Chest Moderator

on


Samuel Huang

ID:

RARE MYCOBACTERIUM NEBRASKENSE LUNG DISEASE IN COPD: TREAT OR OBSERVE?


sella boneh, sella boneh, Sara Tama-Shekan, MD, Sara Tama-Shekan, MD, Hina Arsh, Hina Arsh, Micaela Prisco, MD, Micaela Prisco, MD, Sahar Haider, Sahar Haider, Santino Patrizi, DO, Santino Patrizi, DO, fnu shazna, fnu shazna, Theo D. Trandafirescu, MD, FCCP, Theo D. Trandafirescu, MD, FCCP


Purpose: To describe a unique case of recurrent nontuberculous mycobacterial (NTM) lung disease culminating in rare Mycobacterium nebraskense isolation amid migratory pulmonary nodules in severe COPD, highlighting diagnostic pitfalls, biopsy risks, and therapeutic uncertainty in treating uncommon NTM pathogens
Methods: Retrospective review of clinical encounter, serial imaging (CT/PET 2016–11/2024), microbiology, histopathology, and hospital course for a 63-year-old former heavy smoker with advanced COPD/emphysema, chronic hypoxic respiratory failure (baseline 2L NC O2), OSA (CPAP), obesity, HTN, biventricular HF (normal coronaries 2016), and progressive left-sided pulmonary nodules.
Results: A 63-year-old former heavy smoker (1.5 ppd × 24 years, quit 2015) with centrilobular upper-lobe predominant emphysema, chronic hypoxia (on 2L NC), OSA (CPAP), obesity, HTN, and prior biventricular HF developed bilateral pulmonary nodules tracked chronologically from 2016. Initial CTs showed stable 7 mm right upper lobe cavitating nodule (8/2017), new subpleural nodules (4/2017), and scattered subcentimeter nodules up to 8–9 mm (2017–2019) with mixed evolution. By 5/29/2020, a new 2.2–2.4 cm spiculated left apical nodule prompted PET (6/16/2020; SUVmax 14.5) and biopsy (6/14/2020: non-caseating granulomas, AFB/GMS negative); MAC was cultured (8/3/2020), treated with rifampin/ethambutol/azithromycin (started 10/7/2020). Post-treatment imaging showed partial response. Nodules persisted and fluctuated. PET (8/23/2024) revealed new 1×2.4 cm left apical opacity (SUVmax 5.8); continued surveillance prompted biopsy in a left apical nodule (5 mm to 2.3 cm on 11/18/2024 CT), but IR-guided procedure (4/28/2025) caused tension pneumothorax (escalating O2 from 3L NC to 10L oxymask), requiring urgent chest tube (resolved 4/30/2025). Histology showed necrotizing granulomas; cultures progressed most recently growing Mycobacterium nebraskense (8/24/2025).
Conclusions: This case exemplifies the variable manifestations of NTM lung disease in structurally damaged lungs, where migratory granulomatous nodules—multifocal, spiculated, cavitating, and PET-avid—persistently mimic primary bronchogenic carcinoma or metastatic disease despite targeted antimicrobial therapy. Over nearly a decade, this patient's lesions demonstrated a dynamic pattern: emergence of dominant spiculated masses (e.g., 3 cm right apical in 2020), intense metabolic activity warranting oncologic workup, partial regressions to fibrotic scarring post-MAC treatment, and relentless recurrence of new dominant nodules in alternating locations. The shift from non-caseating to necrotizing granulomas underscores evolving pathology, while negative AFB/GMS stains highlight the diagnostic limitations of rapid microbiology in NTM disease. Critically, ongoing surveillance—essential to exclude malignancy—culminated in a high-risk interventional radiology-guided biopsy that precipitated life-threatening tension pneumothorax, illustrating the precarious balance between vigilant monitoring and procedural hazards in frail, emphysematous lungs with poor reserve.
Clinical Implications:
In COPD with recurrent NTM and rare isolates like M. nebraskense. weigh targeted treatment against observation, considering structural lung disease, prior responses, and biopsy risks.


Category:
Chest Infections

Samuel Huang

ID:

FROM SMOG TO STATS: MAPPING LOWER RESPIRATORY TRACT INFECTION BURDEN IN SUBCONTINENT OVER THREE DECADES (1990-2023)


Syed Muhammad Salman Hassan, Syed Muhammad Salman Hassan, Sarim Hassan Shahab, Sarim Hassan Shahab, Syed Muhammad Amad Bukhari, MBBS, FCPS Pulmonary Medicine, Syed Muhammad Amad Bukhari, MBBS, FCPS Pulmonary Medicine, Areej Imtiaz, Areej Imtiaz, Mamoona Muneer, Mamoona Muneer, Anum Faiz, Anum Faiz, aqsa komel, aqsa komel, Azka Aisha, Azka Aisha, Moiz Ul Haq Hashmi, Moiz Ul Haq Hashmi, Ramla Aziz, Ramla Aziz, Hamza Arif, Hamza Arif, Aimen Aman, MBBS, Aimen Aman, MBBS, Tayyaba Saleem, Tayyaba Saleem, Hareem Binte Saleem, Hareem Binte Saleem


Purpose: Lower respiratory tract infections(LRTIs) significantly affect  the health of people accounting for millions of cases and hospitalization each year. Given the adverse effects and burden of this clinical entity, the need to evaluate the long-term epidemiological trends  and the global burden of LRTIs is necessary. This study analyzes the burden and trend of LRTIS  using Global burden of disease database across the African Union
 
 
Methods: The data used were extracted and analyzed from the Global Burden of Diseases (GBD) 2023 study, covering African Union estimates of  Lower Respiratory Tract Infections for both sexes (age-standardized). The evaluation metrics included age standardized rater per 100,000 including ASIR, YLL, ASDR, YLD rates, DALY rates, and ASPR. Through joinpoint regression, trends were analyzed to obtain average annual percent change (AAPC) measures.
 
Results: Between 1990 and 2023, the African Union and its subregions experienced a steady decrease in the burden of lower respiratory tract infections, evidenced by decreasing trends in absolute DALYs, age-standardized death rates (ASDR), incidence rates (ASIR), and prevalence rates (ASPR). In the African Union, DALYs per 100,000 decreased from 6010.65 in 1990 to 2815.80 in 2023. ASDRs showed a sustained decrease from 1990 to 2021, followed by a slight increase from 2021 to 2023, while ASIRs and ASPRs showed smaller reductions, suggesting persistent disease prevalence despite declines in mortality and incidence. Joinpoint regression revealed distinct temporal trends in the African Union. DALYs decreased significantly from 1990 to 1999 (APC: -1.76%; 95% CI: -1.89%to -1.64%; p < 0.000001), 1999 to 2009 (-3.06%; 95% CI: -3.18% to -2.93%; p < 0.000001), and 2009 to 2018 (-1.40%; 95% CI: -1.55% to -1.25%; p < 0.000001), with the steepest reduction observed between 2018 and 2021 (APC: −8.78%; 95% CI: −10.05% to −7.49%; p < 0.000001), followed by a significant rise during 2021–2023 (APC: 5.65%; 95% CI: 4.19% to 7.14%; p < 0.000001). . The overall Average Annual Percent Change (AAPC) from 1990 to 2023 was -2.28% (95% CI: -2.44% to -2.13%; p < 0.000001). Regionally, Northern Africa exhibited the most pronounced decline in DALYs (AAPC: −3.85%; 95% CI: −4.05% to −3.64%), while Eastern Africa (−2.60%), Western Africa (−2.33%), Central Africa (−1.88%), and Southern Africa (−1.72%) (all p < 0.000001). In 2023, DALYs per 100,000 were highest in Central Africa (3695.15), with Western Africa (3441.54), Eastern Africa (2672.64), Southern Africa (2671.96), and Northern Africa (998.62) showing progressively lower values. DALYs per 100,000 declined from 6841.48 to 3695.15 in Central Africa and from 3671.93 to 998.62 in Northern Africa, while ASDRs showed a similar declining trend. ASIRs mirrored this pattern, Western and Central Africa reported the highest ASIRs, and ASPRs decreased modestly, highlighting sustained prevalence in all subregions
 
Conclusions: Over 30 years, the African Union achieved a significant reduction in LRTI mortality and incidence. However, substantial inequalities persist between subregions, and the recent increase in DALYs after 2021 signals a reversal requiring sustained public health efforts.
 
Clinical Implications: The cross sectional retrospective study would help us take necessary measurs required in order to curb the spread of Lower Respiratory Tract Infections in subcontinent 


Category:
Chest Infections

Samuel Huang

ID:

CLINICAL AND ECONOMIC OUTCOMES ASSOCIATED WITH ASPIRATION PNEUMONIA IN HOSPITALIZED PATIENTS WITH PARKINSON'S DISEASE: A NATIONAL INPATIENT SAMPLE ANALYSIS (2018-2020)


Mariam Shahabi, MBBS, Mariam Shahabi, MBBS, Eliza Aisha, MBBS, Eliza Aisha, MBBS, Muhammad Affan, Muhammad Affan, Kashaf Nadeem, Kashaf Nadeem, Rehan Ali, Rehan Ali, Aleena Sharif, MBBS, Aleena Sharif, MBBS, Aneesh Challa, MBBS, Aneesh Challa, MBBS, Aamna Nasir, Aamna Nasir, Husnain Ahmad, Husnain Ahmad, Fizza Mahmood, Fizza Mahmood, Muhammad saad Arshad, MBBS, Muhammad saad Arshad, MBBS, Maham Sherazi, Maham Sherazi, Abdullah Imtias, Abdullah Imtias, Atif Nawaz Malik, MBBS, Atif Nawaz Malik, MBBS


Purpose: Aspiration pneumonia is a leading cause of mortality and morbidity in patients with Parkinson’s disease (PD), mainly driven by dysphagia and other motor and non-motor impairments. This study evaluates the clinical and economic burden of aspiration pneumonia in hospitalized PD patients using the National Inpatient Sample (2018–2020).
 
Methods: We conducted a retrospective cohort study using the 2018-2020 National Inpatient Sample.Patients with a primary diagnosis of PD (ICD-10-CM G20) were included and stratified by the presence or absence of aspiration pneumonia (ICD-10-CM J69.0). Primary outcomes were in-hospital mortality, length of stay, and inflation-adjusted total hospital charges. Secondary outcomes included sepsis, acute respiratory failure, mechanical ventilation, palliative care use, and discharge disposition. Multivariable logistic and linear regression models were used for binary and continuous outcomes, respectively, adjusted for demographics, hospital characteristics, comorbidities, and insurance type.
Results: Of 1,040,055 hospitalizations, 83,855 (8%) involved aspiration pneumonia with a mean age of 79 years (± 9 years). The patients were more often male (71% vs. 58%) and had higher comorbidity burden (Elixhauser Index 5.45 vs. 5.19, p<0.001). Aspiration pneumonia was associated with higher in-hospital mortality (13% vs. 3.2%, adjusted odds ratio 3.55, p<0.001), longer length of stay (8.8 vs. 5.7 days, p<0.001), and greater total hospital charges ($97,293 vs. $59,949, p<0.001). Patients with aspiration pneumonia had higher odds of acute respiratory failure (aOR=6.64), sepsis (aOR=3.93), mechanical ventilation (aOR=5.40), and palliative care utilization (aOR=3.52) [p<0.001 for all outcomes]. They were also less likely to be discharged home (aOR=0.57, p<0.001) and more likely to require skilled care facilities (aOR=1.16, p<0.001). Age (aOR 1.04), male sex (aOR 1.11), and higher comorbidity burden (aOR 1.10) were independently associated with worse outcomes [p<0.001 for all]. Asian, Black, and Hispanic patients suffered higher mortality (aOR 1.43, 1.20, and 1.22, respectively; p<0.001).
Conclusions: Aspiration pneumonia in hospitalized Parkinson’s patients markedly increases mortality, complications, length of hospital stay, and hospital costs. Risk is highest in older males with greater comorbidity burden, and outcomes vary by race and socioeconomic status. Early preventive strategies, multidisciplinary care, and targeted interventions for high-risk and underserved populations are essential to reduce clinical and economic burden.
Clinical Implications: Preventive measures such as bedside swallowing evaluations, early involvement of speech-language pathologists, nutritional optimization, head-of-bed elevation, oral hygiene, and careful review of medications that impair swallowing should be prioritized. Recognizing racial and geographic disparities can help target interventions in underserved populations. Reducing this burden requires a multidisciplinary approach involving neurology, geriatrics, speech therapy, nutrition, and nursing, and future research should explore strategies to lower mortality and hospital costs associated with aspiration pneumonia in hospitalized Parkinson’s disease patients.


Category:
Chest Infections

Samuel Huang

ID:

REAL-WORLD EFFECTIVENESS OF INHALED ANTIBIOTICS ON PULMONARY EXACERBATIONS IN NONCYSTIC FIBROSIS BRONCHIECTASIS: A POPULATION-BASED SELF-CONTROLLED ANALYSIS


Cesar N. Cristancho Rojas, MD, MMSc, Oregon Health & Science University, Cesar N. Cristancho Rojas, MD, MMSc, Emily Henkle, PhD, Emily Henkle, PhD, Sarah A. Siegel, PhD, Sarah A. Siegel, PhD, Rochelle Fu, Rochelle Fu, Philip Polgreen, Philip Polgreen, Jeffrey Curtis, MD, Jeffrey Curtis, MD, Kevin L. Winthrop, MD, MPH, Kevin L. Winthrop, MD, MPH


Purpose: Bronchiectasis is associated with substantial morbidity, frequent exacerbations, and high healthcare utilization, yet evidence for long-term suppressive inhaled antibiotic therapy remains mixed, and implementation-focused studies are needed. Our objective was to assess the real-world long-term effectiveness of inhaled antibiotics as suppressive therapy for exacerbations
Methods: We conducted a longitudinal self-controlled case series (SCCS) analysis comparing exacerbation rates before and after inhaled antibiotics using a U.S. population–representative retrospective cohort of adults with bronchiectasis identified in MarketScan® databases, which contain longitudinal healthcare claims from Commercial, Medicare Supplemental, and Multi-State Medicaid programs. A bronchiectasis case was defined as ≥2 claims with bronchiectasis ICD codes >30 days apart. We excluded those with CF, HIV, or organ transplantation claims. The observation period began on the date of the second bronchiectasis claim and ended with the loss of insurance coverage. Respiratory exacerbation was defined as outpatient initiation of a qualifying systemic antibiotic or inpatient claims for pneumonia, lower respiratory infection, or bronchiectasis exacerbation. We identified inhaled antibiotic new users (≥28 days’ supply during follow-up and no use before time zero) and compared exacerbation rates during the 12 months before vs. 12 months after treatment initiation using a conditional Poisson model. Analyses were stratified by sex, age group, macrolide use, and antibiotic class
Results: Among 80749 individuals with bronchiectasis, 1169 (1.4%) initiated inhaled antibiotics; 31.1% experienced multiple treatment episodes. Mean episode duration ranged from 95.1 (Medicaid) to 144.6 days (Commercial), and <6% received ≥2 antibiotic classes. At treatment initiation, 37% had Pseudomonas, 38.3% had NTM, and 3.1% had ABPA codes; mean age was 63 years, and 71.9% were female. During the pretreatment year, mean exacerbations were 2 (SD 1.6), and 57.5% experienced ≥2 exacerbations. Crude exacerbation rates declined from 2.14 to 1.45 events per person-year from pre- to posttreatment. In SCCS models (n=1006 with ≥1 exacerbation during the pre- or post-initiation year), inhaled antibiotic initiation was associated with reduced exacerbation rates (RR 0.69; 95% CI, 0.64–0.74), corresponding to an absolute rate difference of −0.66 exacerbations per person-year and a rate-based NNT of 1.52 person-years. Sensitivity analyses were directionally consistent, including first-event-only (RR 0.84) and models assuming background secular declines (attenuated but <1 across scenarios). Macrolide prescriptions during the posttreatment year showed a significant interaction (RR 0.75 with macrolides vs. 0.63 without), whereas a nonsignificant interaction was observed with pretreatment year macrolide use. Significant reductions were maintained for tobramycin (RR 0.68), amikacin (RR 0.72), and gentamicin (RR 0.63), whereas colistin (RR 0.83) and aztreonam (RR 0.72) were directionally protective but not statistically significant; tobramycin and amikacin comprised >90% of class-stratified observations
Conclusions: In a large U.S. claims-based cohort, initiation of inhaled antibiotics was associated with a statistically significant within-person reduction in exacerbation rates over the subsequent year. The treatment-associated reduction was broadly consistent across key subgroups, with slight variation by concurrent posttreatment macrolide use and by inhaled antibiotic class
Clinical Implications: Findings support the real-world effectiveness of inhaled antibiotics for reducing exacerbation frequency in bronchiectasis and provide implementation-relevant context across insurance types, informing patient selection and therapeutic strategies in routine care


Category:
Chest Infections

Samuel Huang

ID:

SIMPLIFIED VS COMPREHENSIVE LUNG POCUS PROTOCOLS FOR PULMONARY TB TRIAGE IN A HIGH-BURDEN SETTING


Rohan Dhamdhere, MS, Rohan Dhamdhere, MS, Lydia Nakiyingi, Lydia Nakiyingi, Nate Wycliff, Nate Wycliff, Keith P. Guevarra, DO, FCCP, Keith P. Guevarra, DO, FCCP, Eva Eva Nabawanuka, MBChB, MMed, Eva Eva Nabawanuka, MBChB, MMed, Elena Jovanovska Janeva, Elena Jovanovska Janeva, Guadalupe Astorga, Guadalupe Astorga, Padmini Salgame, Padmini Salgame, Jerrold Ellner, Jerrold Ellner, Anant Madabhushi, Anant Madabhushi, Yingda Xie, Yingda Xie


Purpose: Point-of-care ultrasound (POCUS) is a low-cost, radiation-free triage tool with potential utility for tuberculosis (TB) in high-burden settings, but standardized acquisition protocols remain limited. We evaluated streamlined symmetric lung POCUS protocols for distinguishing pulmonary TB from TB-negative individuals, including those with other respiratory conditions (ORC), and contextualized performance against WHO triage test benchmarks (sensitivity ≥90%, specificity ≥70%).
Methods: Ugandan participants aged ≥13 years were enrolled if they had (1) pulmonary TB, (2) household contact of a TB case, or (3) a non-TB respiratory condition (ORC). Pulmonary TB was defined by positive sputum GeneXpert Ultra and/or culture. All underwent an 18-zone POCUS exam (12 lung plus 6 extrapulmonary “FASH” zones). Using Random Forest models, we evaluated simplified symmetric protocols (2, 4, and 6 zones) derived from the 12-zone lung exam. Data were split into 70% training and 30% holdout sets using random stratified sampling, with synthetic minority oversampling (SMOTE) applied to the training set. Each simplified model was zone-symmetric (e.g., inclusion of R1 required inclusion of L1) with at least one feature from each selected zone retained in the final model. AUC comparisons used DeLong's test.
Results: Among 318 participants,118 (37.1%) had confirmed TB and 76.3% were smear-positive. Of 200 TB-negative participants (No TB), 98 (49%) were asymptomatic household contacts and 102 (51%) had symptomatic ORC. Persons living with HIV comprised 20-21% of the TB and no-TB groups. All reported metrics are from the 30% holdout set. For TB vs. No TB, discrimination improved with protocol extent: 2-zone AUC 0.74 (95% CI 0.64–0.84), 4-zone 0.80 (0.70–0.90), 6-zone 0.82 (0.73–0.91), and 12-zone 0.88 (0.80–0.94); the 6-zone was not significantly different from the 12-zone by DeLong's test. Adding FASH did not improve discrimination (18-zone AUC 0.86, 0.77–0.93). At 70% specificity, sensitivity was 0.80 (6-zone) and 0.84 (12-zone), below the WHO ≥90% threshold. For TB vs. ORC, symmetric 4- and 6-zone models did not identify significant discriminating features; the 2-zone AUC was 0.78 (0.67–0.89) versus 12-zone 0.89 (0.80–0.95) and 18-zone 0.90 (0.82–0.97). At 70% specificity, the 18-zone protocol achieved sensitivity of 0.90, meeting the WHO target. Top features for TB vs. No TB emphasized absence of normal lung patterns in bilateral upper zones and right upper anterior consolidation signs (air bronchograms, shred sign, A-lines), consistent with upper-lobe predominance of TB. For TB vs. ORC, bilateral lower lateral pleural curtain signs were among the important discriminators.
Conclusions: A parsimonious 6-zone symmetric lung POCUS protocol preserved diagnostic accuracy relative to the 12-zone exam (no significant difference by DeLong's test) and may improve scalability for high-throughput triage.  For differentiating TB from ORC relevant to symptomatic patients in a health facility, a comprehensive 12- to 18- zone exam remained most accurate and approached or met WHO targets.
Clinical Implications: The 6-zone exam offers a scalable tool for TB screening in community-based active case-finding settings. For symptomatic triage at health facilities, where shared sonographic patterns make diagnostic separation more challenging, a comprehensive 12-zone lung or 18-zone lung+FASH exam may provide greater diagnostic value.


Category:
Chest Infections

Samuel Huang

ID:

CHUBA AS A PREDICTOR OF MORTALITY IN COMMUNITY-ACQUIRED PNEUMONIA


Sharmistha Dutta, Sharmistha Dutta, AMARTYA CHAKRABORTI, MBBS, AMARTYA CHAKRABORTI, MBBS, Maldev A. Sonigra, MBBS, Maldev A. Sonigra, MBBS, Sagar khot, DNB, Sagar khot, DNB


Purpose: CURB 65 and Pneumonia Severity Index (PSI) are both well-established scores for outcomes of patients with community-acquired pneumonia (CAP). PSI can often be complicated to calculate in an acute setting. Studies have shown that, in the elderly, CURB-65 fares much worse than PSI in predicting mortality. CHUBA (Confusion, Hypoxemia PaO2≤60 mmHg, Blood Urea Nitrogen > 30 mg /dl, Bedridden state, Albumin<3gm/dl) has shown promise to be a good predictor of mortality in CAP patients, performing better than CURB-65 and as good as PSI in patients aged >65 years. Per our review of literature, this score has not been evaluated in any study apart from the original study done in Japan 1, and may be a good prognosticator of the outcome of patients with advanced age diagnosed with CAP.
 
Methods: This was a prospective observational study done at a tertiary care hospital in India. Sixty patients aged> 65 yrs with a diagnosis of CAP were enrolled over a period of 12 months. Patients underwent routine blood examinations, procalcitonin and imaging with Chest Xray and/or CT chest. Microbiological investigations in the form of Gram stain, AFB ZN stain, aerobic and fungal culture were performed if indicated. Nasopharyngeal swabs for influenza and coronavirus were done in patients suspected of viral pneumonia. All patients were followed up to a period of 30 days from admission and outcomes like discharge, death and requirement of ICU admission were noted. PSI, CURB-65 AND CHUBA were calculated at the time of admission and their relationship with the outcome variables were evaluated. Univariate analysis followed by logistic regression was carried out to examine independent risk factors of worse clinical outcomes. Statistical analyses were done by R studio v. 1.2.5019 and p value <0.05 was taken to be significant.
 
Results: In the logistic regression, PSI, CURB-65 score, B/A ratio and CHUBA  were found to be independent risk factors for ICU admission and mortality. CHUBA was determined to be a better discriminator of worse clinical outcomes than its counterparts, with odds ratios of 19.1 (8.9-25.1) and 32.3 (16.8-43.2). Receiver Operating Characteristic(ROC) curve analysis showed that the Area Under Curve (AUC) of CHUBA, CURB-65, PSI and B/A ratio with respect to mortality were 0.89, 0.72, 0.8 and 0.79, respectively.
 
Conclusions: In elderly patients with a diagnosis of community acquired pneumonia, CHUBA can be a dependable predictor of clinical outcomes. Larger studies are needed to establish its role.
 
Clinical Implications: Conventional severity scores like the Pneumonia Severity Index (PSI) and CURB-65 were developed in heterogeneous adult populations and may not accurately predict mortality in elderly patients. These models underrepresent functional status, nutritional deficits, sarcopenia, and social determinants of health, all of which affect prognosis. As the aging population grows, there is a need for newer, geriatric-focused prediction models incorporating frailty indices, biomarkers, and functional measures to improve risk stratification, guide disposition decisions, and optimize care planning.


Category:
Chest Infections

Samuel Huang

ID:

MORTALITY TRENDS AND DISPARITIES OF PNEUMONIA AND ISCHEMIC HEART DISEASE IN THE US, 1999-2023: A CDC WONDER STUDY


Noor Fatima, Noor Fatima, Usman Ghani, Usman Ghani, HUZAIFA SABIR NAWAZ, HUZAIFA SABIR NAWAZ, Muhammad Bilal Aamir, Muhammad Bilal Aamir, Faisal Khan, MD, Faisal Khan, MD, Madho Mal, MD, Madho Mal, MD, Hameer Ali, Hameer Ali, Madeeha Subhan Waleed, Madeeha Subhan Waleed, Waleed Sadiq, MD, Waleed Sadiq, MD, Sharmeen Naz, MD, Sharmeen Naz, MD


Purpose: Pneumonia represents a major acute inflammatory illness and a recognized trigger of cardiovascular complications, including ischemic heart disease (IHD), through systemic inflammation, endothelial dysfunction, and prothrombotic activation. Patients hospitalized with acute pneumonia experience elevated short-term cardiovascular risk, yet long-term national trends in pneumonia-associated IHD mortality remain incompletely characterized, particularly across demographic and geographic subgroups. We examined the trend and disparities of national mortality using 25 years of population-based data.
Methods: Death certificate data from the CDC WONDER Multiple Cause of Death database (1999–2023) were analyzed. Adults aged ≥25 years were included when both pneumonia (ICD-10 codes J12–J18) and ischemic heart disease (ICD-10 codes I20–I25) were listed anywhere on the death certificate, either as underlying or contributing causes of death. Age-adjusted and age-specific mortality rates per 100,000 persons were calculated. Temporal trends were assessed using annual percent change (APC) and average annual percent change (AAPC) via Joinpoint regression.
Results:

A total of 633,861 deaths were recorded from 1999 to 2023. Pneumonia-associated IHD mortality declined substantially, with age-adjusted mortality rates decreasing from 21.15 in 1999 to 6.51 in 2023 (AAPC −5.13%; 95% CI [−7.81 to −2.36]; p<0.001). The overall all-ages AAMR for 1999–2020 was 7.58 per 100,000. A significant decline occurred from 1999 to 2018 (APC −6.66%; p<0.001), followed by a marked increase during the COVID-19 pandemic period (2018–2021 APC +31.43), and a subsequent decline from 2021–2023 (APC −32.04; p=0.002).
Age-stratified analyses demonstrated substantially higher mortality among older adults, with the greatest burden in individuals aged ≥65 years. Sex disparities were pronounced, with higher mean AAMR in men (16.69) compared with women (8.56) and a sharper pandemic-associated increase among men (2018–2021 APC +34.57%).
Racial disparities persisted, with the highest mean AAMR observed among White individuals (12.12), followed by Hispanic or Latino (11.73), American Indian or Alaska Native (10.56), Black or African American (10.39), and Asian or Pacific Islander populations (9.70). Regionally, mortality rates were highest in the Midwest and West. These regional differences may partly reflect variations in population demographics, healthcare access, and death-certificate coding practices. Nonmetropolitan areas experienced a higher mortality burden (mean AAMR 14.54) compared with metropolitan areas (11.13), although the pandemic-associated increase was more pronounced in metropolitan regions.
Conclusions: Pneumonia-associated ischemic heart disease mortality declined significantly over two decades but demonstrated a marked increase during the COVID-19 pandemic with subsequent correction. Persistent demographic and geographic disparities remain. These findings underscore the importance of cardiovascular risk recognition and mitigation during acute pneumonia, particularly among hospitalized and high-risk populations, and support strategies aimed at early cardioprotective intervention during severe respiratory infections.
Clinical Implications: The persistent disparities in pneumonia-related IHD mortality highlight the need for rigorous systematic cardiovascular risk assessment during acute pneumonia, particularly in high-risk groups, supporting the integration of early cardioprotective strategies and optimization of cardiometabolic risk factors during hospitalization for severe respiratory infections. Targeted interventions and preventive measures, such as vaccination uptake and equitable access to post-discharge cardiovascular care, to reduce excess mortality in vulnerable and underserved populations.


Category:
Chest Infections

Samuel Huang

ID:

SMOKING, MALIGNANCY, AND THE 'SMOKER'S PARADOX' IN NECROTIZING PNEUMONIA: A NATIONAL INPATIENT SAMPLE ANALYSIS


Arpit Jain, MBBS, Arpit Jain, MBBS, Mudit Moondra, MBBS, Mudit Moondra, MBBS, Srushti Sahukar, Srushti Sahukar


Purpose: Necrotizing pneumonia (NEC-PNA) is a fulminant parenchymal infection characterized by abscess formation and pulmonary gangrene. While cigarette smoking is a primary driver of chronic lung disease, epidemiological data in acute sepsis occasionally demonstrate a “smoker’s paradox,” wherein active smokers exhibit superior short-term survival compared to non-smokers. It remains unclear whether this paradox persists in patients with malignancy, a population with distinct immunologic and physiologic vulnerabilities. We utilized a national cohort to determine if smoking status modifies the impact of solid and hematologic malignancies on mortality and resource utilization in NEC-PNA.
Methods: We performed a retrospective study of the 2022–2023 National Inpatient Sample. Adult hospitalizations with NEC-PNA were identified using ICD-10-CM codes. Smoking status and malignancy subtype (none, solid tumor, metastatic cancer, lymphoma) were derived from diagnosis fields. Analyses were restricted to the NEC-PNA subpopulation using survey weights. Mortality was modeled with survey-weighted logistic regression. LOS and TOTCHG were modeled using gamma-log generalized linear models and additionally adjusted for in-hospital mortality to account for competing risk from early death. Models adjusted for demographics, payer, hospital characteristics, and Elixhauser comorbidities. Smoking–malignancy interaction was formally tested. Sensitivity analyses using the Elixhauser summary score were performed.
Results: The analysis included a weighted estimate of 31,680 admissions for necrotizing pneumonia. Tests for interaction between smoking and malignancy type were not statistically significant for in-hospital mortality (F=0.80, p=0.495), length of stay (F=1.30, p=0.274), or total charges (F=1.45, p=0.226). Consequently, smoking exerted a consistent effect across all malignancy subgroups.

In the main effects analysis, smoking was independently associated with significantly reduced odds of in-hospital mortality (OR 0.51; 95% CI 0.38–0.67; p<0.001). Smokers also demonstrated lower resource utilization, with a relative decrease in length of stay (Ratio 0.80; 95% CI 0.75–0.85; p<0.001) and total hospital charges (Ratio 0.73; 95% CI 0.68–0.79; p<0.001). Regarding malignancy, metastatic cancer was associated with reduced LOS (Ratio 0.86; 95% CI 0.77–0.97; p=0.011) and charges (Ratio 0.85; 95% CI 0.74–0.98; p=0.024), with a trend toward increased mortality (OR 1.37; 95% CI 0.99–1.90; p=0.060).
Conclusions: In this national cohort of necrotizing pneumonia, smoking was paradoxically associated with lower mortality, shorter length of stay, and reduced hospital costs. This "smoker's paradox" remained robust and consistent across patients with solid tumors, metastatic cancer, and lymphoma, as evidenced by the lack of significant interaction.
Clinical Implications: The apparent survival advantage in smokers likely reflects a "healthy smoker effect" or selection bias rather than a true protective benefit. Smokers may develop necrotizing pneumonia at a higher baseline functional status due to compromised local lung defenses, whereas non-smokers often possess severe unmeasured frailty or immunosuppression. Additionally, lower resource utilization in metastatic patients may reflect earlier transitions to palliative care or hospice. Future prospective studies are needed to better delineate the "smoker's paradox" and the specific pathophysiological or care-process mechanisms driving these outcomes.


Category:
Chest Infections




Based on the full text you pasted, here’s a moderator guide with one main question and one backup per poster. These are questions about the studies’ own methods and claims, rather than treatment recommendations.

3571 — M. nebraskense in COPD: treat or observe?

Summary: A patient with severe COPD had years of changing, PET-avid pulmonary nodules, prior MAC treatment, and later M. nebraskense isolation. A repeat biopsy caused a tension pneumothorax. The case illustrates uncertainty about infection, malignancy, treatment, and procedural risk. The abstract doesn’t report the final treatment decision or subsequent outcome.

  • Ask: “After identifying M. nebraskense, did you treat or observe, and what findings drove that decision?”
  • Backup: “Which specimen grew the organism, and was it isolated repeatedly?”

3572 — LRTI burden, 1990–2023

Summary: GBD analysis reports declining African Union LRTI burden, with DALYs per 100,000 falling from 6,011 to 2,816, followed by a rebound after 2021. The title says ‘subcontinent,’ but the methods and results describe Africa; pollution exposure wasn’t directly analyzed.

  • Ask: “Could you clarify the geographic population—the title refers to the subcontinent, while the methods and results describe the African Union?”
  • Backup: “How did GBD classify COVID-related disease, and could that help explain the sharp decline through 2021 followed by the rebound?”

3573 — Aspiration pneumonia in Parkinson’s disease

Summary: Among approximately 1.04 million hospitalizations, 8% involved aspiration pneumonia. Mortality was 13% versus 3.2%, with an adjusted mortality OR of 3.55; stays and charges were also higher. Important ambiguities are whether Parkinson’s was truly the principal diagnosis, and whether the reported numbers are survey-weighted. The economic outcome is charges, not measured costs.

  • Ask: “Was Parkinson’s required to be the principal diagnosis, as written, or could it appear in any diagnosis position?”
  • Backup: “Could you identify aspiration present on admission versus developing during hospitalization, and how might that affect the interpretation?”

3574 — Inhaled antibiotics in bronchiectasis

Summary: A claims-based, within-person analysis found exacerbation rates decreased after inhaled antibiotic initiation: RR 0.69, or approximately 0.66 fewer exacerbations per person-year. Only 1.4% initiated treatment. NTM codes occurred in 38.3%, raising the question of whether some inhaled antibiotics were prescribed for NTM treatment rather than bronchiectasis suppression.

  • Ask: “How did you distinguish inhaled antibiotics prescribed for NTM treatment from those prescribed to suppress bronchiectasis exacerbations?”
  • Backup: “How did you address regression to the mean when treatment may have been initiated after a particularly bad exacerbation year?”

3575 — Simplified lung POCUS for TB

Summary: In 318 participants, the six-zone model had AUC 0.82, versus 0.88 for 12 zones. At 70% specificity, six-zone sensitivity was 80%, below the stated WHO target. The comprehensive 18-zone model reached 90% sensitivity against symptomatic respiratory controls. A nonsignificant AUC difference does not establish equivalence.

  • Ask: “Given the numerical AUC difference and small holdout set, how confident are you that six zones preserve performance rather than the comparison being underpowered?”
  • Backup: “Were zone selection, feature selection, and tuning completed entirely within the training data before evaluating the holdout set?”

3576 — CHUBA for elderly patients with CAP

Summary: A prospective study of 60 patients over 65 found mortality AUCs of 0.89 for CHUBA, 0.80 for PSI, and 0.72 for CURB-65. CHUBA incorporates confusion, hypoxemia, urea, bedridden status, and albumin. The small sample and unreported number of deaths make precision and model stability difficult to assess.

  • Ask: “How many deaths occurred, and what were the confidence intervals around the AUCs and their differences?”
  • Backup: “Were the overlapping severity scores assessed in separate regression models or entered together?”

3577 — Pneumonia and ischemic heart disease mortality

Summary: CDC WONDER identified 633,861 deaths with both diagnoses listed. Age-adjusted mortality fell from 21.15 to 6.51 per 100,000, interrupted by a pandemic-era increase. Co-listing on a death certificate cannot establish that pneumonia triggered an ischemic event.

  • Ask: “Did the trends change when you separated deaths with pneumonia as the underlying cause from those with ischemic heart disease as the underlying cause?”
  • Backup: “How did you handle deaths also listing COVID-19, and did excluding them change the pandemic spike?”

3578 — ‘Smoker’s paradox’ in necrotizing pneumonia

Summary: In approximately 31,680 weighted admissions, coded smoking was associated with lower mortality odds (OR 0.51), shorter stays, and lower charges. Smoking–malignancy interactions weren’t significant. That supports no detected interaction, rather than proving identical effects across cancer groups.

  • Ask: “How did you distinguish current, former, and undocumented smoking, and could the reference group include former smokers?”
  • Backup: “What were the subgroup event counts and interaction confidence intervals—was there enough precision to exclude clinically meaningful effect modification?”

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