Daily Respiratory Research Analysis
Analyzed 87 papers and selected 3 impactful papers.
Summary
Analyzed 87 papers and selected 3 impactful articles.
Selected Articles
1. YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism in Patients With Cancer: A Randomized Clinical Trial.
In a multicenter randomized noninferiority trial of 698 cancer patients with suspected PE, the YEARS algorithm was as safe as CTPA-only management and enabled avoidance of CTPA in 22% of patients. The 90-day thromboembolic event rate after PE exclusion was lower in the YEARS group in per-protocol analysis, meeting noninferiority criteria.
Impact: This trial provides high-level evidence to safely reduce imaging and contrast exposure in a high-risk oncology population while maintaining diagnostic safety.
Clinical Implications: For cancer patients with suspected PE, applying the YEARS algorithm can safely reduce CTPA utilization and streamline diagnostic workflows. Implementation may lower contrast-related risks and resource use without increasing missed VTE events.
Key Findings
- Noninferiority met: 90-day symptomatic VTE/PE-related death after PE exclusion was 1.8% (YEARS) vs 5.5% (CTPA-only) in per-protocol analysis.
- CTPA was avoided in 22% of patients managed with the YEARS algorithm.
- No difference in the proportion of negative CTPA between groups (P=.93).
- Central blinded adjudication and intention-to-diagnosis analysis confirmed robustness.
Methodological Strengths
- Randomized, multicenter noninferiority design with blinded central outcome adjudication
- Both per-protocol and intention-to-diagnosis analyses performed
Limitations
- Open-label design may introduce management biases
- Heterogeneity of cancer types and treatments may affect generalizability; no reduction in negative CTPA proportion
Future Directions: Assess implementation in diverse oncology settings, evaluate patient-centered outcomes and cost-effectiveness, and explore integration with cancer-specific pretest probability tools.
IMPORTANCE: Although the YEARS algorithm is a safe and efficient way to rule out acute pulmonary embolism (PE), robust evidence on its accuracy in patients with cancer is lacking, and current guidelines suggest proceeding directly to computed tomographic pulmonary angiography (CTPA). OBJECTIVE: To compare the safety and efficiency of the YEARS algorithm with CTPA only to rule out acute PE in patients with active cancer. DESIGN, SETTING, AND PARTICIPANTS: The Hydra study was an open-label, randomized, investigator-initiated, noninferiority trial with blinded central outcome adjudication conducted from August 22, 2019, to August 21, 2025, the date of final follow-up. Patients with active cancer and suspected acute PE were recruited from emergency departments or medical units in 21 hospitals in the Netherlands, Italy, Switzerland, Belgium, France, and Spain. INTERVENTIONS: Patients were randomly assigned in a 1:1 ratio to receive diagnostic management by the YEARS algorithm (n = 352)-consisting of assessing YEARS items, D-dimer levels, and performing risk-dependent CTPA-or by CTPA only (n = 346). MAIN OUTCOMES AND MEASURES: The primary outcome was centrally adjudicated symptomatic venous thromboembolism or (possible) PE-related death within 90 days after ruling out PE at baseline, assessed in a per-protocol noninferiority analysis with a 2.6% margin for the upper bound of a 1-sided 99.9% CI. The key secondary outcome was the proportion of negative CTPA results at baseline, assessed in a superiority analysis. RESULTS: A total of 698 patients were randomized (median age, 65 years [IQR, 56-72 years], 422 female [60%]), and 104 patients (15%) had PE diagnosed at baseline. One patient was lost to follow-up. Of those in whom PE was considered excluded, 5 of 282 patients (1.8%) in the per-protocol YEARS group vs 15 of 273 patients (5.5%) in the per-protocol CTPA-only group had a primary outcome (absolute risk difference, -3.7%; 99.9% CI, -8.8% to 1.4%; P = 3.4 × 10-5 for noninferiority). In the intention-to-diagnosis analysis, the absolute risk difference between the YEARS algorithm and CTPA only was -2.6% (99.9% CI, -7.5% to 2.4%; P = 5.9 × 10-4 for noninferiority). Diagnostic management of PE was carried out for 77 of 352 patients (22%) in the YEARS group without CTPA. No difference in the proportion of negative CTPA (P = .93) was observed between the groups. CONCLUSIONS AND RELEVANCE: In patients with cancer and suspected PE, a diagnostic strategy using the YEARS diagnostic algorithm was as safe as using CTPA only, thus, obviating the need to perform CTPA in 22% of patients. TRIAL REGISTRATION: ccmo.nl Identifier: NL-OMON52383.
2. Real-time estimation of pathogen transmission dynamics from wastewater.
EpiSewer is a Bayesian semi-mechanistic framework that integrates infection dynamics, shedding kinetics, and measurement noise (including outliers and non-detects) to infer transmission parameters such as the effective reproduction number directly from wastewater data. This addresses key barriers to multi-pathogen wastewater epidemiology beyond SARS-CoV-2.
Impact: Provides a generalizable, statistically robust approach to real-time transmission estimation from wastewater for multiple pathogens, filling a critical methodological gap in public health surveillance.
Clinical Implications: Public health agencies can use wastewater-derived R estimates to trigger timely interventions, allocate resources, and augment clinical testing, especially when case ascertainment is limited.
Key Findings
- Introduces EpiSewer, a Bayesian semi-mechanistic model that jointly models infection incidence, shedding, and measurement noise.
- Explicitly accounts for outliers and non-detects, improving robustness of wastewater-based inference.
- Enables direct real-time inference of effective reproduction number from wastewater for pathogens beyond SARS-CoV-2.
Methodological Strengths
- Bayesian semi-mechanistic modeling integrates biological and measurement processes
- Handling of outliers and non-detects enhances real-world applicability
Limitations
- Clinical validation across diverse pathogens and settings is limited in scope
- Uncertainty in shedding kinetics and variable wastewater systems may affect calibration
Future Directions: Prospective validation against clinical incidence across pathogens, integration with environmental covariates, and deployment in early-warning systems for outbreak management.
Wastewater monitoring proved effective for tracking SARS-CoV-2 transmission during the COVID-19 pandemic. However, estimating transmission parameters for other pathogens remains difficult due to lower concentrations in sewage, uncertain shedding kinetics, and limited clinical validation data. Here we present EpiSewer, a Bayesian semi-mechanistic wastewater model that jointly accounts for infection dynamics, pathogen shedding, and measurement noise, including outliers and non-detects. This enables direct inference of the effective reproduction number (R
3. Beyond Device Downloads: Residual Sleep Apnea and Hypoxemia Missed by Flow-Based CPAP Monitoring.
In 465 patients contributing 24,939 concomitant nights, flow-based PAP AHI (mean 2.4/h) substantially underestimated residual respiratory burden relative to CPC-derived AHI3% (mean 12.1/h). Even when device AHI was <5/h, most nights still showed elevated CPC-AHI and frequent hypoxemia, indicating clinically meaningful residual disease.
Impact: Challenges the prevailing reliance on device-derived AHI alone to judge PAP efficacy and supports integrating physiologic sleep metrics to avoid missed residual disease.
Clinical Implications: Consider adjunct longitudinal physiologic monitoring (e.g., CPC) to detect residual sleep-disordered breathing and hypoxemia under PAP, particularly REM-related events, and tailor therapy accordingly.
Key Findings
- Across 24,939 matched nights, mean device-derived AHIFLOW was 2.4/h vs CPC-derived AHICPC 12.1/h.
- When AHIFLOW <5/h, 85% of nights still had AHICPC ≥5/h and 47.7% had AHICPC ≥10/h.
- Hypoxemia was common despite low AHIFLOW: 28.3% of nights had ≥5 minutes with SpO2 <90% and 10.6% had ≥5 minutes with SpO2 <88%.
Methodological Strengths
- Large longitudinal dataset with 465 patients and 24,939 concomitant nights
- Concomitant device and CPC data allow direct comparison on the same nights
Limitations
- Retrospective observational design limits causal inference
- Generalizability may be influenced by device ecosystem and CPC methodology vs PSG
Future Directions: Prospective studies comparing CPC, device downloads, and polysomnography to define composite efficacy metrics and guide treatment adjustments.
STUDY OBJECTIVES: Positive Airway Pressure (PAP) therapy download reports are the currentobjective data standard for assessing sleep apnea treatment success, providing information onusage, leak, and residual apnea-hypopnea index (AHI). However, follow-up parallel testing can offer added value in measuring sleep and respiratory health in patients receiving PAP therapy. This study compares residual PAP-derived AHI (AHIFLOW) with cardiopulmonary coupling (CPC)-derived AHI3% (AHICPC). We specifically examined patients for whom PAP therapy would be considered effective, but follow-up testing indicated potentially significant residual disease. METHODS: As part of standard clinical care, patients in our telemedicine sleep program undergo longitudinal home sleep testing using CPC through the SleepImage system. We retrospectively analyzed remote physiological monitoring data from ResMed PAP devices and CPC-based sleep testing on nights with concomitant data. RESULTS: A total of 465 patients met the inclusion criteria, contributing 24,939 nights of matched PAP and CPC data. Mean AHIFLOW was 2.4 events/hour, while mean AHICPC was 12.1 events/hour. Among nights with AHIFLOW <5 events/hour, 85% of nights had AHICPC ≥5 events/hour, 47.7% had AHICPC ≥10 events/hour; 28.3% had ≥5 minutes with SpO2 <90%, and 10.6% had ≥5 minutes with SpO2 <88%. CONCLUSIONS: PAP download reports are useful for assessing usage and leak, but mayunderestimate residual respiratory burden. Besides periods of non-use, device-based flow-based metrics alone can miss clinically meaningful residual disease, including hypoxic events during REM sleep. Reliance on PAP-derived AHI as the sole efficacy metric risks overlooking persistent disease.