asthma. Following RV infection, airway levels of sMIC are upregulated, and there are positive correlations between sputum MICB levels and the percentage of bronchoalveolar natural killer cells in healthy subjects but not subjects with asthma.

CONCLUSIONS:  RV infection induces MIC molecules in respiratory epithelial cells in vitro and in vivo. Induction of MICB molecules is impaired in subjects with asthma, suggesting these molecules may have a role in the antiviral immune response to RV infections.

Original Research: Diffuse Lung Disease

Chest. 2014;146(1):41-50. doi:10.1378/chest.13-1394

BACKGROUND:  Approximately 10% of patients with rheumatoid arthritis (RA) have interstitial lung disease (ILD), and one-third have subclinical ILD on chest CT scan. In this study, we aimed to further characterize functional decrements in a spectrum of RA-associated ILD.

METHODS:  All subjects were enrolled in the Brigham and Women’s Hospital Rheumatoid Arthritis Sequential Study (BRASS). The presence of interstitial lung abnormalities (ILAs) on clinically indicated chest CT scans was determined using a previously validated sequential reading method. Univariate and multivariate analyses were used to assess the association between degree of ILAs and physiologic, functional, and demographic variables of interest.

RESULTS:  Of 1,145 BRASS subjects, 91 subjects (8%) were included in this study. Twelve had radiologically severe ILAs, 34 had ILAs, and 38 had no ILAs on CT scan. Subjects with radiologically severe ILAs were older (P = .0037), had increased respiratory symptoms (cough, P = .027; dyspnea, P = .010), and more severe RA disease (rheumatoid factor, P = .018; total swollen joints, P = .046) compared with subjects with no ILAs. Participants also had a trend toward having an increased smoking history (P = .16) and having lower FVC % predicted (77% vs 94%, P = .097) and diffusion capacity of carbon monoxide % predicted (52% vs 77%, P = .068). Similar but attenuated increases in respiratory symptoms, functional decrements, and RA disease severity were observed in subjects with ILAs compared with those with no ILAs.

CONCLUSIONS:  We have shown that patients with RA have varying degrees of ILAs that are associated with a spectrum of functional and physiologic decrements. Our findings suggest that improved risk stratification and detection of ILAs will provide a therapeutic window that could improve RA-ILD outcomes.

Original Research: Critical Care

Chest. 2014;146(1):51-57. doi:10.1378/chest.13-2160

BACKGROUND:  The optimal approach for managing increased risk of VTE among critically ill adults is unknown.

METHODS:  An observational study of 294,896 episodes of critical illness among adults was conducted in 271 geographically dispersed US adult ICUs. The primary outcomes were all-cause ICU and in-hospital mortality after adjustment for acuity and other factors among groups of patients assigned, based on clinical judgment, to prophylactic anticoagulation, mechanical devices, both, or neither. Outcomes of those managed with prophylactic anticoagulation or mechanical devices were compared in a separate paired, propensity-matched cohort.

RESULTS:  After adjustment for propensity to receive VTE prophylaxis, APACHE (Acute Physiology and Chronic Health Evaluation) IV scores, and management with mechanical ventilation, the group treated with prophylactic anticoagulation was the only one with significantly lower risk of dying than those not provided VTE prophylaxis (ICU, 0.81 [95% CI, 0.79-0.84]; hospital, 0.84 [95% CI, 0.82-0.86; P < .0001). The mortality risk of those receiving mechanical device prophylaxis was not lower than that of patients without VTE prophylaxis. A study of 87,107 pairs of patients matched for propensity to receive VTE prophylaxis found that those managed with prophylactic anticoagulation therapy had significantly lower risk of death (ICU subhazard ratio, 0.82 [95% CI, 0.78-0.85]; hospital subhazard ratio, 0.82 [95% CI, 0.79-0.85]; P < .001) than those receiving only mechanical device prophylaxis.

CONCLUSIONS:  These findings support a recommendation for prophylactic anticoagulation therapy in preference to mechanical device prophylaxis for critically ill adult patients who do not have a contraindication to anticoagulation.

Chest. 2014;146(1):58-65. doi:10.1378/chest.13-2564

BACKGROUND:  Pulmonary edema may alter alveolar bacterial clearance and infectivity. Manipulation of fluid balance aimed at reducing fluid overload may, therefore, influence ventilator-associated pneumonia (VAP) occurrence in intubated patients. The objective of the present study was to assess the impact of a depletive fluid-management strategy on ventilator-associated complication (VAC) and VAP occurrence during weaning from mechanical ventilation.

METHODS:  We used data from the B-type Natriuretic Peptide for the Fluid Management of Weaning (BMW) randomized controlled trial performed in nine ICUs across Europe and America. We compared the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid-management group and the usual-care group during the 14 days following randomization, using specific competing-risk methods (the Fine and Gray model).

RESULTS:  Among the 304 patients analyzed, 41 experienced VAP, including 27 (17.8%) in the usual-care group vs 14 (9.2%) in the interventional group (P = .03). From the Fine and Gray model, the probabilities of VAC and VAP occurrence were both significantly reduced with the interventional strategy while adjusting for weaning outcome as a competing event (subhazard ratios [25th-75th percentiles], 0.44 [0.22-0.87], P = .02 and 0.50 [0.25-0.96], P = .03, respectively).

CONCLUSIONS:  Using proper competing risk analyses, we found that a depletive fluid-management strategy, when initiating the weaning process, has the potential for lowering VAP risk in patients who are mechanically ventilated.

TRIAL REGISTRY:  ClinicalTrials.gov; No.: NCT00473148; URL: www.clinicaltrials.gov

Original Research: Sleep Disorders

Chest. 2014;146(1):66-72. doi:10.1378/chest.14-0097

BACKGROUND:  Perimenopause is associated with increased cardiovascular risk. OSA is an emerging risk factor for cardiovascular disease, particularly among men, but the independent contribution of OSA to cardiovascular risk in climacteric women is not clear.

METHODS:  We evaluated 277 consecutive women (age, 56 [52-61] years; BMI, 28 [25-32] kg/m2) without manifest cardiovascular disease (heart failure, coronary disease, or stroke). All women underwent 24-h ambulatory BP monitoring, arterial stiffness evaluation (pulse wave velocity), and portable sleep study.

RESULTS:  OSA (apnea-hypopnea index ≥ 5 events/h) and moderate to severe OSA (apnea-hypopnea index ≥ 15 events/h) were diagnosed in 111 (40.1%) and 31 (11.1%) women, respectively. None of the participants had received a previous diagnosis of OSA. Women with moderate to severe OSA vs those without OSA had a higher prevalence of hypertension, were prescribed more medications for hypertension, had higher awake BP (systolic, 133 [125-142] vs 126 [119-134] mm Hg [P < .01]; diastolic, 82 [78-88] vs 79 [74-85] mm Hg [P = .07]), higher nocturnal BP (systolic, 125 [118-135] vs 115 [109-124] mm Hg [P < .01]; diastolic, 73 [69-79] vs 69 [62-75] mm Hg [P < .01]), and more arterial stiffness (pulse wave velocity, 11.5 [10.1-12.3] m/s vs 9.5 [8.6-10.8] m/s, P < .001). Oxygen desaturation index during the night was independently associated with 24-h arterial BP and arterial stiffness (per five-unit increase in oxygen desaturation index, β = 1.30 [95% CI, 0.02-2.54; P = .04] vs 0.22 [95% CI, 0.03-0.40; P = .02] in women with vs without OSA, respectively).

CONCLUSIONS:  OSA is common, underdiagnosed, and independently associated with high BP and increased arterial stiffness in perimenopausal women.

Chest. 2014;146(1):73-80. doi:10.1378/chest.13-2885

OBJECTIVE:  Refractory angina is a severe form of coronary artery disease (CAD) characterized by persistent angina despite optimal medical therapy. OSA and depression are common in patients with stable CAD and may contribute to a poor prognosis. We hypothesized that OSA and depression are more common and more severe in patients with refractory angina than in patients with stable CAD.

METHODS:  We used standardized questionnaires and full polysomnography to compare consecutive patients with well-established refractory angina vs consecutive patients with stable CAD evaluated for coronary artery bypass graft surgery.

RESULTS:  Patients with refractory angina (n = 70) compared with patients with stable CAD (n = 70) were similar in sex distribution (male, 61.5% vs 75.5%; P = .07) and BMI (29.5 ± 4 kg/m2 vs 28.5 ± 4 kg/m2, P = .06), and were older (61 ± 10 y vs 57 ± 7 y, P = .013), respectively. Patients with refractory angina had significantly more symptoms of daytime sleepiness (Epworth Sleepiness Scale score, 12 ± 6 vs 8 ± 5; P < .001), had higher depression symptom scores (Beck Depression Inventory score, 19 ± 8 vs 10 ± 8; P < .001) despite greater use of antidepressants, had a higher apnea-hypopnea index (AHI) (AHI, 37 ± 30 events/h vs 23 ± 20 events/h; P = .001), higher proportion of oxygen saturation < 90% during sleep (8% ± 13 vs 4% ± 9, P = .04), and a higher proportion of severe OSA (AHI ≥ 30 events/h, 48% vs 27%; P = .009) than patients with stable CAD. OSA (P = .017), depression (P < .001), higher Epworth Sleepiness Scale score (P = .007), and lower sleep efficiency (P = .016) were independently associated with refractory angina in multivariate analysis.

CONCLUSIONS:  OSA and depression are independently associated with refractory angina and may contribute to poor cardiovascular outcome.

Chest. 2014;146(1):81-87. doi:10.1378/chest.13-2060

BACKGROUND:  Cardiorespiratory fitness, assessed during cardiopulmonary exercise tests by peak oxygen uptake (V˙ o2pk), is an independent predictor of mortality in obesity. We investigated whether V˙ o2pk and systemic responses measured during field walking tests were similar to those measured during an incremental treadmill test (ITMT) in obese individuals with treated OSA.

METHODS:  Individuals with treated OSA and a BMI > 30 kg/m2 were recruited. Participants completed an ITMT, two 6-min walk tests (6MWTs), and two incremental shuttle walk tests (ISWTs) on three separate days in a randomized order. Expired gas analysis was performed during all tests.

RESULTS:  The study was completed by 16 patients (nine men) (mean [SD] age, 58 [12] y; BMI, 36.1 [7.6] kg/m2). There was no difference (P = .27) in V˙ o2pk assessed by the ITMT and the ISWT (2,266 [478] and 2,017 [561] mL/min, respectively). The V˙ o2pk measured by the 6MWT (1,778 [360] mL/min) was lower than that measured by the ITMT (P < .01). The limits of agreement for V˙ o2pk between the ISWT and the ITM were ± 730 mL/min. Cardiorespiratory responses during the ISWT and the ITMT reflected a graded response to a peak, whereas the 6MWT demonstrated a rapid rise to a plateau.

CONCLUSIONS:  The ISWT can be used instead of an ITMT and in preference to the 6MWT to assess cardiorespiratory fitness for a cohort of obese people with treated OSA. However, the imprecision of the agreement in V˙ o2pk between the ITMT and ISWT means they cannot be used interchangeably in an individual.

TRIAL REGISTRY:  ClinicalTrials.gov; No.: NCT01930513; www.clinicaltrials.gov

Chest. 2014;146(1):88-95. doi:10.1378/chest.13-2288

BACKGROUND:  OSA is highly prevalent in children and usually initially treated by adenotonsillectomy. Nonsurgical alternatives for mild OSA primarily consisting of antiinflammatory approaches have emerged, but their efficacy has not been extensively assessed.

METHODS:  A retrospective review of clinically and polysomnographically diagnosed patients with OSA treated between 2007 and 2012 was performed to identify otherwise healthy children ages 2 to 14 years who fulfilled the criteria for mild OSA and who were treated with a combination of intranasal corticosteroid and oral montelukast (OM) for 12 weeks (ICS + OM). A subset of children continued OM treatment for 6 to 12 months.

RESULTS:  A total of 3,071 children were diagnosed with OSA, of whom 836 fulfilled mild OSA criteria and 752 received ICS + OM. Overall, beneficial effects occurred in > 80% of the children, with nonadherence being documented in 61 children and adenotonsillectomy being ultimately performed in 12.3%. Follow-up polysomnography in a subset of 445 patients showed normalization of sleep findings in 62%, while 17.1% showed either no improvement or worsening of their OSA. Among the latter, older children (aged > 7 years; OR, 2.3; 95% CI, 1.43-4.13; P < .001) and obese children (BMI z-score > 1.65; OR: 6.3; 95% CI, 4.23-11.18; P < .000001) were significantly more likely to be nonresponders.

CONCLUSIONS:  A combination of ICS + OM as initial treatment of mild OSA appears to provide an effective alternative to adenotonsillectomy, particularly in younger and nonobese children. These results support implementation of multicenter randomized trials to more definitively establish the role of ICS + OM treatment in pediatric OSA.

Chest. 2014;146(1):96-103. doi:10.1378/chest.13-0309

BACKGROUND:  Central sleep apnea (CSA) is common among patients with heart failure (HF) and is promoted by elevated CO2 chemosensitivity. Left atrial size is a marker of the hemodynamic severity of HF. The aim of this study was to determine if left atrial size predicts chemosensitivity to CO2 and CSA in patients with HF.

METHODS:  Patients with HF with left ventricular ejection fraction ≤ 35% underwent polysomnography for detection of CSA, echocardiography, and measurement of CO2 chemosensitivity. CSA was defined as an apnea-hypopnea index (AHI) ≥ 15/h with ≥ 50% central apneic events. The relation of clinical and echocardiographic parameters to chemosensitivity and CSA were evaluated by linear regression, estimation of ORs, and receiver operator characteristics.

RESULTS:  Of 46 subjects without OSA who had complete data for analysis, 25 had CSA. The only parameter that significantly correlated with chemosensitivity was left atrial volume index (LAVI) (r = 0.40, P < .01). LAVI was greater in those with CSA than those without CSA (59.2 mL/m2 vs 36.4 mL/m2, P < .001) and significantly correlated with log-transformed AHI (r = 0.46, P = .001). LAVI was the best predictor of CSA (area under the curve = 0.83). A LAVI ≤ 33 mL/m2 was associated with 22% risk for CSA, while LAVI ≥ 53 mL/m2 was associated with 92% risk for CSA.

CONCLUSIONS:  Increased LAVI is associated with heightened CO2 chemosensitivity and greater frequency of CSA. LAVI may be useful to guide referral for polysomnography for detection of CSA in patients with HF.

Original Research: COPD

Chest. 2014;146(1):104-110. doi:10.1378/chest.13-2017

BACKGROUND:  Measures of physical function, daily physical activity, and exercise capacity have been proposed for the care of patients with COPD but are not used routinely in daily office care. Gait speed is a powerful and simple measure of physical function in elderly patients and seems to be a promising measure for the daily care of patients with COPD. The objective of this study was to comprehensively evaluate the determinants and factors influencing gait speed in COPD, particularly the association of gait speed with objectively measured physical activity and the most used exercise capacity field test in cardiopulmonary disease: the 6-min walk test (6MWT).

METHODS:  One hundred thirty patients with stable COPD performed two different 4-m gait speed protocols (usual and maximal pace). We modeled gait speed using demographics, lung function, dyspnea, quality of life, physical activity monitoring, exercise capacity, mood, cognitive function, and health-care use.

RESULTS:  Gait speed was independently associated with 6MWT but not with daily physical activity. The correlation between gait speed and 6MWT was high regardless of protocol used (r = 0.77-0.80). Both 6MWT and gait speed shared similar constructs. Gait speed had an excellent ability to predict poor (≤ 350 m) or very poor (≤ 200 m) 6MWT distances (areas under the curve, 0.87 and 0.98, respectively). Gait speed was not independently associated with quality of life, mood, or cognitive function.

CONCLUSIONS:  Gait speed is more indicative of exercise capacity (6MWT) than daily physical activity in COPD. Despite its simplicity, gait speed has outstanding screening properties for detecting poor and very poor 6MWT performance, making it a useful and informative tool for the clinical care of patients with COPD.

Chest. 2014;146(1):111-122. doi:10.1378/chest.13-2246

OBJECTIVE:  The COPD Assessment Test (CAT) has been proposed for assessing health status in COPD, but little is known about its longitudinal changes. The objective of this study was to evaluate 1-year CAT variability in patients with stable COPD and to relate its variations to changes in other disease markers.

METHODS:  We evaluated the following variables in smokers with and without COPD at baseline and after 1 year: CAT score, age, sex, smoking status, pack-year history, BMI, modified Medical Research Council (mMRC) scale, 6-min walk distance (6MWD), lung function, BODE (BMI, obstruction, dyspnea, exercise capacity) index, hospital admissions, Hospital and Depression Scale, and the Charlson comorbidity index. In patients with COPD, we explored the association of CAT scores and 1-year changes in the studied parameters.

RESULTS:  A total of 824 smokers with COPD and 126 without COPD were evaluated at baseline and 441 smokers with COPD and 66 without COPD 1 year later. At 1 year, CAT scores for patients with COPD were similar (± 4 points) in 56%, higher in 27%, and lower in 17%. Of note, mMRC scale scores were similar (± 1 point) in 46% of patients, worse in 36%, and better in 18% at 1 year. One-year CAT changes were best predicted by changes in mMRC scale scores (β-coefficient, 0.47; P < .001). Similar results were found for CAT and mMRC scale score in smokers without COPD.

CONCLUSIONS:  One-year longitudinal data show variability in CAT scores among patients with stable COPD similar to mMRC scale score, which is the best predictor of 1-year CAT changes. Further longitudinal studies should confirm long-term CAT variability and its clinical applicability.

TRIAL REGISTRY:  ClinicalTrials.gov; No.: NCT01122758; URL: www.clinicaltrials.gov

Original Research: Asthma

Chest. 2014;146(1):123-134. doi:10.1378/chest.13-2129

BACKGROUND:  The presence of visible mold in households is associated with asthma. However, the role of “classroom fungus” in the development of childhood asthma, as well as the fungal species that may lead to asthma, remains controversial. This nationwide school survey was conducted to investigate the correlation between fungal spores in classrooms and asthma in schoolchildren.

METHODS:  From April to May 2011, a cross-sectional survey was conducted to assess allergic/asthmatic conditions in schoolchildren aged 6 to 15 years old in 44 schools across Taiwan. Personal histories and current asthmatic conditions were collected using a modified International Study of Asthma and Allergies in Childhood questionnaire. Fungal spores in classroom were collected using a Burkard Personal Air Sampler and counted under light microscopy. Three-level hierarchical modeling was used to determine the complex correlation between fungal spores in classrooms and childhood asthma.

RESULTS:  The survey was completed by 6,346 out of 7,154 parents (88.7%). The prevalences of physician-diagnosed asthma, current asthma, and asthma with symptoms reduced on holidays or weekends (ASROH) were 11.7%, 7.5%, and 3.1%, respectively. The geometric mean spore concentrations of total fungi, Aspergillus/Penicillium, and basidiospores were 2,181, 49, and 318 spores/m3. Aspergillus/Penicillium and basidiospores were significantly correlated with current asthma and ASROH after adjusting for personal and school factors. Of those with current asthma, 41% reported relief of symptoms during weekends.

CONCLUSIONS:  Classroom Aspergillus/Penicillium and basidiospores are significantly associated with childhood asthma and ASROH. Government health policy should explore environmental interventions for the elimination of fungal spores in classrooms to reduce the prevalence of childhood asthma.

Original Research: Signs and Symptoms of Chest Disease

Chest. 2014;146(1):135-141. doi:10.1378/chest.13-2536

OBJECTIVE:  Reflex cough is a defensive response generated in the brainstem in response to chemical and mechanical stimulation of the airways. However, converging evidence shows that reflex cough is also influenced by central neural control processes. In this study, we investigate whether reflex cough can be modulated by attentional focus on either external stimuli or internal cough-related stimuli.

METHODS:  Healthy volunteers (N = 24; seven men; age range, 18-25 years) completed four blocks of citric acid-induced cough challenges while, simultaneously, auditory stimuli were presented. Within each block, four concentrations were administered (30, 100, 300 and 1,000 mM, randomized). During two subsequent blocks, participants focused their attention externally (counting tones). During the other two blocks, participants focused their attention internally (counting coughs). The order of attentional focus was counterbalanced across participants. Ratings of the urge to cough were collected after each challenge. Cough frequency was determined by audio recording.

RESULTS:  Cough frequency was higher when participants focused their attention internally vs externally (P < .05). Also urge to cough was greater during internal vs external focus (P < .05), but the effect was smaller in later blocks of trials.

CONCLUSIONS:  Reflex cough can be modulated by attentional focus. Internally focused attention may be a mechanism involved in excessive (idiopathic) cough, while an external focus may be introduced as part of treatments targeting excessive cough.

Topics: cough , cough reflex

Original Research: Genetic and Developmental Disorders

Chest. 2014;146(1):142-151. doi:10.1378/chest.13-1926

BACKGROUND:  Poor treatment adherence is common in cystic fibrosis (CF) and may lead to worse health outcomes and greater health-care use. This study evaluated associations of adherence to pulmonary medications, age, health-care use, and cost among patients with CF.

METHODS:  Patients with CF aged ≥ 6 years were identified in a national commercial claims database. A 12-month medication possession ratio (MPR) was computed for each pulmonary medication and then averaged for a composite MPR (CMPR) for each patient. The CMPR was categorized as low (< 0.50), moderate (0.50-0.80), or high (≥ 0.80). Annual health-care use and costs were measured during the first and second year and compared across adherence categories by multivariable modeling.

RESULTS:  Mean CMPR for the sample (N = 3,287) was 48% ± 31%. Age was inversely related to CMPR. In the concurrent year, more CF-related hospitalizations were observed among patients with low (event rate ratio [ERR], 1.35; 95% CI, 1.15-1.57) and moderate (ERR, 1.25; 95% CI, 1.05-1.48) vs high adherence; similar associations were observed for all-cause hospitalizations and CF-related and all-cause acute care use (hospitalizations + ED) in the concurrent and subsequent year. Rates of CF-related and all-cause outpatient visits did not differ by adherence. Low and moderate adherence predicted higher concurrent health-care costs by $14,211 ($5,557-$24,371) and $8,493 (−$1,691 to $19,709), respectively, compared with high adherence.

CONCLUSIONS:  Worse adherence to pulmonary medications was associated with higher acute health-care use in a national, privately insured cohort of patients with CF. Addressing adherence may reduce avoidable health-care use.

Chest. 2014;146(1):152-158. doi:10.1378/chest.13-2397

BACKGROUND:  The development of ivacaftor represents a significant advance in therapeutics for patients with cystic fibrosis (CF) who carry the G551D mutation. Patients with an FEV1 < 40% predicted represent a considerable proportion of eligible patients but were excluded from phase 3 clinical trials, and the effectiveness of the drug in this population is, therefore, unknown.

METHODS:  Data were collected from adult CF centers in the United Kingdom and Ireland with patients enrolled in an ivacaftor compassionate use program (FEV1 < 40% or on lung transplant waiting list). Clinically recorded data were collated from patient records for 1 year prior and for a period of 90 to 270 days following ivacaftor commencement. Each patient was matched to two control subjects who would have met the requirements for the compassionate use program with the exception of genotype.

RESULTS:  Twenty-one patients received ivacaftor for a median of 237 days. Mean FEV1 improved from 26.5% to 30.7% predicted (P = .01), representing a 16.7% relative improvement. Median weight improved from 49.8 to 51.6 kg (P = .006). Median inpatient IV antibiotic days declined from 23 to 0 d/y (P = .001) and median total IV treatment days decreased from 74 to 38 d/y (P = .002) following ivacaftor. Changes in pulmonary function and IV antibiotic requirements were significant compared with control subjects.

CONCLUSIONS:  Ivacaftor was clinically effective in patients with CF who carry the G551D mutation and have severe pulmonary disease. The reductions in treatment requirements were clinically and statistically significant and have not been described in less severe populations.

Original Research: Pulmonary Vascular Disease

Chest. 2014;146(1):159-166. doi:10.1378/chest.13-1900

BACKGROUND:  Pulmonary hypertension (PH) is common in elderly patients, but a detailed analysis of the causes of PH in the elderly has not been performed. We hypothesized that pulmonary arterial hypertension (PAH) is rare in elderly patients and sought to describe the characteristics of these patients at a large referral center.

METHODS:  Clinical and hemodynamic data were collected on consecutive patients ≥ 65 years of age referred for evaluation of PH. The subtype of PH was determined after standard evaluation using the World Health Organization (WHO) classification. Patients with PH not meeting criteria for PAH with “out-of-proportion” PH related to group 2 or group 3 disease were classified as “other/mixed PH.” A model using age, presence of connective tissue disease, and left atrial size was developed to predict the probability of PAH diagnosis.

RESULTS:  Two hundred forty-six elderly patients were evaluated (mean age, 72.9 ± 5.5 years, 78% women); 36 had PAH (15%). Idiopathic PAH was rare (four patients, 1.6%). WHO group 2 PH was the most frequent diagnosis (n = 70, 28% of cohort); mixed/other PH (n = 43, 17%) and WHO group 3 PH (n = 34, 14%) were also common diagnoses. Connective tissue disease strongly predicted PAH diagnosis (OR, 27.2; 95% CI, 9.5-77.6).

CONCLUSIONS:  PAH is an uncommon cause of PH in elderly patients, most frequently associated with connective tissue disease. WHO group 2 PH and mixed disease are common, highlighting a need for careful phenotyping of elderly patients with PH prior to initiating PAH therapy.

Chest. 2014;146(1):167-174. doi:10.1378/chest.13-0172

BACKGROUND:  Pulmonary venoocclusive disease (PVOD) is a rare lung disease, diagnosed in 5% to 10% of patients with pulmonary hypertension (PH). The incidence, prevalence, and etiology of PVOD in children are not well defined. The mortality remains high, related, at least partly, to the limited treatment options.

METHODS:  This retrospective analysis (1985-2011) summarizes symptoms, associated factors, treatment, and outcomes of nine pediatric patients (five girls, four boys) with histologic confirmation of PVOD.

RESULTS:  PH was diagnosed at a mean age of 13.5 years (range, 8-16 years), followed by the definitive diagnosis of PVOD at a mean age of 14.3 years (range, 10-16 years). Symptoms such as decreased exercise tolerance (n = 6) and/or shortness of breath (n = 9) preceded the diagnosis by 21 months on average; the mean survival time after diagnosis was 14 months (range, 0-47 months). CT scans of the lungs showed typical radiologic features. Treatment included supplemental home oxygen (n = 5), diuretics (n = 9), warfarin (n = 4), and pulmonary vasodilators (n = 4). Four children were listed for lung transplantation, and three have undergone transplantation. Eight patients died, including two after lung transplantation. One patient with lung transplant survived with good quality of life.

CONCLUSIONS:  PVOD is an important differential diagnosis for pediatric patients with PH. CT scanning is a valuable tool to image lung abnormalities; the definitive diagnosis can only be made by examination of lung biopsy specimens, which subjects the patient to additional risk. Early listing for lung transplantation is essential, as the mean survival time is only 14 months.

Original Research: Lung Cancer

Chest. 2014;146(1):175-181. doi:10.1378/chest.13-2506

OBJECTIVE:  The 2011 International Association for the Study of Lung Cancer (IASLC)/American Thoracic Society (ATS)/European Respiratory Society (ERS) classification of pulmonary adenocarcinomas introduces adenocarcinoma in situ and minimally invasive carcinoma and categorizes adenocarcinoma with more extensive invasion by the predominant subtype. Data have shown that wedge or segmentectomy (W/S) may be appropriate for in situ and minimally invasive adenocarcinoma, but whether sublobar resection is appropriate for tumors with more extensive invasion is unclear. The aim of this pilot study is to evaluate whether there are any trends regarding the impact of invasion and subtypes of carcinoma regarding survival in lobectomy vs W/S procedures using a comprehensive histologic evaluation.

METHODS:  Eighty-five surgical specimens (59 lobectomies, 26 W/Ss) were reviewed. Histologic type, size, pleural, lymphovascular invasion, and necrosis were recorded. Adenocarcinomas were classified by 2011 IASLC/ATS/ERS guidelines with each histologic pattern recorded as a percentage of the total tumor. Statistical analysis was performed using SAS, version 9.2. Proportional hazards regression analysis was used to evaluate survival according to resection type (lobectomy or W/S) adjusting for tumor size and the predominant histology.

RESULTS:  Multivariate analysis did not show a statistically significant difference in survival between lobectomy and W/S specimens adjusting for tumor size, regardless of histologic subtype or other negative predictors of prognosis (P = .7704).

CONCLUSIONS:  Our findings corroborate the prognostic significance of the 2011 adenocarcinoma subtyping classification and additionally suggest that lobectomy does not offer an overall survival advantage over W/S regardless of histologic subtype. Therefore, this finding suggests that limited resection may be appropriate for small size tumors, particularly those ≤ 2 cm with invasive histology.

Evidence-Based Medicine

Chest. 2014;146(1):182-192. doi:10.1378/chest.14-0824

BACKGROUND:  American College of Chest Physicians’ (CHEST) new Living Guidelines Model will not only provide clinicians with guidance based on the most clinically relevant and current science but will also allow expert-informed guidance to fill in any gaps in the existing evidence. These guidance documents will be updated, as necessary, using one or more of three processes: (1) evidence-based guidelines, (2) trustworthy consensus statements, and (3) a hybrid of the other two. The new Living Guidelines Model will be more sustainable and will encourage maintenance of current and targeted recommendations and suggestions.

METHODS:  Over recent years, the Guidelines Oversight Committee (GOC), which consists of CHEST members with methodologic experience and other stakeholders, developed a rigorous process for evidence-based clinical practice guidelines. This guideline methodology will be used to the greatest extent permitted by the peer-reviewed literature. However, for some important problems clinicians seek guidance but insufficient research prevents establishing guidelines. For such cases, the GOC has created a carefully structured approach permitting a convened expert panel to develop such guidance. The foundation of this approach includes a systematic review of current literature and rigorously vetted, entrusted experts.

RESULTS:  Existing evidence, even if insufficient for a guideline, can be combined with a Delphi process for consensus achievement resulting in trustworthy consensus statements. This article provides a review of the CHEST methodologies for these guidance documents as well as the evidence-based guidelines.

CONCLUSIONS:  These reliable statements of guidance for health-care providers and patients are based on a rigorous methodology and transparency of process.

Translating Basic Research Into Clinical Practice

Chest. 2014;146(1):193-204. doi:10.1378/chest.13-2736

The advent of techniques such as microarrays and high-throughput sequencing has revolutionized our ability to examine messenger RNA (mRNA) expression within the respiratory system. Importantly, these approaches have also uncovered the widespread expression of “noncoding RNAs,” including microRNAs and long noncoding RNAs, which impact biologic responses through the regulation of mRNA transcription and/or translation. To date, most studies of the role of noncoding RNAs have focused on microRNAs, which regulate mRNA translation via the RNA interference pathway. These studies have shown changes in microRNA expression in cells and tissues derived from patients with asthma, pulmonary fibrosis, cystic fibrosis, COPD, and non-small cell lung cancer. Although the evidence is currently limited, we review the work that has been carried out in cell and animal models that has identified the function and mechanism of action of a small number of these microRNAs in disease etiology. In addition to microRNAs, we assess the emerging evidence that long noncoding RNAs regulate respiratory phenotype. Because these investigations into long noncoding RNAs were performed almost exclusively in non-small cell lung cancer, future work will need to extend these into other respiratory diseases and to analyze how microRNAs and long noncoding RNAs interact to regulate mRNA expression. From a clinical perspective, the targeting of noncoding RNAs as a novel therapeutic approach will require a deeper understanding of their function and mechanism of action. However, in the short term, changes in miRNA and long noncoding RNA expression are likely to be of use as biomarkers for disease stratification and/or assessment of drug action.

Recent Advances in Chest Medicine

Chest. 2014;146(1):205-214. doi:10.1378/chest.13-2942

Pertussis, or whooping cough, has had a dramatic resurgence in the past several years and is the most common vaccine-preventable disease in the world. The year 2012 marked the most cases in the United States in > 50 years. Large outbreaks have occurred in multiple states, and infant deaths have drawn the attention of not only health-care providers but also the media. Although the disease is theoretically preventable by vaccination, it remains a challenge to control. New vaccination strategies have been implemented across different age groups and populations of patients, but vaccine coverage remains dismally low. Acellular vaccines, although safe, do not afford the same long-lasting immunity as the previously used whole-cell vaccine. Ultimately, improvements in the development of vaccines and in vaccination coverage will be essential to decrease the burden of pertussis on society. This article provides a review of pertussis infection and discusses advances related to the epidemiology, diagnosis, treatment, and prevention of infection, as well as continued areas of uncertainty.

Topics in Practice Management

Chest. 2014;146(1):215-219. doi:10.1378/chest.13-2292

Changes in medical practice, such as retiring, selling a practice, and switching employment, have significant legal impacts on physicians. These decisions should be carefully analyzed prior to being made. Physicians who do not make decisions in a well-considered manner may face economic penalties, licensure sanctions, and/or other legal issues. This article explores some key legal issues including (1) timing, (2) patient care continuity, (3) medical records retention, (4) licensure and board certification, (5) professional liability insurance, and (6) postemployment restrictions on practice. Within these topics, sources of physicians’ legal and ethical obligations are examined, including possible resolutions to identified issues. Not all changes affect physicians in the same manner. This article further considers how these important legal issues may impact differently situated physicians, such as retiring physicians vs transitioning physicians and physicians employed by groups or hospital systems vs physicians in solo practice.

Contemporary Reviews in Critical Care Medicine

Chest. 2014;146(1):220-227. doi:10.1378/chest.12-2745

Lung transplantation reduces mortality in patients with end-stage lung disease; however, only approximately 21% of lungs from potential donor patients undergo transplantation. A large number of donor lungs become categorized as unsuitable for lung transplantation as a result of lung injury around the time of brain death. Limiting this injury is key to increasing the number of successful lung procurements and subsequent transplants. This narrative review by a working group of pulmonologists, respiratory therapists, and lung transplant specialists elucidates principles of mechanical ventilatory support that can be used to limit lung injury in potential lung donor patients and examines the implementation of protocolized strategies in enhancing the procurement of donor lungs for transplantation.

Contemporary Reviews in Sleep Medicine

Chest. 2014;146(1):228-234. doi:10.1378/chest.14-0084

Sleep-disordered breathing (SDB) may be a treatable risk factor in patients with hypertrophic cardiomyopathy (HCM), the most common inherited cardiomyopathy. Evidence suggests a high prevalence of SDB in HCM. We summarize the pathophysiology of SDB as it relates to hypertension, coronary artery disease, atrial fibrillation, and sudden cardiac death in patients with HCM. The implications regarding the care of patients with HCM and SDB are discussed as well as the knowledge deficits needing further exploration.

Pectoriloquy

Chest. 2014;146(1):235. doi:10.1378/chest.13-2044
FREE TO VIEW

Inside the hush of this humid night,
I feel your thoughts landing on me:
feathers
feathers moving with the weight
of bones.
That is your way. The constant pulling
then pushing of you,
you whom I birthed
in the middle of a windy storm. I remember
listening
to the pelting of ice
against the blackened hospital windows
the soft water droplets mingling
with the shards of ice
the way the ice splintered
against the solid window as you moved
down my shifting bones
and into this world
Was it in you then? Planted in
that wet storm with the wild spatter
of stars,
was something born within you
that makes you want to move
outside of your own bones
The way you hide by swallowing tablets,
or inside the smoke of your room
the blue waves you ride
Once, we rode blue waves together
underwater like that
when you lived inside me:
dove down to feel weightless, to feel the arc
of gravity break for a moment
that first summer I found out I was having you
eighteen years ago
I rode blue waves with you, spoke to you
said your name
Now
I sit in the cupped chair
of this hospital
hoping they can wake you,
the way I once woke you to this world
You who won’t let me in
not into your thoughts and now
banned from the room
the nurse says you are of age
and it’s my choice to wait for you
Always my choice, sweet son,
always waiting for the rage
you hold toward me to abate
the way I waited for the storm
to abate the night you were born
your words,
tangible as ice, splintering
against my skin
The way you take love
and transform it
into rupture.

Chest. 2014;146(1):236. doi:10.1378/chest.13-2330
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I lie on the pad
Feet extended into a metal tube
A sprout with troubled lungs.
The middle-aged tech
Nametag Bobbie
Says Lie Still
And injects the dye
Missing the vein.
My arm inflates
An instant painful bulb.
I cry out.
Bobbie says Wait a Minute
But my arm mushrooms
Until my cries bring a doctor
Who removes the needle
Places warm towels
Deflates the growth
Mutters excuses.
Bobbie apologizes
Looks wilted
Older.
My anger expands
To blossoms of scorn
For technicians and doctors
But I keep silent
As dirt.
I’m laid out again
Thinking of death and worms
Afraid of rooted tumors
While Bobbies scurry
Like busy gardeners.
More needles.
More dye.
I feel set upon by crows.
After
I rise from the table
Gather my courage
Like a bouquet I dropped
Accidentally.
And leave the landscapers
To dig in the soil
Of other lungs.

Chest. 2014;146(1):237. doi:10.1378/chest.13-2454
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I watch them die as they take the Medicaid but
refuse the medicine. My nurses give me hell—
soft ol’ Smith. That jerk Gorinski just yells
at his patients until they eat the paper-cup pills.
I can’t afford that. Every day brings new bills:
new clothes for the new wife, the second mortgage.
Kid number 4 thinks I owe her, gives me garbage
in exchange for gadgets. Kid 2 I don’t discuss.
Kid 1, a boy, turned out the best, but it took guts
to total a sports car then smuggle liquor to prom.
If guts were brains... But sons are sons, and songs
haven’t changed. My favorite, kid 3, the middle
girl, writes stuff. I don’t read her little scribbles
that show a life twisted from what I know: her mother
in a mirror, the casserole years, some southern
disaster consoled and forgotten through pecan pie.
If this brittle kid had my job, she would cry
over every idiot’s death, each a metaphor
she’d write to shame us. But we can’t be the editors
of death. Everyone thinks the south is moonlit
magnolias, but I know that when you get
your pathetic obituary, it’s too late to revise.

Chest. 2014;146(1):237. doi:10.1378/chest.13-2512
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the chest pain could have been
a pulled muscle, but the doc found
something he couldn’t put
his finger on and scheduled me
for a mammogram.
the waiting rooms were all pink
and pretty and i was looking
for a quick fix in blue or gray;
an hour later i was out of there,
thinking to myself, now i know.
my wife said, “no, you don’t.”
the results were clean. i felt
somehow diminished, as if
i’d been ordered to undertake
a meaningless expense,
a procedure that found nothing
... but could have saved my life.
the letter was buoyant,
could have been an invitation
to a garden party, but it didn’t
make me feel any better.
I wondered what they write
on darker days, how much more
difficult, then, to just move on.

Errata

Chest. 2014;146(1):238. doi:10.1378/chest.14-1207
FREE TO VIEW

In the January 2014 issue of CHEST, the authors informed us that a contributor was omitted from the contributor list in “Roflumilast for the Treatment of COPD in an Asian Population: A Randomized, Double-Blind, Parallel-Group Study” (Chest. 2014;145(1):44-52).

Selected Reports

Chest. 2014;146(1):e1-e7. doi:10.1378/chest.13-2224

Short telomeres are frequently identified in patients with idiopathic pulmonary fibrosis (IPF) and its inherited form, familial interstitial pneumonia (FIP). We identified a kindred with FIP with short telomeres who did not carry a mutation in known FIP genes TERT or hTR. We performed targeted sequencing of other telomere-related genes to identify the genetic basis of FIP in this kindred. The proband was a 69 year-old man with dyspnea, restrictive pulmonary function test results, and reticular changes on high-resolution CT scan. An older male sibling had died from IPF. The proband had markedly shortened telomeres in peripheral blood and undetectably short telomeres in alveolar epithelial cells. Polymerase chain reaction-based sequencing of NOP10, TINF2, NHP2, and DKC1 revealed that both affected siblings shared a novel A to G 1213 transition in DKC1 near the hTR binding domain that is predicted to encode a Thr405Ala amino acid substitution. hTR levels were decreased out of proportion to DKC1 expression in the T405A DKC1 proband, suggesting this mutation destabilizes hTR and impairs telomerase function. This DKC1 variant represents the third telomere-related gene identified as a genetic cause of FIP. Further investigation into the mechanism by which dyskerin contributes to the development of lung fibrosis is warranted.

Chest. 2014;146(1):e8-e10. doi:10.1378/chest.13-2897

We report a case of a 41-year-old man who was noted to have position-dependent Cheyne-Stokes respiration with central sleep apnea (CSA) during sleep. The patient had multiple cardiovascular risk factors and target organ damages, including a history of two myocardial infarctions, transient ischemic attack, and chronic kidney disease. His hypertension was refractory to a number of antihypertensive medicines, however, a complete elimination of sleep-disordered breathing with oral theophylline treatment was paralleled by a significant BP fall with a subsequent need for reduction of antihypertensive drugs. Following these surprising observations we decided to withdraw theophylline from treatment (in-clinic). Theophylline discontinuation resulted in a gradual increase in BP and an urgent call for antihypertensive treatment modification. These observations suggest a potent hypotensive action of oral theophylline via Cheyne-Stokes respiration with CSA elimination. Our data suggest that CSA may be a mechanism that raises BP even during the daytime.

Ultrasound Corner

Chest. 2014;146(1):e11-e13. doi:10.1378/chest.13-2997

A male patient in his 40s was brought to the ED from the medicine clinic for admission with a presumptive diagnosis of spontaneous bacterial peritonitis (SBP). His medical history included hypertension, cirrhosis, liver cancer, and diverticulosis. The patient had had two prior admissions for SBP, and he felt like he had “that stomach infection again.”

Chest Imaging and Pathology for Clinicians

Chest. 2014;146(1):e14-e18. doi:10.1378/chest.13-1871

A 70-year-old white woman presented to the hospital for evaluation of shortness of breath and chest pain. Her dyspnea began 10 months ago and progressively worsened in the last 2 months. In the 48 h prior to admission, she also had right-sided pleuritic chest pain. She complained of cough with clear sputum for approximately 1 month, but denied hemoptysis, voice changes, or dysphagia. She reported weight loss of 15 pounds over the prior 3 months, as well as fatigue and occasional night sweats. She denied fever or chills. She smoked one pack of cigarettes a day for 15 years, until she quit smoking 30 years ago. She consumed two to three glasses of wine daily, until she quit 6 months ago. Her past medical history was significant only for hypertension. She had worked as a nurse, but denied any occupational exposures to animals, fumes, metals, or dusts.

Pulmonary, Critical Care, and Sleep Pearls

Chest. 2014;146(1):e19-e23. doi:10.1378/chest.13-2471

A 26-year-old man presented with complaints of left-sided chest pain and shortness of breath with moderate exertion, of 6 month duration. The patient had a history of asthma but reported that the exertional shortness of breath was not like his typical asthma symptoms and was not associated with wheezing. The left-sided chest pain was a dull and constant ache, without any aggravating or relieving factors. The patient denied fever, chills, night sweats, cough, or weight loss. Past medical history was significant for asthma since childhood, which was well controlled on budesonide inhaler. He had received a gunshot wound 1½ years earlier and had abdominal surgery at that time “to stop the bleeding,” but records of the procedure were not accessible.

Chest. 2014;146(1):e24-e27. doi:10.1378/chest.13-2680

A 54-year-old woman presented to the ED complaining of dysuria. Following basic diagnostic testing, she received a diagnosis of cystitis and was discharged with ciprofloxacin. Urine cultures later grew pan-susceptible Escherichia coli. Three days later, she returned, complaining of progressively worsening shortness of breath and confusion. The patient’s medical history was significant for poorly controlled type 2 diabetes mellitus. She had no significant history of kidney disease prior to presentation.

Correspondence

Chest. 2014;146(1):e28-e29. doi:10.1378/chest.14-0582
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Chest. 2014;146(1):e30. doi:10.1378/chest.14-0443
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ResponseResponse ONLINE EXCLUSIVES
Chest. 2014;146(1):e30-e31. doi:10.1378/chest.14-0712
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Chest. 2014;146(1):e32. doi:10.1378/chest.14-0643
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ResponseResponse ONLINE EXCLUSIVES
Chest. 2014;146(1):e32-e33. doi:10.1378/chest.14-0674
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  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543