Chest
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There is growing interest in the re-emerging interaction between type 2 diabetes (DM) and TB, but the underlying biologic mechanisms are poorly understood despite their possible implications in clinical management. Experts in epidemiologic, public health, basic science, and clinical studies recently convened and identified research priorities for elucidating the underlying mechanisms for the co-occurrence of TB and DM. We identified gaps in current knowledge of altered immunity in patients with DM during TB, where most studies suggest an underperforming innate immunity, but exaggerated adaptive immunity to Mycobacterium tuberculosis. ⋯ Studies in humans at different stages of DM (no DM, pre-DM, and DM) or TB (latent or active TB) should be complemented with findings in animal models, which provide the unique opportunity to study early events in the host-pathogen interaction. Such studies could also help identify biomarkers that will complement clinical studies in order to tailor the prevention of TB-DM, or to avoid the adverse TB treatment outcomes that are more likely in these patients. Such studies will also inform new approaches to host-directed therapies.
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Fractional exhaled nitric oxide (Feno) is used clinically as a biomarker of eosinophilic airway inflammation. Awareness of the factors influencing Feno values is important for valid clinical interpretation. ⋯ Ethnicity influences Feno values, and for some ethnic groups this influence likely affects clinical interpretation according to current guidelines. There is a need to establish healthy Feno reference ranges for specific ethnic groups to improve clinical application.
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Lung cancer screening with low-dose CT (LDCT) scan was shown to reduce lung cancer mortality in the National Lung Screening Trial, a large randomized controlled trial of high-risk current and former smokers. Despite ongoing uncertainty over the effectiveness of LDCT scan in the real-world setting, the Centers for Medicare and Medicaid Services (CMS) decided to cover LDCT scan as a preventive service. As part of its National Coverage Determination, CMS set forth a series of requirements for reimbursement of LDCT scan, including a counseling and shared decision-making visit prior to a LDCT scan being ordered. ⋯ Two new billing codes were introduced for the counseling and shared decision-making visit and subsequent LDCT scan. In this review, we summarize the evidence around lung cancer screening and describe practical aspects of the counseling and shared decision-making, including billing considerations. We conclude with a discussion of the greater implications of CMS National Coverage Determination, especially as it pertains to quality assurance around new screening tests.
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Malignant pleural mesothelioma is a highly aggressive tumor associated with asbestos exposure. There are few effective treatment options for mesothelioma, and patients have a very poor prognosis with a median survival of < 12 months from diagnosis. Biomarkers have been proposed as a cost-effective means of cancer management, and the search for a mesothelioma biomarker has been ongoing for the last 30 years. ⋯ Mesothelin is a glycoprotein normally expressed on the surface of mesothelial cells, and in the cancerous state it can be present in circulation. Mesothelin has a limited expression on normal, nonmalignant tissue and is thus an attractive therapeutic target for mesothelin-positive tumors. In this review we will focus on the discovery and clinical usages of mesothelin and provide an update on other mesothelioma biomarkers and show how such biomarker studies might impact on the management of this deadly tumor in the future.
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Multicenter Study Observational Study
Direct oral anticoagulant- or warfarin-related major bleeding: characteristics, reversal strategies and outcomes from a multi-center observational study.
Direct oral anticoagulants (DOACs) have expanded the armamentarium for antithrombotic therapy. Although DOAC-related major bleeding was associated with favorable outcomes compared with warfarin in clinical trials, warfarin effects were reversed in < 40% of cases, raising concerns about the generalizability of this finding. ⋯ In this unselected cohort of patients with oral anticoagulant-related hemorrhage with high rates of warfarin reversal, in-hospital mortality was lower among DOAC-associated bleeding events. These findings support the safety of DOACs in routine care and present useful baseline measures for evaluations of DOAC-specific reversal agents.