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Diagnostic yield reporting of bronchoscopic peripheral pulmonary nodule biopsies: A call for standardization
THORACIC ONCOLOGY AND CHEST PROCEDURES NETWORK
Interventional Procedures Section
More than 1.5 million Americans are diagnosed with an incidental CT scan-detected lung nodule annually. Advanced bronchoscopy, as a diagnostic tool for evaluation of these nodules, has evolved rapidly, incorporating a range of techniques and tools beyond CT scan-guided biopsies to assess peripheral lesions. The primary goal is to provide patients with accurate benign or malignant diagnoses. However, accurately determining the effectiveness of innovative technologies in providing a diagnosis remains challenging, in part due to limitations in study design and outcome reporting, along with the scarcity of comparative and randomized controlled studies.1,2 Current literature shows significant variability in diagnostic yield definition, lacking generalizability.
To address this issue, an official research statement by the American Thoracic Society and CHEST defines the diagnostic yield as “the proportion of all individuals undergoing the diagnostic procedure under evaluation in whom a specific malignant or benign diagnosis is established.”3 To achieve this measure, the numerator includes all patients with lung nodules in whom the result of a diagnostic procedure establishes a specific benign or malignant diagnosis that is readily sufficient to inform patient care without additional diagnostic workup, and the denominator should include all patients in whom the procedure was attempted or performed. This standardized definition is crucial for ensuring consistency across studies, allowing for comparison or pooling of results, enhancing the reliability of diagnostic yield data, and informing clinical decisions.
The adoption of standardized outcome definitions is essential to critically evaluate modern, minimally invasive procedures for peripheral lung nodules diagnosis and to guide patient-centered care while minimizing the downstream effects of nondiagnostic biopsies. Clear, transparent, and consistent reporting will enable physicians to choose the most appropriate diagnostic tools, improve patient outcomes by reducing unnecessary procedures, and expedite accurate diagnoses. This initiative is a crucial first step toward creating high-quality studies that can inform technology implementation decisions and promote equitable health care.
References
1. Tanner NT, Yarmus L, Chen A, et al. Standard bronchoscopy with fluoroscopy vs thin bronchoscopy and radial endobronchial ultrasound for biopsy of pulmonary lesions: a multicenter, prospective, randomized trial. Chest. 2018;154(5):1035-1043.
2. Ost DE, Ernst A, Lei X, et al. Diagnostic yield and complications of bronchoscopy for peripheral lung lesions. Results of the AQuIRE Registry. Am J Resp Crit Care Med. 2016;193(1):68-77.
3. Gonzalez AV, Silvestri GA, Korevaar DA, et al. Assessment of advanced diagnostic bronchoscopy outcomes for peripheral lung lesions: a Delphi consensus definition of diagnostic yield and recommendations for patient-centered study designs. An official American Thoracic Society/American College of Chest Physicians research statement. Am J Respir Crit Care Med. 2024;209(6):634-646.
THORACIC ONCOLOGY AND CHEST PROCEDURES NETWORK
Interventional Procedures Section
More than 1.5 million Americans are diagnosed with an incidental CT scan-detected lung nodule annually. Advanced bronchoscopy, as a diagnostic tool for evaluation of these nodules, has evolved rapidly, incorporating a range of techniques and tools beyond CT scan-guided biopsies to assess peripheral lesions. The primary goal is to provide patients with accurate benign or malignant diagnoses. However, accurately determining the effectiveness of innovative technologies in providing a diagnosis remains challenging, in part due to limitations in study design and outcome reporting, along with the scarcity of comparative and randomized controlled studies.1,2 Current literature shows significant variability in diagnostic yield definition, lacking generalizability.
To address this issue, an official research statement by the American Thoracic Society and CHEST defines the diagnostic yield as “the proportion of all individuals undergoing the diagnostic procedure under evaluation in whom a specific malignant or benign diagnosis is established.”3 To achieve this measure, the numerator includes all patients with lung nodules in whom the result of a diagnostic procedure establishes a specific benign or malignant diagnosis that is readily sufficient to inform patient care without additional diagnostic workup, and the denominator should include all patients in whom the procedure was attempted or performed. This standardized definition is crucial for ensuring consistency across studies, allowing for comparison or pooling of results, enhancing the reliability of diagnostic yield data, and informing clinical decisions.
The adoption of standardized outcome definitions is essential to critically evaluate modern, minimally invasive procedures for peripheral lung nodules diagnosis and to guide patient-centered care while minimizing the downstream effects of nondiagnostic biopsies. Clear, transparent, and consistent reporting will enable physicians to choose the most appropriate diagnostic tools, improve patient outcomes by reducing unnecessary procedures, and expedite accurate diagnoses. This initiative is a crucial first step toward creating high-quality studies that can inform technology implementation decisions and promote equitable health care.
References
1. Tanner NT, Yarmus L, Chen A, et al. Standard bronchoscopy with fluoroscopy vs thin bronchoscopy and radial endobronchial ultrasound for biopsy of pulmonary lesions: a multicenter, prospective, randomized trial. Chest. 2018;154(5):1035-1043.
2. Ost DE, Ernst A, Lei X, et al. Diagnostic yield and complications of bronchoscopy for peripheral lung lesions. Results of the AQuIRE Registry. Am J Resp Crit Care Med. 2016;193(1):68-77.
3. Gonzalez AV, Silvestri GA, Korevaar DA, et al. Assessment of advanced diagnostic bronchoscopy outcomes for peripheral lung lesions: a Delphi consensus definition of diagnostic yield and recommendations for patient-centered study designs. An official American Thoracic Society/American College of Chest Physicians research statement. Am J Respir Crit Care Med. 2024;209(6):634-646.
THORACIC ONCOLOGY AND CHEST PROCEDURES NETWORK
Interventional Procedures Section
More than 1.5 million Americans are diagnosed with an incidental CT scan-detected lung nodule annually. Advanced bronchoscopy, as a diagnostic tool for evaluation of these nodules, has evolved rapidly, incorporating a range of techniques and tools beyond CT scan-guided biopsies to assess peripheral lesions. The primary goal is to provide patients with accurate benign or malignant diagnoses. However, accurately determining the effectiveness of innovative technologies in providing a diagnosis remains challenging, in part due to limitations in study design and outcome reporting, along with the scarcity of comparative and randomized controlled studies.1,2 Current literature shows significant variability in diagnostic yield definition, lacking generalizability.
To address this issue, an official research statement by the American Thoracic Society and CHEST defines the diagnostic yield as “the proportion of all individuals undergoing the diagnostic procedure under evaluation in whom a specific malignant or benign diagnosis is established.”3 To achieve this measure, the numerator includes all patients with lung nodules in whom the result of a diagnostic procedure establishes a specific benign or malignant diagnosis that is readily sufficient to inform patient care without additional diagnostic workup, and the denominator should include all patients in whom the procedure was attempted or performed. This standardized definition is crucial for ensuring consistency across studies, allowing for comparison or pooling of results, enhancing the reliability of diagnostic yield data, and informing clinical decisions.
The adoption of standardized outcome definitions is essential to critically evaluate modern, minimally invasive procedures for peripheral lung nodules diagnosis and to guide patient-centered care while minimizing the downstream effects of nondiagnostic biopsies. Clear, transparent, and consistent reporting will enable physicians to choose the most appropriate diagnostic tools, improve patient outcomes by reducing unnecessary procedures, and expedite accurate diagnoses. This initiative is a crucial first step toward creating high-quality studies that can inform technology implementation decisions and promote equitable health care.
References
1. Tanner NT, Yarmus L, Chen A, et al. Standard bronchoscopy with fluoroscopy vs thin bronchoscopy and radial endobronchial ultrasound for biopsy of pulmonary lesions: a multicenter, prospective, randomized trial. Chest. 2018;154(5):1035-1043.
2. Ost DE, Ernst A, Lei X, et al. Diagnostic yield and complications of bronchoscopy for peripheral lung lesions. Results of the AQuIRE Registry. Am J Resp Crit Care Med. 2016;193(1):68-77.
3. Gonzalez AV, Silvestri GA, Korevaar DA, et al. Assessment of advanced diagnostic bronchoscopy outcomes for peripheral lung lesions: a Delphi consensus definition of diagnostic yield and recommendations for patient-centered study designs. An official American Thoracic Society/American College of Chest Physicians research statement. Am J Respir Crit Care Med. 2024;209(6):634-646.
Post–intensive care syndrome and insomnia
SLEEP MEDICINE NETWORK
Nonrespiratory Sleep Section
There has been a recent interest in post–intensive care syndrome (PICS), as an increasing number of patients are surviving critical illness. PICS is defined as “new onset or worsening of impairments in physical, cognitive, and/or mental health that arises after an ICU stay and persists beyond hospital discharge.1 We know that poor sleep is a common occurrence in the ICU, which can contribute to cognitive impairment and could be due to various risk factors, including age, individual comorbidities, reason for admission, and ICU interventions.2 Sleep impairment after hospital discharge is highly prevalent for up to 1 year after hospitalization.
The most common sleep impairment described after hospital discharge from the ICU is insomnia, which coexists with anxiety, depression, and posttraumatic stress disorder.3 When patients are seen in a post-ICU clinic, a multimodal strategy is needed for the treatment of insomnia, which includes practicing good sleep hygiene, cognitive behavioral therapy for insomnia (CBT-I), and pharmacotherapy if indicated.
Since the American Academy of Sleep Medicine (AASM) 2021 clinical practice guideline on behavioral and psychological treatments for chronic insomnia, which made a strong recommendation for CBT-I, we continue to face barriers to incorporating CBT-I into our own clinical practice.4 This is due to limited access to CBT-I psychotherapists and patients’ lack of knowledge or treatment beliefs, among other reasons. However, there are numerous digital CBT-I platforms that patients can freely access from their mobile phone and are listed in the AASM article, “Digital cognitive behavioral therapy for insomnia: Platforms and characteristics,” which can help with treatment of insomnia.
For patients who are seen in post-ICU clinics, the first step in treating insomnia is discussing good sleep hygiene, providing resources for CBT-I (digital or in person), and treating coexistent psychiatric conditions.
References
1. Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: an overview. J Transl Int Med. 2017;5(2):90-92.
2. Zampieri FG, et al. Ann Am Thorac Soc. 2023;20(11):1558-1560.
3. Altman MT, Knauert MP, Pisani MA. Sleep disturbance after hospitalization and critical illness: a systematic review. Ann Am Thorac Soc. 2017;14(9):1457-1468.
4. Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17(2):255-262.
SLEEP MEDICINE NETWORK
Nonrespiratory Sleep Section
There has been a recent interest in post–intensive care syndrome (PICS), as an increasing number of patients are surviving critical illness. PICS is defined as “new onset or worsening of impairments in physical, cognitive, and/or mental health that arises after an ICU stay and persists beyond hospital discharge.1 We know that poor sleep is a common occurrence in the ICU, which can contribute to cognitive impairment and could be due to various risk factors, including age, individual comorbidities, reason for admission, and ICU interventions.2 Sleep impairment after hospital discharge is highly prevalent for up to 1 year after hospitalization.
The most common sleep impairment described after hospital discharge from the ICU is insomnia, which coexists with anxiety, depression, and posttraumatic stress disorder.3 When patients are seen in a post-ICU clinic, a multimodal strategy is needed for the treatment of insomnia, which includes practicing good sleep hygiene, cognitive behavioral therapy for insomnia (CBT-I), and pharmacotherapy if indicated.
Since the American Academy of Sleep Medicine (AASM) 2021 clinical practice guideline on behavioral and psychological treatments for chronic insomnia, which made a strong recommendation for CBT-I, we continue to face barriers to incorporating CBT-I into our own clinical practice.4 This is due to limited access to CBT-I psychotherapists and patients’ lack of knowledge or treatment beliefs, among other reasons. However, there are numerous digital CBT-I platforms that patients can freely access from their mobile phone and are listed in the AASM article, “Digital cognitive behavioral therapy for insomnia: Platforms and characteristics,” which can help with treatment of insomnia.
For patients who are seen in post-ICU clinics, the first step in treating insomnia is discussing good sleep hygiene, providing resources for CBT-I (digital or in person), and treating coexistent psychiatric conditions.
References
1. Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: an overview. J Transl Int Med. 2017;5(2):90-92.
2. Zampieri FG, et al. Ann Am Thorac Soc. 2023;20(11):1558-1560.
3. Altman MT, Knauert MP, Pisani MA. Sleep disturbance after hospitalization and critical illness: a systematic review. Ann Am Thorac Soc. 2017;14(9):1457-1468.
4. Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17(2):255-262.
SLEEP MEDICINE NETWORK
Nonrespiratory Sleep Section
There has been a recent interest in post–intensive care syndrome (PICS), as an increasing number of patients are surviving critical illness. PICS is defined as “new onset or worsening of impairments in physical, cognitive, and/or mental health that arises after an ICU stay and persists beyond hospital discharge.1 We know that poor sleep is a common occurrence in the ICU, which can contribute to cognitive impairment and could be due to various risk factors, including age, individual comorbidities, reason for admission, and ICU interventions.2 Sleep impairment after hospital discharge is highly prevalent for up to 1 year after hospitalization.
The most common sleep impairment described after hospital discharge from the ICU is insomnia, which coexists with anxiety, depression, and posttraumatic stress disorder.3 When patients are seen in a post-ICU clinic, a multimodal strategy is needed for the treatment of insomnia, which includes practicing good sleep hygiene, cognitive behavioral therapy for insomnia (CBT-I), and pharmacotherapy if indicated.
Since the American Academy of Sleep Medicine (AASM) 2021 clinical practice guideline on behavioral and psychological treatments for chronic insomnia, which made a strong recommendation for CBT-I, we continue to face barriers to incorporating CBT-I into our own clinical practice.4 This is due to limited access to CBT-I psychotherapists and patients’ lack of knowledge or treatment beliefs, among other reasons. However, there are numerous digital CBT-I platforms that patients can freely access from their mobile phone and are listed in the AASM article, “Digital cognitive behavioral therapy for insomnia: Platforms and characteristics,” which can help with treatment of insomnia.
For patients who are seen in post-ICU clinics, the first step in treating insomnia is discussing good sleep hygiene, providing resources for CBT-I (digital or in person), and treating coexistent psychiatric conditions.
References
1. Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: an overview. J Transl Int Med. 2017;5(2):90-92.
2. Zampieri FG, et al. Ann Am Thorac Soc. 2023;20(11):1558-1560.
3. Altman MT, Knauert MP, Pisani MA. Sleep disturbance after hospitalization and critical illness: a systematic review. Ann Am Thorac Soc. 2017;14(9):1457-1468.
4. Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17(2):255-262.
Short telomere length and immunosuppression: Updates in nonidiopathic pulmonary fibrosis, interstitial lung disease
DIFFUSE LUNG DISEASE AND LUNG TRANSPLANT NETWORK
Interstitial Lung Disease Section
Interstitial lung diseases (ILDs) are a diverse group of relentlessly progressive fibroinflammatory disorders. Pharmacotherapy includes antifibrotics and immunosuppressants as foundational strategies to mitigate loss of lung function. There has been a growing interest in telomere length and its response to immunosuppression in the ILD community.
Telomeres are repetitive nucleotide sequences that “cap” chromosomes and protect against chromosomal shortening during cell replication. Genetic and environmental factors can lead to premature shortening of telomeres. Once a critical length is reached, the cell enters senescence. Short telomere length has been linked to rapid progression, worse outcomes, and poor response to immunosuppressants in idiopathic pulmonary fibrosis (IPF).
Data in patients with non-IPF ILD (which is arguably more difficult to diagnose and manage) were lacking until a recent retrospective cohort study of patients from five centers across the US demonstrated that immunosuppressant exposure in patients with age-adjusted telomere length <10th percentile was associated with a reduced 2-year transplant-free survival in fibrotic hypersensitivity pneumonitis and unclassifiable ILD subgroups.1 This study was underpowered to detect associations in the connective tissue disease-ILD group. Interestingly, authors noted that immunosuppressant exposure was not associated with lung function decline in the short telomere group, suggesting that worse outcomes may be attributable to unmasking extrapulmonary manifestations of short telomeres, such as bone marrow failure and impaired adaptive immunity. Studies like these are essential to guide decision-making in the age of personalized medicine and underscore the necessity for prospective studies to validate these findings.
References
1. Zhang D, Adegunsoye A, Oldham JM, et al. Telomere length and immunosuppression in non-idiopathic pulmonary fibrosis interstitial lung disease. Eur Respir J. 2023;62(5):2300441.
DIFFUSE LUNG DISEASE AND LUNG TRANSPLANT NETWORK
Interstitial Lung Disease Section
Interstitial lung diseases (ILDs) are a diverse group of relentlessly progressive fibroinflammatory disorders. Pharmacotherapy includes antifibrotics and immunosuppressants as foundational strategies to mitigate loss of lung function. There has been a growing interest in telomere length and its response to immunosuppression in the ILD community.
Telomeres are repetitive nucleotide sequences that “cap” chromosomes and protect against chromosomal shortening during cell replication. Genetic and environmental factors can lead to premature shortening of telomeres. Once a critical length is reached, the cell enters senescence. Short telomere length has been linked to rapid progression, worse outcomes, and poor response to immunosuppressants in idiopathic pulmonary fibrosis (IPF).
Data in patients with non-IPF ILD (which is arguably more difficult to diagnose and manage) were lacking until a recent retrospective cohort study of patients from five centers across the US demonstrated that immunosuppressant exposure in patients with age-adjusted telomere length <10th percentile was associated with a reduced 2-year transplant-free survival in fibrotic hypersensitivity pneumonitis and unclassifiable ILD subgroups.1 This study was underpowered to detect associations in the connective tissue disease-ILD group. Interestingly, authors noted that immunosuppressant exposure was not associated with lung function decline in the short telomere group, suggesting that worse outcomes may be attributable to unmasking extrapulmonary manifestations of short telomeres, such as bone marrow failure and impaired adaptive immunity. Studies like these are essential to guide decision-making in the age of personalized medicine and underscore the necessity for prospective studies to validate these findings.
References
1. Zhang D, Adegunsoye A, Oldham JM, et al. Telomere length and immunosuppression in non-idiopathic pulmonary fibrosis interstitial lung disease. Eur Respir J. 2023;62(5):2300441.
DIFFUSE LUNG DISEASE AND LUNG TRANSPLANT NETWORK
Interstitial Lung Disease Section
Interstitial lung diseases (ILDs) are a diverse group of relentlessly progressive fibroinflammatory disorders. Pharmacotherapy includes antifibrotics and immunosuppressants as foundational strategies to mitigate loss of lung function. There has been a growing interest in telomere length and its response to immunosuppression in the ILD community.
Telomeres are repetitive nucleotide sequences that “cap” chromosomes and protect against chromosomal shortening during cell replication. Genetic and environmental factors can lead to premature shortening of telomeres. Once a critical length is reached, the cell enters senescence. Short telomere length has been linked to rapid progression, worse outcomes, and poor response to immunosuppressants in idiopathic pulmonary fibrosis (IPF).
Data in patients with non-IPF ILD (which is arguably more difficult to diagnose and manage) were lacking until a recent retrospective cohort study of patients from five centers across the US demonstrated that immunosuppressant exposure in patients with age-adjusted telomere length <10th percentile was associated with a reduced 2-year transplant-free survival in fibrotic hypersensitivity pneumonitis and unclassifiable ILD subgroups.1 This study was underpowered to detect associations in the connective tissue disease-ILD group. Interestingly, authors noted that immunosuppressant exposure was not associated with lung function decline in the short telomere group, suggesting that worse outcomes may be attributable to unmasking extrapulmonary manifestations of short telomeres, such as bone marrow failure and impaired adaptive immunity. Studies like these are essential to guide decision-making in the age of personalized medicine and underscore the necessity for prospective studies to validate these findings.
References
1. Zhang D, Adegunsoye A, Oldham JM, et al. Telomere length and immunosuppression in non-idiopathic pulmonary fibrosis interstitial lung disease. Eur Respir J. 2023;62(5):2300441.
Expanding recommendations for RSV vaccination
AIRWAYS DISORDERS NETWORK
Asthma and COPD Section
Respiratory syncytial virus (RSV) has been increasingly recognized as a prevalent cause of lower respiratory tract infection (LRTI) among adults in the United States. The risk of hospitalization and mortality from RSV-associated respiratory failure is higher in those with chronic lung disease. In adults aged 65 years or older, RSV has shown to cause up to 160,000 hospitalizations and 10,000 deaths annually.
RSV has been well established as a major cause of LRTI and morbidity among infants. Maternal vaccination with RSVPreF in patients who are pregnant is suggested between 32 0/7 and 36 6/7 weeks of gestation if the date of delivery falls during RSV season to prevent severe illness in young infants in their first months of life. At present, there are no data supporting vaccine administration to patients who are pregnant delivering outside of the RSV season.
What about the rest of the patients? A phase 3b clinical trial to assess the safety and immunogenicity of the RSVPreF3 vaccine in individuals 18 to 49 years of age at increased risk for RSV LRTI, including those with chronic respiratory diseases, is currently underway with projected completion in April 2025 (clinical trials.gov; ID NCT06389487). Additional studies examining safety and immunogenicity combining RSV vaccines with PCV20, influenza, COVID, or Tdap vaccines are also underway. These outcomes will be significant for future recommendations to further lower the risk of developing LRTI, hospitalization, and death among patients less than the age of 60 with chronic lung diseases.
Resources
1. Melgar M, Britton A, Roper LE, et al. Use of respiratory syncytial virus vaccines in older adults: recommendations of the Advisory Committee on Immunization Practices - United States, 2023. MMWR Morb Mortal Wkly Rep. 2023;72(29):793-801.
2. Healthcare Providers: RSV Vaccination for Adults 60 Years of Age and Over. Centers for Disease Control and Prevention. Updated March 1, 2024. https://www.cdc.gov/vaccines/vpd/rsv/hcp/older-adults.html
3. Ault KA, Hughes BL, Riley LE. Maternal Respiratory Syncytial Virus Vaccination. The American College of Obstetricians and Gynecologists. Updated December 11, 2023. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2023/09/maternal-respiratory-syncytial-virus-vaccination
AIRWAYS DISORDERS NETWORK
Asthma and COPD Section
Respiratory syncytial virus (RSV) has been increasingly recognized as a prevalent cause of lower respiratory tract infection (LRTI) among adults in the United States. The risk of hospitalization and mortality from RSV-associated respiratory failure is higher in those with chronic lung disease. In adults aged 65 years or older, RSV has shown to cause up to 160,000 hospitalizations and 10,000 deaths annually.
RSV has been well established as a major cause of LRTI and morbidity among infants. Maternal vaccination with RSVPreF in patients who are pregnant is suggested between 32 0/7 and 36 6/7 weeks of gestation if the date of delivery falls during RSV season to prevent severe illness in young infants in their first months of life. At present, there are no data supporting vaccine administration to patients who are pregnant delivering outside of the RSV season.
What about the rest of the patients? A phase 3b clinical trial to assess the safety and immunogenicity of the RSVPreF3 vaccine in individuals 18 to 49 years of age at increased risk for RSV LRTI, including those with chronic respiratory diseases, is currently underway with projected completion in April 2025 (clinical trials.gov; ID NCT06389487). Additional studies examining safety and immunogenicity combining RSV vaccines with PCV20, influenza, COVID, or Tdap vaccines are also underway. These outcomes will be significant for future recommendations to further lower the risk of developing LRTI, hospitalization, and death among patients less than the age of 60 with chronic lung diseases.
Resources
1. Melgar M, Britton A, Roper LE, et al. Use of respiratory syncytial virus vaccines in older adults: recommendations of the Advisory Committee on Immunization Practices - United States, 2023. MMWR Morb Mortal Wkly Rep. 2023;72(29):793-801.
2. Healthcare Providers: RSV Vaccination for Adults 60 Years of Age and Over. Centers for Disease Control and Prevention. Updated March 1, 2024. https://www.cdc.gov/vaccines/vpd/rsv/hcp/older-adults.html
3. Ault KA, Hughes BL, Riley LE. Maternal Respiratory Syncytial Virus Vaccination. The American College of Obstetricians and Gynecologists. Updated December 11, 2023. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2023/09/maternal-respiratory-syncytial-virus-vaccination
AIRWAYS DISORDERS NETWORK
Asthma and COPD Section
Respiratory syncytial virus (RSV) has been increasingly recognized as a prevalent cause of lower respiratory tract infection (LRTI) among adults in the United States. The risk of hospitalization and mortality from RSV-associated respiratory failure is higher in those with chronic lung disease. In adults aged 65 years or older, RSV has shown to cause up to 160,000 hospitalizations and 10,000 deaths annually.
RSV has been well established as a major cause of LRTI and morbidity among infants. Maternal vaccination with RSVPreF in patients who are pregnant is suggested between 32 0/7 and 36 6/7 weeks of gestation if the date of delivery falls during RSV season to prevent severe illness in young infants in their first months of life. At present, there are no data supporting vaccine administration to patients who are pregnant delivering outside of the RSV season.
What about the rest of the patients? A phase 3b clinical trial to assess the safety and immunogenicity of the RSVPreF3 vaccine in individuals 18 to 49 years of age at increased risk for RSV LRTI, including those with chronic respiratory diseases, is currently underway with projected completion in April 2025 (clinical trials.gov; ID NCT06389487). Additional studies examining safety and immunogenicity combining RSV vaccines with PCV20, influenza, COVID, or Tdap vaccines are also underway. These outcomes will be significant for future recommendations to further lower the risk of developing LRTI, hospitalization, and death among patients less than the age of 60 with chronic lung diseases.
Resources
1. Melgar M, Britton A, Roper LE, et al. Use of respiratory syncytial virus vaccines in older adults: recommendations of the Advisory Committee on Immunization Practices - United States, 2023. MMWR Morb Mortal Wkly Rep. 2023;72(29):793-801.
2. Healthcare Providers: RSV Vaccination for Adults 60 Years of Age and Over. Centers for Disease Control and Prevention. Updated March 1, 2024. https://www.cdc.gov/vaccines/vpd/rsv/hcp/older-adults.html
3. Ault KA, Hughes BL, Riley LE. Maternal Respiratory Syncytial Virus Vaccination. The American College of Obstetricians and Gynecologists. Updated December 11, 2023. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2023/09/maternal-respiratory-syncytial-virus-vaccination
Commentary: Topical Treatments for AD and Possible Lifestyle Adjustments, July 2024
In this real-life study, Patruno and colleagues found that dupilumab worked well but more slowly in patients with a higher body mass index (BMI). On the basis of these findings, if patients are not in a hurry, the standard dose of dupilumab should eventually work, regardless of BMI. If patients are in a hurry to see improvement, perhaps dose escalation could be considered for patients with a high BMI, or perhaps topical triamcinolone could be used to speed time-to–initial resolution in the high-BMI population.
In the very well-done study by Silverberg and colleagues, tapinarof was effective, well tolerated, and generally safe for atopic dermatitis in adults and children. Great! Topical tapinarof should soon be another good option for our patients with atopic dermatitis. How valuable will it be? We already have topical corticosteroids that are very effective for atopic dermatitis, and we have multiple other nonsteroidal topical agents, including topical calcineurin inhibitors and topical ruxolitinib.
Perhaps the biggest limitation of all these treatments is poor adherence to topical treatment. I'm not sure how effective even highly effective nonsteroidal topicals will be for patients who did not respond to topical steroids when the primary reason for topical steroid failure is poor treatment adherence. I'd love to see the development of a once-a-week or once-a-month topical therapy that would address the poor-adherence hurdle.
Abrocitinib is an effective treatment for improving atopic dermatitis. Although atopic dermatitis is a chronic condition requiring long-term management, we'd like to minimize exposure to the drug to avoid side effects. Thyssen and colleagues described the effectiveness of two maintenance treatment regimens: continuing 200 mg/d or reducing the dose to 100 mg/d. Both regimens prevented flares more than did placebo. This study also provided information on safety of the maintenance regimens. Rates of herpetic infections were low across all the groups, but unlike the two treatment groups, there were no cases of herpes simplex infection in the patients in the placebo arm.
In this real-life study, Patruno and colleagues found that dupilumab worked well but more slowly in patients with a higher body mass index (BMI). On the basis of these findings, if patients are not in a hurry, the standard dose of dupilumab should eventually work, regardless of BMI. If patients are in a hurry to see improvement, perhaps dose escalation could be considered for patients with a high BMI, or perhaps topical triamcinolone could be used to speed time-to–initial resolution in the high-BMI population.
In the very well-done study by Silverberg and colleagues, tapinarof was effective, well tolerated, and generally safe for atopic dermatitis in adults and children. Great! Topical tapinarof should soon be another good option for our patients with atopic dermatitis. How valuable will it be? We already have topical corticosteroids that are very effective for atopic dermatitis, and we have multiple other nonsteroidal topical agents, including topical calcineurin inhibitors and topical ruxolitinib.
Perhaps the biggest limitation of all these treatments is poor adherence to topical treatment. I'm not sure how effective even highly effective nonsteroidal topicals will be for patients who did not respond to topical steroids when the primary reason for topical steroid failure is poor treatment adherence. I'd love to see the development of a once-a-week or once-a-month topical therapy that would address the poor-adherence hurdle.
Abrocitinib is an effective treatment for improving atopic dermatitis. Although atopic dermatitis is a chronic condition requiring long-term management, we'd like to minimize exposure to the drug to avoid side effects. Thyssen and colleagues described the effectiveness of two maintenance treatment regimens: continuing 200 mg/d or reducing the dose to 100 mg/d. Both regimens prevented flares more than did placebo. This study also provided information on safety of the maintenance regimens. Rates of herpetic infections were low across all the groups, but unlike the two treatment groups, there were no cases of herpes simplex infection in the patients in the placebo arm.
In this real-life study, Patruno and colleagues found that dupilumab worked well but more slowly in patients with a higher body mass index (BMI). On the basis of these findings, if patients are not in a hurry, the standard dose of dupilumab should eventually work, regardless of BMI. If patients are in a hurry to see improvement, perhaps dose escalation could be considered for patients with a high BMI, or perhaps topical triamcinolone could be used to speed time-to–initial resolution in the high-BMI population.
In the very well-done study by Silverberg and colleagues, tapinarof was effective, well tolerated, and generally safe for atopic dermatitis in adults and children. Great! Topical tapinarof should soon be another good option for our patients with atopic dermatitis. How valuable will it be? We already have topical corticosteroids that are very effective for atopic dermatitis, and we have multiple other nonsteroidal topical agents, including topical calcineurin inhibitors and topical ruxolitinib.
Perhaps the biggest limitation of all these treatments is poor adherence to topical treatment. I'm not sure how effective even highly effective nonsteroidal topicals will be for patients who did not respond to topical steroids when the primary reason for topical steroid failure is poor treatment adherence. I'd love to see the development of a once-a-week or once-a-month topical therapy that would address the poor-adherence hurdle.
Abrocitinib is an effective treatment for improving atopic dermatitis. Although atopic dermatitis is a chronic condition requiring long-term management, we'd like to minimize exposure to the drug to avoid side effects. Thyssen and colleagues described the effectiveness of two maintenance treatment regimens: continuing 200 mg/d or reducing the dose to 100 mg/d. Both regimens prevented flares more than did placebo. This study also provided information on safety of the maintenance regimens. Rates of herpetic infections were low across all the groups, but unlike the two treatment groups, there were no cases of herpes simplex infection in the patients in the placebo arm.
Frequent or Severe Flares Linked to Increased Atopic Dermatitis Severity
Key clinical point: Patients with atopic dermatitis (AD) who had many or severe flares were more likely to report higher disease severity and impairment in quality of life than those who had no or few flares.
Major finding: Patients with 1-5, 6-10, or >10 flares had higher median Patient-Oriented SCORing for Atopic Dermatitis (29.7, 36.3, and 42.9, respectively) and Dermatology Life Quality Index (3, 4, and 7, respectively) scores than those without flares.
Study details: This Danish population-based study included 1557 patients with AD who had 0 (n = 57), 1-5 (n = 698), 6-10 (n = 324), or >10 (n = 478) flares during the past 12 months.
Disclosures: The study was funded by Almirall S.A., Barcelona, Spain. Three authors declared being employees of Almirall, whereas the remaining authors reported having various ties with Almirall and other sources.
Source: Nielsen M-L, Nymand LK, Domenech Pena A, et al. Characterization of patients with atopic dermatitis based on flare patterns and severity of disease: A Danish population-based study. J Eur Acad Dermatol Venereol. 2024 (May 30). doi: 10.1111/jdv.20160 Source
Key clinical point: Patients with atopic dermatitis (AD) who had many or severe flares were more likely to report higher disease severity and impairment in quality of life than those who had no or few flares.
Major finding: Patients with 1-5, 6-10, or >10 flares had higher median Patient-Oriented SCORing for Atopic Dermatitis (29.7, 36.3, and 42.9, respectively) and Dermatology Life Quality Index (3, 4, and 7, respectively) scores than those without flares.
Study details: This Danish population-based study included 1557 patients with AD who had 0 (n = 57), 1-5 (n = 698), 6-10 (n = 324), or >10 (n = 478) flares during the past 12 months.
Disclosures: The study was funded by Almirall S.A., Barcelona, Spain. Three authors declared being employees of Almirall, whereas the remaining authors reported having various ties with Almirall and other sources.
Source: Nielsen M-L, Nymand LK, Domenech Pena A, et al. Characterization of patients with atopic dermatitis based on flare patterns and severity of disease: A Danish population-based study. J Eur Acad Dermatol Venereol. 2024 (May 30). doi: 10.1111/jdv.20160 Source
Key clinical point: Patients with atopic dermatitis (AD) who had many or severe flares were more likely to report higher disease severity and impairment in quality of life than those who had no or few flares.
Major finding: Patients with 1-5, 6-10, or >10 flares had higher median Patient-Oriented SCORing for Atopic Dermatitis (29.7, 36.3, and 42.9, respectively) and Dermatology Life Quality Index (3, 4, and 7, respectively) scores than those without flares.
Study details: This Danish population-based study included 1557 patients with AD who had 0 (n = 57), 1-5 (n = 698), 6-10 (n = 324), or >10 (n = 478) flares during the past 12 months.
Disclosures: The study was funded by Almirall S.A., Barcelona, Spain. Three authors declared being employees of Almirall, whereas the remaining authors reported having various ties with Almirall and other sources.
Source: Nielsen M-L, Nymand LK, Domenech Pena A, et al. Characterization of patients with atopic dermatitis based on flare patterns and severity of disease: A Danish population-based study. J Eur Acad Dermatol Venereol. 2024 (May 30). doi: 10.1111/jdv.20160 Source
Frequent or Severe Flares Linked to Increased Atopic Dermatitis Severity
Key clinical point: Patients with atopic dermatitis (AD) who had many or severe flares were more likely to report higher disease severity and impairment in quality of life than those who had no or few flares.
Major finding: Patients with 1-5, 6-10, or >10 flares had higher median Patient-Oriented SCORing for Atopic Dermatitis (29.7, 36.3, and 42.9, respectively) and Dermatology Life Quality Index (3, 4, and 7, respectively) scores than those without flares.
Study details: This Danish population-based study included 1557 patients with AD who had 0 (n = 57), 1-5 (n = 698), 6-10 (n = 324), or >10 (n = 478) flares during the past 12 months.
Disclosures: The study was funded by Almirall S.A., Barcelona, Spain. Three authors declared being employees of Almirall, whereas the remaining authors reported having various ties with Almirall and other sources.
Source: Nielsen M-L, Nymand LK, Domenech Pena A, et al. Characterization of patients with atopic dermatitis based on flare patterns and severity of disease: A Danish population-based study. J Eur Acad Dermatol Venereol. 2024 (May 30). doi: 10.1111/jdv.20160 Source
Key clinical point: Patients with atopic dermatitis (AD) who had many or severe flares were more likely to report higher disease severity and impairment in quality of life than those who had no or few flares.
Major finding: Patients with 1-5, 6-10, or >10 flares had higher median Patient-Oriented SCORing for Atopic Dermatitis (29.7, 36.3, and 42.9, respectively) and Dermatology Life Quality Index (3, 4, and 7, respectively) scores than those without flares.
Study details: This Danish population-based study included 1557 patients with AD who had 0 (n = 57), 1-5 (n = 698), 6-10 (n = 324), or >10 (n = 478) flares during the past 12 months.
Disclosures: The study was funded by Almirall S.A., Barcelona, Spain. Three authors declared being employees of Almirall, whereas the remaining authors reported having various ties with Almirall and other sources.
Source: Nielsen M-L, Nymand LK, Domenech Pena A, et al. Characterization of patients with atopic dermatitis based on flare patterns and severity of disease: A Danish population-based study. J Eur Acad Dermatol Venereol. 2024 (May 30). doi: 10.1111/jdv.20160 Source
Key clinical point: Patients with atopic dermatitis (AD) who had many or severe flares were more likely to report higher disease severity and impairment in quality of life than those who had no or few flares.
Major finding: Patients with 1-5, 6-10, or >10 flares had higher median Patient-Oriented SCORing for Atopic Dermatitis (29.7, 36.3, and 42.9, respectively) and Dermatology Life Quality Index (3, 4, and 7, respectively) scores than those without flares.
Study details: This Danish population-based study included 1557 patients with AD who had 0 (n = 57), 1-5 (n = 698), 6-10 (n = 324), or >10 (n = 478) flares during the past 12 months.
Disclosures: The study was funded by Almirall S.A., Barcelona, Spain. Three authors declared being employees of Almirall, whereas the remaining authors reported having various ties with Almirall and other sources.
Source: Nielsen M-L, Nymand LK, Domenech Pena A, et al. Characterization of patients with atopic dermatitis based on flare patterns and severity of disease: A Danish population-based study. J Eur Acad Dermatol Venereol. 2024 (May 30). doi: 10.1111/jdv.20160 Source
Study Shows Bidirectional Association Between Polycystic Ovary Syndrome and Atopic Dermatitis
Key clinical point: Patients with polycystic ovary syndrome (PCOS) had a significantly increased risk for atopic dermatitis (AD), and patients with AD had a significantly increased risk for PCOS.
Major finding: The risk of developing AD was significantly higher in patients with PCOS (adjusted odds ratio [aOR] 1.99; P < .001) than in control participants. Similarly, the risk of developing PCOS was significantly higher in patients with AD (aOR 1.86; P < .001) than in control participants.
Study details: This nested case-control study included 3234 participants with PCOS who were matched with 12,936 control participants without PCOS using nearest-neighbor propensity-score matching, of whom 293 (4.55%) with PCOS and 588 (9.06%) without PCOS had AD.
Disclosures: This study did not disclose any source of funding. The authors declared no conflicts of interest.
Source: Kim IH, Andrade LF, Haq Z, et al. Association of polycystic ovary syndrome with atopic dermatitis: A case control study. Arch Dermatol Res. 2024;316:258. doi: 10.1007/s00403-024-03102-0 Source
Key clinical point: Patients with polycystic ovary syndrome (PCOS) had a significantly increased risk for atopic dermatitis (AD), and patients with AD had a significantly increased risk for PCOS.
Major finding: The risk of developing AD was significantly higher in patients with PCOS (adjusted odds ratio [aOR] 1.99; P < .001) than in control participants. Similarly, the risk of developing PCOS was significantly higher in patients with AD (aOR 1.86; P < .001) than in control participants.
Study details: This nested case-control study included 3234 participants with PCOS who were matched with 12,936 control participants without PCOS using nearest-neighbor propensity-score matching, of whom 293 (4.55%) with PCOS and 588 (9.06%) without PCOS had AD.
Disclosures: This study did not disclose any source of funding. The authors declared no conflicts of interest.
Source: Kim IH, Andrade LF, Haq Z, et al. Association of polycystic ovary syndrome with atopic dermatitis: A case control study. Arch Dermatol Res. 2024;316:258. doi: 10.1007/s00403-024-03102-0 Source
Key clinical point: Patients with polycystic ovary syndrome (PCOS) had a significantly increased risk for atopic dermatitis (AD), and patients with AD had a significantly increased risk for PCOS.
Major finding: The risk of developing AD was significantly higher in patients with PCOS (adjusted odds ratio [aOR] 1.99; P < .001) than in control participants. Similarly, the risk of developing PCOS was significantly higher in patients with AD (aOR 1.86; P < .001) than in control participants.
Study details: This nested case-control study included 3234 participants with PCOS who were matched with 12,936 control participants without PCOS using nearest-neighbor propensity-score matching, of whom 293 (4.55%) with PCOS and 588 (9.06%) without PCOS had AD.
Disclosures: This study did not disclose any source of funding. The authors declared no conflicts of interest.
Source: Kim IH, Andrade LF, Haq Z, et al. Association of polycystic ovary syndrome with atopic dermatitis: A case control study. Arch Dermatol Res. 2024;316:258. doi: 10.1007/s00403-024-03102-0 Source
Maintenance Optimization in Abrocitinib Induction Responders With Atopic Dermatitis
Key clinical point: Patients with moderate to severe atopic dermatitis (AD) who initially responded to a 12-week induction with 200 mg abrocitinib had a low risk for flares during the 40-week maintenance period, irrespective of whether the dose was continued or stepped down to 100 mg.
Major finding: The range of probabilities of not flaring were 6%-82%, 31%-92%, and 14%-34% in patients who received 100 mg abrocitinib, 200 mg abrocitinib, and placebo, respectively. An increased percentage change in the Eczema Area and Severity Index score from baseline to randomization and an Investigator's Global Assessment score of 0 at randomization (both P < .001) were predictors of not flaring.
Study details: This post hoc analysis of the JADE REGIMEN trial included 798 patients with moderate to severe AD who responded to 200 mg abrocitinib induction therapy and were randomly assigned to receive abrocitinib (200 or 100 mg) or placebo during the maintenance period.
Disclosures: This study was funded by Pfizer Inc. Four authors declared being employees and shareholders of Pfizer Inc. Other authors declared having other ties with various sources, including Pfizer Inc.
Source: Thyssen JP, Silverberg JI, Ruano J, et al. Optimizing maintenance therapy in responders to abrocitinib induction: A post hoc analysis of JADE REGIMEN. J Eur Acad Dermatol Venereol. 2024 (May 16). doi: 10.1111/jdv.20095 Source
Key clinical point: Patients with moderate to severe atopic dermatitis (AD) who initially responded to a 12-week induction with 200 mg abrocitinib had a low risk for flares during the 40-week maintenance period, irrespective of whether the dose was continued or stepped down to 100 mg.
Major finding: The range of probabilities of not flaring were 6%-82%, 31%-92%, and 14%-34% in patients who received 100 mg abrocitinib, 200 mg abrocitinib, and placebo, respectively. An increased percentage change in the Eczema Area and Severity Index score from baseline to randomization and an Investigator's Global Assessment score of 0 at randomization (both P < .001) were predictors of not flaring.
Study details: This post hoc analysis of the JADE REGIMEN trial included 798 patients with moderate to severe AD who responded to 200 mg abrocitinib induction therapy and were randomly assigned to receive abrocitinib (200 or 100 mg) or placebo during the maintenance period.
Disclosures: This study was funded by Pfizer Inc. Four authors declared being employees and shareholders of Pfizer Inc. Other authors declared having other ties with various sources, including Pfizer Inc.
Source: Thyssen JP, Silverberg JI, Ruano J, et al. Optimizing maintenance therapy in responders to abrocitinib induction: A post hoc analysis of JADE REGIMEN. J Eur Acad Dermatol Venereol. 2024 (May 16). doi: 10.1111/jdv.20095 Source
Key clinical point: Patients with moderate to severe atopic dermatitis (AD) who initially responded to a 12-week induction with 200 mg abrocitinib had a low risk for flares during the 40-week maintenance period, irrespective of whether the dose was continued or stepped down to 100 mg.
Major finding: The range of probabilities of not flaring were 6%-82%, 31%-92%, and 14%-34% in patients who received 100 mg abrocitinib, 200 mg abrocitinib, and placebo, respectively. An increased percentage change in the Eczema Area and Severity Index score from baseline to randomization and an Investigator's Global Assessment score of 0 at randomization (both P < .001) were predictors of not flaring.
Study details: This post hoc analysis of the JADE REGIMEN trial included 798 patients with moderate to severe AD who responded to 200 mg abrocitinib induction therapy and were randomly assigned to receive abrocitinib (200 or 100 mg) or placebo during the maintenance period.
Disclosures: This study was funded by Pfizer Inc. Four authors declared being employees and shareholders of Pfizer Inc. Other authors declared having other ties with various sources, including Pfizer Inc.
Source: Thyssen JP, Silverberg JI, Ruano J, et al. Optimizing maintenance therapy in responders to abrocitinib induction: A post hoc analysis of JADE REGIMEN. J Eur Acad Dermatol Venereol. 2024 (May 16). doi: 10.1111/jdv.20095 Source
High Prevalence of Overweight or Obesity in Children With Atopic Dermatitis
Key clinical point: Children with atopic dermatitis (AD) have a significantly higher likelihood of increased body mass index (BMI) corresponding to overweight or obesity, with a positive correlation observed between increased BMI and AD severity.
Major finding: Patients with AD had a three times higher risk for overweight (odds ratio [OR] 3.61; P < .01) and a six times higher risk for obesity (OR 6.61; P < .05) than control participants. Furthermore, the risk for overweight or obesity was almost 20 times higher in patients with moderate to severe AD (OR 20.4; P < .001) vs those with mild AD.
Study details: This retrospective case-control study included 130 children with AD and 130 age- and sex-matched control participants who were categorized according to their BMI and nutritional status as underweight (percentile < 5), normal weight (percentile 5-84), overweight (percentile 85-94), or obese (percentile ≥ 95).
Disclosures: The authors did not disclose any source of funding. The authors declared no conflicts of interest.
Source: Sendrea AM, Cristea S, Salavastru CM. Association between increased body mass index (BMI) and atopic dermatitis in children attending a tertiary referral center: A case-control study. Cureus. 2024;16:e60770. doi: 10.7759/cureus.60770 Source
Key clinical point: Children with atopic dermatitis (AD) have a significantly higher likelihood of increased body mass index (BMI) corresponding to overweight or obesity, with a positive correlation observed between increased BMI and AD severity.
Major finding: Patients with AD had a three times higher risk for overweight (odds ratio [OR] 3.61; P < .01) and a six times higher risk for obesity (OR 6.61; P < .05) than control participants. Furthermore, the risk for overweight or obesity was almost 20 times higher in patients with moderate to severe AD (OR 20.4; P < .001) vs those with mild AD.
Study details: This retrospective case-control study included 130 children with AD and 130 age- and sex-matched control participants who were categorized according to their BMI and nutritional status as underweight (percentile < 5), normal weight (percentile 5-84), overweight (percentile 85-94), or obese (percentile ≥ 95).
Disclosures: The authors did not disclose any source of funding. The authors declared no conflicts of interest.
Source: Sendrea AM, Cristea S, Salavastru CM. Association between increased body mass index (BMI) and atopic dermatitis in children attending a tertiary referral center: A case-control study. Cureus. 2024;16:e60770. doi: 10.7759/cureus.60770 Source
Key clinical point: Children with atopic dermatitis (AD) have a significantly higher likelihood of increased body mass index (BMI) corresponding to overweight or obesity, with a positive correlation observed between increased BMI and AD severity.
Major finding: Patients with AD had a three times higher risk for overweight (odds ratio [OR] 3.61; P < .01) and a six times higher risk for obesity (OR 6.61; P < .05) than control participants. Furthermore, the risk for overweight or obesity was almost 20 times higher in patients with moderate to severe AD (OR 20.4; P < .001) vs those with mild AD.
Study details: This retrospective case-control study included 130 children with AD and 130 age- and sex-matched control participants who were categorized according to their BMI and nutritional status as underweight (percentile < 5), normal weight (percentile 5-84), overweight (percentile 85-94), or obese (percentile ≥ 95).
Disclosures: The authors did not disclose any source of funding. The authors declared no conflicts of interest.
Source: Sendrea AM, Cristea S, Salavastru CM. Association between increased body mass index (BMI) and atopic dermatitis in children attending a tertiary referral center: A case-control study. Cureus. 2024;16:e60770. doi: 10.7759/cureus.60770 Source