Farah, Wigdan

Abstract Background Community-acquired pneumonia (CAP) is a significant public health concern associated with increased rates of hospital admissions and mortality. The purpose of the current study was to compare beta-lactam plus azithromycin or doxycycline vs fluoroquinolones in adults hospitalized with CAP. Methods We searched several databases from inception to 10 June 2024. Two reviewers independently screened, selected, and extracted data. Disagreements were resolved by consensus or a third reviewer. Study quality was assessed in duplicate with the Cochrane Risk of Bias 2 for randomized studies and the Newcastle-Ottawa Scale for nonrandomized studies. Meta-analysis was conducted by a random effect model when feasible. Network meta-analysis was performed to compare direct and indirect evidence. The GRADE approach (Grading of Recommendations Assessment, Development, and Evaluation) was followed to rate the certainty of evidence. Results Twenty studies were included (20 beta-lactam + azithromycin, 7 beta-lactam + doxycycline, 12 levofloxacin, and 4 moxifloxacin): 6 were randomized, enrolling 861 participants (mean age, 61.8 years; 43.2% women), and 14 were nonrandomized, enrolling 185 928 participants (mean age, 65.2 years; 42.9% women). Direct comparison and network meta-analysis results showed no statistically significant differences and likely equal effectiveness between beta-lactam + azithromycin and beta-lactam + doxycycline in terms of in-hospital mortality, need for intensive care unit admission or invasive mechanical ventilation, or safety outcomes including Clostridioides difficile infection and QT prolongation. Conclusions The current evidence demonstrated no likely difference in outcomes between azithromycin and doxycycline in adults hospitalized with CAP receiving beta-lactam. Head-to-head randomized clinical trials are needed to validate these results.

Abstract Introduction:IgG4-related disease (IgG4-RD) is a systemic fibroinflammatory condition marked by lymphoplasmacytic infiltrates that tend to affect various organs, leading to diverse clinical manifestations. While commonly linked to conditions like pancreatitis and sialadenitis, it can also impact the lungs, causing pulmonary masses, consolidations, or pneumonia. Key histopathological features include IgG4-positive plasma cells and storiform fibrosis, although these may not always be present. Case Presentation: We present a case of an 82-year-old male with a past medical history significant for pulmonary cryptococcal infection and a previous COVID-19 infection, who presented to our pulmonology clinic with fatigue for two months followed by an upper respiratory infection that did not respond to several rounds of antibiotics. A chest CT scan revealed bilateral consolidative airspace opacities and lymphadenopathy. Subsequent bronchoscopy with transbronchial biopsy and bronchoalveolar lavage (BAL) suggested a possible cryptococcal infection; however, his symptoms did not improve after a course of fluconazole. A follow-up PET-CT scan showed increased metabolic activity in the bilateral pulmonary consolidations, thoracic adenopathy, a possible right supraclavicular lymph node, and bilateral inguinal lymph nodes. He underwent a repeat bronchoscopy with EBUS-guided biopsy of the FDG-avid lymphadenopathy, and pathology results indicated granulomatous inflammation. He was evaluated by ophthalmology for uveitis and signs of retinal detachment on brain MRI, as well as nephrology for a progressive decline in kidney function. A renal biopsy showed numerous plasma cells staining for IgG and IgG4, along with storiform interstitial nephritis, consistent with IgG4-related interstitial nephritis. His autoimmune evaluation revealed elevated levels of ANA, double-stranded DNA, RNP antibodies, and various IgG subclasses, including IgG1, IgG3, and IgG4. Considering the biopsy results and the reduced suspicion of an infectious process, he was initiated on immunosuppression treatment with prednisone and rituximab for the IgG4-related disease which resulted in significant improvement in both the patient's symptoms and kidney function. Discussion:In conclusion, this case emphasizes the diagnostic challenges of IgG4-related pulmonary disease, largely due to the nonspecific nature of the respiratory manifestations. In our case, the diagnosis remained unclear despite the patient undergoing both transbronchial and EBUS-guided lymph node biopsies. This highlights the importance of maintaining a high clinical suspicion for this underdiagnosed condition as early treatment can lead to notable recovery.

Abstract Introduction: The variety of pulmonary function tests (PFTs) offered in the pulmonary function lab (PFL) can confuse providers unfamiliar with the clinical role of the individual components of the PFT, potentially leading to repeat tests, diagnostic delays, patient burden, and reduced lab efficiency. We hypothesized that a symptom- and diagnosis-based ordering set will reduce the need for repeat testing visits. Methods: Baseline data (June 2022-June 2023) were first collected to establish PFL performance benchmarks and identify common reasons for incomplete or repeat PFL visits. We then implemented an electronic order set reflecting the clinical need of the PFT, based on symptoms, diagnoses, suspected diagnoses, or other common clinical indication in addition to a physician-supervised, results-driven protocol to allow de-escalation of testing when appropriate The pre-implementation data was compared to the post-implementation data (July 2023-June 2024), evaluating for its impact on PFL access, utilization of the specific PFT components (e.g. methacholine challenge test, MCT), and on diagnoses. Results: During the study period 52,292 PFTs were performed during the pre-implementation phase compared to 58,310 tests in the post-implementation phase. Following intervention, the need for a second PFL visit for the same clinical indication decreased from 26% to 13% (p<0.0001). The same day PFL capacity increased by 3-4 patients per day. 80% of primary care providers reported the new order design was more intuitive and easier to use. Among the specific components of the PFT, there was a significant increase in the number MCTs being performed, from 2.5% to 4%, (p<0.0001), with a change rate ranging between 26 – 81% / month. In a subset analysis of 57 consecutive patients having MCTs, the primary indications were evaluation for cough or wheezing (57.9%), initial asthma evaluation (22.8%), and specifically requested by the ordering provider (19.3%). MCT was not performed in 23% due to a low baseline lung function, difficulty with repeatable efforts, recent bronchodilator administration, or due to complicating comorbidities. Of the 39 tests completed, 89% were deemed appropriate, with 32% having positive results and 42% ultimately diagnosed with asthma. Conclusions: A symptom and/or diagnosis guided ordering set for pulmonary function testing appears to improve the efficiency of the PFL, while improving provider experience, PFL access, as well as on patient burden and diagnoses. Further research is needed to determine potential benefits for provider decision-making and patient outcomes.

Abstract Introduction Abemaciclib is a selective CDK4/6 inhibitor approved for metastatic breast cancer. We report the clinical course of Abemaciclib-induced pneumonitis, emphasizing the need for vigilant monitioring for interstitial lung disease (ILD) in patients receiving this therapy. Case description An 85-year-old woman with a history of HR-positive, HER2-negative breast cancer, Atrial fibrillation, and stage 3 chronic kidney disease presented with cough and weakness and a temperature of 100.1° F. She was hypoxic, requiring 4 liters of oxygen, she was in atrial fibrillation with a heart rate of 114, and blood pressure was 98/46. Laboratory testing showed an NT-Pro BNP: 5768, leukocytes: 2900 with 420 lymphocytes and an acutely elevated creatinine of 1.83 mg/dL (basline 1.3-1.4 mg/dL). Her CRP was 245 mg/L. Chest X-Ray revealed diffuse interstitial opacities. She was treated for pneumonia with cefepime and azithromycin, volume resuscitation and subsequent diuresis. However, her hypoxia continued to worsen. A chest CTA excluded pulmonary embolism but revealed progression of diffuse ground-glass and reticular opacities with a basilar apical gradient and enlarged mediastinal and hilar lymph nodes. An echocardiogram showed a mildly enlarged right ventricle and elevated right ventricular systolic pressure of 60. Subsequent infectious and autoimmune workups were inconclusive, bronchoscopy evaluation was deferred due worsening respiratory status. Given the concern for drug induced pneumonitis she was started on a steroid taper with 2 mgs/kg of IV Methylprednisolone. Over two weeks, her condition improved, and she was discharged without supplemental oxygen. Discussion Pneumonitis is a rare adverse effect of abemaciclib likely driven from CDK4/6 inhibitors. In a safety analysis of the MONARCH 2&3 trials, the incidence of pneumonitis was 2-5%, compared to 0.4-0.6% in the placebo arms. In these trials, two and one patients died of pneumonitis respectively. Our patient received abemaciclib for 2 years and 10 months, during which her follow up PET CT scan few months after treatment initiation demonstrated a new ground-glass and reticular opacities that continued to worsen on subsequent surveillance PET CT scans with significant progression noted on admission CT. In the absence of other contributing factors, our patient was diagnosed with Grade 3 lung toxicity, and abemaciclib was discontinued. The progression of her imaging before admission highlights the need for close monitoring for interstitial lung disease in patients receiving abemaciclib, to determine if dose reduction or treatment adjustment is warranted.

The optimal patient panel size (PPS) in primary care and the factors determining it remain unclear. We conducted a meta-narrative review of the literature to evaluate factors influencing PPS and assess its association with patient outcomes. A comprehensive search of electronic databases was performed from inception through December 2023, focusing on original studies reporting factors used to determine PPS and related outcomes (eg, clinical outcomes, process measures, and resource utilization). A total of 48 studies were included, identifying 7 key factors influencing PPS. Smaller panels were associated with improved patient satisfaction, continuity of care, and health promotion, while clinical outcomes, utilization, and costs showed minimal impact by PPS. Panel size was primarily associated with patient age, sex, comorbidities, and practice type and structure. Community-based centers typically managed smaller panels, often staffed by female clinicians and serving socioeconomically disadvantaged populations with greater health needs than hospital-based practices. Female clinicians were also independently associated with managing smaller panels, higher quality care indicators, fewer emergency department visits, and improved patient satisfaction. Determining the ideal PPS is a multifaceted process influenced by practice setting, patient demographics, and clinician characteristics. While practice-related factors showed limited association with PPS, patient-reported outcomes were more closely linked to it. Primary care practices should tailor panel sizes to their patient populations, emphasizing a patient-centered approach and ensuring adequate infrastructure support to optimize care delivery.

Background: Previous reports have emphasized disparities in the utilization of invasive respiratory support for bacterial pneumonia among various racial and ethnic minority groups with bacterial pneumonia. However, there is a shortage of detailed epidemiological data on this, particularly after the onset of the COVID-19 pandemic. Methods: We used the National In-patient Sample to conduct a retrospective cohort analysis from 2017 to 2021. We included patients hospitalized across the United States with a primary diagnosis of bacterial pneumonia. Statistical methods used included Pearson chi-square and multivariable regression analyses. Examining racial and ethnic differences in hospitalized subjects’ usage of invasive mechanical ventilation for bacterial pneumonia was the primary outcome of the study. Secondary outcomes included mortality, use of noninvasive ventilation, and hospital stay. Results: The study found significant differences among racial and ethnic groups in pneumonia-related outcomes and the need for advanced respiratory ventilator assistance. Black and Asian American and Pacific Islander (AAPI) subjects had the highest rates of invasive mechanical ventilation compared with other racial groups, with adjusted odds ratios (ORs) indicating a higher likelihood of requiring this intervention for Black (OR 1.15) and AAPI (OR 1.31) subjects. For secondary outcomes, Black and AAPI subjects experienced longer hospital stays than other racial and ethnic groups. Noninvasive ventilation rates were comparable across groups. Mortality rates were the highest among Black subjects, but were elevated for all racial and ethnic minority subjects compared with white subjects. The pandemic exacerbated these disparities, leading to increased rates of both invasive and noninvasive ventilation and higher mortality, with particularly pronounced effects seen in AAPI patients, thereby worsening existing health inequities. Conclusions: The study suggests potential racial–ethnic disparities in invasive mechanical ventilation use among Black and AAPI subjects, but further investigation is needed to confirm these findings and explore underlying causes.