CRITICAL CARE NETWORK

Nonrespiratory Critical Care Section

Nutrition plays an important role in the management and recovery of critically ill patients admitted to the ICU. Major guidelines recommend that critically ill patients should receive 1.2 to 2.0 g/kg/day of protein, with an emphasis on early (within 48 hours of ICU admission) enteral nutrition.^1-3

In a randomized controlled trial involving 173 critically ill patients who stayed in the ICU in Zhejiang, China, Wang and colleagues studied the impact of early high protein intake (1.5 g/kg/day vs 0.8 g/kg/day).⁴ The primary outcome of 28-day mortality was lower among the high protein intake group (8.14% vs 19.54%). Still, this intention-to-treat analysis did not reach a statistical significance (P = .051). However, a time-to-event analysis using the Cox proportional hazard model showed that the high protein intake group had a significantly lower 28-day mortality rate, shorter ICU stays, and improved nutritional status, particularly in patients with sepsis (P = .045).

CHEST

CHEST

References

1. Taylor BE, McClave SA, Martindale RG, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). Crit Care Med. 2016;44(2):390-438. doi:10.1097/CCM.0000000000001525

2. Singer P, Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38(1):48-79. doi:10.1016/j.clnu.2018.08.037

3. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). JJPEN J Parenter Enteral Nutr. 2016;40(2):159-211. doi:10.1177/0148607115621863

4. Wang Y, Ye Y, Xuan L, et al. Impact of early high protein intake in critically ill patients: a randomized controlled trial. Nutr Metab. 2024;21(1):39. doi.org/10.1186/s12986-024-00818-8

5. Lee ZY, Yap CSL, Hasan MS, et al. The effect of higher versus lower protein delivery in critically ill patients: a systematic review and meta-analysis of randomized controlled trials. Crit Care. 2021;25(1):260. doi.org/10.1186/s13054-021-03693-4

6. Stoppe C, Patel JJ, Zarbock A, et al. The impact of higher protein dosing on outcomes in critically ill patients with acute kidney injury: a post hoc analysis of the EFFORT protein trial. Crit Care. 2023;27(1):399. doi.org/10.1186/s13054-023-04663-8
 

CRITICAL CARE NETWORK

Nonrespiratory Critical Care Section

Nutrition plays an important role in the management and recovery of critically ill patients admitted to the ICU. Major guidelines recommend that critically ill patients should receive 1.2 to 2.0 g/kg/day of protein, with an emphasis on early (within 48 hours of ICU admission) enteral nutrition.^1-3

In a randomized controlled trial involving 173 critically ill patients who stayed in the ICU in Zhejiang, China, Wang and colleagues studied the impact of early high protein intake (1.5 g/kg/day vs 0.8 g/kg/day).⁴ The primary outcome of 28-day mortality was lower among the high protein intake group (8.14% vs 19.54%). Still, this intention-to-treat analysis did not reach a statistical significance (P = .051). However, a time-to-event analysis using the Cox proportional hazard model showed that the high protein intake group had a significantly lower 28-day mortality rate, shorter ICU stays, and improved nutritional status, particularly in patients with sepsis (P = .045).

CHEST

CHEST

References

1. Taylor BE, McClave SA, Martindale RG, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). Crit Care Med. 2016;44(2):390-438. doi:10.1097/CCM.0000000000001525

2. Singer P, Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38(1):48-79. doi:10.1016/j.clnu.2018.08.037

3. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). JJPEN J Parenter Enteral Nutr. 2016;40(2):159-211. doi:10.1177/0148607115621863

4. Wang Y, Ye Y, Xuan L, et al. Impact of early high protein intake in critically ill patients: a randomized controlled trial. Nutr Metab. 2024;21(1):39. doi.org/10.1186/s12986-024-00818-8

5. Lee ZY, Yap CSL, Hasan MS, et al. The effect of higher versus lower protein delivery in critically ill patients: a systematic review and meta-analysis of randomized controlled trials. Crit Care. 2021;25(1):260. doi.org/10.1186/s13054-021-03693-4

6. Stoppe C, Patel JJ, Zarbock A, et al. The impact of higher protein dosing on outcomes in critically ill patients with acute kidney injury: a post hoc analysis of the EFFORT protein trial. Crit Care. 2023;27(1):399. doi.org/10.1186/s13054-023-04663-8
 

CRITICAL CARE NETWORK

Nonrespiratory Critical Care Section

Nutrition plays an important role in the management and recovery of critically ill patients admitted to the ICU. Major guidelines recommend that critically ill patients should receive 1.2 to 2.0 g/kg/day of protein, with an emphasis on early (within 48 hours of ICU admission) enteral nutrition.^1-3

In a randomized controlled trial involving 173 critically ill patients who stayed in the ICU in Zhejiang, China, Wang and colleagues studied the impact of early high protein intake (1.5 g/kg/day vs 0.8 g/kg/day).⁴ The primary outcome of 28-day mortality was lower among the high protein intake group (8.14% vs 19.54%). Still, this intention-to-treat analysis did not reach a statistical significance (P = .051). However, a time-to-event analysis using the Cox proportional hazard model showed that the high protein intake group had a significantly lower 28-day mortality rate, shorter ICU stays, and improved nutritional status, particularly in patients with sepsis (P = .045).

CHEST

CHEST

References

1. Taylor BE, McClave SA, Martindale RG, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). Crit Care Med. 2016;44(2):390-438. doi:10.1097/CCM.0000000000001525

2. Singer P, Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38(1):48-79. doi:10.1016/j.clnu.2018.08.037

3. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). JJPEN J Parenter Enteral Nutr. 2016;40(2):159-211. doi:10.1177/0148607115621863

4. Wang Y, Ye Y, Xuan L, et al. Impact of early high protein intake in critically ill patients: a randomized controlled trial. Nutr Metab. 2024;21(1):39. doi.org/10.1186/s12986-024-00818-8

5. Lee ZY, Yap CSL, Hasan MS, et al. The effect of higher versus lower protein delivery in critically ill patients: a systematic review and meta-analysis of randomized controlled trials. Crit Care. 2021;25(1):260. doi.org/10.1186/s13054-021-03693-4

6. Stoppe C, Patel JJ, Zarbock A, et al. The impact of higher protein dosing on outcomes in critically ill patients with acute kidney injury: a post hoc analysis of the EFFORT protein trial. Crit Care. 2023;27(1):399. doi.org/10.1186/s13054-023-04663-8
 

Editor's Note: This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

Editor's Note: This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

Editor's Note: This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

The Diagnosis: Mycobacterial Infection

An injury sustained in a wet environment that results in chronic indolent abscesses, nodules, or draining sinus tracts suggests a mycobacterial infection. In our patient, a culture revealed MycobacteriuM fortuitum, which is classified in the rapid grower nontuberculous mycobacteria (NTM) group, along with Mycobacterium chelonae and Mycobacterium abscessus.¹ The patient’s history of skin injury while cutting wet grass and the common presence of M fortuitum in the environment suggested that the organism entered the wound. The patient healed completely following surgical excision and a 2-month course of clarithromycin 1 g daily and rifampin 600 mg daily.

MycobacteriuM fortuitum was first isolated from an amphibian source in 1905 and later identified in a human with cutaneous infection in 1938. It commonly is found in soil and water.2 Skin and soft-tissue infections with M fortuitum usually are acquired from direct entry of the organism through a damaged skin barrier from trauma, medical injection, surgery, or tattoo placement.^2,3

Skin lesions caused by NTM often are nonspecific and can mimic a variety of other dermatologic conditions, making clinical diagnosis challenging. As such, cutaneous manifestations of M fortuitum infection can include recurrent cutaneous abscesses, nodular lesions, chronic discharging sinuses, cellulitis, and surgical site infections.4 Although cutaneous infection with M fortuitum classically manifests with a single subcutaneous nodule at the site of trauma or surgery,⁵ it also can manifest as multiple draining sinus tracts, as seen in our patient. Hence, the diagnosis and treatment of cutaneous NTM infection is challenging, especially when M fortuitum skin manifestations can take up to 4 to 6 weeks to develop after inoculation. Diagnosis often requires a detailed patient history, tissue cultures, and histopathology.⁵

In recent years, rapid detection with polymerase chain reaction (PCR) techniques has been employed more widely. Notably, a molecular system based on multiplex real-time PCR with high-resolution melting was shown to have a sensitivity of up to 54% for distinguishing M fortuitum from other NTM.⁶ More recently, a 2-step real-time PCR method has demonstrated diagnostic sensitivity and specificity for differentiating NTM from Mycobacterium tuberculosis infections and identifying the causative NTM agent.⁷

Compared to immunocompetent individuals, those who are immunocompromised are more susceptible to less pathogenic strains of NTM, which can cause dissemination and lead to tenosynovitis, myositis, osteomyelitis, and septic arthritis.^8-12 Nonetheless, cases of infections with NTM—including M fortuitum—are becoming harder to treat. Several single nucleotide polymorphisms and point mutations have been demonstrated in the ribosomal RNA methylase gene erm(39) related to clarithromycin resistance and in the rrl gene related to linezolid resistance.¹³ Due to increasing inducible resistance to common classes of antibiotics, such as macrolides and linezolid, treatment of M fortuitum requires multidrug regimens.^13,14 Drug susceptibility testing also may be required, as M fortuitum has shown low resistance to tigecycline, tetracycline, cefmetazole, imipenem, and aminoglycosides (eg, amikacin, tobramycin, neomycin, gentamycin). Surgery is an important adjunctive tool in treating M fortuitum infections; patients with a single lesion are more likely to undergo surgical treatment alone or in combination with antibiotic therapy.¹⁵ More recently, antimicrobial photodynamic therapy has been explored as an alternative to eliminate NTM, including M fortuitum.¹⁶

The differential diagnosis for skin lesions manifesting with draining fistulae and sinus tracts includes conditions with infectious (cellulitis and chromomycosis) and inflammatory (pyoderma gangrenosum [PG] and hidradenitis suppurativa [HS]) causes.

Cellulitis is a common infection of the skin and subcutaneous tissue that predominantly is caused by gram-positive organisms such as β-hemolytic streptococci.¹⁷ Clinical manifestations include acute skin erythema, swelling, tenderness, and warmth. The legs are the most common sites of infection, but any area of the skin can be involved.17 Cellulitis comprises 10% of all infectious disease hospitalizations and up to 11% of all dermatologic admissions.^18,19 It frequently is misdiagnosed, perhaps due to the lack of a reliable confirmatory laboratory test or imaging study, in addition to the plethora of diseases that mimic cellulitis, such as stasis dermatitis, lipodermatosclerosis, contact dermatitis, lymphedema, eosinophilic cellulitis, and papular urticaria.^20,21 The consequences of misdiagnosis include but are not limited to unnecessary hospitalizations, inappropriate antibiotic use, and delayed management of the disease; thus, there is an urgent need for a reliable standard test to confirm the diagnosis, especially among nonspecialist physicians. ²⁰ Most patients with uncomplicated cellulitis can be treated with empiric oral antibiotics that target β-hemolytic streptococci (ie, penicillin V potassium, amoxicillin).¹⁷ Methicillin-resistant Staphylococcus aureus coverage generally is unnecessary for nonpurulent cellulitis, but clinicians can consider adding amoxicillin-clavulanate, dicloxacillin, and cephalexin to the regimen. For purulent cellulitis, incision and drainage should be performed. In severe cases that manifest with sepsis, altered mental status, or hemodynamic instability, inpatient management is required.¹⁷

Chromomycosis (also known as chromoblastomycosis) is a chronic, indolent, granulomatous, suppurative mycosis of the skin and subcutaneous tissue²² that is caused by traumatic inoculation of various fungi of the order Chaetothyriales and family Herpotrichiellaceae, which are present in soil, plants, and decomposing wood. Chromomycosis is prevalent in tropical and subtropical regions.^23,24 Clinically, it manifests as oligosymptomatic or asymptomatic lesions around an infection site that can manifest as papules with centrifugal growth evolving into nodular, verrucous, plaque, tumoral, or atrophic forms.²² Diagnosis is made with direct microscopy using potassium hydroxide, which reveals muriform bodies. Fungal culture in Sabouraud agar also can be used to isolate the causative pathogen.²² Unfortunately, chromomycosis is difficult to treat, with low cure rates and high relapse rates. Antifungal agents combined with surgery, cryotherapy, or thermotherapy often are used, with cure rates ranging from 15% to 80%.^22,25

Pyoderma gangrenosum is a reactive noninfectious inflammatory dermatosis associated with inflammatory bowel disease and rheumatoid arthritis. The exact etiology is not clearly understood, but it generally is considered an autoinflammatory disorder.²⁶ The most common form—classical PG—occurs in approximately 85% of cases and manifests as a painful erythematous lesion that progresses to a blistered or necrotic ulcer. It primarily affects the lower legs but can occur in other body sites.²⁷ The diagnosis is based on clinical symptoms after excluding other similar conditions; histopathology of biopsied wound tissues often are required for confirmation. Treatment of PG starts with fast-acting immunosuppressive drugs (corticosteroids and/or cyclosporine) followed by slowacting immunosuppressive drugs (biologics).²⁶

Hidradenitis suppurativa is a chronic recurrent disease of the hair follicle unit that develops after puberty.²⁸ Clinically, HS manifests with painful nodules, abscesses, chronically draining fistulas, and scarring in areas of the body rich in apocrine glands.^29,30 Treatment of HS is challenging due to its diverse clinical manifestations and unclear etiology. Topical therapy, systemic treatments, biologic agents, surgery, and light therapy have shown variable results.^28,31

The Diagnosis: Mycobacterial Infection

An injury sustained in a wet environment that results in chronic indolent abscesses, nodules, or draining sinus tracts suggests a mycobacterial infection. In our patient, a culture revealed MycobacteriuM fortuitum, which is classified in the rapid grower nontuberculous mycobacteria (NTM) group, along with Mycobacterium chelonae and Mycobacterium abscessus.¹ The patient’s history of skin injury while cutting wet grass and the common presence of M fortuitum in the environment suggested that the organism entered the wound. The patient healed completely following surgical excision and a 2-month course of clarithromycin 1 g daily and rifampin 600 mg daily.

MycobacteriuM fortuitum was first isolated from an amphibian source in 1905 and later identified in a human with cutaneous infection in 1938. It commonly is found in soil and water.2 Skin and soft-tissue infections with M fortuitum usually are acquired from direct entry of the organism through a damaged skin barrier from trauma, medical injection, surgery, or tattoo placement.^2,3

Skin lesions caused by NTM often are nonspecific and can mimic a variety of other dermatologic conditions, making clinical diagnosis challenging. As such, cutaneous manifestations of M fortuitum infection can include recurrent cutaneous abscesses, nodular lesions, chronic discharging sinuses, cellulitis, and surgical site infections.4 Although cutaneous infection with M fortuitum classically manifests with a single subcutaneous nodule at the site of trauma or surgery,⁵ it also can manifest as multiple draining sinus tracts, as seen in our patient. Hence, the diagnosis and treatment of cutaneous NTM infection is challenging, especially when M fortuitum skin manifestations can take up to 4 to 6 weeks to develop after inoculation. Diagnosis often requires a detailed patient history, tissue cultures, and histopathology.⁵

In recent years, rapid detection with polymerase chain reaction (PCR) techniques has been employed more widely. Notably, a molecular system based on multiplex real-time PCR with high-resolution melting was shown to have a sensitivity of up to 54% for distinguishing M fortuitum from other NTM.⁶ More recently, a 2-step real-time PCR method has demonstrated diagnostic sensitivity and specificity for differentiating NTM from Mycobacterium tuberculosis infections and identifying the causative NTM agent.⁷

Compared to immunocompetent individuals, those who are immunocompromised are more susceptible to less pathogenic strains of NTM, which can cause dissemination and lead to tenosynovitis, myositis, osteomyelitis, and septic arthritis.^8-12 Nonetheless, cases of infections with NTM—including M fortuitum—are becoming harder to treat. Several single nucleotide polymorphisms and point mutations have been demonstrated in the ribosomal RNA methylase gene erm(39) related to clarithromycin resistance and in the rrl gene related to linezolid resistance.¹³ Due to increasing inducible resistance to common classes of antibiotics, such as macrolides and linezolid, treatment of M fortuitum requires multidrug regimens.^13,14 Drug susceptibility testing also may be required, as M fortuitum has shown low resistance to tigecycline, tetracycline, cefmetazole, imipenem, and aminoglycosides (eg, amikacin, tobramycin, neomycin, gentamycin). Surgery is an important adjunctive tool in treating M fortuitum infections; patients with a single lesion are more likely to undergo surgical treatment alone or in combination with antibiotic therapy.¹⁵ More recently, antimicrobial photodynamic therapy has been explored as an alternative to eliminate NTM, including M fortuitum.¹⁶

The differential diagnosis for skin lesions manifesting with draining fistulae and sinus tracts includes conditions with infectious (cellulitis and chromomycosis) and inflammatory (pyoderma gangrenosum [PG] and hidradenitis suppurativa [HS]) causes.

Cellulitis is a common infection of the skin and subcutaneous tissue that predominantly is caused by gram-positive organisms such as β-hemolytic streptococci.¹⁷ Clinical manifestations include acute skin erythema, swelling, tenderness, and warmth. The legs are the most common sites of infection, but any area of the skin can be involved.17 Cellulitis comprises 10% of all infectious disease hospitalizations and up to 11% of all dermatologic admissions.^18,19 It frequently is misdiagnosed, perhaps due to the lack of a reliable confirmatory laboratory test or imaging study, in addition to the plethora of diseases that mimic cellulitis, such as stasis dermatitis, lipodermatosclerosis, contact dermatitis, lymphedema, eosinophilic cellulitis, and papular urticaria.^20,21 The consequences of misdiagnosis include but are not limited to unnecessary hospitalizations, inappropriate antibiotic use, and delayed management of the disease; thus, there is an urgent need for a reliable standard test to confirm the diagnosis, especially among nonspecialist physicians. ²⁰ Most patients with uncomplicated cellulitis can be treated with empiric oral antibiotics that target β-hemolytic streptococci (ie, penicillin V potassium, amoxicillin).¹⁷ Methicillin-resistant Staphylococcus aureus coverage generally is unnecessary for nonpurulent cellulitis, but clinicians can consider adding amoxicillin-clavulanate, dicloxacillin, and cephalexin to the regimen. For purulent cellulitis, incision and drainage should be performed. In severe cases that manifest with sepsis, altered mental status, or hemodynamic instability, inpatient management is required.¹⁷

Chromomycosis (also known as chromoblastomycosis) is a chronic, indolent, granulomatous, suppurative mycosis of the skin and subcutaneous tissue²² that is caused by traumatic inoculation of various fungi of the order Chaetothyriales and family Herpotrichiellaceae, which are present in soil, plants, and decomposing wood. Chromomycosis is prevalent in tropical and subtropical regions.^23,24 Clinically, it manifests as oligosymptomatic or asymptomatic lesions around an infection site that can manifest as papules with centrifugal growth evolving into nodular, verrucous, plaque, tumoral, or atrophic forms.²² Diagnosis is made with direct microscopy using potassium hydroxide, which reveals muriform bodies. Fungal culture in Sabouraud agar also can be used to isolate the causative pathogen.²² Unfortunately, chromomycosis is difficult to treat, with low cure rates and high relapse rates. Antifungal agents combined with surgery, cryotherapy, or thermotherapy often are used, with cure rates ranging from 15% to 80%.^22,25

Pyoderma gangrenosum is a reactive noninfectious inflammatory dermatosis associated with inflammatory bowel disease and rheumatoid arthritis. The exact etiology is not clearly understood, but it generally is considered an autoinflammatory disorder.²⁶ The most common form—classical PG—occurs in approximately 85% of cases and manifests as a painful erythematous lesion that progresses to a blistered or necrotic ulcer. It primarily affects the lower legs but can occur in other body sites.²⁷ The diagnosis is based on clinical symptoms after excluding other similar conditions; histopathology of biopsied wound tissues often are required for confirmation. Treatment of PG starts with fast-acting immunosuppressive drugs (corticosteroids and/or cyclosporine) followed by slowacting immunosuppressive drugs (biologics).²⁶

Hidradenitis suppurativa is a chronic recurrent disease of the hair follicle unit that develops after puberty.²⁸ Clinically, HS manifests with painful nodules, abscesses, chronically draining fistulas, and scarring in areas of the body rich in apocrine glands.^29,30 Treatment of HS is challenging due to its diverse clinical manifestations and unclear etiology. Topical therapy, systemic treatments, biologic agents, surgery, and light therapy have shown variable results.^28,31

The Diagnosis: Mycobacterial Infection

An injury sustained in a wet environment that results in chronic indolent abscesses, nodules, or draining sinus tracts suggests a mycobacterial infection. In our patient, a culture revealed MycobacteriuM fortuitum, which is classified in the rapid grower nontuberculous mycobacteria (NTM) group, along with Mycobacterium chelonae and Mycobacterium abscessus.¹ The patient’s history of skin injury while cutting wet grass and the common presence of M fortuitum in the environment suggested that the organism entered the wound. The patient healed completely following surgical excision and a 2-month course of clarithromycin 1 g daily and rifampin 600 mg daily.

MycobacteriuM fortuitum was first isolated from an amphibian source in 1905 and later identified in a human with cutaneous infection in 1938. It commonly is found in soil and water.2 Skin and soft-tissue infections with M fortuitum usually are acquired from direct entry of the organism through a damaged skin barrier from trauma, medical injection, surgery, or tattoo placement.^2,3

Skin lesions caused by NTM often are nonspecific and can mimic a variety of other dermatologic conditions, making clinical diagnosis challenging. As such, cutaneous manifestations of M fortuitum infection can include recurrent cutaneous abscesses, nodular lesions, chronic discharging sinuses, cellulitis, and surgical site infections.4 Although cutaneous infection with M fortuitum classically manifests with a single subcutaneous nodule at the site of trauma or surgery,⁵ it also can manifest as multiple draining sinus tracts, as seen in our patient. Hence, the diagnosis and treatment of cutaneous NTM infection is challenging, especially when M fortuitum skin manifestations can take up to 4 to 6 weeks to develop after inoculation. Diagnosis often requires a detailed patient history, tissue cultures, and histopathology.⁵

In recent years, rapid detection with polymerase chain reaction (PCR) techniques has been employed more widely. Notably, a molecular system based on multiplex real-time PCR with high-resolution melting was shown to have a sensitivity of up to 54% for distinguishing M fortuitum from other NTM.⁶ More recently, a 2-step real-time PCR method has demonstrated diagnostic sensitivity and specificity for differentiating NTM from Mycobacterium tuberculosis infections and identifying the causative NTM agent.⁷

Compared to immunocompetent individuals, those who are immunocompromised are more susceptible to less pathogenic strains of NTM, which can cause dissemination and lead to tenosynovitis, myositis, osteomyelitis, and septic arthritis.^8-12 Nonetheless, cases of infections with NTM—including M fortuitum—are becoming harder to treat. Several single nucleotide polymorphisms and point mutations have been demonstrated in the ribosomal RNA methylase gene erm(39) related to clarithromycin resistance and in the rrl gene related to linezolid resistance.¹³ Due to increasing inducible resistance to common classes of antibiotics, such as macrolides and linezolid, treatment of M fortuitum requires multidrug regimens.^13,14 Drug susceptibility testing also may be required, as M fortuitum has shown low resistance to tigecycline, tetracycline, cefmetazole, imipenem, and aminoglycosides (eg, amikacin, tobramycin, neomycin, gentamycin). Surgery is an important adjunctive tool in treating M fortuitum infections; patients with a single lesion are more likely to undergo surgical treatment alone or in combination with antibiotic therapy.¹⁵ More recently, antimicrobial photodynamic therapy has been explored as an alternative to eliminate NTM, including M fortuitum.¹⁶

The differential diagnosis for skin lesions manifesting with draining fistulae and sinus tracts includes conditions with infectious (cellulitis and chromomycosis) and inflammatory (pyoderma gangrenosum [PG] and hidradenitis suppurativa [HS]) causes.

Cellulitis is a common infection of the skin and subcutaneous tissue that predominantly is caused by gram-positive organisms such as β-hemolytic streptococci.¹⁷ Clinical manifestations include acute skin erythema, swelling, tenderness, and warmth. The legs are the most common sites of infection, but any area of the skin can be involved.17 Cellulitis comprises 10% of all infectious disease hospitalizations and up to 11% of all dermatologic admissions.^18,19 It frequently is misdiagnosed, perhaps due to the lack of a reliable confirmatory laboratory test or imaging study, in addition to the plethora of diseases that mimic cellulitis, such as stasis dermatitis, lipodermatosclerosis, contact dermatitis, lymphedema, eosinophilic cellulitis, and papular urticaria.^20,21 The consequences of misdiagnosis include but are not limited to unnecessary hospitalizations, inappropriate antibiotic use, and delayed management of the disease; thus, there is an urgent need for a reliable standard test to confirm the diagnosis, especially among nonspecialist physicians. ²⁰ Most patients with uncomplicated cellulitis can be treated with empiric oral antibiotics that target β-hemolytic streptococci (ie, penicillin V potassium, amoxicillin).¹⁷ Methicillin-resistant Staphylococcus aureus coverage generally is unnecessary for nonpurulent cellulitis, but clinicians can consider adding amoxicillin-clavulanate, dicloxacillin, and cephalexin to the regimen. For purulent cellulitis, incision and drainage should be performed. In severe cases that manifest with sepsis, altered mental status, or hemodynamic instability, inpatient management is required.¹⁷

Chromomycosis (also known as chromoblastomycosis) is a chronic, indolent, granulomatous, suppurative mycosis of the skin and subcutaneous tissue²² that is caused by traumatic inoculation of various fungi of the order Chaetothyriales and family Herpotrichiellaceae, which are present in soil, plants, and decomposing wood. Chromomycosis is prevalent in tropical and subtropical regions.^23,24 Clinically, it manifests as oligosymptomatic or asymptomatic lesions around an infection site that can manifest as papules with centrifugal growth evolving into nodular, verrucous, plaque, tumoral, or atrophic forms.²² Diagnosis is made with direct microscopy using potassium hydroxide, which reveals muriform bodies. Fungal culture in Sabouraud agar also can be used to isolate the causative pathogen.²² Unfortunately, chromomycosis is difficult to treat, with low cure rates and high relapse rates. Antifungal agents combined with surgery, cryotherapy, or thermotherapy often are used, with cure rates ranging from 15% to 80%.^22,25

Pyoderma gangrenosum is a reactive noninfectious inflammatory dermatosis associated with inflammatory bowel disease and rheumatoid arthritis. The exact etiology is not clearly understood, but it generally is considered an autoinflammatory disorder.²⁶ The most common form—classical PG—occurs in approximately 85% of cases and manifests as a painful erythematous lesion that progresses to a blistered or necrotic ulcer. It primarily affects the lower legs but can occur in other body sites.²⁷ The diagnosis is based on clinical symptoms after excluding other similar conditions; histopathology of biopsied wound tissues often are required for confirmation. Treatment of PG starts with fast-acting immunosuppressive drugs (corticosteroids and/or cyclosporine) followed by slowacting immunosuppressive drugs (biologics).²⁶

Hidradenitis suppurativa is a chronic recurrent disease of the hair follicle unit that develops after puberty.²⁸ Clinically, HS manifests with painful nodules, abscesses, chronically draining fistulas, and scarring in areas of the body rich in apocrine glands.^29,30 Treatment of HS is challenging due to its diverse clinical manifestations and unclear etiology. Topical therapy, systemic treatments, biologic agents, surgery, and light therapy have shown variable results.^28,31

PULMONARY VASCULAR AND CARDIOVASCULAR NETWORK

Cardiovascular Medicine and Surgery Section

Patients with intermediate-risk pulmonary embolism (IRPE), or those with right ventricular dysfunction without overt hemodynamic instability, represent a heterogenous population with short-term mortality ranging from 2% to 17%.¹ While systemic anticoagulation is the mainstay therapy, select individuals may benefit from more immediate reperfusion. Catheter-based therapies (CBT), including thrombus aspiration, fragmentation, or catheter-directed thrombolysis, have seen rapid uptake over the last decade, with promising retrospective data. Unfortunately, only small, randomized trials exploring surrogate outcomes are available to guide modality and patient selection.²

CHEST

To better define which patients with IRPE are best managed with which therapy, several large-scale randomized controlled trials are underway. PE-TRACT, a study funded by the National Institutes of Health, aims to randomize 500 patients with IRPE to anticoagulation alone vs one of several modalities of CBT with a focus on long-term functional outcomes, including peak oxygen consumption at 3 months and functional class at 1 year. Aspiration thrombectomy with the FlowTriever^® device is being compared with anticoagulation alone in a study of 1,200 patients examining short-term composite end points.

CHEST

References

1. Fernández C, Bova C, Sanchez O, et al. Validation of a model for identification of patients at intermediate to high risk for complications associated with acute symptomatic pulmonary embolism. Chest. 2015;148(1):211-218. doi:10.1378/chest.14-2551

2. Yuriditsky E, Horowitz JM. The role of the PERT in the management and therapeutic decision-making in pulmonary embolism. Eur Heart J Acute Cardiovasc Care. 2022;11(9):693-694. doi:10.1093/ehjacc/zuac102

3. National Library of Medicine (US). A Randomized Trial of Ultrasound-facilitated, Catheter-directed, Thrombolysis Versus Anticoagulation for Acute Intermediate-high Risk Pulmonary Embolism: The Higher-risk Pulmonary Embolism Thrombolysis Study. Updated July 16, 2024. https://clinicaltrials.gov/study/NCT04790370

4. National Library of Medicine (US). PEERLESS II: RCT of FlowTriever vs. Anticoagulation Alone in Pulmonary Embolism. Updated July 17, 2024. https://clinicaltrials.gov/study/NCT06055920

5. National Library of Medicine (US). A Reduced Dose of Thrombolytic Treatment for Patients With Intermediate High-risk Acute Pulmonary Embolism: a Randomized Controled Trial. Updated July 17, 2024. https://clinicaltrials.gov/study/NCT04430569

PULMONARY VASCULAR AND CARDIOVASCULAR NETWORK

Cardiovascular Medicine and Surgery Section

Patients with intermediate-risk pulmonary embolism (IRPE), or those with right ventricular dysfunction without overt hemodynamic instability, represent a heterogenous population with short-term mortality ranging from 2% to 17%.¹ While systemic anticoagulation is the mainstay therapy, select individuals may benefit from more immediate reperfusion. Catheter-based therapies (CBT), including thrombus aspiration, fragmentation, or catheter-directed thrombolysis, have seen rapid uptake over the last decade, with promising retrospective data. Unfortunately, only small, randomized trials exploring surrogate outcomes are available to guide modality and patient selection.²

CHEST

To better define which patients with IRPE are best managed with which therapy, several large-scale randomized controlled trials are underway. PE-TRACT, a study funded by the National Institutes of Health, aims to randomize 500 patients with IRPE to anticoagulation alone vs one of several modalities of CBT with a focus on long-term functional outcomes, including peak oxygen consumption at 3 months and functional class at 1 year. Aspiration thrombectomy with the FlowTriever^® device is being compared with anticoagulation alone in a study of 1,200 patients examining short-term composite end points.

CHEST

References

1. Fernández C, Bova C, Sanchez O, et al. Validation of a model for identification of patients at intermediate to high risk for complications associated with acute symptomatic pulmonary embolism. Chest. 2015;148(1):211-218. doi:10.1378/chest.14-2551

2. Yuriditsky E, Horowitz JM. The role of the PERT in the management and therapeutic decision-making in pulmonary embolism. Eur Heart J Acute Cardiovasc Care. 2022;11(9):693-694. doi:10.1093/ehjacc/zuac102

3. National Library of Medicine (US). A Randomized Trial of Ultrasound-facilitated, Catheter-directed, Thrombolysis Versus Anticoagulation for Acute Intermediate-high Risk Pulmonary Embolism: The Higher-risk Pulmonary Embolism Thrombolysis Study. Updated July 16, 2024. https://clinicaltrials.gov/study/NCT04790370

4. National Library of Medicine (US). PEERLESS II: RCT of FlowTriever vs. Anticoagulation Alone in Pulmonary Embolism. Updated July 17, 2024. https://clinicaltrials.gov/study/NCT06055920

5. National Library of Medicine (US). A Reduced Dose of Thrombolytic Treatment for Patients With Intermediate High-risk Acute Pulmonary Embolism: a Randomized Controled Trial. Updated July 17, 2024. https://clinicaltrials.gov/study/NCT04430569

PULMONARY VASCULAR AND CARDIOVASCULAR NETWORK

Cardiovascular Medicine and Surgery Section

Patients with intermediate-risk pulmonary embolism (IRPE), or those with right ventricular dysfunction without overt hemodynamic instability, represent a heterogenous population with short-term mortality ranging from 2% to 17%.¹ While systemic anticoagulation is the mainstay therapy, select individuals may benefit from more immediate reperfusion. Catheter-based therapies (CBT), including thrombus aspiration, fragmentation, or catheter-directed thrombolysis, have seen rapid uptake over the last decade, with promising retrospective data. Unfortunately, only small, randomized trials exploring surrogate outcomes are available to guide modality and patient selection.²

CHEST

To better define which patients with IRPE are best managed with which therapy, several large-scale randomized controlled trials are underway. PE-TRACT, a study funded by the National Institutes of Health, aims to randomize 500 patients with IRPE to anticoagulation alone vs one of several modalities of CBT with a focus on long-term functional outcomes, including peak oxygen consumption at 3 months and functional class at 1 year. Aspiration thrombectomy with the FlowTriever^® device is being compared with anticoagulation alone in a study of 1,200 patients examining short-term composite end points.

CHEST

References

1. Fernández C, Bova C, Sanchez O, et al. Validation of a model for identification of patients at intermediate to high risk for complications associated with acute symptomatic pulmonary embolism. Chest. 2015;148(1):211-218. doi:10.1378/chest.14-2551

2. Yuriditsky E, Horowitz JM. The role of the PERT in the management and therapeutic decision-making in pulmonary embolism. Eur Heart J Acute Cardiovasc Care. 2022;11(9):693-694. doi:10.1093/ehjacc/zuac102

3. National Library of Medicine (US). A Randomized Trial of Ultrasound-facilitated, Catheter-directed, Thrombolysis Versus Anticoagulation for Acute Intermediate-high Risk Pulmonary Embolism: The Higher-risk Pulmonary Embolism Thrombolysis Study. Updated July 16, 2024. https://clinicaltrials.gov/study/NCT04790370

4. National Library of Medicine (US). PEERLESS II: RCT of FlowTriever vs. Anticoagulation Alone in Pulmonary Embolism. Updated July 17, 2024. https://clinicaltrials.gov/study/NCT06055920

5. National Library of Medicine (US). A Reduced Dose of Thrombolytic Treatment for Patients With Intermediate High-risk Acute Pulmonary Embolism: a Randomized Controled Trial. Updated July 17, 2024. https://clinicaltrials.gov/study/NCT04430569

AIRWAYS DISORDERS NETWORK

Bronchiectasis Section

Bronchiectasis is an extremely heterogeneous airways disease, making it difficult to study. For years, the noncystic fibrosis (CF) bronchiectasis community has been trying to organize to provide better care for more than half a million adults with bronchiectasis in the United States. Internationally, the Europeans created the European Bronchiectasis Registry, which has been a powerful tool including nearly 20,000 patients, to answer important epidemiologic and management questions. We must do more for the bronchiectasis community.

Clinicaltrials.gov indicates that there are 8 international phase 3 or 4 clinical trials that are currently enrolling; 3 of those have enrollment sites in the United States. One such study from University of North Carolina at Chapel Hill is looking at the use of nebulized hypertonic saline in patients with non-CF bronchiectasis to understand the effect it has on mucociliary clearance. Emory University is looking at the use of elexacaftor/tezacaftor/ivacaftor (Trikafta) in patients with non-CF bronchiectasis; these patients have only 1 targetable mutation and a phenotype that resembles CF. This 8-week, open-label, single-center study aims to measure both clinical and biomarker outcomes after treatment with Trikafta. Finally, a phase 3 trial out of Florida, the ICoN-1 study, is examining the efficacy and safety of inhaled clofazimine in the treatment of nontuberculous mycobacteria (NTM). This double-blind, randomized trial will look at culture conversion and quality of life measures. Additionally, the COPD Foundation has created the Bronchiectasis and NTM Research Registry, an American cohort containing more than 5,000 patients and data from 22 different sites, to answer some of the most important questions for clinicians and patients.

CHEST

We have made significant progress in bronchiectasis research; however, there is still much to learn. Together, we must make a concerted effort to enroll patients in clinical trials. Doing so will allow us to define our epidemiologic profile more precisely and explore new treatments and airway clearance techniques.

AIRWAYS DISORDERS NETWORK

Bronchiectasis Section

Bronchiectasis is an extremely heterogeneous airways disease, making it difficult to study. For years, the noncystic fibrosis (CF) bronchiectasis community has been trying to organize to provide better care for more than half a million adults with bronchiectasis in the United States. Internationally, the Europeans created the European Bronchiectasis Registry, which has been a powerful tool including nearly 20,000 patients, to answer important epidemiologic and management questions. We must do more for the bronchiectasis community.

Clinicaltrials.gov indicates that there are 8 international phase 3 or 4 clinical trials that are currently enrolling; 3 of those have enrollment sites in the United States. One such study from University of North Carolina at Chapel Hill is looking at the use of nebulized hypertonic saline in patients with non-CF bronchiectasis to understand the effect it has on mucociliary clearance. Emory University is looking at the use of elexacaftor/tezacaftor/ivacaftor (Trikafta) in patients with non-CF bronchiectasis; these patients have only 1 targetable mutation and a phenotype that resembles CF. This 8-week, open-label, single-center study aims to measure both clinical and biomarker outcomes after treatment with Trikafta. Finally, a phase 3 trial out of Florida, the ICoN-1 study, is examining the efficacy and safety of inhaled clofazimine in the treatment of nontuberculous mycobacteria (NTM). This double-blind, randomized trial will look at culture conversion and quality of life measures. Additionally, the COPD Foundation has created the Bronchiectasis and NTM Research Registry, an American cohort containing more than 5,000 patients and data from 22 different sites, to answer some of the most important questions for clinicians and patients.

CHEST

We have made significant progress in bronchiectasis research; however, there is still much to learn. Together, we must make a concerted effort to enroll patients in clinical trials. Doing so will allow us to define our epidemiologic profile more precisely and explore new treatments and airway clearance techniques.

AIRWAYS DISORDERS NETWORK

Bronchiectasis Section

Bronchiectasis is an extremely heterogeneous airways disease, making it difficult to study. For years, the noncystic fibrosis (CF) bronchiectasis community has been trying to organize to provide better care for more than half a million adults with bronchiectasis in the United States. Internationally, the Europeans created the European Bronchiectasis Registry, which has been a powerful tool including nearly 20,000 patients, to answer important epidemiologic and management questions. We must do more for the bronchiectasis community.

Clinicaltrials.gov indicates that there are 8 international phase 3 or 4 clinical trials that are currently enrolling; 3 of those have enrollment sites in the United States. One such study from University of North Carolina at Chapel Hill is looking at the use of nebulized hypertonic saline in patients with non-CF bronchiectasis to understand the effect it has on mucociliary clearance. Emory University is looking at the use of elexacaftor/tezacaftor/ivacaftor (Trikafta) in patients with non-CF bronchiectasis; these patients have only 1 targetable mutation and a phenotype that resembles CF. This 8-week, open-label, single-center study aims to measure both clinical and biomarker outcomes after treatment with Trikafta. Finally, a phase 3 trial out of Florida, the ICoN-1 study, is examining the efficacy and safety of inhaled clofazimine in the treatment of nontuberculous mycobacteria (NTM). This double-blind, randomized trial will look at culture conversion and quality of life measures. Additionally, the COPD Foundation has created the Bronchiectasis and NTM Research Registry, an American cohort containing more than 5,000 patients and data from 22 different sites, to answer some of the most important questions for clinicians and patients.

CHEST

We have made significant progress in bronchiectasis research; however, there is still much to learn. Together, we must make a concerted effort to enroll patients in clinical trials. Doing so will allow us to define our epidemiologic profile more precisely and explore new treatments and airway clearance techniques.

TOPLINE:

Black children with vitiligo are significantly more likely to be diagnosed with psychiatric disorders, including depression, suicidal ideation, and disruptive behavior disorders, than matched controls who did not have vitiligo, according to a case-control study.

METHODOLOGY:

• Researchers conducted a retrospective, single-center, case-control study at Texas Children’s Hospital in Houston on 327 Black children with vitiligo and 981 matched controls without vitiligo.
• The average age of participants was 11.7 years, and 62% were girls.
• The study outcome was the prevalence of psychiatric conditions and rates of treatment (pharmacotherapy and/or psychotherapy) initiation for those conditions.

TAKEAWAY:

• Black children with vitiligo were more likely to be diagnosed with depression (odds ratio [OR], 3.63; P < .001), suicidal ideation (OR, 2.88; P = .005), disruptive behavior disorders (OR, 7.68; P < .001), eating disorders (OR, 15.22; P = .013), generalized anxiety disorder (OR, 2.61; P < .001), and substance abuse (OR, 2.67; P = .011).
• The likelihood of having a psychiatric comorbidity was not significantly different between children with segmental vitiligo and those with generalized vitiligo or between girls and boys.
• Among the patients with vitiligo and psychiatric comorbidities, treatment initiation rates were higher for depression (76.5%), disruptive behavior disorders (82.1%), and eating disorders (100%).
• Treatment initiation rates were lower in patients with vitiligo diagnosed with generalized anxiety disorder (55.3%) and substance abuse (61.5%). Treatment was not initiated in 14% patients with suicidal ideation.

IN PRACTICE:

“Pediatric dermatologists have an important role in screening for psychiatric comorbidities, and implementation of appropriate screening tools while treating vitiligo is likely to have a bidirectional positive impact,” the authors wrote, adding: “By better understanding psychiatric comorbidities of African American children with vitiligo, dermatologists can be more aware of pediatric mental health needs and provide appropriate referrals.”

SOURCE:

This study was led by Emily Strouphauer, BSA, Baylor College of Medicine, Houston, and was published online in JAAD International.

LIMITATIONS:

The study limitations were the retrospective design, small sample size, and heterogeneity in the control group.

DISCLOSURES:

The study did not receive any funding. The authors declared no competing interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Black children with vitiligo are significantly more likely to be diagnosed with psychiatric disorders, including depression, suicidal ideation, and disruptive behavior disorders, than matched controls who did not have vitiligo, according to a case-control study.

METHODOLOGY:

• Researchers conducted a retrospective, single-center, case-control study at Texas Children’s Hospital in Houston on 327 Black children with vitiligo and 981 matched controls without vitiligo.
• The average age of participants was 11.7 years, and 62% were girls.
• The study outcome was the prevalence of psychiatric conditions and rates of treatment (pharmacotherapy and/or psychotherapy) initiation for those conditions.

TAKEAWAY:

• Black children with vitiligo were more likely to be diagnosed with depression (odds ratio [OR], 3.63; P < .001), suicidal ideation (OR, 2.88; P = .005), disruptive behavior disorders (OR, 7.68; P < .001), eating disorders (OR, 15.22; P = .013), generalized anxiety disorder (OR, 2.61; P < .001), and substance abuse (OR, 2.67; P = .011).
• The likelihood of having a psychiatric comorbidity was not significantly different between children with segmental vitiligo and those with generalized vitiligo or between girls and boys.
• Among the patients with vitiligo and psychiatric comorbidities, treatment initiation rates were higher for depression (76.5%), disruptive behavior disorders (82.1%), and eating disorders (100%).
• Treatment initiation rates were lower in patients with vitiligo diagnosed with generalized anxiety disorder (55.3%) and substance abuse (61.5%). Treatment was not initiated in 14% patients with suicidal ideation.

IN PRACTICE:

“Pediatric dermatologists have an important role in screening for psychiatric comorbidities, and implementation of appropriate screening tools while treating vitiligo is likely to have a bidirectional positive impact,” the authors wrote, adding: “By better understanding psychiatric comorbidities of African American children with vitiligo, dermatologists can be more aware of pediatric mental health needs and provide appropriate referrals.”

SOURCE:

This study was led by Emily Strouphauer, BSA, Baylor College of Medicine, Houston, and was published online in JAAD International.

LIMITATIONS:

The study limitations were the retrospective design, small sample size, and heterogeneity in the control group.

DISCLOSURES:

The study did not receive any funding. The authors declared no competing interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Black children with vitiligo are significantly more likely to be diagnosed with psychiatric disorders, including depression, suicidal ideation, and disruptive behavior disorders, than matched controls who did not have vitiligo, according to a case-control study.

METHODOLOGY:

• Researchers conducted a retrospective, single-center, case-control study at Texas Children’s Hospital in Houston on 327 Black children with vitiligo and 981 matched controls without vitiligo.
• The average age of participants was 11.7 years, and 62% were girls.
• The study outcome was the prevalence of psychiatric conditions and rates of treatment (pharmacotherapy and/or psychotherapy) initiation for those conditions.

TAKEAWAY:

• Black children with vitiligo were more likely to be diagnosed with depression (odds ratio [OR], 3.63; P < .001), suicidal ideation (OR, 2.88; P = .005), disruptive behavior disorders (OR, 7.68; P < .001), eating disorders (OR, 15.22; P = .013), generalized anxiety disorder (OR, 2.61; P < .001), and substance abuse (OR, 2.67; P = .011).
• The likelihood of having a psychiatric comorbidity was not significantly different between children with segmental vitiligo and those with generalized vitiligo or between girls and boys.
• Among the patients with vitiligo and psychiatric comorbidities, treatment initiation rates were higher for depression (76.5%), disruptive behavior disorders (82.1%), and eating disorders (100%).
• Treatment initiation rates were lower in patients with vitiligo diagnosed with generalized anxiety disorder (55.3%) and substance abuse (61.5%). Treatment was not initiated in 14% patients with suicidal ideation.

IN PRACTICE:

“Pediatric dermatologists have an important role in screening for psychiatric comorbidities, and implementation of appropriate screening tools while treating vitiligo is likely to have a bidirectional positive impact,” the authors wrote, adding: “By better understanding psychiatric comorbidities of African American children with vitiligo, dermatologists can be more aware of pediatric mental health needs and provide appropriate referrals.”

SOURCE:

This study was led by Emily Strouphauer, BSA, Baylor College of Medicine, Houston, and was published online in JAAD International.

LIMITATIONS:

The study limitations were the retrospective design, small sample size, and heterogeneity in the control group.

DISCLOSURES:

The study did not receive any funding. The authors declared no competing interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

CHEST

As we find ourselves in September, I cannot help but dedicate my column to the upcoming CHEST Annual Meeting quickly approaching, October 6 to 9, in Boston.

If you haven’t yet been to a CHEST Annual Meeting, it’s an unmatched experience. We have top-notch experts in the field delivering content and materials in a variety of learning formats—lectures, interactive sessions, case-based scenarios, simulations, etc—and there’s an atmosphere unlike any other that’s welcoming to any level of practice.

For those who have attended, there’s always something new to see. Every year is different, with the culture of the location guiding the way and new opportunities to network while engaging in activity. No matter how many times you have been, attending the CHEST Annual Meeting never gets old.

CHEST

CHEST

As we find ourselves in September, I cannot help but dedicate my column to the upcoming CHEST Annual Meeting quickly approaching, October 6 to 9, in Boston.

If you haven’t yet been to a CHEST Annual Meeting, it’s an unmatched experience. We have top-notch experts in the field delivering content and materials in a variety of learning formats—lectures, interactive sessions, case-based scenarios, simulations, etc—and there’s an atmosphere unlike any other that’s welcoming to any level of practice.

For those who have attended, there’s always something new to see. Every year is different, with the culture of the location guiding the way and new opportunities to network while engaging in activity. No matter how many times you have been, attending the CHEST Annual Meeting never gets old.

CHEST

CHEST

As we find ourselves in September, I cannot help but dedicate my column to the upcoming CHEST Annual Meeting quickly approaching, October 6 to 9, in Boston.

If you haven’t yet been to a CHEST Annual Meeting, it’s an unmatched experience. We have top-notch experts in the field delivering content and materials in a variety of learning formats—lectures, interactive sessions, case-based scenarios, simulations, etc—and there’s an atmosphere unlike any other that’s welcoming to any level of practice.

For those who have attended, there’s always something new to see. Every year is different, with the culture of the location guiding the way and new opportunities to network while engaging in activity. No matter how many times you have been, attending the CHEST Annual Meeting never gets old.

CHEST

TOPLINE:

Mobile images may be reliable for assessing cutaneous neurofibroma (cNF) features in patients with neurofibromatosis type 1 (NF1), according to a crowd-sourced registry study that also suggests correlations between cNF burden and quality of life (QoL), particularly the impact of facial severity on emotional well-being.

METHODOLOGY:

• To learn more about the association of cNFs with QoL, pain, and itch in patients with this rare disease, researchers enrolled 1016 individuals aged 40 years and older with NF1 who had at least one cNF, from May 2021 to December 2023, after reaching out to patient-led or NF1 advocacy organizations in 13 countries, including the United States.
• Participants provided demographic data, detailed photographs, and saliva samples for genetic sequencing, with 583 participants (mean age, 51.7 years; 65.9% women) submitting high-quality photographs from seven body regions at the time of the study analysis.
• A subset of 50 participants also underwent whole-body imaging.
• Four researchers independently rated the photographs for various cNF features, including general severity, number, size, facial severity, and subtypes.

TAKEAWAY:

• Based on evaluations by NF1 specialists, the agreement between mobile and whole-body images was “substantial” (74%-88% agreement) for the number of cNFs, general severity, and facial severity. Agreement between self-reported numbers of cNFs and investigator-rated numbers based on photographs was “minimal to fair.”
• Female sex, the number of cNFs, severity of cNFs on the face, and globular cNFs were associated with worse QoL (based on Skindex scores); severity of cNFs on the face had the strongest impact on overall QoL (P < .001).
• An increasing number of cNFs and worsening facial severity were strongly correlated with higher emotion subdomain scores.
• A higher number of cNFs, more severe cNFs on the face, and larger cNFs were all slightly associated with increased itch and pain (P < .01).

IN PRACTICE:

“To develop effective therapeutics, meaningful clinical outcomes that are tied with improvement in QoL for persons with NF1 must be clearly defined,” the authors wrote. The results of this study, they added, “suggested the benefit of this crowd-sourced resource by identifying the features of cNFs with the greatest association with QoL and symptoms of pain and itch in persons with NF1, highlighting new intervention strategies and features to target to most improve QoL in NF1.”

SOURCE:

The study was led by Michelle Jade Lin, BS, Stanford University School of Medicine, Redwood City, California, and was published online in JAMA Dermatology.

LIMITATIONS:

The study included only a small number of individuals from racial and ethnic minority groups and did not capture ethnicity information, which could have provided further insights into disease impact across different demographics.

DISCLOSURES:

This study was supported by Johns Hopkins University, Baltimore, and the Bloomberg Family Foundation. Ms. Lin reported support from the Stanford Medical Scholars Research Program. Three authors reported personal fees or grants outside this work. Other authors reported no competing interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Mobile images may be reliable for assessing cutaneous neurofibroma (cNF) features in patients with neurofibromatosis type 1 (NF1), according to a crowd-sourced registry study that also suggests correlations between cNF burden and quality of life (QoL), particularly the impact of facial severity on emotional well-being.

METHODOLOGY:

• To learn more about the association of cNFs with QoL, pain, and itch in patients with this rare disease, researchers enrolled 1016 individuals aged 40 years and older with NF1 who had at least one cNF, from May 2021 to December 2023, after reaching out to patient-led or NF1 advocacy organizations in 13 countries, including the United States.
• Participants provided demographic data, detailed photographs, and saliva samples for genetic sequencing, with 583 participants (mean age, 51.7 years; 65.9% women) submitting high-quality photographs from seven body regions at the time of the study analysis.
• A subset of 50 participants also underwent whole-body imaging.
• Four researchers independently rated the photographs for various cNF features, including general severity, number, size, facial severity, and subtypes.

TAKEAWAY:

• Based on evaluations by NF1 specialists, the agreement between mobile and whole-body images was “substantial” (74%-88% agreement) for the number of cNFs, general severity, and facial severity. Agreement between self-reported numbers of cNFs and investigator-rated numbers based on photographs was “minimal to fair.”
• Female sex, the number of cNFs, severity of cNFs on the face, and globular cNFs were associated with worse QoL (based on Skindex scores); severity of cNFs on the face had the strongest impact on overall QoL (P < .001).
• An increasing number of cNFs and worsening facial severity were strongly correlated with higher emotion subdomain scores.
• A higher number of cNFs, more severe cNFs on the face, and larger cNFs were all slightly associated with increased itch and pain (P < .01).

IN PRACTICE:

“To develop effective therapeutics, meaningful clinical outcomes that are tied with improvement in QoL for persons with NF1 must be clearly defined,” the authors wrote. The results of this study, they added, “suggested the benefit of this crowd-sourced resource by identifying the features of cNFs with the greatest association with QoL and symptoms of pain and itch in persons with NF1, highlighting new intervention strategies and features to target to most improve QoL in NF1.”

SOURCE:

The study was led by Michelle Jade Lin, BS, Stanford University School of Medicine, Redwood City, California, and was published online in JAMA Dermatology.

LIMITATIONS:

The study included only a small number of individuals from racial and ethnic minority groups and did not capture ethnicity information, which could have provided further insights into disease impact across different demographics.

DISCLOSURES:

This study was supported by Johns Hopkins University, Baltimore, and the Bloomberg Family Foundation. Ms. Lin reported support from the Stanford Medical Scholars Research Program. Three authors reported personal fees or grants outside this work. Other authors reported no competing interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Mobile images may be reliable for assessing cutaneous neurofibroma (cNF) features in patients with neurofibromatosis type 1 (NF1), according to a crowd-sourced registry study that also suggests correlations between cNF burden and quality of life (QoL), particularly the impact of facial severity on emotional well-being.

METHODOLOGY:

• To learn more about the association of cNFs with QoL, pain, and itch in patients with this rare disease, researchers enrolled 1016 individuals aged 40 years and older with NF1 who had at least one cNF, from May 2021 to December 2023, after reaching out to patient-led or NF1 advocacy organizations in 13 countries, including the United States.
• Participants provided demographic data, detailed photographs, and saliva samples for genetic sequencing, with 583 participants (mean age, 51.7 years; 65.9% women) submitting high-quality photographs from seven body regions at the time of the study analysis.
• A subset of 50 participants also underwent whole-body imaging.
• Four researchers independently rated the photographs for various cNF features, including general severity, number, size, facial severity, and subtypes.

TAKEAWAY:

• Based on evaluations by NF1 specialists, the agreement between mobile and whole-body images was “substantial” (74%-88% agreement) for the number of cNFs, general severity, and facial severity. Agreement between self-reported numbers of cNFs and investigator-rated numbers based on photographs was “minimal to fair.”
• Female sex, the number of cNFs, severity of cNFs on the face, and globular cNFs were associated with worse QoL (based on Skindex scores); severity of cNFs on the face had the strongest impact on overall QoL (P < .001).
• An increasing number of cNFs and worsening facial severity were strongly correlated with higher emotion subdomain scores.
• A higher number of cNFs, more severe cNFs on the face, and larger cNFs were all slightly associated with increased itch and pain (P < .01).

IN PRACTICE:

“To develop effective therapeutics, meaningful clinical outcomes that are tied with improvement in QoL for persons with NF1 must be clearly defined,” the authors wrote. The results of this study, they added, “suggested the benefit of this crowd-sourced resource by identifying the features of cNFs with the greatest association with QoL and symptoms of pain and itch in persons with NF1, highlighting new intervention strategies and features to target to most improve QoL in NF1.”

SOURCE:

The study was led by Michelle Jade Lin, BS, Stanford University School of Medicine, Redwood City, California, and was published online in JAMA Dermatology.

LIMITATIONS:

The study included only a small number of individuals from racial and ethnic minority groups and did not capture ethnicity information, which could have provided further insights into disease impact across different demographics.

DISCLOSURES:

This study was supported by Johns Hopkins University, Baltimore, and the Bloomberg Family Foundation. Ms. Lin reported support from the Stanford Medical Scholars Research Program. Three authors reported personal fees or grants outside this work. Other authors reported no competing interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

When parents are perceived as distracted by their phones or other technology during social or family interactions, it can affect the mental health of children between ages 9 and 11 years, according to a new study based in Canada.

In fact, this parental “technoference” is associated with higher levels of inattention and hyperactivity symptoms later in the child’s development, the researchers found.

“We hear a lot about children’s and adolescents’ screen time in the media, but we forget that parents are also on their screens a lot. In fact, past research shows that when parents are with their children, they spend 1 in 3 minutes on a screen,” said lead author Audrey-Ann Deneault, PhD, assistant professor of social psychology at the University of Montreal, Montreal, Quebec, Canada.

“We’ve all experienced moments when we’re on the phone and not hearing someone call us or don’t notice something happening right before our eyes,” she said. “We think that’s why it’s important to look at technoference. When parents use screens, they are more likely to miss when their child needs them.”

The study was published online in JAMA Network Open.
 

Analyzing Parental Technoference

As part of the All Our Families study, Dr. Deneault and colleagues analyzed a cohort of mothers and 1303 emerging adolescents between ages 9 and 11 years in Calgary, with the aim of understanding long-term associations between perceived parental interruptions (or technoference) and their children’s mental health.

Women were recruited during pregnancy between May 2008 and December 2010. For this study, the adolescents were assessed three times — at ages 9 years (in 2020), 10 years (in 2021), and 11 years (in 2021 and 2022). The mothers gave consent for their children to participate, and the children gave assent as well.

During the assessments, the adolescents completed questionnaires about their perceptions of parental technoference and their mental health symptoms, such as anxiety, depression, inattention, and hyperactivity. The study focused on the magnitude of effect sizes rather than statistical significance.

Overall, higher levels of anxiety symptoms at ages 9 and 10 years were prospectively associated with higher levels of perceived parental technoference at ages 10 and 11 years. The effect size was small.

In addition, higher levels of perceived parental technoference at ages 9 and 10 years were prospectively associated with higher levels of hyperactivity at ages 10 and 11 years and higher levels of inattention at age 11 years. There were no significant differences by gender.

“Technoference and youth mental health interact in complex ways. We found that when emerging adolescents have higher rates of anxiety, this can prompt parents to engage in more technoference,” Dr. Deneault said. “This latter bit highlights that parents may be struggling when their youths have mental health difficulties.”
 

Considering Healthy Changes

The findings call for a multitiered approach, Dr. Deneault said, in which adolescents and parents receive support related to mental health concerns, technology use, and healthy parent-child interactions.

“The key takeaway is that parents’ screen time matters and should begin to be a part of the conversation when we think about child and adolescent mental health,” she said.

Future research should look at the direction of associations between adolescent mental health and parental technoference, as well as underlying mechanisms, specific activities linked to technoference, and different age groups and stages of development, the study authors wrote.

“As a society, we need to understand how parents’ use of technology can interfere or not with youths’ mental health,” said Nicole Letourneau, PhD, a research professor of pediatrics, psychiatry, and community health sciences focused on parent and child health at the University of Calgary, Calgary, Alberta, Canada.

Dr. Letourneau, who wasn’t involved in this study, has researched the effects of parental technoference on parent-child relationships and child health and developmental outcomes. She and her colleagues found that parents recognized changes in their child’s behavior.

“Parental support is important for healthy development, and if parents are distracted by their devices, they can miss important but subtle cues that youth are using to signal their needs,” she said. “Given the troubling rise in youth mental health problems, we need to understand potential contributors so we can offer ways to reduce risks and promote youth mental health.”

Communication with parents should be considered as well. For instance, healthcare providers can address the positive and negative aspects of technology use.

“There is enough research out now that we should be more concerned than we currently are about how parents’ own technology habits might influence child and teen well-being. Yet, taking an overall negative lens to parent technology and smartphone habits may not prove very fruitful,” said Brandon McDaniel, PhD, a senior research scientist at the Parkview Mirro Center for Research & Innovation in Fort Wayne, Indiana.

Dr. McDaniel, who also wasn’t involved with this study, has researched technoference and associations with child behavior problems, as well as parents’ desires to change phone use. He noted that parents may use their devices for positive reasons, such as finding support from others, regulating their own emotions, and escaping from stress, so they can be more emotionally available for their children soon after using their phone.

“Many parents already feel an immense amount of guilt surrounding smartphone use in the presence of their child,” he said. “I suggest that practitioners address parent technology use in ways that validate parents in their positive uses of technology while helping them identify areas of their tech habits that may be counterproductive for their own or their child’s health and mental health.”

The All Our Families study was supported by an Alberta Innovates–Health Solutions Interdisciplinary Team Grant and the Alberta Children’s Hospital Foundation. The current analysis received funding from the Canadian Institutes of Health Research, a Children and Screens: Institute of Digital Media and Child Development COVID-19 grant, an Alberta Innovates grant, and a Banting Postdoctoral Fellowship. Dr. Deneault, Dr. Letourneau, and Dr. McDaniel reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

When parents are perceived as distracted by their phones or other technology during social or family interactions, it can affect the mental health of children between ages 9 and 11 years, according to a new study based in Canada.

In fact, this parental “technoference” is associated with higher levels of inattention and hyperactivity symptoms later in the child’s development, the researchers found.

“We hear a lot about children’s and adolescents’ screen time in the media, but we forget that parents are also on their screens a lot. In fact, past research shows that when parents are with their children, they spend 1 in 3 minutes on a screen,” said lead author Audrey-Ann Deneault, PhD, assistant professor of social psychology at the University of Montreal, Montreal, Quebec, Canada.

“We’ve all experienced moments when we’re on the phone and not hearing someone call us or don’t notice something happening right before our eyes,” she said. “We think that’s why it’s important to look at technoference. When parents use screens, they are more likely to miss when their child needs them.”

The study was published online in JAMA Network Open.
 

Analyzing Parental Technoference

As part of the All Our Families study, Dr. Deneault and colleagues analyzed a cohort of mothers and 1303 emerging adolescents between ages 9 and 11 years in Calgary, with the aim of understanding long-term associations between perceived parental interruptions (or technoference) and their children’s mental health.

Women were recruited during pregnancy between May 2008 and December 2010. For this study, the adolescents were assessed three times — at ages 9 years (in 2020), 10 years (in 2021), and 11 years (in 2021 and 2022). The mothers gave consent for their children to participate, and the children gave assent as well.

During the assessments, the adolescents completed questionnaires about their perceptions of parental technoference and their mental health symptoms, such as anxiety, depression, inattention, and hyperactivity. The study focused on the magnitude of effect sizes rather than statistical significance.

Overall, higher levels of anxiety symptoms at ages 9 and 10 years were prospectively associated with higher levels of perceived parental technoference at ages 10 and 11 years. The effect size was small.

In addition, higher levels of perceived parental technoference at ages 9 and 10 years were prospectively associated with higher levels of hyperactivity at ages 10 and 11 years and higher levels of inattention at age 11 years. There were no significant differences by gender.

“Technoference and youth mental health interact in complex ways. We found that when emerging adolescents have higher rates of anxiety, this can prompt parents to engage in more technoference,” Dr. Deneault said. “This latter bit highlights that parents may be struggling when their youths have mental health difficulties.”
 

Considering Healthy Changes

The findings call for a multitiered approach, Dr. Deneault said, in which adolescents and parents receive support related to mental health concerns, technology use, and healthy parent-child interactions.

“The key takeaway is that parents’ screen time matters and should begin to be a part of the conversation when we think about child and adolescent mental health,” she said.

Future research should look at the direction of associations between adolescent mental health and parental technoference, as well as underlying mechanisms, specific activities linked to technoference, and different age groups and stages of development, the study authors wrote.

“As a society, we need to understand how parents’ use of technology can interfere or not with youths’ mental health,” said Nicole Letourneau, PhD, a research professor of pediatrics, psychiatry, and community health sciences focused on parent and child health at the University of Calgary, Calgary, Alberta, Canada.

Dr. Letourneau, who wasn’t involved in this study, has researched the effects of parental technoference on parent-child relationships and child health and developmental outcomes. She and her colleagues found that parents recognized changes in their child’s behavior.

“Parental support is important for healthy development, and if parents are distracted by their devices, they can miss important but subtle cues that youth are using to signal their needs,” she said. “Given the troubling rise in youth mental health problems, we need to understand potential contributors so we can offer ways to reduce risks and promote youth mental health.”

Communication with parents should be considered as well. For instance, healthcare providers can address the positive and negative aspects of technology use.

“There is enough research out now that we should be more concerned than we currently are about how parents’ own technology habits might influence child and teen well-being. Yet, taking an overall negative lens to parent technology and smartphone habits may not prove very fruitful,” said Brandon McDaniel, PhD, a senior research scientist at the Parkview Mirro Center for Research & Innovation in Fort Wayne, Indiana.

Dr. McDaniel, who also wasn’t involved with this study, has researched technoference and associations with child behavior problems, as well as parents’ desires to change phone use. He noted that parents may use their devices for positive reasons, such as finding support from others, regulating their own emotions, and escaping from stress, so they can be more emotionally available for their children soon after using their phone.

“Many parents already feel an immense amount of guilt surrounding smartphone use in the presence of their child,” he said. “I suggest that practitioners address parent technology use in ways that validate parents in their positive uses of technology while helping them identify areas of their tech habits that may be counterproductive for their own or their child’s health and mental health.”

The All Our Families study was supported by an Alberta Innovates–Health Solutions Interdisciplinary Team Grant and the Alberta Children’s Hospital Foundation. The current analysis received funding from the Canadian Institutes of Health Research, a Children and Screens: Institute of Digital Media and Child Development COVID-19 grant, an Alberta Innovates grant, and a Banting Postdoctoral Fellowship. Dr. Deneault, Dr. Letourneau, and Dr. McDaniel reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

When parents are perceived as distracted by their phones or other technology during social or family interactions, it can affect the mental health of children between ages 9 and 11 years, according to a new study based in Canada.

In fact, this parental “technoference” is associated with higher levels of inattention and hyperactivity symptoms later in the child’s development, the researchers found.

“We hear a lot about children’s and adolescents’ screen time in the media, but we forget that parents are also on their screens a lot. In fact, past research shows that when parents are with their children, they spend 1 in 3 minutes on a screen,” said lead author Audrey-Ann Deneault, PhD, assistant professor of social psychology at the University of Montreal, Montreal, Quebec, Canada.

“We’ve all experienced moments when we’re on the phone and not hearing someone call us or don’t notice something happening right before our eyes,” she said. “We think that’s why it’s important to look at technoference. When parents use screens, they are more likely to miss when their child needs them.”

The study was published online in JAMA Network Open.
 

Analyzing Parental Technoference

As part of the All Our Families study, Dr. Deneault and colleagues analyzed a cohort of mothers and 1303 emerging adolescents between ages 9 and 11 years in Calgary, with the aim of understanding long-term associations between perceived parental interruptions (or technoference) and their children’s mental health.

Women were recruited during pregnancy between May 2008 and December 2010. For this study, the adolescents were assessed three times — at ages 9 years (in 2020), 10 years (in 2021), and 11 years (in 2021 and 2022). The mothers gave consent for their children to participate, and the children gave assent as well.

During the assessments, the adolescents completed questionnaires about their perceptions of parental technoference and their mental health symptoms, such as anxiety, depression, inattention, and hyperactivity. The study focused on the magnitude of effect sizes rather than statistical significance.

Overall, higher levels of anxiety symptoms at ages 9 and 10 years were prospectively associated with higher levels of perceived parental technoference at ages 10 and 11 years. The effect size was small.

In addition, higher levels of perceived parental technoference at ages 9 and 10 years were prospectively associated with higher levels of hyperactivity at ages 10 and 11 years and higher levels of inattention at age 11 years. There were no significant differences by gender.

“Technoference and youth mental health interact in complex ways. We found that when emerging adolescents have higher rates of anxiety, this can prompt parents to engage in more technoference,” Dr. Deneault said. “This latter bit highlights that parents may be struggling when their youths have mental health difficulties.”
 

Considering Healthy Changes

The findings call for a multitiered approach, Dr. Deneault said, in which adolescents and parents receive support related to mental health concerns, technology use, and healthy parent-child interactions.

“The key takeaway is that parents’ screen time matters and should begin to be a part of the conversation when we think about child and adolescent mental health,” she said.

Future research should look at the direction of associations between adolescent mental health and parental technoference, as well as underlying mechanisms, specific activities linked to technoference, and different age groups and stages of development, the study authors wrote.

“As a society, we need to understand how parents’ use of technology can interfere or not with youths’ mental health,” said Nicole Letourneau, PhD, a research professor of pediatrics, psychiatry, and community health sciences focused on parent and child health at the University of Calgary, Calgary, Alberta, Canada.

Dr. Letourneau, who wasn’t involved in this study, has researched the effects of parental technoference on parent-child relationships and child health and developmental outcomes. She and her colleagues found that parents recognized changes in their child’s behavior.

“Parental support is important for healthy development, and if parents are distracted by their devices, they can miss important but subtle cues that youth are using to signal their needs,” she said. “Given the troubling rise in youth mental health problems, we need to understand potential contributors so we can offer ways to reduce risks and promote youth mental health.”

Communication with parents should be considered as well. For instance, healthcare providers can address the positive and negative aspects of technology use.

“There is enough research out now that we should be more concerned than we currently are about how parents’ own technology habits might influence child and teen well-being. Yet, taking an overall negative lens to parent technology and smartphone habits may not prove very fruitful,” said Brandon McDaniel, PhD, a senior research scientist at the Parkview Mirro Center for Research & Innovation in Fort Wayne, Indiana.

Dr. McDaniel, who also wasn’t involved with this study, has researched technoference and associations with child behavior problems, as well as parents’ desires to change phone use. He noted that parents may use their devices for positive reasons, such as finding support from others, regulating their own emotions, and escaping from stress, so they can be more emotionally available for their children soon after using their phone.

“Many parents already feel an immense amount of guilt surrounding smartphone use in the presence of their child,” he said. “I suggest that practitioners address parent technology use in ways that validate parents in their positive uses of technology while helping them identify areas of their tech habits that may be counterproductive for their own or their child’s health and mental health.”

The All Our Families study was supported by an Alberta Innovates–Health Solutions Interdisciplinary Team Grant and the Alberta Children’s Hospital Foundation. The current analysis received funding from the Canadian Institutes of Health Research, a Children and Screens: Institute of Digital Media and Child Development COVID-19 grant, an Alberta Innovates grant, and a Banting Postdoctoral Fellowship. Dr. Deneault, Dr. Letourneau, and Dr. McDaniel reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Editor's Note: This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

Editor's Note: This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

Editor's Note: This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.