Annals of the American Thoracic Society

Background: Aging has a critical role in lung changes and the outcome of lung disease. Several lung aging equations have been proposed to measure deviation from physiological aging of the respiratory system. In this study, we aimed to develop a single measure of accelerated lung aging and show its application as a measure of lung aging. Method: We used a pre-bronchodilator pulmonary function test (PFT) from NHANES adult participants recruited from 2007 to 2011. We applied Klemera-Dubal Method (KDM) to four PFT measurements, FEV1, FVC, FEF25-75, and PEF, to calculate a measure of lung biological aging. Physiological Aging of the Respiratory System (PARS) was calculated from the residual method vs. chronological age. We tested the construct validity of PARS by measuring its association with risk factors of lung health. The prognostic validity was measured using a survival analysis. Sampling weights were applied to all analyses. Results: In 14,123 adult participants, the mean (SD) of accelerated lung age (PARS) was 0 (8.2) years. Participants with a history of asthma and emphysema had 4- and 10-year higher PARS. Cigarette smoking, lower socioeconomic status, black race, higher serum cadmium, and lower serum selenium and magnesium were associated with higher PARS. During 116 months of follow-up, PARS was associated with a higher mortality (HR = 1.06, 95%CI: 1.05-1.07 per year). Females with higher PARS had a higher risk of death (P for interaction < 0.001). Results were consistent across different subgroups and sensitivity analyses. Conclusion: PARS is a noninvasive lung aging marker and can be applied as a single measure of lung accelerated aging in the adult population. Its strong construct and predictive validity support its future application among different populations with and without lung disease.

Rationale. Racial disparities in outcomes among patients with acute respiratory failure are well-described, but the contributions of clinicians to these disparities have not been evaluated. Objectives. Among mechanically ventilated patients, we evaluated racial disparities in severity of illness trajectories and adapted value-added modeling to quantify nurse and physician relationships with these disparities. Methods. In a retrospective cohort of mechanically ventilated patients across five hospitals between 2018 and 2022, we used generalized estimating equations to model the change in Laboratory-based Acute Physiology Score version 2 (LAPS) from the start to end of intensive care unit admission ({Delta}LAPS). Consistent with value-added modeling, we randomly allocated the cohort into development and testing partitions, and fit separate multiple linear regression models of {Delta}LAPS using concurrent nurse and physician assignments (determined at 4-hour intervals), patient race, and clinician-race interaction terms as fixed effects. Clinician-specific and clinician-race interaction coefficients were extracted to determine race-specific value-add for each clinician. We defined the race-contextual value-add difference (RCVAD) as a clinician-level measurement of the difference in that clinician's value-add between Black and White patients in their care; a positive RCVAD indicates a more favorable severity of illness trajectory for Black relative to White patients and vice versa. Measurement and Main Results. Among 6,555 distinct patients, 7,247 clinical encounters, 405 nurses, and 70 physicians, Black patients accounted for 2,926 (40%) encounters. Overall, Black patients had significantly less improvement in {Delta}LAPS than White patients (difference in LAPS decline = 2.26 [0.23, 4.29], p=0.029). In the development partition, median nurse RCVAD was -0.10 (interquartile range [IQR]: -1.17, 1.14) with 191 (47%) nurses having a positive RCVAD; median physician RCVAD was -0.18 (IQR: -1.34, 0.56) with 29 (41%) having a positive RCVAD. Conclusions. Black mechanically ventilated patients experience less improvement in severity of illness during intensive care unit admission than White patients. While the majority of physicians and nurses were associated with disparities-exacerbating illness trajectories, many other clinicians were associated with disparities-mitigating trajectories. Future work to understand practices associated with disparities-exacerbating and disparities-mitigating care profiles could inform interventions to reduce disparities overall.

Background Hypercapnia may indicate a primary ventilatory syndrome, a complication of another illness, or an epiphenomenon of severe disease. The presenting context of hypercapnia is poorly quantified, limiting clinical interpretation and synthesis of epidemiologic studies. Methods We performed a retrospective cross-sectional study of Medical Information Mart for Intensive Care IV (MIMIC-IV) hospital admissions linked to an emergency department (ED) presentation from 2011 through 2019. Admissions were included if the triage chief complaint was not missing and at least one prespecified criterion for hypercapnia was met: an International Classification of Diseases (ICD) code for hypercapnic respiratory failure or obesity hypoventilation syndrome, arterial blood gas (ABG) PCO2 45 mmHg, venous blood gas (VBG) PCO2 50 mmHg, or indeterminate-source blood gas PCO2 50 mmHg. Triage chief-complaint text was classified by natural language processing (NLP) into 17 National Hospital Ambulatory Medical Care Survey reason-for-visit (RFV) categories using a multi-label framework. Primary analyses estimated admission-level RFV category prevalences; secondary analyses compared distributions by overlapping ascertainment indicator, age, and acidemia. Results The total cohort included 11,941 admissions: 1,542 (12.9%) met both blood-gas and ICD-code criteria, 9,958 (83.4%) met blood-gas criteria only, and 441 (3.7%) met ICD-code criteria only. Median age at admission was 68 years (IQR 56-78), and 6,423 admissions (53.8%) were for male patients. Respiratory RFV categories were most prevalent (30.2%), followed by administrative reasons (17.5%), digestive symptoms (14.0%), injuries and adverse effects (14.0%), and nervous-system symptoms (13.8%); categories were not mutually exclusive. Respiratory categories were more common in ICD-positive admissions (50.2%) than in VBG-defined (36.3%) or ABG-defined admissions (27.3%). Injuries and adverse effects were most prevalent among admissions for patients aged 18-39 years (34.4%), whereas respiratory categories increased from 13.7% among admissions for patients aged 18-39 years to 36.5% among admissions for patients aged 80 years. NLP-derived classifications showed mean set-F1 of 0.84 against adjudicated clinician labels in the full annotated benchmark sample. Conclusions Among ED-linked admissions with hypercapnia by diagnosis code, blood gas, or both, respiratory complaints were the most common chief-complaint category but represented fewer than one-third of admissions. Presentation context should be incorporated when defining, comparing, and interpreting hypercapnia cohorts, particularly those ascertained by blood-gas criteria.

BACKGROUND Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive, life-threatening disease. Sociodemographic factors may influence time to treatment initiation and resulting clinical outcomes, yet these relationships are poorly characterized. OBJECTIVE Assess the effects of sex and race on tafamidis initiation and subsequent outcomes and their interaction with factors such as ATTR-CM type and social deprivation measures. METHODS A retrospective cohort analysis was conducted using the US Komodo Healthcare Map (01/2016-06/2024) among patients with amyloidosis, identified by ICD-10-CM diagnosis codes. Cumulative incidence of treatment initiation and survival probabilities for cardiovascular-related hospitalization (CVH) or death were estimated by Kaplan-Meier, stratified by sex and race. Cox proportional hazards models were fitted for both endpoints to estimate hazard ratios, adjusting for demographics and clinical characteristics. RESULTS Of 11,311 patients identified, White and Black patients (n=9,223) were included in subsequent analyses. Within 12 months of diagnosis, White women had the lowest cumulative incidence of tafamidis initiation (11.4%), followed by Black women (22.0%), Black men (26.7%), and White men (31.0%). Event-free survival at 12 months was lowest in Black women (42.9%), followed by Black men (46.8%), White women (48.6%), and White men (54.4%). Median (95% CI) time to CVH or death was shortest for Black women (8.0 months [6.8-10.0]) followed by Black men (9.9 months [8.8-12.0]), White women (11.0 months [9.6-13.0]), and White men (15.0 months [14.0-16.0]). CONCLUSIONS In this large, real-world cohort of US patients with ATTR-CM, sex and race contributed to disparities in tafamidis initiation and survival, underscoring compounded disparities in both access and outcomes.

Background: Respiratory rate (RR) predicts short-term mortality in acute care settings, yet its prognostic significance in clinically stable outpatients remains poorly defined. Objectives: To determine whether the median and variability of nocturnal respiratory rate (NRR) are independently associated with long-term cardiovascular and all-cause mortality in outpatients with cardiovascular disease. Methods: We analyzed overnight chest belt waveforms from elective polysomnography in 5,679 older adults with cardiovascular disease enrolled in the Sleep Heart Health Study (SHHS). NRR was quantified at 30-second resolution, and per-subject median NRR and within-night variability (standard deviation) were derived. Kaplan-Meier survival analysis and Cox proportional hazards models were used to evaluate associations with cardiovascular and all-cause mortality over 3-year and 15-year follow-up periods, adjusting for demographic characteristics, cardiopulmonary comorbidities, and sleep apnea severity. Results: Higher median NRR and greater NRR variability were each associated with increased cardiovascular and all-cause mortality. Combining these metrics identified a high-risk group characterized by elevated median and high variability of NRR, with approximately five-fold higher 3-year all-cause mortality compared with a low-risk group; this association remained significant in Cox models (unadjusted HR: 2.61; 95% CI: 1.65, 4.14; p<0.001; adjusted HR: 2.15; 95% CI: 1.30, 3.55; p=0.003). Conclusions: Both the baseline level and variability of NRR independently predict mortality in clinically stable outpatients with cardiovascular disease. Densely profiled NRR represents a promising, underutilized biomarker for long-term risk stratification.

ABSTRACT: BACKGROUND: Cardiac arrest(CA) and acute respiratory failure(ARF) are collectively at high risk of causing deaths among adults aged 25 and older in the United States. However, long-term trends to prevent these two coexisting conditions among adults are not well defined. OBJECTIVES: The objective of this study was to analyse mortality trends for CA with ARF among U.S. adults aged 25 years and older from 1999 to 2023. METHODS: Using the CDC WONDER Multiple Cause of Death database, we conducted a retrospective analysis of death certificates listing relevant ICD-10 codes for CA (I46) and ARF (J80, J96) among adults aged 25 years and older. Age-adjusted mortality rates (AAMRs) per 100,000 persons and the annual percentage change (APC) were calculated and stratified by demographics and geography. Trends were assessed using Joinpoint regression to estimate annual percentage change with 95% confidence intervals. RESULTS: From 1999 to 2023, 807,236 deaths were recorded. The overall AAMR showed a significant upward trend (AAPC: 4.06%), rising sharply to a peak in 2021 (28.56) before declining. Males consistently had higher AAMRs than females. Both of them increased till 2021 and later decreased. Racial differences were observed in that Non-Hispanic (NH) Black individuals had the highest average AAMR, while NH Whites had the lowest. Geographically, the Western census region had the highest AAMR, increasing to 37.5 in 2021 (APC: 23.92; 95% CI: 16.21 to 28.35; p=0.0004), and rural areas demonstrated higher mortality than urban areas(13.45 vs 10.53). Adults aged 65 and older showed the highest AAMR, with a sudden rise to 96.7 in 2021 (APC: 17.4; 95% CI: 11.7 to 20.7, p<0.000001), followed by a subsequent decline, compared with the other age groups. CONCLUSIONS: There was a marked AAMR due to CA and ARF over the past 24-year period, with a surge around the COVID-19 pandemic. Significant differences were observed by sex, race, and geography. These findings highlight that efforts are needed to prevent and manage mortalities by interventions among high-risk populations who have both HF and ARF.

Purpose: Population-level lung cancer screening programs require denominators that reflect age, smoking history, geography, and changing eligibility over time. We estimated annual prevalent and 20-year cumulative unique low-dose computed tomography screening eligibility for Maryland residents under alternative screening criteria. Methods: We built a deterministic cohort-cell stock-flow simulation using Maryland county-equivalent jurisdiction projections by age, sex, and race/ethnicity, with ACS socioeconomic/nativity covariates and smoking-history priors for ever-smoked status, pack-years, and quit-years. Scenarios included USPSTF 2013 legacy, USPSTF 2021, ACS 2023/2024, a risk-model-expanded sensitivity, and ever-smoked-only capacity stress tests. Cumulative unique eligibility counted people once at first eligibility rather than summing annual prevalent person-years. Results: Under USPSTF 2021, an estimated 238,346 Maryland residents were eligible in 2026 and 245,326 in 2045. The 20-year cumulative unique denominator was 768,668, whereas naively summing annual prevalent counts produced 4,850,735 person-years, a 6.31-fold overcount. ACS 2023/2024 expanded annual eligibility to 314,616 in 2026 and cumulative unique eligibility to 902,796 by adding remote former smokers. Ever-smoked-only adult eligibility was 1,957,699 in 2026 and 3,383,683 cumulative unique over 20 years. Conclusion: A Maryland statewide screening initiative should plan from cumulative unique eligibility and county-equivalent jurisdiction-specific burden rather than annual prevalence alone. Explicit pack-year and quit-year modeling materially changes statewide and county allocation compared with current-smoking proxy models.

Background. Diagnosis and risk stratification in rare hematologic malignancies such as myeloproliferative neoplasms (MPNs) - polycythemia vera (PV), essential thrombocythemia (ET), and myelofibrosis (MF) - require expert review of longitudinal, heterogeneous clinical records. This process is cognitively demanding, inconsistently applied, and difficult to scale beyond tertiary centers. No automated phenotyping workflow currently exists for hematologic malignancies. Methods. A HIPAA-compliant large language model (LLM) framework for phenotyping MPN was developed to integrate (i) rule-based retrieval of bone marrow biopsy reports, clinical notes, and structured laboratory results from the electronic health record (EHR); (ii) zero-shot extraction of diagnostic and prognostic variables from unstructured text using GPT-4 Turbo; (iii) a clinician-informed source-prioritization algorithm to reconcile conflicting multi-source data; (iv) WHO/ICC-criteria-based diagnostic classification; and (v) NCCN-based risk stratification using the conventional risk model for PV, IPSET-thrombosis for ET, and DIPSS, DIPSS-plus, and MIPSS70/MIPSS70+ v2 for MF. Patients were identified via MPN-related ICD-9/10 codes; cases met 2017 WHO criteria or had a hematologist-documented diagnosis, and controls did not. The cohort was split into a prompt-development set (n = 60) and a held-out test set (n = 450; 75 cases and 75 controls per disease). Ground truth was established by independent dual-clinician chart review with consensus adjudication. LLM performance was evaluated against the ground truth: variable-level extraction using accuracy, F1 score, and Cohen's kappa; patient-level diagnostic classification using sensitivity, specificity, and Cohen's kappa; and prognostic risk stratification (among confirmed cases) using accuracy, weighted F1 score, and quadratic-weighted Cohen's kappa. Wilson 95% confidence intervals (CIs) were used for proportions and bootstrap 95% CIs with 500 resamples for F1 scores. Results. The held-out test set included 450 patients (PV: 150; ET: 150; MF: 150) with pathology reports and structured laboratory results, and 172 patients (PV: 52; ET: 55; MF: 65) with clinical notes. From pathology reports, overall variable extraction accuracy and F1 score were 99% (95% CI, 98-100) and 1.00 (0.99-1.00) for PV, 100% (99-100) and 0.99 (0.96-1.00) for ET, and 100% (99-100) and 0.99 (0.97-1.00) for MF. From clinical notes, overall accuracy and F1 score were 96% (91-100) and 0.94 (0.85-1.00) for PV, 100% (100-100) and 1.00 (1.00-1.00) for ET, and 100% (99-100) and 0.98 (0.95-1.00) for MF. Diagnostic sensitivity was 100% (95% CI, 95.1-100.0) for PV, ET, and MF; specificity was 98.7% (92.8-99.8) for PV and 100% (95.1-100.0) for both ET and MF, with Cohen's kappa of 0.99 for PV and 1.00 for ET and MF. Risk stratification accuracy was 100% with weighted F1 score of 1.00 and quadratic-weighted Cohen's kappa of 1.00 across all three diseases. A pre-specified source-ablation analysis showed that pathology reports alone were sufficient for diagnosis (sensitivity 98.7% for PV, 100% for ET, 96.0% for MF; specificity 100% across all three subtypes) but inadequate for prognostication (accuracy 69.3% for PV, 93.3% for ET, 77.3% for MF). Adding clinical notes to pathology reports recovered full prognostic accuracy of 100% across all three diseases. Conclusions. This first-in-class automated framework achieved expert-level performance for MPN diagnosis and risk stratification from real-world EHR data, establishing a foundation for scalable, standardized phenotyping in rare hematologic malignancies. Prospective, multi-site validation is warranted before clinical deployment.

Background: Digoxin use after the Norwood procedure has been associated with improved interstage survival in hypoplastic left heart syndrome and related conditions. Whether this benefit translates into improved longer-term outcomes through staged palliation remains unknown. We aimed to determine the association of digoxin use at Norwood discharge with transplant-free survival and Fontan completion. Methods: We conducted a retrospective cohort study using the Pediatric Heart Network (PHN) Single Ventricle Reconstruction trial public dataset, including 549 infants enrolled at 15 North American centers between 2005 and 2008. Competing risk analysis was used to evaluate Fontan completion and Cox regression to assess death or transplantation within 6 years after the Norwood procedure. Mixed-effects models compared pre-Fontan hemodynamic and echocardiographic right ventricular indices between patients treated with and without digoxin after accounting for center clustering and adjustment for sex, shunt type, heart failure medications at Norwood discharge, and census block poverty level. Results: The 6-year cumulative incidence of Fontan completion was higher among patients discharged on digoxin than among those not receiving digoxin (82% vs 71%; p = 0.013). Competing-risk analysis accounting for death and transplant demonstrated a greater likelihood of Fontan completion among digoxin users (aHR 1.31; 95%CI 1.09-1.58; p = 0.005), without significant difference in the hazard of death or transplant (aHR 0.78; 95%CI 0.53-1.15; p = 0.208). No significant differences in pre-Fontan hemodynamic or echocardiographic indices were observed between groups. Initiation of digoxin post Stage II procedure was not associated with improved survival or likelihood to complete Fontan. Conclusion: Digoxin use at the time of Norwood discharge was associated with a 30% greater likelihood of Fontan completion by 6 years, without accompanying improvement in transplant-free survival. These findings extend prior observations of improved interstage outcomes associated with digoxin use and suggest that treatment may facilitate progression through staged palliation.

Abstract Background Non-cardiac chest pain (NCCP) is commonly regarded as a low-risk condition. However, long-term mortality, cause-specific death, and high-risk subgroup characteristics remain poorly defined. Methods In this multicentre registry-linked cohort study, we linked the Chest Pain Center Registry from 101 hospitals in Hunan, China, with the Mortality and Cause of Death Registry. Adults diagnosed with NCCP from Jan 1, 2017, to Dec 31, 2021, were included. We assessed 3-year all-cause, cardiovascular, and non-cardiovascular mortality using Cox, restricted cubic spline, and Fine-Gray models. Findings Among 160,245 patients, 4674 deaths occurred within 3 years (2.9%). Mortality increased sharply after 60.5 years. Age [&ge;] 60.5 years (adjusted hazard ratio [aHR] 7.49 [95% CI 6.89-8.14]), rural residence (time-varying aHR 1.46 [1.35-1.57] in year 1 and 1.66 [1.46-1.89] in years 1-3), and male sex (aHR 1.47 [1.38-1.57]) independently predicted death. Three-year mortality ranged from 0.3% in younger urban women to 8.4% in older rural men. Cardiovascular diseases accounted for 56.4% of deaths among older patients, whereas other non-cardiovascular causes (22.8%) and malignancy (20.8%) were the largest categories among younger decedents. Interpretation NCCP is not uniformly benign. Age, rural residence, and sex identify patients who could benefit from risk-stratified follow-up, with cardiovascular prevention prioritised for older rural men and broader non-cardiovascular assessment considered for younger patients.

Background: Risk stratification in pericarditis relies mainly on clinical presentation, suspected etiology, imaging findings, and conventional inflammatory biomarkers. Whether complete blood count-derived inflammatory indices are associated with mortality in pericarditis and whether these associations are directionally consistent across independent real-world datasets remain unclear. Methods: We conducted a retrospective dual-cohort study of hospitalized adults with pericarditis using a Hong Kong cohort from the Clinical Data Analysis and Reporting System (CDARS) as the primary analysis cohort and the Medical Information Mart for Intensive Care IV (MIMIC-IV) cohort as an independent reproducibility cohort. Baseline neutrophil-to-lymphocyte ratio (NLR) and systemic immune-inflammation index (SII) were analyzed as continuous variables and cohort-specific tertiles. The primary outcome was long-term all-cause mortality in the Hong Kong cohort. Secondary and reproducibility outcomes included 90-day mortality in the Hong Kong cohort and 30-day, 90-day, and observable follow-up mortality in MIMIC-IV. Cox models were adjusted for age, sex, renal disease, diabetes mellitus, hypertension, ischemic heart disease, and malignancy. Results: Among 504 patients in the Hong Kong cohort and 464 patients in MIMIC-IV, all-cause mortality occurred in 241 and 113 patients during cohort-specific follow-up, respectively. In the Hong Kong cohort, higher NLR was associated with long-term all-cause mortality after full adjustment. Compared with NLR tertile 1, the adjusted hazard ratio was 1.60 for tertile 3. Higher SII was also associated with long-term mortality, with an adjusted hazard ratio of 1.55 for tertile 3 versus tertile 1. NLR and SII showed directionally consistent associations with 90-day mortality in the Hong Kong cohort and with 30-day, 90-day, and observable follow-up mortality in MIMIC-IV. Sensitivity analyses yielded broadly consistent findings. Conclusions: In two independent real-world cohorts of hospitalized patients with pericarditis, higher baseline NLR and SII were associated with increased all-cause mortality, with NLR showing the more consistent prognostic signal. These complete blood count-derived indices may provide simple adjunctive information for mortality risk stratification, although prospective validation is needed before incorporation into formal management algorithms.

Background Five-year survival from lung cancer exceeds 60% at stage I-II but falls below 10% once metastasis occurs. Low-dose CT (LDCT) screening reduces mortality in heavy smokers but carries a false-positive rate of approximately 29% and is restricted to smoking-based eligibility, leaving most cases undetected. We aimed to develop and independently validate an interpretable machine-learning urinary metabolite risk index (uLCI) for non-invasive lung cancer detection. Methods Four urinary metabolites - creatine riboside (CR), N-acetylneuraminic acid (NANA), 27-nor-5-beta-cholestane-3-alpha,7-alpha,12-alpha,24,25-pentol (CP), and cortisol sulfate (CS) - and three clinical variables (age, race, smoking) were integrated by Lasso-regularised logistic regression into a uLCI score. The model was developed under 10-fold cross-validation in the NCI-Maryland (NCI-MD) cohort (n=845; 470 controls, 375 cases, stages I-IV) and applied without refitting to the independent Colorado Lung Cancer Cohort (n=488; 211 controls, 277 cases). Analyses were prespecified; reporting followed TRIPOD+AI. Findings uLCI achieved an area under the curve (AUC) of 0.906 (95% CI 0.887-0.926) in NCI-MD and 0.748 (0.701-0.793) in the independent Colorado cohort. Scores rose monotonically across stages in both cohorts (Spearman rho=0.69 and 0.45; both p<0.0001). Stage-specific discrimination was preserved from stage I to IV (NCI-MD 0.900-0.927; Colorado 0.722-0.843). Net reclassification improvement over clinical variables was 1.24 (1.14-1.36) and 0.74 (0.56-0.90). uLCI tertiles stratified post-resection survival in stage I-II disease (adjusted hazard ratio 2.03, 1.26-3.27). Interpretation uLCI is an independently validated, interpretable urinary risk index that detects lung cancer across all stages, with monotonic stage progression and post-resection prognostic value. Its false-positive rate compares favourably with published estimates for LDCT and cell-free-DNA assays, supporting prospective head-to-head evaluation as a non-invasive triage tool, including in screening-ineligible populations. Funding Intramural Research Program, Center for Cancer Research, National Cancer Institute, US National Institutes of Health.

ABTRACT Background Children from low- and middle-income countries are particularly vulnerable to air pollution, a major environmental health risk, due to the immaturity of their lungs and their proximity to sources of household pollution. This study aimed to investigated the effect of exposure to biomass combustion through domestic and maternal occupational activities on respiratory health of children living in disadvantaged urban areas of Abidjan, Cote dIvoire. Methods Between February and December 2023, we conducted a cross-sectional observational study among children <16 years from households of women using biomass fuel for cooking (Group (G) 1), engaged in occupational fish smoking activities (G2), or primarily using gas for domestic cooking (G3). We assessed reported respiratory symptoms through standardized questionnaires and the presence of lung function impairments (LFI) though pulmonary function tests (spirometry and Rint). We assessed the association between study groups and key covariates with respiratory symptoms and LFI using mixed-effects regression models. Results Of 210 children enrolled - 119 (56.8%) female, median age 9 (6-12) years, 82 (39.0%) in G1, 47 (22.4%) in G2, and 81 (38.6%) in G3 - 15 (7.1%) reported wheezing in the last 12 months, 82 (39.0%) reported dry cough at night, 9 (4.9%) presented with dyspnea and 5 (2.7%) had chest pain on clinical examination, for an overall proportion of children with reported respiratory symptoms of 43.8% (92/210). Of 176 children who underwent pulmonary function testing, 59 (33.5%) had LFI detected, including 34 (45.9%) in G1, 8 (22.2%) in G2, and 17 (25.8%) in G3 (p = 0.011). Study group was associated with respiratory symptoms (G1 vs G3; aOR 3.82, 95% CI 1.68-8.68; p < 0.001), as well as with LFI (p = 0.042). Girls were at greater risk of LFI than boys (aOR 2.69, 95% CI 1.24-5.80; p = 0.012). Children whose mothers used charcoal or wood as cooking fuel had higher odds of respiratory symptoms (OR 2.61, 95% CI 1.22-5.58; p = 0.013) but no association was found with LFI (p = 0.459) compared with unexposed children. Conclusion Respiratory symptoms and lung function impairments were highly prevalent among children living disadvantaged, especially when mothers cook with wood or charcoal. Targeted maternal awareness and broader interventions to reduce household air pollution in disadvantaged urban areas are urgently needed to protect long-term respiratory health.

Background: Postoperative atrial fibrillation (POAF) is a frequent complication following coronary artery bypass grafting (CABG) and is associated with increased acute morbidity and resource utilization. However, its independent role in driving post-discharge adverse events in contemporary practice remains debated. Objective: To evaluate the association between POAF and short-term outcomes after CABG, and to utilize empirical Bayesian risk updating to stratify 90-day post-discharge vulnerabilities. Methods: A retrospective cohort analysis of 4,684 adult patients who underwent isolated CABG in Florida between January 1, 2021, and June 30, 2024, was conducted, excluding those with documented preoperative AFib. We employed multivariable negative binomial and logistic regression models to assess length of stay (LOS), discharge disposition, 90-day readmission, and 90-day composite complications. Additionally, a Bayesian Beta-Binomial conjugate model with an objective Jeffreys Prior was utilized to estimate the posterior probabilities of adverse outcomes across key clinical phenotypes. Results: POAF occurred in 355 patients (7.58%). Multivariable analysis demonstrated a 30% relative increase in expected LOS (IRR 1.30, 95% CI [1.23 - 1.36], P < .001) and 33% higher odds of facility discharge (OR 1.33, 95% CI [1.03 - 1.72], P = .030) for patients with POAF. However, POAF was not independently associated with 90-day readmission (OR 1.25, P = .063) or composite complications (OR 1.20, P = .118). Chronic heart failure (CHF) emerged as the dominant predictor. Bayesian risk updating revealed that while the baseline posterior probability for a 90-day complication was 27.2%, the synergistic presence of both POAF and CHF radically shifted this posterior risk to 42.6% (Probability of Direction > 0.999 vs. baseline). Conclusions: POAF prolongs hospitalization and drives non-home discharges, but it does not independently dictate 90-day morbidity. Bayesian stratification demonstrates that post-discharge outcomes are predominantly driven by underlying chronic conditions. Effective reduction of readmissions requires robust transition-of-care frameworks, empowering primary care clinicians to aggressively optimize heart failure and metabolic disease rather than focusing solely on the acute surgical arrhythmic event.

Background: Transthyretin amyloidosis cardiomyopathy (ATTR-CM) is an infiltrative cardiomyopathy and an increasingly recognized cause of heart failure. With improved survival from disease-modifying therapies, an increasing number of patients are presenting for surgery and may be at increased risk of adverse postoperative outcomes. This study reports outcomes of ATTR-CM patients undergoing surgery and evaluates the utility of the Revised Cardiac Risk Index (RCRI), a perioperative risk tool. Methods: A total of 145 ATTR-CM patients were included, among which 51 patients underwent at least one eligible surgical procedure. Preoperative risk was assessed using the RCRI, analyzed both as a categorical and as a dichotomized ({greater than or equal to}3 vs <3) variable. Postoperative outcomes included unplanned hospital admission, length of stay (LOS), prolonged hospitalization (>48 hours), and major adverse cardiac events. Models were adjusted for frailty (Clinical Frailty Scale {greater than or equal to}5) and major surgery, using multivariable, ordinal, and Firth penalized logistic regression analyses. Results: Patients were predominantly male (86%) with a mean age of 76 {plus minus} 9 years, and 61% were frail. Higher RCRI scores were associated with unplanned postoperative hospital admission (RCRI {greater than or equal to}3: adjusted OR 48.9, 95% CI 4.8-502.2) and longer LOS (RCRI {greater than or equal to}3: adjusted OR 40.7, 95% CI 4.3-382.8). RCRI {greater than or equal to}3 was also associated with prolonged hospitalization (>48 hours) in Firth penalized logistic regression, whereas frailty was not independently associated. Conclusions: In a real-world ATTR-CM cohort undergoing major non-cardiac surgery, the overall risk of adverse outcomes was low, and higher RCRI scores were associated with increased postoperative hospital admission and longer LOS, including hospitalization exceeding 48 hours. The RCRI retains prognostic utility in this high-risk cohort and may support peri-operative risk stratification.

Background: Chronic obstructive pulmonary disease (COPD) is a leading cause of global morbidity and mortality, and its heterogeneity demands better biomarkers of severity and progression risk. Extracellular vesicles (EVs) are promising blood-based biomarkers, but have not been examined for COPD severity and outcomes in a large multicentre cohort. Methods: We analysed 600 COSYCONET participants (up to 54 months of follow-up). EV surface markers were profiled with the MACSPlex EV Kit IO. Cross-sectional associations with severity (GOLD, FEV1) were primary (ordinal and linear regression); longitudinal trajectories and all-cause mortality were prespecified exploratory endpoints. Results: Six EV markers showed robust associations with cross-sectional severity: CD29, CD49e and CD31 increased with severity (a cell-adhesion/matrix-remodelling signal), whereas CD81 and CD8 decreased; HLA-ABC (increasing) was less specific. No marker was linked to FEV1 decline. After FDR correction, lower levels of three markers with higher 54-month mortality (all HR<1): CD25 (HR 0.77, 95% CI 0.65-0.90, q=0.018), CD56 (HR 0.75, 95% CI 0.63-0.89, q=0.018) and CD142 (HR 0.74, 95% CI 0.60-0.90, q=0.024). CD25 and CD142 also improved reclassification, CD56 did not; a CD25 + CD69 combination showed the largest incremental signal ({Delta}C 0.017, 95% CI 0.002-0.032, p=0.027). Conclusion: Circulating EV surface markers are associated with cross-sectional COPD severity. Exploratory analyses nominate CD25, CD142 and CD25 + CD69 as candidate prognostic markers requiring external validation, suggesting minimally invasive EV profiling could complement clinical assessment in COPD.

Background: Outpatient chronic heart failure (HF) assessment relies on NYHA class and distance-based testing that can obscure physiological heterogeneity. Near-infrared spectroscopy (NIRS) enables tissue oxygenation phenotyping but is underexplored during standardized stressors in outpatient HF. We tested whether wearable NIRS-derived oxygenation kinetics during a vascular occlusion test (VOT) and six-minute walk test (6MWT) differ across NYHA classes. Methods: In this prospective, single-center pilot study, 44 chronic HF outpatients (mean age 70.9 {+/-} 8.7 years, 75% male; NYHA I [n=19], II [n=12], III [n=13]) were monitored with a novel wearable NIRS device (NIRSense Envello Core) during a VOT and 6MWT. Primary endpoints were the post-occlusion net area under the curve (net AUC; VOT) and post-walk recovery net AUC (modified 6MWT). Secondary endpoints included the exertional tissue oxygenation (Oxy) nadir, VOT reperfusion kinetics, gait metrics, and tolerability. Results: Despite NYHA I and II walking identical median distances (420 m), post-walk recovery net AUC was lower in NYHA II (-16.3 a.u.xs) and III (-12.8 a.u.xs) than NYHA I (46.1 a.u.xs, p=0.004). The exertional Oxy nadir did not differ (p=0.722), but NYHA III walked 27% and 38% slower than NYHA II and I (p<0.001). NYHA II had higher VOT net AUC (134.2 a.u.xs) than NYHA I (71.9; p=0.018) and III (61.1; p=0.011). Post-walk recovery net AUC correlated with gait velocity (rs=0.44) and distance (rs=0.39; both p<0.05). VOT net AUC did not correlate with functional metrics, but resting reperfusion kinetics correlated with 6MWT performance (rs=0.41-0.46, p<0.05). The sensor was well tolerated. Conclusions: Wearable NIRS-derived recovery kinetics differentiated NYHA I from NYHA II despite these classes walking identical median distances. Coupled with distinct resting VOT hyperemic differences, these preliminary findings indicate wearable NIRS may capture physiological heterogeneity in outpatient HF not reflected by NYHA class and standard functional metrics.

Background: Biologically distinct asthma subgroups may obscure genetic effects when analyzed as a single phenotype. We examined whether asthma susceptibility signals are shared, heterogeneous, or stratum-specific across ancestry, obesity status, and sex. Methods: We performed ancestry-specific GWAS meta-analyses in African ancestry participants (9,965 asthma cases; 37,391 controls) and European ancestry participants (6,074 cases; 116,255 controls), followed by obesity- and sex-stratified analyses. Analyses used imputed dosages and fixed-effect meta-analysis within ancestry. Results: Stratification detected asthma association signals that were less apparent in the combined phenotype. Shared cross-ancestry loci implicated epithelial antiviral susceptibility and immune regulation, represented by signals near CDHR3 and FOXO1. An ancestry-heterogeneous signal at the 17q21 locus, harboring ORMDL3/GSDMB, supported population-dependent effects at an epithelial inflammatory locus. Obesity stratification mapped the genome-wide significant burden to asthma without obesity. Sex stratification detected genome-wide significant signals in AFR females with asthma and obesity and in both sex strata with asthma without obesity, with the strongest signal burden in EU females without obesity. Conclusions: Asthma genetic architecture differed by ancestry, obesity status, and sex. Stratified analyses identified group-specific susceptibility related to epithelial and immune regulation, airway inflammation, remodeling, and neural signaling, supporting precision approaches to asthma.

Background: Acute pulmonary embolism (PE) is a leading cause of morbidity and mortality with persistent difficulties in choosing interventions and predicting outcomes for patients defined clinically as intermediate risk. Computational fluid dynamics (CFD) tools have been used to understand the hemodynamic environment and plan interventions in the pulmonary arteries across a variety of disease conditions. Several biomechanical metrics have been used to evaluate risk in narrowed vessels, including hemodynamic resistance, power dissipation, and fractional flow reserve (FFR). In this study, we evaluate differences in these CFD-derived biomarkers between healthy controls (HC) and intermediate risk, acute PE patients. Additionally, we examine the response of patient hemodynamics to mechanical thrombectomy and compare values of these biomarkers across post-intervention pressure status. Methods: A CFD framework was developed to simulate patient-specific hemodynamics within the pulmonary vasculature identifiable from clinical imaging. The pipeline involved reconstructing three-dimensional (3D) structures of the pulmonary arteries and modeling blood flow with the finite element method. Patient-specific boundary conditions were derived from matching pre-intervention inlet mPAP to the patient's measured value given their measured CO as steady inflow. Converged simulations allowed for precise quantification of primary hemodynamic characteristics (flow and pressure) as well as secondary flow phenomena, primarily wall shear stress (WSS) and simulated pressure metrics such as fractional flow reserve (FFR). Results: Our simulations revealed significant elevations in resistance, power dissipation, and the number of vessels with low FFR in those patients with acute PE (n=6) compared to HC (n=3). Occlusions of hemodynamic significance were generally found in segmental pulmonary arteries. For patients with normalized pulmonary pressures post-thrombectomy (n=3), we found significantly higher proximal power dissipation and counts of low FFR vessels in comparison to those with elevated pressures after intervention (n=3). Distal resistance, which was derived from the portion of resistance attributed to the outflow boundary conditions, was significantly higher in patients with elevated pressures post-intervention. Across all PE patients, FFR count was significantly correlated with post-thrombectomy pulmonary pressure and cardiac index. Discussion: CFD-derived biomarkers offer a promising tool for understanding disease severity in acute PE. Differences between HCs and acute PE patients reveal expected increases in metrics associated with proximal disease burden. Yet, in examining acute PE patients with varying post-intervention hemodynamics, we found that these metrics of proximal disease burden could also be useful to predict the efficacy of mechanical thrombectomy. Those patients with normalized pressures had higher values for proximal disease metrics and lower values for distal disease metrics than those with continued elevations in pressure. This suggests that accessibility of hemodynamically-significant emboli to thrombectomy may be useful as a predictor for outcomes.

Background: Clonal hematopoiesis (CH) is associated with increased risks of diverse cardiovascular diseases, hematologic malignancies and mortality, yet no preventive therapies are approved. As emerging data implicate lipid pathways in CH pathogenesis, we investigated the association of statin use and genetically proxied inhibition of HMG-CoA reductase (HMGCR) with CH risk, and validated findings using primary peripheral blood mononuclear cells (PBMCs). Methods: We performed an observational analysis of 416,118 UK Biobank participants of European ancestry using multivariable logistic regression to compare CH prevalence among statin users and nonusers. Mendelian randomization (MR) analyses evaluated the causal association of genetically proxied lowering of low-density lipoprotein cholesterol (LDL-C) with risk of CH using two instruments; (i) the lead HMGCR variant (rs12916) which proxied LDL-C lowering by statins, and, (ii) 303 genome-wide LDL-C-lowering variants representing polygenic mechanisms. Summary statistics were obtained from the Global Lipid Genetics Consortium genome-wide association study (N = 842,634). Experimentally, primary PBMCs from a DNMT3AR882 hotspot mutation carrier were cultured in methylcellulose with pravastatin or vehicle control to evaluate colony-forming dynamics. Results: Among 416,118 individuals, 20,488 had CH, including 11,550 with single DNMT3A-mutant and 4,375 with single TET2-mutant CH. Pre-recruitment statin users had reduced odds of DNMT3A-mutant CH (OR=0.93; 95% CI:0.88-0.98; P=0.009), driven primarily by associations with DNMT3AR882-mutant (OR=0.78; 95% CI:0.66-0.92; P=0.003), but not TET2-mutant CH (OR=1.05; 95% CI:0.97-1.14; P=0.20). Similarly, genetically predicted HMG-CoA-reductase inhibition equivalent to a 1 SD reduction in circulating LDL-C levels was associated with lower odds of DNMT3A-mutant CH (OR=0.66; 95% CI:0.45-0.95; P=0.03) but not TET2-mutant CH (OR=1.34; 95% CI:0.76-2.36; P = 0.31). By contrast, polygenic estimation of LDL-C lowering was not associated with DNMT3A-mutant CH (OR=1.05; 95% CI:0.97-1.14; P=0.20), suggesting protective effects were independent of LDL-C lowering per se. Genetically predicted HMG-CoA reductase inhibition had wide effects on blood cell counts and indices, suggesting effects on bone marrow cell dynamics. In vitro, pravastatin selectively suppressed colony formation of primary human DNMT3AR882-mutant relative to wild-type cells (P=0.031). Conclusions: Statin therapy and genetically predicted lifelong inhibition of HMG-CoA reductase were significantly associated with reduced risk of DNMT3A-mutant CH, likely via LDL-C-independent mechanisms, which may be specific to DNMT3A-mutant CH. This provides a strong rationale for prospective trials evaluating the effect of statins on risk of developing DNMT3A-mutant CH, subsequent clonal expansion, and associated clinical sequelae.