Rationale: Coronary artery disease (CAD) is a major cause of morbidity and mortality. Elevated coronary artery calcium (CAC) levels are common among individuals eligible for CT lung screening (CTLS), Agatston scores >400 indicate high CAD risk. Identifying CAC on CTLS offers an opportunity to detect high-risk individuals who may benefit from closer monitoring and targeted interventions. This study explored associations between Agatston scores >400, adverse outcomes and modifiable risk factors. Methods: This retrospective, multi-center CTLS cohort study included 4,673 patients from Lahey Hospital and Medical Center (LHMC) and 1,271 scans from Mount Auburn Hospital (MAH). Baseline scans (2012-2017 at LHMC; 2015-2019 at MAH) utilized the 4DMedical CAC algorithm to calculate Agatston scores. Follow-up extended through 2019 at LHMC and 2020 at MAH. A subset of 1,384 LHMC and 419 MAH patients with Agatston scores >400 and primary care within the health system were analyzed for risk factor modification and gender disparities. Chi-square tests examined group differences, and Cox proportional hazards models assessed associations with mortality, lung cancer incidence, and hospital admissions (all-cause, myocardial infarction, and congestive heart failure), with significance at p < 0.05. Results: Of the scans, 4,637 (99.2%) at LHMC and 1,251 (98.4%) at MAH successfully generated Agatston scores. A score >400 was associated with increased lung cancer risk at both LHMC (HR 2.11, CI 1.19-3.73, p = 0.01) and MAH (HR 1.75, CI 1.03-2.96, p = 0.037), and correlated with all-cause hospitalization at LHMC (HR 3.16, CI 1.43-6.99, p = 0.004) and MAH (HR 1.70, CI 1.17-2.48, p = 0.005). High scores were also linked to greater myocardial infarction events at LHMC (HR 2.8, CI 1.47-5.27, p = 0.002) and MAH (HR 2.8, CI 1.2-6.7, p = 0.017), as well as congestive heart failure admissions at LHMC (HR 1.99, CI 2.17-3.39, p = 0.011) and MAH (HR 7.87, CI 2.84-21.8, p < 0.001). Among those with Agatston scores >400, tobacco use was prevalent in 49% at LHMC and 58% at MAH. Elevated LDL (>100 mg/dL) was more common in women than men at both LHMC (55.2% vs. 40.25%, p < 0.001) and MAH (38.5% vs. 27.8%, p = 0.028). Conclusion: An Agatston score >400 on CTLS exams reliably indicates elevated risks for adverse outcomes. Targeted interventions, including smoking cessation and LDL management, are essential, with gender disparities in LDL among women warranting focused attention to improve outcomes in this high-risk group.

Rationale: Barriers to recognizing and treating acute respiratory distress syndrome (ARDS) exist. Prior studies have not investigated whether these barriers differ between academic and community settings or whether there were differences in critical care clinicians' reported ARDS management strategies during the coronavirus disease (COVID-19) pandemic. Objectives: Grounded in the Consolidated Framework for Implementation Research, we sought to determine whether there are differences between academic and community critical care clinicians in their team- and intensive care unit (ICU)-based culture; interprofessional communication; knowledge, attitudes, and perceived barriers to ARDS recognition and management; and ICU organization and ARDS management associated with the COVID-19 pandemic. Methods: Multidisciplinary survey from September 2020 to April 2021 of critical care physicians, nurses, advanced practice providers, and respiratory therapists (RTs) in six academic and nine community hospitals across the United States and Canada. Individual item and cumulative domain scores were compared between academic and community clinicians. Statistical adjustment was performed for multiple comparisons. Results: A total of 1,906 clinicians responded to at least one survey item (53% response rate). Mean (standard deviation [SD]) culture scores were higher for community physicians versus academic physicians (5.3 [1.8] vs. 4.4 [2.0]; P < 0.001) and community nurses versus academic nurses (4.4 [2.2] vs. 3.8 [2.1]; P = 0.007). Academic nurses and RTs had higher knowledge scores than community nurses and RTs (P < 0.001 for each comparison). Community physicians, nurses, and RTs reported higher mean (SD) number of changes in ICU organization and practice during the COVID-19 pandemic than academic clinicians (e.g., community physicians: 13.7 [2.7] changes vs. academic physicians: 11.8 [4.3] changes; P = 0.001). Although academic physicians, nurses, and RTs were approximately twice as likely to care for patients with ARDS daily or several days per week compared with community clinicians, ARDS management, attitudes, and belief in evidence was similar between academic and community clinicians in most respects. Conclusions: A large, multidisciplinary survey identified differences between academic and community critical care clinicians' culture and knowledge in the care of patients with ARDS. The COVID-19 pandemic had a greater impact on community ICU organization and ARDS management. Multifaceted implementation strategies should target implementation barriers differently in academic and community settings.

Background Lung cancer is the leading cause of cancer-related death in women. Lung cancer screening (LCS) uptake remains low despite clear scientific evidence of benefit and recommendations for screening from leading organizations. In a previous US study, 58% of LCS-eligible women reported having a mammogram within 2 years compared with only 7.9% who underwent LCS, suggesting an opportunity to improve LCS uptake. Study design and methods Mammography participants from November 2019 to December 2022 at two academic hospitals (site A and site B) were evaluated for potential LCS eligibility. Outreach was conducted to potentially eligible participants and referring providers to confirm eligibility and offer LCS. Women with metastatic malignancy or already enrolled in LCS were excluded. Historical enrollment rates at each site were used to predict successful implementation of enrollment strategies. Targeted outreach was performed for 12 months at each site. Results Of 32,165 mammography participants reviewed, 1,569 women (4.9%) were confirmed eligible with chart review for LCS and 1,089 of the 1,569 women (69%) had not previously undergone LCS. A significant increase in total LCS examinations among women during the study period was observed at both institutions. Baseline LCS scans in women increased from 12 and 28 scans per month at the two institutions, respectively, in the prestudy period to 18 and 38 scans per month during the study period (P = .0038 and .0125, respectively). There was no corresponding significant change in baseline LCS scans among men at either institution over the same time frame. Interpretation Identifying women eligible for LCS through screening mammography programs is an opportunity to increase lung screening enrollment. The tactics employed identified women eligible for LCS from the screening mammography population and demonstrated a significant increase in LCS examinations in women.

Rationale: The widespread adoption of low-dose-CT (LDCT) for lung cancer screening has created opportunities to identify undiagnosed interstitial lung disease (ILD) through finding interstitial lung abnormalities (ILA). ILA are frequently present, but often under-recognized, in these high-risk populations. ILA are associated with adverse clinical outcomes, including mortality and progression to ILD, underscoring the need for timely diagnosis. We investigated the association between a deep learning (DL)-based IQ-UIP classifier and Lung Texture Analysis (LTA) (4DMedical, Los Angeles) quantitative measurements for ILA and key outcomes: mortality; lung cancer incidence; and all-cause and pneumonia-related hospitalizations. Methods: This multicenter, retrospective cohort study included patients undergoing LDCT at Lahey Hospital and Medical Center (LHMC) (2012-2017) and Mt. Auburn Hospital (MAH) (2015-2017) per NCCN high-risk criteria for lung cancer screening. IQ-UIP and LTAwere utilized to generateIQUIP-high-riskand IQUIP-moderate-risk scores andhoneycombing and reticulation extent on LDCT. Follow-up through 2019 (LHMC) and 2020 (MAH) tracked key clinical outcomes. Cox proportional hazards models assessed associations between IQ-UIP and LTA for each outcome, adjusting for age, sex, BMI, smoking status/pack-years, with significance set at p<0.05 for associations that replicated in the MAH cohort. Results: Of 4673 scans at LHMC and 1271 at MAH, 4644 (99.4%) and 1253 (98.6%) were processed for IQ-UIP; and 3951 (84.5%) and 1253 (98.6%) for LTA, respectively. Mean age was 62.4 years (54.4% male) at LHMC and 64.3 years (49.5% male) at MAH. There were 11 and 5 IQ-high-risk; and 29 and 7 IQ-moderate-risk scans at LHMC and MAH, respectively. Hazard ratios (HRs) for mortality in LHMC and MAH cohorts were 11.0 and 12.54 for IQ-high-risk; 3.99 and 8.45 for IQ-moderate-risk; 4.37 and 1.73 for honeycombing, respectively. In LHMC cohort, IQ-high-risk (HR 6.72), IQ-moderate-risk (HR 3.61) and honeycombing (HR 5.30) were associated with lung cancer (MAH without association). Association with all-cause hospitalization was highest among LHMC IQ-high-risk (HR 5.90) and MAH IQ-moderate-risk patients (HR 4.32). Pneumonia-related hospitalizations showed the strongest associations: HRs in LHMC and MAH cohorts of 13.20 and 8.79 for IQ-high-risk; 4.99 and 6.99 for IQ-moderate-risk; 5.20 and 1.85 for honeycombing (Table#1). Conclusion: This study highlights the strong association between ILA identified by quantitative algorithms and pneumonia-related hospitalizations, suggesting that ILA are often misclassified as pneumonia, contributing to diagnostic delays in ILD. These results support the use of DL-based tools within lung screening programs to detect and classify ILA patterns, potentially enabling early diagnosis and appropriate intervention to reduce the clinical burden of undiagnosed ILD.

Rationale: Chronic obstructive pulmonary disease (COPD) and lung cancer are major causes of morbidity and mortality. The low attenuation area at -950 Hounsfield units (%LAA-950) on CT scans quantifies emphysema severity, with levels between 1-5% linked to higher mortality and cancer risk. However, its potential in predicting COPD-specific hospital admissions and guiding preventive measures remains understudied. This study aimed to identify a %LAA threshold corresponding to a two-fold hazard ratio (HR) for COPD hospitalizations, proposing that this could inform preventive care through accessible strategies, such as smoking cessation, vaccinations, and COPD screening. Methods: This retrospective, multi-center cohort study included patients from Lahey Hospital and Medical Center (LHMC) and Mount Auburn Hospital (MAH), eligible for CT lung screening (CTLS) per NCCN high-risk criteria. Baseline CTLS scans (2012-2017 at LHMC; 2015-2019 at MAH) were analyzed using the 4DMedical Lung Density Analysis (LDA) algorithm to generate global %LAA-950 scores. Follow-up through 2019 (LHMC) and 2020 (MAH) included assessments of mortality, lung cancer incidence, COPD hospitalizations, and clinical opportunities. Cox proportional hazards models evaluated associations between %LAA-950 thresholds and COPD admissions, adjusted for age, sex, BMI, smoking status, and pack-years (p<0.05 for significance). Results: At LHMC, 4,642 of 4,673 scans (99.3%) and, at MAH, 1,254 of 1,271 scans (98.7%) were successfully processed. The LHMC cohort had a mean age of 62.4 years (54.4% male, 94.3% white), and the MAH cohort averaged 64.3 years (49% male, 90% white). A 2% LAA threshold corresponded to a two-fold HR for COPD admissions: HR 2.03 (CI: 1.45-2.83, p < 0.001) at LHMC and HR 3.47 (CI: 1.93-6.24, p < 0.001) at MAH. Preventive care opportunities for these high-risk patients included: smoking cessation for 389 (45.0%) at LHMC and 44 (44%) at MAH; PCV13 vaccination review for 350 (41%) at LHMC and 27 (27%) at MAH; PCV23 review for 182 (21%) at LHMC and 42 (42%) at MAH; and PFT screening for 516 (60%) at LHMC and 30 (30%) at MAH. Table 1 details primary care and risk factor modification opportunities. Conclusion: The 2% LAA threshold is an effective marker for identifying patients at high risk of COPD admissions, presenting significant opportunities for preventive interventions. By incorporating this threshold into lung cancer screening, providers can target high-risk individuals for interventions that could reduce hospitalizations, healthcare costs, and disease burden. This study supports the 2% LAA threshold as a practical tool for early identification and management of at-risk patients.

Lung cancer is the leading cause of cancer-related death in women. Uptake remains low despite clear scientific evidence of benefit, a USPSTF recommendation for lung cancer screening (LCS) and multiple professional society guidelines recommending screening. In a recent U.S. study, 58% of LCS-eligible women reported undergoing screening mammography in the previous 2 years compared to only 7.9% who reported undergoing LCS. The success of screening mammography implementation is an opportunity to improve LCS uptake.

Background Pulmonary tuberculosis (TB) is a major source of global morbidity and mortality. Latent infection has enabled it to spread to a quarter of the world's population. The late 1980s and early 1990s saw an increase in the number of TB cases related to the HIV epidemic, and the spread of multidrug-resistant TB. Few studies have reported pulmonary TB mortality trends. Our study reports and compares trends in pulmonary TB mortality. Methods We utilized the World Health Organization (WHO) mortality database from 1985 through 2018 to analyze TB mortality using the International Classification of Diseases-10 codes. Based on the availability and quality of data, we investigated 33 countries including two countries from the Americas; 28 countries from Europe; and 3 countries from the Western Pacific region. Mortality rates were dichotomized by sex. We computed age-standardized death rates per 100,000 population using the world standard population. Time trends were investigated using joinpoint regression analysis. Results We observed a uniform decrease in mortality in all countries across the study period except the Republic of Moldova, which showed an increase in female mortality (+ 0.12 per 100,000 population). Among all countries, Lithuania had the greatest reduction in male mortality (-12) between 1993–2018, and Hungary had the greatest reduction in female mortality (-1.57) between 1985–2017. For males, Slovenia had the most rapid recent declining trend with an estimated annual percentage change (EAPC) of -47% (2003–2016), whereas Croatia showed the fastest increase (EAPC, + 25.0% [2015–2017]). For females, New Zealand had the most rapid declining trend (EAPC, -47.2% [1985–2015]), whereas Croatia showed a rapid increase (EAPC, + 24.9% [2014–2017]). Conclusions Pulmonary TB mortality is disproportionately higher among Central and Eastern European countries. This communicable disease cannot be eliminated from any one region without a global approach. Priority action areas include ensuring early diagnosis and successful treatment to the most vulnerable groups such as people of foreign origin from countries with a high burden of TB and incarcerated population. Incomplete reporting of TB-related epidemiological data to WHO excluded high-burden countries and limited our study to 33 countries only. Improvement in reporting is crucial to accurately identify changes in epidemiology, the effect of new treatments, and management approaches.

PURPOSE:Lung cancer is the leading cause of cancer-related death in women.Despite clear evidence of benefit, multiple society recommendations and a USPSTF recommendation for lung cancer screening (LCS), uptake remains low.A recent study reported that nearly 70% of women who completed colon or breast cancer screening and were eligible for LCS had not been screened.The success of mammography implementation offers a unique opportunity to improve the uptake of lung screening for women who are screened for breast cancer.This American Cancer Society/National Lung Cancer Roundtable supported study was conducted to increase the uptake of LCS among breast cancer screening participants. METHODS:Mammogram participants from November 2019 -December 2022 in two academic hospitals were evaluated for potential eligibility for LCS.Electronic health record reports, outreach to primary care providers, advertisements and surveys completed at the time of mammography were utilized to identify eligible participants.Outreach was conducted to potentially eligible participants and/or referring providers to confirm eligibility and offer LCS.Women with metastatic malignancy or who were already enrolled in LCS were excluded. RESULTS:We reviewed 32,165 mammogram participants during the study period.Of those, 1,569 women were determined to be eligible for LCS and 1,089 (69%) of those had not previously been referred.After identification of potential LCS eligibility, patients and/or referring providers were notified.A significant increase in total LCS exams (annual + baseline) among women during the study period at both institutions was observed.Baseline LCS scans among women at the two institutions increased from 12 and 28 scans/month in the pre-study period to 18 and 38 scans/month during the study period (p value 0.0038 and 0.0125 respectively).There was not a corresponding significant change in baseline scans among men at either institution, increasing only from 16 to 17 scans/month and 32 to 36 scans/month (p¼0.3089 and 0.1228 respectively).CONCLUSIONS: To improve early diagnosis and reduce mortality, it is imperative to identify mechanisms to increase LCS uptake.This study demonstrated a significant increase in LCS enrollment among women scheduled for screening mammography during the intervention period using targeted outreach with no significant change among men.Though the expanded 2021 United States Preventive Services Task Force LCS guidelines could have confounded the data, the stability of the male enrollment acting as a control, indicates that the observed increase among female patients can be attributed to the study intervention.CLINICAL IMPLICATIONS: Identifying potential LCS participants through current cancer screening programs, including mammography, offers a pathway for improved awareness and uptake of LCS in people who are already demonstrating screening behaviors.

Hereditary Breast and Ovarian Cancer (HBOC) and Lynch Syndrome (LS) are the most common inherited cancer syndromes identified with genetic testing. Testing, though, commonly reveals variants of uncertain significance (VUSs). This is a retrospective observational study designed to determine the prevalence of pathogenic mutations and VUSs in patients tested for HBOC and/or LS and to explore the characteristics of the VUS population. Patients 18-80 years old that met NCCN criteria for HBOC and/or LS genetic screening were tested between 2006 and 2020 at Mount Auburn Hospital in Cambridge, Massachusetts. A total of 663 patients were included in the study, with a mean age of 50 years old and 90% being females. Pathogenic mutations were identified in 12.5% and VUSs in 28.3%. VUS prevalence was associated with race (p-value = 0.019), being particularly higher in Asian populations. Patients with a personal history of breast cancer or family history of breast or ovarian cancer were more likely to have a VUS (personal breast: OR: 1.55; CI: 1.08-2.25; family breast: OR: 1.68; CI: 1.08-2.60, family ovarian OR: 2.29; CI: 1.04-5.45). In conclusion, VUSs appear to be detected in almost one third patients tested for cancer genetic syndromes, and thus future work is warranted to determine their significance in cancer development.

CASE PRESENTATION: A 54-year-old South African man with a medical history of type 2 diabetes mellitus, seizure disorder, OSA, and latent TB presented to the ER with gradually progressive dyspnea over months. He also reported occasional dry cough and fatigue at presentation but denied fever, chills, chest pain, leg swelling, palpitations, or lightheadedness. He was treated with a course of levofloxacin for presumed community-acquired pneumonia as an outpatient without improvement and had tested negative for COVID-19. He denied occupational or environmental exposures or sick contacts, though he had traveled back to South Africa 1 year before presentation. He had complex partial seizures for the past 22 years, which had been well controlled on phenytoin (300 mg daily). His other home medications included dulaglutide, sertraline, and atorvastatin and had no recent changes. He quit smoking 30 years ago after smoking one pack per day for 10 years.

Abstract Introduction Pulmonary tuberculosis (TB) is a major source of global mortality and morbidity, particularly in the developing world. Latent infection has enabled it to spread to approximately a quarter of the world's population. The late 1980s and early 1990s saw an increase in the number of reported TB cases related to the HIV epidemic and immigration, as well as the spread of multidrug-resistant TB (MDR TB). Few studies have reported pulmonary TB mortality trends. Our study reports and compares trends in pulmonary TB mortality between 1985 and 2018 in countries throughout the world. Methods We utilized the World Health Organization (WHO) mortality database to extract TB mortality data based on the International Classification of Diseases (ICD) 10 system. Based on the availability and quality of data, we included Canada and the United States (US) from the Americas; Austria, Belgium, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Israel, Italy, Latvia, Lithuania, Netherlands, Poland, Portugal, Republic of Moldova, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, and United Kingdom from Europe; Australia, New Zealand, and Japan from the Western Pacific region. Crude mortality rates were dichotomized by sex and reported by year. We computed age standardized death rates (ASRDs) per 100,000 population using the world standard population. Pulmonary TB mortality trends were examined using Joinpoint regression analysis and reported using estimated annual percentage changes (EAPCs). Results We observed a decrease in mortality in males and females in all countries except the Republic of Moldova, which showed an increase in female mortality (+0.12%). Among all countries, Lithuania had the greatest reduction in male mortality (-12.01%) between 1993-2018, and Hungary had the greatest reduction in female mortality (-1.57%) between 1985-2017. Male mortality declined at a steady rate across the study period. Slovenia had the most rapid recent declining trend for males with an EAPC of -47% (2003-2016), followed by Australia (-33.6%, 2014-2017), whereas Croatia and Austria showed an increase in EAPC of +25.0% (2015-2017) and +17.8% (2010-2014), respectively. For females, New Zealand had the most rapid recent declining trend (-47.2%, 1985-2015), followed by Hungary (-35.1%, 2004-2007), whereas Croatia showed an increase in EAPC (+24.9%, 2014-2017). Conclusion Pulmonary TB mortality is disproportionately higher among Central and Eastern European countries. This communicable disease cannot be eliminated from any one region without a global approach. Priority action areas include ensuring early diagnosis and appropriate treatment to the most vulnerable groups. In low- and middle-income countries with high TB incidence, attenuation of socioeconomic determinants including extreme poverty, inadequate living conditions, and malnutrition remains crucial.

Objectives Intracerebral Hemorrhage (ICH) accounts for 10% of strokes annually in the United States (US). Up-to-date trends in disease burden and regional variations remain unknown. Our study reports updated trends of ICH incidence, mortality, and mortality to incidence ratio (MIR) across the US. Materials and Methods Observational study to evaluate the incidence and mortality from ICH across the US. Data was obtained from Global Burden of Disease (GBD) database. Age-Standardized Incidence (ASIRs) and Death (ASDRs) Rates, as well as the Mortality- to-Incidence ratios (MIRs) for ICH in the US overall and state-wise from 1990-2017. Joinpoint regression analysis was used, with presentation of estimated annual percentage changes (EAPCs). Results Overall decrease in ASIRs, ASDRs, and MIRs in the US for both sexes. The 2017 mean ASIR was 25.67/100,000 for men and 19.17/100,000 for women, whereas mean ASDR was 13.96/100,000 for men and 11.35/100,000 for women. District of Columbia had greatest decreases in ASIR EAPCs for both men and women at -41.25% and -40.58%, respectively, and greatest decreases in ASDR EAPCs for men and women at -55.38% and -48.51%, respectively. MIR between 1990-2017 decreased in men by -12.12% and women by -7.43%. MIR increased in men from 2014-2017 (EAPC +2.2%) and in women from 2011-2017 (EAPC +1.0%). Conclusion Decreasing trends in incidence, mortality, and MIR. No significant trends in mortality were found in the last 6 years of the study period. MIR worsened in males from 2014-2017 and females from 2011-2017, suggesting decreased ICH-related survival lately.

BACKGROUND:Inadequate follow-up of suspicious lung nodules can result in diagnostic delays and potential progression to advanced lung cancer. In 2015, a multidisciplinary lung nodule management program, Nodule Net, was implemented to increase the timely follow-up rate. In this study, we sought to evaluate the effectiveness of the program.METHODS:2398 chest CT reports were reviewed for the presence of a lung nodule. Baseline demographics, nodule characteristics, and follow-up recommendations were collected. For reports that did not include structured recommendations, Fleischner Society guidelines were applied if appropriate. The rate of follow-up imaging was recorded and compared with historical rates.RESULTS:Lung nodules were reported on 1367 (57%) of scans. Of the 632 participants with recommendations for follow-up, the Nodule Net nurse navigator was notified on 523 (83%). Of these, 408 (78%) completed follow-up, compared to 57/109 (52%) in those who were not reported to Nodule Net tracking system (risk ratio: 1.49, 95% CI: 1.24-1.79, p-value < 0.05). Out of these 408, nodule net outreach was required to prompt the follow-up in 116 (28%). Of these, a lung malignancy was diagnosed in 4 (4%).CONCLUSIONS:Management of lung nodules is a complex process. Implementation of a lung nodule tracking program led to a significant increase in the completion of recommended follow-up imaging compared with usual care. Developing a comprehensive lung nodule program using an automated software system rather than manual processes to refer and track incidental findings may further reduce barriers to completion of follow-up.

Platypnea-orthodeoxia syndrome (POS) is an underdiagnosed clinical syndrome characterized by dyspnea (platypnea) and hypoxemia (orthodeoxia) in the upright position that resolves when recumbent. POS is often due to an underlying right-to-left shunt. Four broad mechanisms for the shunt have been described: intracardiac shunts, intrapulmonary shunts, hepatopulmonary syndrome, and pulmonary ventilation-perfusion mismatch. A 68-year-old male with a past medical history of chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, ascending aortic dilation (3.9 cm), myelofibrosis, and status post stem cell transplant complicated by graft versus host disease was found hypoxemic (oxygen saturation: 82%) on routine visit prompting hospitalization. Hypoxemia initially responded to 40% FiO2 but subsequently progressed to refractory hypoxemia on 100% FiO2. A chest computed tomography (CT) scan showed evidence of multiple segmental pulmonary emboli with patent central pulmonary arteries. Hypoxemia out of proportion to pulmonary embolism clot burden and examination findings consistent with orthodeoxia prompted further investigations. Nuclear medicine scan showed radiotracer activity in both brain and kidneys consistent with a small right-to-left shunt (5.9%). Transesophageal echocardiography (TEE) revealed a patent foramen ovale (PFO) with a right-to-left shunt across the atrial septum, with a maximum opening of 3.5 mm and tunnel length of 25 mm. Right heart catheterization (RHC) is consistent with the right-to-left shunt and normal right heart pressures. The degree of the shunt was not significant enough to explain the degree of hypoxemia, but all the diagnostic studies were performed in a supine position, possibly underestimating the degree of the shunt. PFO closure with transcatheter 30-mm Gore device (GORE® CARDIOFORM, Arizona, USA) decreased supplemental oxygen requirement from 75% high-flow nasal cannula (NC) to room air (RA) immediately after the procedure. The patient was subsequently discharged home on a baseline oxygen requirement of 2 L NC at nighttime. POS should be suspected when a patient develops severe hypoxemia after changing from a recumbent position to a sitting or standing position. The identification and correction of the shunting or mismatch often allow complete resolution of POS. Transthoracic echocardiography with agitated saline, TEE, and RHC are the diagnosis modalities of choice. Left heart cardiac catheterization remains the gold standard, which would demonstrate a mismatch in oxygen saturation between the pulmonary vein and the aorta. Our patient’s PFO was successfully closed by a percutaneous transcatheter closure device leading to the complete resolution of hypoxemia immediately.

1564 Background: Inadequate follow-up of suspicious lung nodules can result in a delay in diagnosis and potential progression to advanced staged lung cancer. A multidisciplinary lung nodule program entitled "Nodule Net" was implemented in 2017 to provide a safety net, increase the rate of follow-up, streamline management. The program consisted of a multidisciplinary team with EMR notification by the radiologist to a centralized nurse navigator for inclusion in a follow-up database, outreach with reminders to the primary care provider if follow-up was not completed, and referral for management where appropriate. In this study, we sought to evaluate program effectiveness in tracking and rate of follow-up imaging of suspicious pulmonary nodules. Methods: 2,398 chest CT scans were reviewed between January and May 2018 for the presence of a lung nodule that required follow-up. Nodules known to be inflammatory or associated with a metastatic malignancy were excluded. Baseline demographics, medical history, primary care affiliation, type of imaging scan, nodule characteristics, and presence and specifics of follow-up recommendations were collected. For reports that did not include a follow-up recommendation, Fleischner’s recommendations were applied or an independent pulmonologist’s review was completed. The rate of follow-up imaging was recorded and compared with historical rates prior to Nodule Net implementation. Prevalence ratios were generated for each comparison. Results: 1,367 (57%) reported lung nodules. Recommendations for follow-up imaging were recorded in 632 (46.2%), and 523 (82.8%) of these were reported to the program navigator. The rate of follow-up completion of those referred to the program was significantly higher [408 (78%)] than standard of care prior to program implementation [442/1202 (36.8%), (2.90, 95% CI: 2.65-3.18)]. Out of 408 patients who completed follow-up, nodule net outreach was required in 116 (28.4%). Of these 116, malignancy was identified in 4/116 (3.4%). Increased nodule size requiring referral was identified in 17 (14.7%). Out of 109 who were not transmitted to the program navigator and not present in the database, 57 (52.3%) had completed the recommended follow-up compared with 78% among those referred (1.49, 95% CI:1.23-1.79). Conclusions: Management of lung nodules is a complex process with poor follow-up completion reported in prior studies (29%-33%). Implementation of a multidisciplinary lung nodule care program for tracking lung nodules led to a significant increase in completion of recommended follow-up imaging. Developing a comprehensive lung nodule management program using software and navigation may further enhance detection, reduce human errors, augment the necessary follow-up for suspicious lung nodules, and ultimately the prevalence of advanced stage lung cancer.

e22506 Background: Genetic testing allows for enhanced prognostication and early intervention in patients with high risk of developing cancer. Genetic testing often reveals variants of uncertain significance (VUS), for which association with disease risk is unclear. The ambiguity of this finding creates a dilemma for patients and providers and has been associated with significant communication error and distress. In this retrospective observational study, we seek to characterize the indications, outcomes, and trends in patients undergoing genetic testing in a community hospital in Cambridge, MA. As our study spanned the beginning of the COVID-19 pandemic, we also assessed its impact on care accessibility. Methods: We included patients undergoing genetic testing at our hospital between December 2019 and October 2020 (n=371). Medical charts were abstracted to identify patient characteristics, family history, indication for genetic testing, genetic findings, and subsequent management. Results: Our population had a mean age of 48 years (SD=15), was predominantly female (88.1%), and had a high proportion of Ashkenazi Jewish descent (15.3%). The vast majority (351, 94.6%) had a family history of cancer, while 123 (33.2%) had a personal history of cancer, most commonly breast (n=89). The most common indications for genetic testing were Hereditary Breast and Ovarian Cancer (HBOC in 280, 75%), Lynch Syndrome (LS in 22, 5.9%), and Familial Adenomatous Polyposis (FAP in 7, 2%). Of patients who met HBOC, LS, or FAP criteria for genetic testing, pathogenic mutations were identified in 9.5% and VUS in 28.6%. Out of total 35 (9.4%) pathogenic mutations found in our entire study population, the most common were in BRCA (9, 25.7%), MUTYH (5, 14.2%), and Lynch genes (3, 8.6%). Out of 103 patients with VUS (27.8%), the most common sites were APC (14) and MSH3 (9). We found no significant trend in genetic counseling consultations over our 11 months study period despite the COVID-19 pandemic (R2 = 0.006). Conclusions: Among patients who met criteria for genetic cancer screening at a community hospital, 9.5% were found to have a pathogenic mutation while 28.6% were found to have VUS. These numbers are comparable to previously published estimates. Despite advances in our understanding of genetic colon and gynecological cancers, the majority of patients presenting for genetic cancer counseling continue to do so due to breast cancer concerns. Lastly, we noted high efficacy in our conversion of in-person genetics consultations to telemedicine during the COVID-19 pandemic, suggesting telemedicine is a robust format for genetic counselling. Mutations (N): BRCA1 (3), BRCA2 (6); MUTHY (5); MSH2 (2), MSH6 (1); ATM (2), and one each in PALB2, RAD50, RAD51C, RAD51D, Tp53, CDKN2A, APC, F2, SDHA, SDHB, VHL. FANCL, NTHL1.

Background: In the United States, 9 to 10 million Americans are estimated to be eligible for computed tomographic lung cancer screening (CTLS). Those meeting criteria for CTLS are at high-risk for numerous cardiopulmonary co-morbidities. The objective of this study was to determine the association between qualitative emphysema identified on screening CTs and risk for hospital admission. Study design and Methods: We conducted a retrospective multicenter study from two CTLS cohorts: Lahey Hospital and Medical Center (LHMC) CTLS program, Burlington, MA and Mount Auburn Hospital (MAH) CTLS program, Cambridge, MA. CTLS exams were qualitatively scored by radiologists at time of screening for presence of emphysema. Multivariable Cox regression models were used to evaluate the association between CT qualitative emphysema and all-cause, COPD-related, and pneumonia-related hospital admission. Results: We included 4673 participants from the LHMC cohort and 915 from the MAH cohort. 57% and 51.9% of the LHMC and MAH cohorts had presence of CT emphysema, respectively. In the LHMC cohort, the presence of emphysema was associated with all-cause hospital admission (HR 1.15, CI 1.07-1.23; p < 0.001) and COPD-related admission (HR 1.64; 95% CI 1.14-2.36; p = 0.007), but not with pneumonia-related admission (HR 1.52; 95% CI 1.27-1.83; p < 0.001). In the MAH cohort, the presence of emphysema was only associated with COPD-related admission (HR 2.05; 95% CI 1.07-3.95; p = 0.031). Conclusion: Qualitative CT assessment of emphysema is associated with COPD-related hospital admission in a CTLS population. Identification of emphysema on CLTS exams may provide an opportunity for prevention and early intervention to reduce admission risk.

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: Pulmonary tuberculosis is common and has infected one-fourth of the population globally with peak incidence and mortality rates in the 1990s due to the HIV/AIDS epidemic, immigration, and the spread of multidrug-resistant TB (MDR TB). Few studies have reported pulmonary TB mortality trends. Our study reports and compares trends in pulmonary TB mortality between 1985 and 2018. METHODS: We utilized the World Health Organization (WHO) Mortality Database to extract Pulmonary TB mortality data based on the ICD 10 system. Based on the availability and quality of data region-wise, we included Canada and the USA from the Americas; Austria, Belgium, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Israel, Italy, Latvia, Lithuania, Netherlands, Poland, Portugal, Republic of Moldova, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, and United Kingdom from Europe; Australia, New Zealand, and Japan from Western Pacific region. Crude mortality rates were dichotomized by sex and reported by year. We computed Age Standardized Death Rates (ASDRs) per 100,000 population using the World Standard Population. Pulmonary Tuberculosis mortality trends were compared using Joinpoint regression analysis and reported using Estimated Annual Percentage Changes (EAPCs). RESULTS: Overall, in all 33 countries studied, we observed a decrease in mortality in both males and females except the Republic of Moldova, which showed an increase in females' mortality (0.12). Among all countries, Lithuania had the largest negative Percentage Change (PC) in male mortality (-12.01) between 1993-2018, and Hungary had the largest negative PC in female mortality (-1.57) between 1985-2017. Male mortality declined at a steady rate across the study period. Slovenia had the most rapid recent mortality decline for males with an EAPC of -47% (2003-2016), followed by Australia (-33.6%, 2014-2017), whereas Croatia and Austria showed an increase in EAPC of 25.0% (2015-2017) and, 17.8% (2010-2014) respectively. For females, New Zealand showed the most rapid recent mortality decline (-47.2%, 1985-2015), followed by Hungary (-35.1%, 2004-2007), whereas Croatia showed an increase in EAPC (24.9%, 2014-2017). CONCLUSIONS: Pulmonary TB mortality is disproportionately higher among Central and Eastern European countries. CLINICAL IMPLICATIONS: This contagious disease cannot be eliminated from any one region without a global approach. Priority action areas include ensuring early diagnosis and appropriate treatment to the most vulnerable groups. In low- and middle-income countries with high TB incidence, attenuation of socioeconomic determinants including extreme poverty, inadequate living conditions, and malnutrition remains crucial. DISCLOSURES: No relevant relationships by Chinmay Jani, source=Web Response No relevant relationships by Dominic Marshall, source=Web Response no disclosure on file for Omar Omari; No relevant relationships by Arashdeep Rupal, source=Web Response No relevant relationships by Justin Salciccioli, source=Web Response No relevant relationships by Joseph Shalhoub, source=Web Response No relevant relationships by Harpreet Singh, source=Web Response no disclosure on file for Carey Thomson; no disclosure on file for ALEXANDER WALKER