Annals of the American Thoracic Society最新文献

Rationale: Previous studies have shown that glucagon-like peptide-1 (GLP-1) agonists and dual GLP-1/glucose-dependent insulinotropic peptide (GIP) agonists (tirzepatide) reduced severity of sleep apnea. However, whether these medications impact incidence of new cases of physician-reported sleep apnea (PRSA) is unknown.

Objective: To determine the potential impact of GLP-1 and dual agonists on the incidence of sleep apnea reports and to explore potential treatment consequences for this sleep-disordered breathing.

Methods: We conducted a retrospective cohort study using the TriNetX Global Health Research Network through anonymized electronic medical records. We identified adult patients with obesity and/or type 2 diabetes mellitus never prescribed GLP-1 or dual agonist therapy (reference arm) and those new initiators of these medications. The index event (June 2022) was chosen to coincide with the launching of tirzepatide in the market. We excluded patients with type 1 diabetes; previous diagnosis of PRSA; previous use of GLP-1/dual agonists, orlistat, phentermine/topiramate, or bupropion/naltrexone; or previous bariatric surgery. Initiators were matched to the reference cohort using propensity score matching in a 1:1 ratio for age, sex, ethnicity, body mass index, and menopause. We used a validated algorithm to identify PRSA using International Classification of Diseases, 10th Revision codes.

Results: The follow-up time was 1044 days. After propensity score matching, a total of 1 253 188 patients were included in the reference arm and GLP-1/dual agonist comparison. Overall, GLP-1/dual agonists were associated with a 54% lower incidence of PRSA (HR, 0.46 [95% CI, 0.45-0.49]). Individually, all drugs were able to reach this outcome as compared to the reference arm: liraglutide (HR, 0.64 [95% CI, 0.51-0.80]), dulaglutide (HR, 0.32 [95% CI, 0.28-0.36]), semaglutide (HR, 0.57 [95% CI, 0.54-0.61]), and tirzepatide (HR, 0.74 [95% CI, 0.67-0.92]). Exploratory analysis revealed a 79% lower incidence of positive airway pressure reports in the GLP-1/dual agonist group as compared to controls.

Conclusions: GLP-1/dual agonists reduced the incidence of new cases of PRSA in patients with obesity and/or type 2 diabetes.

Rationale: In smokers with and without chronic obstructive pulmonary disease (COPD), the differential strengths of association between chest computed tomography (CT)-based metrics of pulmonary vascular disease and adverse outcomes are unknown.

Objectives: We aimed to quantify the differential strengths of association of CT features, from the distal pulmonary arteries to the central great vessels and cardiac chambers, with acute respiratory exacerbations (AREs) and mortality in smokers with and without COPD.

Methods: Smokers with and without COPD with pulmonary vascular morphology and outcomes data were identified in COPDGene. Negative binominal and multivariable Cox proportional hazard models were used to investigate the association of CT features, including volume of the distal pulmonary arterial vasculature or pruning (<5 mm2 normalized to total arterial blood vessel volume [aBV5/aTBV]), preacinar vessels (5-20 mm2), and pulmonary artery to aorta (PA/Ao) and right to left ventricular epicardial volume (RV/LV) ratios, with outcomes. Kaplan-Meier curves were used to describe pruning risk on mortality.

Results: A total of 3169 smokers with COPD and 2530 smokers without COPD were analyzed. Among smokers with COPD, PA/Ao was the only imaging feature significantly associated with AREs (incidence rate ratio, 1.08 [95% CI, 1.04-1.12]), even after adjusting for aBV5/aTBV. Conversely, pruning demonstrated the strongest association with mortality, even in smokers without COPD (hazard ratio, 1.22 [95% CI, 1.14-1.30] and 1.26 [95% CI, 1.11-1.42], respectively). The association of preacinar vessels with mortality in smokers with COPD and in those without COPD, but with significant emphysema on imaging (≥5%), was novel.

Conclusions: Pruning is significantly associated with mortality risk in smokers with and without COPD; however, PA/Ao selectively associates with AREs in COPD, even when accounting for distal vasculopathy.

Rationale: There are limited longer-term follow-up data on bronchiolitis obliterans (BOS)- and retransplant-free survival among patients who underwent lung transplantation for COVID-related lung disease.

Objectives: To evaluate overall, retransplant-free, and BOS- and retransplant-free survival in a national cohort of COVID lung transplant recipients (LTRs).

Methods: We identified all US adult LTRs in the Scientific Registry of Transplant Recipients who underwent transplant for COVID-related lung disease between August 2020 and February 2025. We used propensity score matching (PSM) to construct balanced cohorts of COVID LTRs and non-COVID group D (restrictive lung disease) LTRs, comparing overall, transplant-free, and BOS- and retransplant-free survival in the 2 populations.

Results: There were 605 LTRs with COVID lung disease and 8809 with non-COVID group D diagnoses. Among patients with at least a 3-year follow-up time, survival was 79.1% in COVID LTRs and 73.7% in non-COVID LTRs. In a PSM cohort of 451 matched pairs, overall survival (LTR; hazard ratio [HR], 0.81; 95% CI, 0.60-1.10; P = .17) and retransplant-free survival (HR, 0.81; 95% CI, 0.60-1.09; P = .16) did not differ between the groups. Among non-COVID LTRs, 51 (16.0%) developed BOS, and 56 (16.3%) COVID LTRs developed BOS. Overall, 122 (33.7%) non-COVID LTRs died, were retransplanted, or developed BOS, and 110 (29.1%) COVID LTRs died, were retransplanted, or developed BOS. COVID LTRs had improved retransplant- and BOS-free survival compared to non-COVID LTRs (HR, 0.76; 95% CI, 0.58-0.98; P = .04), driven by 8 fewer deaths in the COVID LTR cohort. COVID acute respiratory distress syndrome LTRs had similar overall, retransplant-free, and BOS- and retransplant survival as COVID fibrosis LTRs.

Conclusions: In this national cohort study, there was no significant difference in overall and retransplant-free survival for COVID LTRs compared to non-COVID, restrictive lung disease LTRs at a median follow-up time of 2.5 years. COVID LTRs, however, had slightly lower hazard for BOS- and retransplant-free survival.

Rationale: The United States experienced a considerable decline in tuberculosis (TB) incidence in 2020 following the COVID-19 pandemic.

Objectives: While TB rates have since returned to near prepandemic levels, analyzing the pandemic's impact offers insight into TB epidemiology in the United States.

Methods: Focusing on California, Florida, New York, and Texas-the 4 states with the highest TB incidence-we explored 3 potential mechanisms of pandemic-related disruption on TB epidemiology: (1) reduced immigration, (2) reduced Mtb transmission (through social distancing and other behavior changes), and (3) delays in care-seeking. We used data on the volume of nonimmigrant arrivals and new permanent residents, Google mobility and US transit data, and data on the volume of emergency department visits and cancer screenings to inform the magnitude of these effects at the state level, adapting previously developed state-specific transmission models. We then estimated the impact of each mechanism and projected future TB incidence through 2032.

Measurements and main results: Disruptions to migration and care-seeking across all 4 states were considerable but short-lasting, with 70% to 90% reductions in the first 4 months of the pandemic that returned to prepandemic levels by 2021. In contrast, transmission disruptions were moderate but more prolonged, with mobility still 10% to 20% lower than prepandemic in 2022. No statistical evidence was identified to favor models emphasizing immigration and transmission vs access to care.

Conclusions: Revised projections for pandemic-related disruptions did not substantially differ from prepandemic projections beyond 2024. Future declines in TB incidence in the 4 states are likely to be small without additional interventions.

Background: Hypertensive emergency is characterized by end-organ dysfunction due to markedly elevated blood pressure. Although guidelines recommend rapid blood pressure lowering with intravenous antihypertensives and continuous monitoring in an intensive care unit (ICU), many patients are managed in intermediate care (IMC) settings. In this study, we compare outcomes of hypertensive emergency patients admitted to ICU vs IMC settings.

Methods: Adult patients in the emergency departments of 3 hospitals were included if they had 2 or more systolic blood pressure measurements greater than 180 mm Hg within 12 hours of one another, were treated with continuous intravenous antihypertensive medications, and were subsequently admitted to an ICU or IMC setting. We excluded patients receiving mechanical ventilation in the emergency department and those presenting with acute coronary syndrome, aortic dissection, or acute cerebrovascular accident. The primary outcome was hospital length of stay (LOS) penalized for death and adjusted for baseline patient features. Secondary outcomes included ICU and IMC LOS and hospital mortality. Process outcomes included arterial line usage, frequency of blood pressure measurements in the first 24 hours, and escalations of care. Lastly, we report the proportion of patients reaching blood pressure targets and/or episodes of hypotension in each setting.

Results: Intensive care unit patients (n = 649) were younger, with a male predominance, more frequently received noninvasive respiratory support and were dialysis dependent than IMC patients (n = 629). In an adjusted analysis, there was no difference in time to hospital discharge between patients admitted to ICU vs IMC settings (absolute difference: +0.29 days; 95% CI, -0.07 to 0.70). Similarly, there was no difference in ICU vs IMC LOS, hospital readmission rate, or hospital mortality. Blood pressures were more frequently measured in the ICU, but there was no difference in time to target blood pressure goal. Any hypotensive episode in the first 24 hours was more common in the ICU.

Conclusions: In this retrospective observational study of patients with hypertensive emergency, we did not observe significantly different LOS outcomes between patients admitted to ICU vs IMC settings or detect a signal of harm among those admitted to IMC. Intermediate care settings may be a reasonable alternative to ICU admission for select patients with hypertensive emergency.

Rationale: Coexisting chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) is known as overlap syndrome. This may represent a distinct clinical phenotype that shows different responses after being initiated on noninvasive ventilation (NIV) for hypercapnic chronic respiratory failure. However, current data remain scarce.

Objective(s): This study estimated the impact of overlap syndrome versus COPD without OSA on transitions between 3 states (without/recovery from severe exacerbation, severe exacerbation and death) in patients initiated on domiciliary NIV therapy.

Methods: Multistate model data came from the French national health insurance reimbursement system database for individuals with COPD aged ≥40 years and ≥1 NIV reimbursement in 2015-2019. Outcomes in the overlap syndrome and COPD without OSA groups were compared using a Cox model and inverse probability of treatment weighting analysis, adjusted for patient characteristics.

Results: Data from 54,545 patients were included (median age 70 years, 51.2% male). Probabilities of transitioning from severe exacerbation to death (10% vs. 22%) and without severe exacerbation to death (5% vs. 18%) were lower in the overlap syndrome versus COPD without OSA group. The rate of transition from severe exacerbation to without exacerbation/recovery was also higher in the overlap syndrome group. After NIV initiation, the mortality rate was 33% lower in people with overlap syndrome vs COPD without OSA.

Conclusions: For people with COPD started on domiciliary NIV, those with overlap syndrome might benefit from NIV to a greater extent than those without OSA. This highlights the need for OSA screening in people with COPD.