Conference Highlights: CHEST 2017

Conference Highlights: CHEST 2017
New research was presented at CHEST 2017, the annual International Scientific Assembly of the American College of Chest Physicians, from October 28 to November 1 in Toronto, Canada. The features below highlight some of the studies emerging from the conference.
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Shared Decision Making & Lung Cancer Screening

Shared decision-making for lung cancer screening is recommended by the U.S. Preventive Services Task Force and required for screening reimbursement by CMS. However, comparisons of the widely used Option Grid (physician-led) and ShouldIScreen (web-based) decision aids are lacking. Study investigators looking to do so randomized lung cancer screening participants to either decision prior to screening. A validated shared decision-making assessment tool (CollaboRATE) was used to assess participant experience immediately after screening. Patients were contacted 1 week later to answer questions designed to assess knowledge retention about lung cancer and the harms and benefits of screening. Knowledge retention did not differ significantly, with average scores of 62.4% and 64.7% for the online aid and Option Grid, respectively. Post-intervention/screening patient-satisfaction scores were 98.6% for ShouldIScreen and 97.4% for Option Grid.

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A Novel Sedative for Bronchoscopy

While midazolam has been the cornerstone of moderate procedural sedation for years, the agent has a half-life of 4.3 hours. An agent with a quicker onset of action and clearance may prove more beneficial in the sedation of patients undergoing bronchoscopy. For a phase III trial, researchers randomly assigned bronchoscopy patients who had undergone pre-treatment with fentanyl to open-label midazolam or the novel agent remimazolam. Average times to bronchoscopy start were 5 minutes for remimazolam and 15.5 for midazolam. Average times to full alertness after the procedure were 6 minutes for remimazolam and 12 for midazolam. The primary endpoint—a composite of completion of the bronchoscopy, no rescue medication, and no more than five doses within a 15-minute window for remimazolam or no more than three doses within any 12-minute window for midazolam—was met by 82.5% who received remimazolam, compared with 33.8% who received midazolam.

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Balanced Crystalloids Vs. Saline for Fluid Replacement

Balanced crystalloids and saline are both commonly used as fluid replacement but have never been tested head-to-head. To address this research gap, researchers compared the fluids in two linked studies that included nearly 30,000 patients. Overall, saline was associated with a greater risk of a composite endpoint including death, new renal replacement therapy, or persistent renal dysfunction. The difference was slight but statistically significant—about 1% between the arms in each trial—and held true whether patients were critically ill when they presented to the ED and and ended up in the ICU or were treated and sent to other hospital wards.

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Heparin & VTE in Acute Kidney Injury

Whether obesity and renal function affect performance of venous thromboembolism (VTE) prophylaxis with heparin in the hospital setting has yet to be determined. To address this gap, study investigators analyzed data on more than 6,500 consecutive patients admitted to Walter Reed Army Medical Center for at least 2 days. Patient BMI was found to not be associated with VTE at 90 days. Conversely, decrease in creatinine clearance was associated with an increased rate, but only among those who were not being treated with heparin. Patients with acute kidney injury had an increased rate of VTE, regardless of whether or not they were on heparin prophylaxis.

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Trends in Asthma Mortality Rates

As of 2010, an estimated 26 million Americans were living with asthma, with data suggesting that prevalence of the condition was increasing. To investigate the trends of asthma mortality in the United States from 1999 to 2015 and explore variation by age, gender, and race, researchers analyzed nationwide data on patients aged 15 and older with asthma as the underlying cause of their death. During the study period, the overall incidence of asthma-related deaths was 1.5 per 100,000 people. African American women had the highest age-adjusted asthma mortality rate, (3.4) whereas Caucasian men had the lowest. Asthma mortality incidence decreased from 2.1 per 100,000 people in 1999 to 1.2 in 2015. Although asthma-related mortality decreased across age groups, the highest decrease was among patients older than 65, a finding that was consistent across gender and race.

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New Hope for Excessive Sleepiness

Previous research has shown that 13% to 65% of patients with sleep apnea treated with continuous positive airway pressure (CPAP) still experience excessive sleepiness. The selective dopamine norepinephrine reuptake inhibitor solriamfetol has a different neuro-transmittter than other agents currently used to treat excessive sleepiness and therefore may be a useful alternative. To test this theory, patients with obstructive sleep apnea (OSA) and excessive sleepiness were randomized to one of four doses of solriamfetol—300 mg, 150 mg, 75 mg, or 37.5 mg—or placebo for 12 weeks. Similarly, patient Global Impression of Change scores were significantly better after 12 weeks for all but the lowest dose of solriamfetol. Twenty-one patients in the 300 mg group discontinued treatment, as did 10 in the 150 mg, four in the 75 mg group, seven in the 37.5 mg group, and 13 in the placebo group.

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