American College Of Chest Physicians Research Articles

Guideline Compliance and Indications for Inferior Vena Cava Filter Placement at a Quaternary Care Medical Center.

This study investigated physician compliance with indications for inferior vena cava (IVC) filter placement according to the 2012 American College of Chest Physicians (ACCP) and the 2011 Society of Interventional Radiology (SIR) guidelines. A retrospective medical record review of 231 retrievable IVC filters placed between August 15, 2016, and December 28, 2017, at a large urban academic medical center. Guideline compliance to the 2012 ACCP and the 2011 SIR guidelines, and indications for IVC filter placements were assessed through an adjudication protocol. Filter retrieval and complication rates were also examined. Compliance to guidelines was low (60.2% for ACCP; 74.0% for SIR), especially for non-intensive care unit (ICU) patients (ICU 74.6% vs non-ICU 54.8%, p=0.007 for ACCP; ICU 82.5% vs non-ICU 70.8%, p=0.092 for SIR). After adjudication, 8.2% (19/231) of filters were considered non-indicated but reasonable, 17.7% (41/231) non-indicated and unreasonable, and 13.9% (32/231) SIR-indicated but not ACCP-indicated. The most common indication was venous thromboembolism with contraindication to anticoagulation. The most common reasons for non-compliance were distal deep venous thrombosis with contraindication to anticoagulation (19/60, 31.6%) and clot burden (19/60, 31.6%). One-year filter retrieval and 90-day complication rates were 32.0% (74/231) and 6.1% (14/231), respectively. Compliance to established guidelines was low. Reasons for non-compliance included limitations or discrepancies in guidelines, as well as non-evidence-based filter placements. Despite increasing utilization of inferior vena cava (IVC) filters, guideline compliance for IVC filter placement among providers is unclear. The results of this study indicate that physician compliance to established guidelines is poor, especially in non-intensive-care-unit patients. Noncompliance stems from non-evidence-based filter placement as well as differences and limitations in guidelines. Avoiding non-indicated IVC filter placement and consolidation of guidelines may significantly improve guideline compliance. The critical insights gained from this study can help promote judicious use of IVC filters and highlight the role of venous thromboembolism experts in navigating complex cases and nuances of guidelines.

Racial and ethnic disparities in eligibility for postpartum venous thromboembolism prophylaxis in the United States

BackgroundPostpartum venous thromboembolism (VTE) incidence differs by race and ethnicity in the United States. However, it is unclear whether the eligibility criteria for postpartum VTE prophylaxis mirror this disparity. ObjectiveTo characterize the prevalence of risk factors and eligibility for postpartum VTE prophylaxis, among US Birthing people, stratified by race and ethnicity. MethodsWe analyzed the National Inpatient Sample from October 2015 to December 2019, using diagnosis and procedure codes to identify postpartum individuals and their VTE risk factors. We compared proportion of delivery hospitalizations meeting eligibility for thromboprophylaxis stratified by race or ethnicity, according to American College of Gynecology and Obstetrics, American College of Chest Physicians, Royal College of Obstetricians and Gynecologists (RCOG), and American Society for Hematology guidelines. ResultsAmong a national estimate of 14 967 861 delivery hospitalizations in the United States, the proportion of individuals eligible for thromboprophylaxis using the RCOG, American College of Chest Physicians, American College of Gynecology and Obstetrics, and American Society for Hematology guidelines were 32.9%, 8.0%, 0.2%, and 0.2%, respectively. Using the RCOG criteria, non-Hispanic Black individuals had the highest proportion of thromboprophylaxis eligibility (39.7%), whereas it was lowest among Hispanic individuals (30.8%). Racial disparities in thromboprophylaxis eligibility were driven by differences in clinical risk factors (38.8% non-Hispanic Black population vs 30.5% Hispanic population) and cesarean section rates (35.9% vs 32.2%), rather than history of VTE (0.3% vs 0.1%), inherited thrombophilia (0.2% vs 0.2%), or sickle cell disease (0.4% vs <0.1%). ConclusionNon-Hispanic Black individuals were most likely to qualify for postpartum thromboprophylaxis, attributable to clinical risk factors rather than inherited risk factors. An urgent need exists to better understand ethno-racial disparities in thromboprophylaxis use and to equitably address modifiable risk factors for postpartum VTE.

WITHDRAWN: Wilderness Medical Society Clinical Practice Guidelines for the Prevention, Diagnosis, and Treatment of Acute Altitude Illness: 2024 Update

To provide guidance to clinicians about best practices, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for prevention, diagnosis, and treatment of acute mountain sickness, high altitude cerebral edema, and high altitude pulmonary edema. Recommendations are graded based on the quality of supporting evidence and the balance between the benefits and risks/burdens according to criteria put forth by the American College of Chest Physicians. The guidelines also provide suggested approaches for managing each form of acute altitude illness that incorporate these recommendations as well as recommendations on how to approach high altitude travel following COVID-19 infection. This is an updated version of the original WMS Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness published in Wilderness & Environmental Medicine in 2010 and the subsequently updated WMS Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness published in 2014 and 2019.

The early use of bisoprolol in patients with severe sepsis and its impact on the patients outcome

Objectives To explore the hypothesis that beta 1 adrenergic receptor blockage might be protective through attenuation of destructive sympathetic activity and catecholaminergic inflammatory effects in severe sepsis patients. Design Prospective, randomized, controlled study. Settings Critical care department in Alexandria main university hospital. Patients and methods The study was conducted on 50 adult patients who were admitted to the Department of Critical Care Medicine in the Alexandria Main University Hospital who fulfilled the criteria for severe sepsis according to The American College Of Chest Physicians, patients were randomly assigned into two groups, group I: Included 25 patients receiving Bisoprolol 2.5 to 10 mg enterally for a target heart rate 80–90 beat/minute within the first 24 h according to the effect on hemodynamic stabilization and group II: Included 25 patients, as a control group, who received routine management of severe sepsis. Both groups were followed up and compared regarding the primary end points (discharge from the intensive care unit after recovery, septic shock or death) and the secondary end points (length of ICU stay, days of mechanical ventilation and need for inotropes). Results The heart rate at the end of the study was significantly lower in survived patients in group I with mean value of 80.06+9.05 beats/minute compared to mean value of 102.22+7.58 beats/minute in the died patients in the same group (P=0.003). The mean arterial blood pressure (mmHg) in studied patients, was not significantly different between the two groups on admission (P=0.099) and on the 1st day (P=0.172) the significant differences started to appear on the 2nd day (P=0.003), and over the whole period of observation till the end point of the study as the mean value of 83.31+16.90 in group I compared to mean value of 72.0+16.07 in group II (P=&lt;0.021), regarding the comparison between the survived and died patients in group I, on admission there was no statistically significant difference between them (p 0.213) while by the end point of the study, there was a statistically significant difference being higher in survived patients with mean value of 95.38+3.38 compared to mean value of 61.44+2.70 in died patients (P&lt;0.001). Regarding the occurrence of septic shock, it was less in group I as 40% compared to 72% in group II (P=0.023), group I had longer ICU stay (5.0 to 24.0 days) compared to group II (7.0 to 20.0 days), with a statistically significant difference (P=0.029). The duration of mechanical ventilation days (P=0.001), as longer in group II compared group I (group I= 8.37±3.43 days, group II=12.0±3.21 days). The mortality was lower in group I about 36% compared to 68% in group II with a statistically significant difference between the two groups (P= 0.024). Conclusion The administration of bisoprolol to patients with severe sepsis decrease the mortality, length of stay in ICU, days of mechanical ventilation and improves tissue perfusion without significant effect on hemodynamics.

Radiofrequency ablation for stage

Pulmonary carcinoma represents the second common cancer for human race while its mortality rate ranked the first all over the world. Surgery remains the primary option for early-stage non-small cell lung cancer (NSCLC) in some surgical traditions. Nevertheless, only less than half of patients are operable subjected to the limited lung function and multiple primary/metastatic lesions. Recent improvements in minimally invasive surgical techniques have made the procedure accessible to more patients, but this percentage still does not exceed half. In recent years, radiofrequency ablation (RFA), one of the thermal ablation procedures, has gradually advanced in the treatment of lung cancer in addition to being utilized to treat breast and liver cancer. Several guidelines, including the American College of Chest Physicians (ACCP), include RFA as an option for some patients with NSCLC although the level of evidence is mostly limited to retrospective studies. In this review, we emphasize the use of the RFA technique in patients with early-stage NSCLC and provide an overview of the RFA indication population, prognosis status, and complications. Meanwhile, the advantages and disadvantages of RFA proposed in existing studies are compared with surgical treatment and radiotherapy. Due to the high rate of gene mutation and immunocompetence in NSCLC, there are considerable challenges to clinical translation of combining targeted drugs or immunotherapy with RFA that the field has only recently begun to fully appreciate.

Patient-Specific Venous Thromboembolic Event Prophylaxis in Total Joint Arthroplasty - Literature-Supported Guidelines.

Following total joint arthroplasty (TJA), venous thromboembolic events (VTE) are a known complication that may result in increased hospitalization cost as well as morbidity. Numerous investigations have documented patient-specific factors that place an individual at increased risk of VTE after TJA. Potential risk factors for VTE include genetic predisposition, history of a prior VTE event, revision surgery and patient comorbidity factors. The American Academy of Orthopedic Surgeons and The American College of Chest Physicians have both provided recommendations for VTE prophylaxis after orthopedic surgery. However, among orthopedic surgeons, there remains a lack of consensus regarding the appropriate agent and time course for prophylactic anticoagulation after TJA. In this study, we review the evidence-supported patient-specific factors that confer an increased risk of VTE in the TJA postoperative period. Furthermore, we describe the VTE prophylaxis regimen used at our home institution after TJA for low- and high-risk patients as well as a recommendation for cessation or continuation of anticoagulation regimens that patients were on preoperatively for comorbid conditions.

Clinicians’ adherence to guidelines for the preoperative management of direct oral anticoagulants in a tertiary hospital: a retrospective study

IntroductionDespite clear, relatively easy-to-use guidance, many clinicians find the preoperative management of direct oral anticoagulants (DOACs) challenging. Inappropriate management can delay procedures and lead to haemorrhagic or thromboembolic complications. We aimed to describe preoperative management practices regarding DOACs in a tertiary hospital and clinicians’ adherence to in-house recommendations.MethodWe included all patients being treated with DOACs who underwent elective surgery in 2019 and 2020 (n = 337). In-house recommendations for perioperative management were largely comparable to the 2022 American College of Chest Physicians guidelines.ResultsTypical patients were older adults with multiple comorbidities and high thrombotic risk stratification scores, and 65.6% (n = 221) had not undergone recommended preoperative anticoagulation management protocols. Patients operated on using local anaesthesia (adjusted OR = 0.30, 95%CI 0.14–0.66; p < 0.01) were less likely to have been treated following institutional recommendations, but no association between their procedure’s bleeding risk and adherence was found. Clinicians’ failures to adhere to recommendations mostly involved late or non-indicated interruptions of anticoagulation treatment (n = 89, 26.4%) or inappropriate heparin bridging (n = 54, 16.0%). Forty-five (13.3%) procedures had to be postponed. Incorrect preoperative anticoagulation management was directly responsible for 12/45 postponements (26.7% of postponements).ConclusionThis study highlights clinicians’ low adherence rates to institutional recommendations for patients treated with DOACs scheduled for elective surgery in a tertiary hospital centre. To the best of our knowledge, this is the first clinical study addressing the issue of clinicians’ adherence to guidelines for the preoperative management of DOACs. Going beyond the issue of whether clinicians are knowledgeable about guidelines or have them available, this study questions how generalisable guidelines are in a tertiary hospital managing many highly polymorbid patients.Further studies should identify the causes of poor adherence.

Withholding of Hormone Replacement Therapy Prior to Total Joint Arthroplasty Surgery to Reduce the Risk of Postoperative Thromboembolic Events: Is It Justified?—A Systematic Review of Clinical Practice Guidelines

BackgroundHormone replacement therapy (HRT), menopausal hormone therapy (MHT), and estrogen-containing medications are frequently withheld before elective lower limb arthroplasty, based on a perceived risk of venous thromboembolism (VTE). However, evidence linking HRT, MHT, and an increased VTE risk is equivocal. This systematic review evaluated the concordance of international clinical practice guidelines (CPGs) on the withholding of HRT or MHT. MethodsThe PubMed, Google Scholar, Cochrane, and Ovid databases were searched for CPGs for the preoperative, perioperative, and postoperative management of patients on HRT and MHT undergoing elective lower limb arthroplasty. This was supplemented by an internet search. There were 7 international CPGs in English, from Europe and North America, published between January 2000 and February 2023 reviewed against the Appraisal of Guidelines for Research & Evaluation Instrument (AGREE-II) criteria, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. ResultsThe guidelines reviewed revealed a mixed picture on HRT or MHT withdrawal and use in arthroplasty, with some featuring detailed advice on the preoperative and postoperative management of HRT or MHT (Scottish Intercollegiate Guidelines Network), while others featured no guidance (American College of Chest Physicians). The evidence referenced in these guidelines highlighted studies showing HRT or MHT to play a limited role in increasing VTE risk, with most studies from the 1990s and 2000s. ConclusionsBased on current evidence, non-estrogen-containing transdermal HRT or MHT should not be withheld in patients undergoing elective joint arthroplasty, though further evidence is required to justify withholding estrogen-containing forms.

Prevalence of and Eligibility for Surveillance Without Anticoagulation Among Adults With Lower-Risk Acute Subsegmental Pulmonary Embolism

Approximately 8% of acute pulmonary emboli are confined to the subsegmental arteries. The 2016 and 2021 American College of Chest Physicians (CHEST) guidelines and expert panel reports suggest the use of structured surveillance without anticoagulation for select ambulatory patients with subsegmental pulmonary embolism who do not have active cancer, deep vein thrombosis, impaired cardiopulmonary reserve, marked symptoms, or increased risk of recurrent venous thromboembolism; however, guideline uptake in community practice is unknown, as is the proportion of outpatients eligible for surveillance. To describe the prevalence of surveillance among outpatients with acute subsegmental pulmonary embolism and to estimate the proportion of patients eligible for structured surveillance using modified CHEST criteria. This retrospective cohort study was conducted across 21 US community hospitals in the Kaiser Permanente Northern California integrated health system from January 1, 2017, to December 31, 2021. Adult outpatients with acute subsegmental pulmonary embolism were included. Patients with the following higher-risk characteristics were excluded: codiagnoses requiring hospitalization, non-low-risk vital signs (ie, systolic blood pressure <90 mm Hg, pulse ≥110 bpm, or peripheral cutaneous pulse oximetry ≤92%), prediagnosis anticoagulant use, or hospice care. Data analysis was performed from November 2022 to February 2023. The main outcomes were the (1) prevalence of surveillance and (2) eligibility for surveillance using 2 sets of criteria: the CHEST criteria modified by excluding patients with higher-risk characteristics or right ventricular dysfunction and a stricter set of criteria requiring age younger than 65 years and no more than 1 embolus. The prevalence of structured surveillance was calculated and the proportion of patients eligible for surveillance was estimated. Of the 666 outpatients with acute subsegmental pulmonary embolism included in this study, 229 with lower-risk characteristics were examined. Their median age was 58 (IQR, 42-68) years; more than half were men (120 [52.4%]) and self-identified as non-Hispanic White (128 [55.9%]). Six patients (2.6%) were initially not treated with anticoagulants. Among the lower-risk cohort, only 1 patient (0.4% [95% CI, 0.01%-2.4%]) underwent structured surveillance, without 90-day sequelae. Thirty-five patients (15.3% of the lower-risk group and 5.3% of the full cohort) were surveillance eligible using modified CHEST criteria. Fifteen patients (6.6% of the lower-risk group and 2.3% of the full cohort) were surveillance eligible using stricter criteria. In this cohort study of lower-risk outpatients with subsegmental pulmonary embolism, few were eligible for structured surveillance, and only a small proportion of eligible patients underwent surveillance despite the CHEST guideline. If forthcoming trials find surveillance safe and effective, substantial uptake into clinical practice may require more than passive diffusion.

Editorial introductions.

Current Opinion in Pulmonary Medicine was launched in 1995. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of pulmonary medicine is divided into nine sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Alan FeinAlan FeinAlan Fein, MD received his medical degree from the State University of New York Downstate Medical Center in Brooklyn, USA in 1973. He completed his internship and residency in internal medicine at Albert Einstein College of Medicine, Bronx Municipal Hospital, New York, USA. From there, Dr Fein moved on to a fellowship in Pulmonary Disease at the University of California, San Francisco Cardiovascular Research Institute, USA. He served as Division Chief for Sleep, Pulmonary & Critical Care Medicine at Winthrop Hospital and then for the North Shore Long Island Jewish Health System. Dr Fein is a member of the American Academy of Sleep Medicine, the American College of Chest Physicians, the American College of Physicians, and the American College of Critical Care Medicine. He is the former President of the American Lung Association of Nassau/Suffolk and served on the national boards of the American Thoracic Society and the American College of Chest Physicians. Dr Fein is a Clinical Professor of Medicine at New York University, USA and Zucker School of Medicine, USA. He was Chief of the Pulmonary, Critical and Sleep Division of Prohealthcare Associates Optum Health. He is currently Medical director of the Post Covid Recovery Center for Optum Health. Dr Fein is on the editorial boards of Current Opinion in Pulmonary Medicine and the American Journal of Respiratory & Critical Care Medicine. Dr Fein has authored almost 100 peer-reviewed manuscripts, over 100 review articles, and book chapters on topics such as diagnosis and treatment of lung cancer, pneumonia, asthma, and chronic obstructive pulmonary diseases. David OstDavid OstDavid Ost, MD, MPH is Professor of Medicine at The University of Texas M. D. Anderson Cancer Center, Department of Pulmonary Medicine, USA. Dr Ost is a Fellow of the American College of Chest Physicians and the American College of Physicians and has served on the board of directors of the American Association of Bronchology and Interventional Pulmonology. Dr Ost is currently editor of the Journal of Bronchology and Interventional Pulmonology. He is a reviewer for many journals including Annals of Internal Medicine, the American Journal of Respiratory and Critical Care Medicine, Chest and the Journal of the American Medical Association. Dr Ost has authored over 100 manuscripts and book chapters on such topics as interventional pulmonology, lung cancer, pulmonary embolism, and ventilator associated pneumonia. Dr Ost received his medical degree from the Thomas Jefferson University, Jefferson Medical College in Philadelphia, USA. He completed his internship and residency in internal medicine at Northwestern University in Chicago, USA. Additionally, Dr Ost was a fellow in pulmonary and critical care at Northwestern. He is board certified in interventional pulmonology. He received his Masters in Public Health from Harvard University, USA, with a focus in quantitative methods. Marlies WijsenbeekMarlies WijsenbeekMarlies Wijsenbeek is pulmonary physician and Professor of Interstitial Lung Diseases at the Erasmus University Medical Centre in Rotterdam, a national expert centre for interstitial lung diseases (ILD) in the Netherlands and member of the European Reference Network for Rare Lung Diseases (ERN-Lung). She is chair of the multidisciplinary ILD centre. Her research interests include e-health, patient centred outcome measures in ILD, cough in ILD and new therapies in ILD and sarcoidosis. She is chair of group 12.01 (Idiopathic Interstitial Pneumonia) of the European Respiratory Society, chair of the functional committee for continued education of the ERN-Lung, member of the scientific advisory boards of different patient associations, Associate Editor of the European Respiratory Journal, and member of the international advisory board of The Lancet Respiratory Medicine. Catharina C. MoorCatharina C. MoorKaren Moor, M.D. Ph.D. is a pulmonologist in training and postdoctoral researcher at the Erasmus Medical Center, Rotterdam, the Netherlands. She is the current Early Career Representative for the ILD assembly within the European Respiratory Society (ERS). Her research focuses on innovative approaches for patient-centered care in interstitial lung disease (ILD), especially digital health care and home monitoring. She coordinated the first-ever randomized controlled trial on home monitoring in ILD (Am J Respir Crit Care Med Vol 202, Iss 3, pp 393–401, Aug 1, 2020). Together with Prof. Dr Marlies Wijsenbeek she is co-leading various home monitoring studies, including a large international patient-led registry study, and a nationwide implementation study.

Evaluation of Chronic Cough in Children Using Management Algorithm: A Prospective Cohort Study.

To assess the use of a standardized evaluation algorithm [American College of Chest Physician (ACCP) 2006] in children with chronic cough. In this prospective cohort study, children with chronic cough were evaluated as per the ACCP 2006 diagnostic algorithm. All children were followed regularly at an interval of 2-4 wk. The study's endpoint was for the patient being cough free for four weeks either following treatment or naturally. The mean age of the 87 studied children (52 male, 35 female) was 11.9±3 y. Forty children (45.9%) had specific cough pointers on history and examination. Radiograph showed abnormalities in 12 (13.8%) children, and spirometry showed a reversible obstructive pattern on spirometry in 6 (6.9%) among 47 (54%) children without specific cough pointers. After a detailed evaluation, 16 (18.3%) children had no remarkable findings and were reviewed after two weeks. Spontaneous resolution of cough occurred in 6 children. A trial of inhalational corticosteroids (ICS) (9 children) or antibiotics (1 child) was given to the rest of the ten children. Specific underlying diagnoses could be established in 80 (91.9%) children. The most common etiology identified in the study was asthma and asthma-like illnesses (n = 52; 59.8%), followed by upper airway cough syndrome (n=13; 14.9%) and tuberculosis (n = 9; 10.4%). Eighty-four (96.5%) children had complete resolution of cough during follow-up. The mean time to resolution in the study was 33.6±16.8 d. This study demonstrated that the ACCP 2006 algorithm is effective in establishing the underlying etiology and managing children with chronic cough.

Somatic aberrations detected in tumor tissue and plasma in Chinese patients with stage I single-lesion and multi-lesions lung cancer.

e20600 Background: Recent studies show that the use of circulating tumor DNA (ctDNA) has potential to guide precision medicine and transform the management of early-stage lung cancers. We aim to investigate whether plasma is suitable for detecting tumor‐derived DNA in patients with stage I single-lesion lung cancer and multifocal lung cancer which has rarely been investigated. Methods: Matched tumor tissues (n = 114) and plasma samples (n = 95) from Chinese patients with stage I lung cancer (n = 95), including 80 patients with single-lesion and 15 patients with multiple primary lung cancer (MPLC) diagnosed by American College of Chest Physicians (ACCP) guidelines, were analyzed by Acornmed panel with 808 cancer-related genes. Results: Using tumor tissue-based results as the gold standard, we performed variant-level assessment of the ctDNA tests. In patients with single-lesion, sequencing detected alterations in 98.8% (79/80) ctDNA and 9.3% (74/797) of variants in ctDNA were detected by corresponding tDNA. Among them, 31.3% (25/80) patients had at least one overlapping variant called by tDNA and ctDNA, and 5% (4/80) patients shared EGFR in both tDNA and ctDNA. Meanwhile, we identified 2 mutated EGFR in ctDNA that were not detected in tissues. As for multiple primary lung cancers, 86.7% (13/15) of MPLC patients had ≥1 alteration in ctDNA. In addition, 7.4% (9/122) of variants in ctDNA were detected by corresponding tDNA in MPLC. The overall concordance for all variants detected in both ctDNA and any tDNA of patients was 53.3% (8/15) in MPLC, with EGFR and KRAS as the most two frequent mutations. Furthermore, mutations consistent with ctDNA were detected in 29.4% (10/34) of the lesions in MPLC. Conclusions: Our analysis showed that plasma with high mutation detection rate and considerable concordance rate with tDNA maybe a powerful complement to tissues for molecular testing in lung cancer. Furthermore, ctDNA detection not only may be able to overcome the heterogeneity of tumors but also more comprehensively reflect the disease state of patients with multifocal lung cancer.

Comprehensive genetic characteristics of multiple primary lung cancer in patients in China.

e20597 Background: With the development of molecular biology and next-generation sequencing (NGS), researchers have been exploring the use of genomic technologies for the classification of lung cancers. The aim of this study was to investigate genetic characteristics of multiple primary lung cancer (MPLC) to facilitate precise diagnosis and therapy by NGS. Methods: A total of 271 lesions from 92 patients with MPLC (225 lesions) and 20 intrapulmonary metastasis (IM, 46 lesions) which were diagnosed by American College of Chest Physicians (ACCP) guidelines, were sequenced by Acornmed panel with 808 cancer-related genes. Results: The most frequent mutation in 225 lesions was EGFR (46.7%), followed by RBM10 (19.6%), BRAF (16.4%) and KRAS (15.1%) among MPLC while IM lesions showed high TP53 (63.0%) mutation frequency. Further analysis showed that MPLC patients had higher proportion of private mutations, and lower proportion of shared mutations and branch shared mutations than IM (p &lt; 0.0001). In our cohort, 95.7% (88/92) of MPLC patients had at least one driver alteration, and EGFR and KRAS comprised 57.4% and 18.0% of 183 driver mutations, respectively. Further analysis showed that only 19.6% (18/92) of MPLC shared the same driver mutation in each patient and 61.1% (11/18) of co-driver mutation was EGFR L858R which was commonly detected in lung cancer. In contrast, 95.0% (19/20) of IM shared the same driver mutation in each patient. MPLCs were associated with a high frequency of T &gt; C transitions (p &lt; 0.001), while T &gt; G transversions (p &lt; 0.001) were more frequent in tumors from IM. MPLC had significantly higher intratumor heterogeneity (ITH) (17.1 vs 4.05, p &lt; 0.001) and lower weighted-genomic integrity index (wGII) than IM (0.01638 vs 0.18321, p &lt; 0.001). Besides, MPLC had lower percentage of clonal mutations (p &lt; 0.001) than IM. However, IM had higher arm-level somatic copy number variations fraction (p &lt; 0.001) than MPLC. Conclusions: Our analysis reveals that patients with MPLC have distinct molecular characteristics different from IM, which may increase the understanding of MPLC. In addition, the molecular features of MPLC may provide new opportunities to distinguish MPLC from IM by broad panel NGS.

Identification of prophylaxis and treatment for hospitalized patients associated with venous thromboembolism.

Identification of prophylaxis and treatment for hospitalized patients associated with venous thromboembolism.

Hypersensitivity pneumonitis: Principles in diagnosis and management.

Hypersensitivity pneumonitis: Principles in diagnosis and management.

ASTRO Radiation Therapy Summary of the ASCO Guideline on Management of Stage III Non-Small Cell Lung Cancer

To develop a radiation therapy summary of recommendations on the management of locally advanced non-small cell lung cancer (NSCLC) based on the Management of Stage III Non-Small Cell Lung Cancer: American Society of Clinical Oncology Guideline, which was endorsed by the American Society for Radiation Oncology (ASTRO). The American Society of Clinical Oncology, ASTRO, and the American College of Chest Physicians convened a multidisciplinary panel to develop a guideline based on a systematic review of the literature and a formal consensus process, that has been separately published. A new panel consisting of radiation oncologists from the original guideline as well as additional ASTRO members was formed to provide further guidance to the radiation oncology community. A total of 127 articles met the eligibility criteria to answer 5 clinical questions. This summary focuses on the 3 radiation therapy questions (neoadjuvant, adjuvant, and unresectable settings). Radiation-specific recommendations are summarized with additional relevant commentary on specific questions regarding the management of preoperative radiation, postoperative radiation, and combined chemoradiation. Patients with stage III NSCLC who are planned for surgical resection, should receive either neoadjuvant chemotherapy or chemoradiation. The addition of neoadjuvant treatment is particularly important in patients planned for surgery in the N2 or superior sulcus settings. Postoperatively, patients who did not receive neoadjuvant chemotherapy should be offered adjuvant chemotherapy. The use of postoperative radiation for completely resected N2 disease is not routinely recommended. Unresectable patients with stage III NSCLC should ideally be managed with combined concurrent chemoradiation using a platinum-based doublet with a standard radiation dose of 60 Gy followed by consolidation durvalumab in patients without progression after initial therapy. Patients who cannot tolerate a concurrent chemoradiation approach can be managed either by sequential chemotherapy followed by radiation or by dose-escalated or hypofractionated radiation alone.

A Review on the Appropriate Dosage of Aspirin as a Prophylactic Agent Against Deep Vein Thrombosis Following Total Knee Arthroplasties

Guidelines regarding Deep Vein Thrombosis prophylaxis following total knee arthroplasties have had conflicting information regarding the use of aspirin as a prophylactic agent in recent years. The National Institute for Clinical Excellence refrains from listing the drug in its guidelines while the American College of Chest Physicians advocates for the drug. Despite the conflicting guidelines, physicians have favored the drug in recent years, with more than 80% utilizing it as a prophylactic agent in total knee arthroplasties. Although a consensus may have been reached by physicians regarding the use of the drug, a consensus has not been reached regarding the preferred dosage. With this in mind, a search of the PubMed database was conducted which yielded six studies that discussed the efficacy of various dose ranges of aspirin. All studies corroborated that not only was aspirin an effective prophylactic agent, but that there was no significant difference between dosages regarding efficacies. Due to factors such as aspirin resistance and the potential of aspirin to cause gastrointestinal injuries, this literature review concludes that the dosage of aspirin given for the prophylaxis of DVT in TKAs should be considered on a patient to patient basis.

Systemic Manifestation of Periprosthetic Joint Infection Is Associated With Increased In-Hospital Mortality.

Introduction Periprosthetic joint infection (PJI) is one of the most devastating complications of total joint arthroplasty. Systemic symptoms of infection may indicate a patient who is at a higher risk of serious complications. The goal of this study was to determine if systemic symptoms of infection in the setting of PJI were associated with greater in-hospital mortality. Materials and methods We used our institutional database to identify all patients urgently treated for deep PJI from 2002-2012. Records were reviewed to collect demographics, surgical data, vital signs prior to surgical intervention, blood and intraoperative culture results, preoperative intensive care unit (ICU) admissions, and deaths that occurred during the hospital admission. Patients were classified as having systemic inflammatory response syndrome (SIRS) based on the criteria established by the American College of Chest Physicians and the Society of Critical Care Medicine. Results During the 10-year timeframe of our study, 484 patients were treated emergently for deep infection, with 130 (27%) meeting SIRS criteria preoperatively and 31 (6%) of the patients with SIRS having positive blood cultures. Patients with positive blood cultures and SIRS demonstrated a higher in-hospital mortality rate (p < 0.001). Neither SIRSnor SIRS with positive blood cultures were associated with ICU admission. Discussion Occasionally, PJI can spread beyond the affected joint, showing physical symptoms of systemic illness and bacteremia. This study demonstrates that patients with SIRS and positive blood cultures are at an increased risk of in-hospital mortality. These patients should be monitored closely before definitive treatment in order to minimize their mortality risk.

Letter from Norway

Letter from Norway

Impact of diagnostic guidelines on the diagnosis of hypersensitivity pneumonitis.

Hypersensitivity pneumonitis (HP) is an immune-mediated interstitial lung disease from exposure to environmental antigens. Diagnosing HP could be challenging. The American College of Chest Physicians (CHEST) and American Thoracic Society/Japanese Respiratory Society/and Asociación Latinoamericana del Tórax (ATS/JRS/ALAT) have published diagnostic guidelines in 2021 and 2020 respectively. The CHEST guideline uses four grades of confidence: confident (>90%), provisional high (70-89%), provisional low (51-69%), and unlikely (≤50%). The ATS/JRS/ALAT guideline uses five grades of confidence: definite (>90%), high (80-89%), moderate (70-79%), low (51-69%) and not excluded (≤50%). In this study, we determined how these two guidelines could have affected the diagnosis of HP made before the guidelines. Two hundred and fifty-nine adult patients from a previous cohort with HP (ICD-9:495) made between Jan. 1, 2008, and Dec. 31, 2013, at Duke University Medical Center were included. We simplified the diagnostic confidence into three categories so we could compare the guidelines: high (≥90%), intermediate (51-89%), and low (≤50%). There were 156 female and 103 male. Mean age was 58 (range: 20-90). 68.8% of the patients had restrictive defects (FVC < 80% pred) and 48.6% had lung biopsy. The CHEST guideline classified 33.6% of the patients into high, 59.5% into intermediate and 6.9% into low confidence categories. The ATS/JRS/ALAT guideline classified 29.7% of the patients into high, 21.2% into intermediate and 49.0% into low confidence categories (p < 0.0001 vs. CHEST). Cohen's kappa was 0.331. In patients with identifiable inciting agents (IAs) (N = 168), the CHEST guideline classified 32.1% of the patients into high, 64.3% into intermediate and 3.6% into low confidence categories. The ATS/JRS/ALAT guideline classified 29.2% of the patients into high, 20.8% into intermediate, and 50.0% into low confidence categories. Cohen's kappa was 0.314. In our HP cohort with two-thirds of the patients with restrictive defects, we found the two guidelines had fair agreement in diagnosing HP with or without identifiable IAs. They agreed more when the diagnostic confidence was high. When the diagnostic confidence was lower, however, the ATS/JRS/ALAT guideline was more stringent. Clinicians should be aware of the differences between the two guidelines when evaluating patients suspicious of HP.