Everybody, welcome back to Palm Peeps.

Thanks for tuning in today.

Make sure to like and subscribe wherever you're listening to us and on any of the social media platforms you follow us on.

Monty, it's been a little live since we recorded.

Always love to be here.

You're on service right now, so you're busy bopping between things.

How are things going?

Hey, Ferf.

Yeah.

It's great.

Great to be back with you, and excited for another BMJ Thorax collaboration.

But, yeah, no.

Service is great.

Great time of the year.

Kind of still new new fellows to the system.

So it's always great to work with new trainees at this time of year, but excited to be back with you all.

We're thrilled to be bringing back our fourth collaboration with BMJ Thorax today.

And, as we have talked about before on prior episodes, Thorax is one of the leading journals in pulmonary and critical care medicine.

And as always, they continue to publish cutting edge science in PCCM, and we're excited to dive into one of their most recent journal clubs today.

Yeah.

This has been a great series.

I I think you guys have all enjoyed it.

It's been very popular.

We've certainly enjoyed collaborating with the folks at BMJ Thorax.

And, we're joined once more by doctor Christopher Turnbull.

He's the associate editor for education at Thorax.

He's a respiratory consultant and honorary researcher at Oxford University Hospitals with his work focusing on sleep related breathing disorders.

And Chris has really been sort of our go to expert on, understanding these articles, some of the implications, and some of the research techniques.

So, Chris, thank you again for joining.

It's always great to have you back on Palm Peeps.

Thanks very much.

Pleasure to be back with you today.

I'm really looking forward to getting stuck into today's episode.

Wonderful, Chris.

I know he's an honorary poem peeper for sure.

We'd like to go ahead and meet the author of the most recent journal club, who is doctor George Jumont.

George completed his medical school at the American University of Beirut and is now an internal medicine resident at UT Southwestern in his second year of training.

Prior to starting residency, George was up in Boston and was doing a research fellowship at MGH studying chronic lung disease.

George, so great to have you on the show today.

Welcome.

Thanks, Christina.

Very happy to be here on the show.

I'm a big fan of the podcast.

I'm really happy to be here and talk about this journal club.

Great.

And I think a a topic that I'm particularly interested in hearing more about is bronchiectasis, and I feel like that's the common theme, in the articles that you selected.

And I think this is really exciting.

Right, there's some new work in the field.

We're actually starting to see some novel therapies emerge for the first time, and I think it's important, right, to when we think about bronchiectasis as someone who does CF as myself, I think of bronchiectasis in the setting of CF a lot.

But I think today we're gonna talk about non CF bronchiectasis, which is exciting.

But, George, before we get into some of the specific article questions, I'd love if you could just share with us, your overarching goal in selecting these four articles.

Was there a common theme or educational value you were hoping to highlight by doing so?

Yeah.

For sure.

So my goal was to highlight both the exciting progress we're seeing in bronchiectasis and at the same time the challenges that remain.

The field is gaining a lot of traction as you just said, especially with the recent FDA approval and the first targeted therapy, which we'll be discussing today.

To capture that momentum, I chose two randomized trials and two large cohorts so we could look at novel therapeutics at the same time, look at some of the comorbidities and other real world outcomes.

So my goal is to highlight the multidimensional aspect and, move toward precision medicine that the field is witnessing at the moment.

That sounds great.

I think that is a really holistic way to sort of study this, and I'm excited to dive in and understand these trials a little bit better.

So let's talk about article one.

So this is bransokateb in bronchiectasis, the ASPEN trial.

Please don't correct me if I pronounce that small molecule wrong, but I think that is pretty close.

Bronchiectasis is something we all see in practice.

I think, in the non CF bronchiectasis world, like, when I'm seeing patient in general clinic, it can be a little bit of frustrating because we're often talking about prevention, area clearance, like, how to not make things worse, but we've had very few targeted therapies.

So this journal club and this article seems like a real time to delve into some upcoming therapies that may be coming out.

So specifically for this trial, I think it's important that we're highlighting for people that we're talking about DPP one inhibition.

That's not something that I'm generally very familiar with, but this is a mechanism of action targeting neutrophilic inflammation.

And that I am familiar with it.

We we've all sort of seen that.

If we've had to bronch these patients or if they come in with infections, then neutrophilic inflammation plays a central role in bronchiectasis pathophysiology.

So, George, can you walk us a little bit through the study design of this article?

Yes.

Sure thing.

So this was a phase three randomized double blind trial that enrolled one thousand seven hundred twenty one patients with non cystic fibrosis bronchiectasis across 35 countries, actually.

Participants were assigned to either once daily branzocatib at ten milligram or higher dose of twenty five milligram or placebo, and they were full for, fifty two weeks.

The primary end goal of this trial was the, annualized rate of pulmonary exacerbations with secondary outcomes like, time to first exacerbation, lung function decline, quality of life, and the safety of the new medication.

Awesome.

Thanks so much, George, for kind of setting the stage for this article.

I think one of the things that just struck me was the sheer scale of trial, as you said, with over 1,700 patients, which is, I think, quite impressive in a disease like bronchiectasis.

But also, managing a trial across 35 countries seems to be quite a huge undertaking.

And, Chris, I'm hoping that you can, comment a little bit on, you know, what strategies do you think the investigators used, to account for the site to site variability across the 35 countries?

And how much confidence should we have that the findings are going to be generalizable?

Thanks, Christina.

So I think the main way that the authors in this study tried to ensure that they balanced and, adjusted for regional variability was by stratified randomization.

So in depending on which region patients were recruited from, they stratified based on on that region.

So forty percent of the participants were from Europe, fifteen percent approximately from The USA, and and then forty percent from the rest of the world.

And and they stratified into the placebo or, men's socketive groups based on that factor.

That was also then included in their modeling, so they adjusted for that in their statistical models.

So I think that was pretty good in terms of making sure that the results are accounting for that geographic variability in the study.

I think in terms of the confidence that we have in the findings of this study, in terms of how generalizable it is, I'd go back to the CONSORT diagram.

And and, actually, they they screened two thousand two hundred and ninety six patients to recruit just over their one thousand seven hundred patients.

That's about seventy five percent of the patients they screened that they enrolled, which I think is suggests that this is pretty generalizable and applicable to the patients that we're seeing every day in our clinic.

Yeah.

Thank you so much, Chris.

That's great.

I love best practices for reading a journal article and, like, the CONSORT diagram as a place to look for generalizability, but also sources of bias is, I think, one of the key practices.

So if you're listening to this and you're trying to read studies and analyze on on your own, looking at that is always a a huge help.

And I love this trial.

I mean, as Christina, as you said, we I feel like we're cardiologists here.

1,700 patients, randomized control, placebo control.

Like, we're really gonna get some, good information out of this.

So, George, if you could highlight for us what were the key outcomes, and and how should we interpret them in the context of prior evidence?

The trial met its primary endpoint with both the higher dose and the lower dose reducing exacerbation rates compared to placebo.

Patients on bransocatib averaged about one exacerbation per year versus 1.3 in the placebo group corresponding to a rate ratio around 0.8.

Time to first exacerbation was also delayed, and nearly half of patients on treatment remained exacerbation free at the one year mark compared to forty percent of the, patients in the placebo arm.

Additionally, quality of life improved, and the higher the dose of presocatib showed smaller FEV one decline, twenty four milliliter versus sixty two milliliters with placebo.

So putting all of this together, it builds on the prior phase two data and positions presocatib as the first therapy with consistent evidence of benefit in bronchiectasis.

Great.

Thank you for walking us through that.

You know, as you mentioned, the exacerbation reduction is clinically meaningful, statistically meaningful.

You also mentioned this lung function decline, and I find these are always tough.

Right?

So you're talking about, a decline of 22 milliliters versus a decline of 64 milliliters.

When you think about that, how clinically significant is a difference like that in in PFT function?

Yeah.

I agree.

That absolute difference in FEV one decline was around 40 milliliters over a year, which is modest and probably not something patients would notice in isolation.

However, looking at it, it's consistent with the overall signal benefit.

If you combine it with the fewer exacerbations per year, the better quality of life, it adds to the case that ransukative is, modifying disease in a meaningful way, but I wouldn't think about it in isolation and especially would not discuss it with patient in isolation.

Yeah.

And it'll be interesting to see more long term follow-up because if it extends and it's 400 milliliters over ten years, that might be more meaningful at what or if it's fixed, after the the one year.

So be interested to see what their phase four and registry studies look like.

Yeah.

And I love that love that your aspect, George, too.

Right?

Just not taking it into isolation.

How do you put all of this in context when you're talking about patients who, you know, those with bronchiectasis are going to clinics.

They're probably hearing about this and gonna wanna be talking to their provider.

So how do we kind of put this into the context?

And I I really liked how you explained putting everything together.

And to go ahead and close our discussion on this first journal article, Chris, I have one more question for you.

What gaps and evidence do you still think need to be filled before Ren Sokatib could realistically, you know, actually become part of guideline based care moving forward?

Yeah.

Good question.

I think we've touched on this a little bit, already in in, Dave's previous comments, really.

I think that long term efficacy data will be important to see and looking perhaps at some of the other associated outcomes that we know are important in non CF bronchiectasis like cardiovascular outcomes, for example.

I think another area and gap that probably is worth highlighting was that whilst this study enrolled adolescent participants, their confidence interval for that group was very broad because they had very few participants in that group.

So I think that's an area I'd like to see more data on is really how how effective is this in adolescents.

Perhaps also things like in patients with the subgroups of having COPD or asthma, it would also be helpful to know whether this is more effective or whether they should have a biologic and look perhaps for some comparative data as what should we be choosing for those exacerbating patients in with other airways disease.

Great, Chris.

Yes.

I love that.

So many, additional opportunities to study this and yes.

But, really, I think exciting talking to, those faculty members here who do bronchiectasis.

I know they're very excited about the study and the, you know, potential implications it has.

So, we'll hear more in a potentially a future journal club, on more more studies that get done.

But we're gonna go ahead and turn our attention to article two, George, which you selected as the AIRLEAF trial, a phase two multicenter, randomized, double blind, placebo controlled study looking at a reversible kathepesin c inhibitor to determine its efficacy in reducing exacerbation risk among adults with bronchiectasis.

George, instead of, you know, trying to pick two different articles where Dave and I can't necessarily say the names of the medications, What drew you to highlight the paper for Journal Club, and how should we see this, in the context of bransokatib, which we just talked about and other evolving treatments in non CF bronchiectasis?

Yes.

So I wanted to highlight this trial, especially after the, bransukatib trial to show that the the pipeline for bronchiectasis is no longer limited to no agents or a single agent.

Bransukatib has been or has already made it to phase three and received FDA approval, but get the absence c inhibition represents a complementary approach to the same pathway of neutrophil inflammation that they was talking about earlier.

Even though AirLeap was smaller and a phase two trial, but, as you mentioned, Christina, it was rigorously designed, And it signals that multiple therapeutic strategies are moving forward, which is exciting for a disease that historically hasn't had any approved targeted treatments.

That's great.

Yeah.

I love that we're talking about multiple targets.

And if you can't say, you can just say BI1291583.

That rolls off the tongue very easily.

One thing that's interesting about this, and especially in the article analysis standpoint, is that it's a phase two.

Now phase twos are super important.

Phase one as well.

We're often used to reading the phase three trials that show up in sort of our largest journals.

But, reading a phase two and understanding it is a little bit different.

And so, for example, in this one, they use this model dose response analysis.

So in a phase three, you might have two doses of a drug and look at the efficacy.

This is sort of a a broader one.

And so, Chris, I was hoping you could walk us through what this means, a model dose response analysis, and how we should think about it.

Yeah.

So this is a really interesting design, in terms of how they looked at, the study.

And I think you you've highlighted the key reason as to why they did this, in in my opinion, was because this was a phase two study, so including multiple dosing regimens, rather than a phase three where you might have that data and selected the best dose to take forwards, although not necessarily as as we saw in the Bren Sockative study.

So what this modeling enabled them to do was to look and assess different dose relationships between, the drug and dose response relationships between the drug and the outcome, modeling as to whether those relationships were either linear or nonlinear and assess those in their statistical model across those different doses in the same model.

And that enables you to increase your statistical power and to look at an outcome point.

I think the you know, this is helpful for phase two studies where you got those multiple doses and allows you to then look at an outcome there, but I think it probably wouldn't be the the the design that you would take forwards in more definitive studies in the future.

Thanks so much, Chris.

I always enjoy these collaborations because we get to learn about, you know, four amazing articles, but I also like how you get you get to highlight different methods and data analysis that are used, which is I find, you know, particularly important as I'm hearing about this.

So thanks for sharing that.

George, wanna go back to you now and just you know, I'm hoping that you can tell us, this, as you said, was a regularly designed study, exciting, potentially new therapeutic.

What were the primary and secondary outcomes of the study, and what do you think was the most clinically important takeaway that you wanna share with listeners today?

Alright.

So the trial randomized three hundred twenty two patients across four arms, three different doses of BI one two nine one five eight three, and a placebo for up to forty eight weeks.

So the primary endpoint was time to first exacerbation.

And using the, model dose response analysis that Chris was talking about, they found a significant dose response relationship overall.

However, individually, the two point five milligram and the five milligram groups, which are the lower doses, showed a trend towards fewer exacerbations, but the results were not did not reach statistical significance compared to placebo.

Safety looked reassuring overall with skin related events, being the most common at higher doses.

So back to your question, Christina, I think the main clinical takeaway is that this drug class is promising.

However, we still need larger confirmatory trials before we move towards implementing this in guidelines or, talking about this with patients at all.

Agree, George.

Thanks so much, for saying that.

I think it's kind of right this this trending towards significance, which I think is important.

You just alluded to this, but I know this is kind of a common question or we get we're reading an article where it's not statistically significant, but looks promising, as I said, trending towards significance.

Would you feel comfortable at this time, you know, discussing this class of drugs with with patients that you may be seeing, or do you think it's still too early?

I I may be able to gauge your gauge your answer because of your last comment, but wanted to see if you could just, comment on, you know, how would you how would you respond if a patient asks you about this, if you're seeing them in clinic or in the hospital?

Yeah.

I'd say it's definitely too early to bring it up into routine clinical conversation outside of trials.

I think right now, bransoketev is the agent with the strongest evidence and the NFDA approval, while cathepsin c inhibition is, still very much in the early investigational stages.

But it's reassuring to patients to know that beyond Bransukative, there's a growing pipeline of therapies being studied that may, soon expand our options.

But at the moment, we're still limited with whatever, is is more advanced and ready for, prime time versus the therapeutics that are still in trial phases.

Yeah.

It makes sense to me for sure.

As as Christina alluded to, I think our dual purpose in this series is to both highlight really interesting articles that are promising or or practice changing in pulmonary and critical care medicine, but also to make people better at reading journal articles and then maybe better at conducting their own research, because we know that's an interest of our listeners.

So to that end, Chris, I was gonna ask you, this is a phase two as we've highlighted.

So maybe not ready for prime time as George just said.

You know, just giving us some information to go on.

So what was the the next follow-up trial design that would help us get to that more definitive answer of this is a a truly therapeutic and safe, clinical option for our patients.

Thanks.

So I think the next step for this agent, as we've all alluded to, is is a similar study to the branzocatib, study that we looked at first.

So a phase three multicenter randomized control trial, potentially just taking forwards the single dose which was most effective from this phase three and and doing that one to one against placebo.

They may potentially want to take forwards two of these doses and do one to one to one randomization.

The data that they've gotten from this study will be very helpful in informing the power calculation so that they get the appropriate sample size for that phase three study.

And I think that's absolutely what we need before we can definitively say whether this is gonna be an option for our patients.

Yeah.

Absolutely.

So we'll be on the lookout for that one.

You guys have to come back for another journal club in probably a few years.

We'll look at that study.

Alright.

Well, let's turn to the third study highlighted, George.

Now this is a article with about five year outcomes in bronchiectasis and nontuberculous mycobacterial infection.

The first two, as you said, were randomized controlled trials at different phases that we've discussed.

But I was hoping you can tell us about the study design and, cohort analysis utilized for this study.

Yeah.

So moving away from trials, this is a longitudinal analysis from the US bronchiectasis and NTM research registry.

This registry includes over two thousand six hundred patients with CT confirmed bronchiectasis.

About fifty nine percent of these patients had NTM identified at baseline, and they were followed up for five years to look at outcomes like mortality, lung function decline, exacerbations, and hospitalizations.

Thanks, George.

And, again, yeah, different cohort that was used.

I mean, I feel like, looking at CF, I've been able to benefit from using our national registry data, which has some positives as well as negatives, but obviously, still great to do and produce some fantastic research.

But, Chris, I'm hoping you can share a little bit.

When we're thinking about large registry, cohorts, what are some strengths and pitfalls that you see regarding using these registry data for longitudinal outcomes?

I mean, I think the registry data can be extremely helpful, can't it, in terms of helping us understand aspects of our care.

One of the real strengths of registry data is it's a potential way of leveraging very large sample sizes, so collecting large amounts of data from patients across different settings in in a country across across multiple countries.

That data is real world as well, rather than necessarily having inclusion exclusion criteria that you get in randomized control trials, which can mean that you cut down and make a less generalizable population.

There's the potential, as they have done in this study, to follow people up over a long long term basis, so to provide that real longitudinal data, which, is incredibly helpful.

I think then the pitfalls in, registries really come around how you set it up and then the quality of the data that you get going into that registry.

So are you relying on information from patient notes and retrospective data, or are you able to collect large amounts of prospective data with good data quality, for all of your outcomes?

I think another potential pitfall which registries can fall into is it's often difficult to determine whether the results represent cause or effect, and and that, when you're certainly looking at interventions, can be influenced by patient choice or clinician behavior.

And I think that's where we need our randomized control trials still to really tell us if an intervention is working.

And I guess you're you're finally, I've spoken about them being real worlds and generalizable, but that really depends on how good you are at getting a representative sample that you're collecting across your patients.

So how easy you make it to put people into the registry, how much resource you have to do that to enable you to have that generalizable real world data.

So true, Chris.

Thank you for commenting on all of those.

And I think as you as you mentioned, George, this purpose of this study was to look at five year outcomes in patients with bronchiectasis.

So I'm hoping that you can walk us through the key results of this study.

Yes.

So the primary outcome was the five year mortality, which was about twelve percent.

And interestingly, there was no significant differences between patients with and without NTM when comparing this five year mortality.

The predictors of mortality were more traditional, things like lower baseline FEV one, older age, male sex, and prior hospitalizations.

Lung function decline was similar across the groups as well with roughly 38 milliliters per year.

And while exacerbations, the hospitalization rates were stable overall.

Patients with baseline NTM actually had fewer exacerbations compared to those without, which, is surprising.

When you look at the literature, this is not usually the trend things are, but this study found that they had fewer exacerbations.

Joy, any thoughts about that?

Any thoughts about explanation of why that would be or any thoughts that the authors could sort of share?

One explanation is that since it's, registry, data, I think that they did not differentiate between NTM colonization versus active NTM disease, which can bias some of these findings.

The other thing, which was highlighted in the article was that maybe the actual diagnosis can trigger referral to specialized centers and so patients can get more holistic care or more more specialized care compared to, for example, a patient who does not have any NTM in their sputum or in their cultures.

So these are some of the explanations to these findings, in my opinion, the author's opinions.

Yeah.

Yeah.

That's really interesting.

Thinking about the referral and how you end up getting into the registry is a really interesting way and and sort of highlight some of the weaknesses and strengths, potentially that Chris was talking about.

Yeah.

And you mentioned this NTM colonization from active disease.

Such an interesting question in this cohort.

Right?

Because NTM is a risk factor for bronchitis.

Bronchitis is a risk factor for NTM.

You know, there's been a lot of debate about NTM treatment.

Chris, just curious if this adds any nuance or or other thoughts about how we think about that or apply these findings based on some of these limitations.

Yeah.

I mean, I think it I think it's difficult to really interpret this result, isn't it?

I think it's a challenging finding, and and it challenges conventional wisdom.

But I think, really, what you would want to know is what we've all been just speaking about is knowing that granularity of whether this really is this just a single isolate of, a particular type of NTM which is likely to be commensal rather than pathogenic?

Or or is this truly NTM disease, and NTM disease is some in some way protective here?

I'm not sure that is the case, and I think it's more is needed to understand what this result truly means.

But it's interesting in that it it goes against what we've perhaps all been taught.

Yeah.

Very more to come, but an interesting sort of hypothesis generated and finding for sure.

Yeah.

I know.

We'd be interested to see because I think a lot of people will probably have questions, right, of, like, how do we explain this to to patients?

How do we explain this kind of in the in the bronchiectasis community?

But I think, Mennel, this is kind of a great study, as we talked about, you know, pros and cons of using registry data.

But I think overall, it was interesting study and glad that you selected this one, George, for us to talk about.

But we'll go ahead and turn to our final journal article of the day, which is focused on the prevalence and impact of anxiety and depression in patients with bronchiectasis using the bronch UK national cohort.

George, why did you feel this study was important to feature?

And I guess my my follow-up question to you on that as well right now is, how do you think these findings might influence clinical practice or future research in bronchiectasis?

Yeah.

Thank you for that question.

So I I wanted to include this study because it reminds us that bronchiectasis, like other chronic respiratory diseases, are not just about infection, inflammation, and lung function.

Anxiety and depression are very common, and they're underrecognized, and they have real word impact on the outcomes of bronchiectasis.

Bringing mental health into the conversation can shift us to a more holistic model of bronchiectasis care.

And we can actually start doing that by screening, utilizing some of the short and quick questionnaires that we have, at our disposal in clinics like the PHQ and the GACC questionnaires so we can identify, anxiety and depression early on and, having pathways for referral to psychology, psychiatry, or any other needs that are readily available for, clinicians in in clinic to offer the best care possible and help patients feel that their care is more person centered versus just focusing on the lungs.

Yeah.

100%.

I feel like this is one of those interesting, and very important topics.

And when we're counseling patients, I feel like there's a lot of therapies that we can say will increase your six minute walk by this amount, but then, you know, the patient centered, how are you gonna feel about this?

How is your symptoms gonna be?

What's your quality of life?

It's something that's always a secondary, and we might not talk about as much.

So I'm really glad you're highlighting this.

You mentioned this is another cohort study.

We're using a a national cohort for this.

Cohort studies can be conducted and studied a little bit differently.

Just hoping you could walk us through the study design of this.

And was this just descriptive?

Were they looking trying to look at any timing of exposures?

How did they go about trying to describe this a bit further?

So, yeah, this cohort study actually had, one thousand three hundred forty adults with CT confirmed bronchiectasis.

It's the Bronch UK national cohort.

Anxiety and depression symptoms were measured using the, well validated hospital anxiety and depression scales.

And, the authors also looked at the outcomes including disease severity, quality of life, and out and exacerbation optimizations.

As you said, it's more descriptive versus the, previous study, which looked at five years outcomes.

This is more, focused on the anxiety and depression outcomes now.

That's great, Georgi.

And I'm hoping, yeah, if you wouldn't mind just extending a bit.

Yeah.

What were the rates of anxiety and depression, and how did they affect outcomes in this study?

Yeah.

So the, actually, the the authors found that one in three patients had clinically relevant anxiety and one in five had depression.

These rates were well above the general population.

And one notable feature in this paper was the substantial proportion of these patients who did not have any mental health diagnosis prior to enrolling, which was twenty six percent for the anxiety group and sixteen percent for depression.

This highlights the under recognition in routine care, especially when, as Dave was saying, we were focusing more on the six minute walk, the, FEV one, and, some of these comorbidities go unnoticed.

So patients with anxiety and depression also had worse quality of life scores.

They had more severe disease and more frequent exacerbations.

For example, patient with depression had a one point eight fold higher risk of hospitalization, and their first time to severe exacerbation was also shorter compared to patients without depression.

This highlights the clinical impact of mental health as we were talking about in the holistic care bronchiectasis.

Yeah.

Definitely not something for us to to forget about or take lightly at all.

And anxiety and depression is associated with lung diseases is not uncommon at all, certainly not isolated to bronchiectasis.

So, Chris, curious if you've seen, other interventions, in bronchiectasis or other respiratory diseases that have been successful or things that you think would be worth studying based on a result like this?

Yeah.

I think it's a really interesting result, isn't it?

I I guess one thing to say before coming on to that is, again, with the cohort studies, one of the challenges is that you're seeing anxiety and depression, which is linked to that increase in rates of hospital admissions, etcetera.

Now it's always hard to to tease out cause and effects in a cohort study and and you could argue it the other way around that those people who are have more severe disease and more likely to be admitted to hospital are more likely to have anxiety and depression associated with that.

It's very difficult to tease that apart.

Nevertheless, I think that does not detract from the important message that this is an incredibly important topic for us to tackle and and how we do that I think is a challenging question because of the the size of the scale of the problem finding in this study approximately a third of individuals who have, mental health, issues which are undiagnosed.

So I think my approach and what I'd like to see taken forwards would be whether there are things that can be done in the structured consultation within the bronchiectasis clinic that can help and improve this impact.

So are there, educational packages and training that can be delivered to staff who are already seeing these patients rather than us needing to refer all patients to psychiatry or psychologists for support.

I think that wouldn't be a sustainable model certainly within the NHS in in The UK.

So that will be my my goal would be, look, Are there things that we can do about education and talking to patients, perhaps cognitive behavioral therapy based approaches that can help and and and support this anxiety?

Of course, if you're doing that, you need to make sure that you are picking up those individuals who do need psychiatric and psychological support well, because some of them certainly will do.

But I think that if you were to refer simply refer everyone to psychology or psychiatry or to prescribe an antidepressant medication for these, I think that will be the wrong approach.

Yeah.

Absolutely.

Yeah.

We should we should get some shirts made up that are, say, Paul and Phips BMJ Thorax Association is not causation.

Right?

And then we can always take our lessons, but we can still certainly let it influence our practice.

And to that, we'll come to our final question of the day.

So, George, you know, you're you're training.

You're in residency.

You're in training.

You've done a lot of research on, respiratory diseases.

How does a study like this and that association practically influence you if you were in clinic and you were seeing a patient with bronchiectasis?

How do you think it practically should, influence the bronchiectasis care for these patients?

Yeah.

I think it, as Chris was saying, knowing about these comorbidities, knowing how, common they are, I think I would start screening more whether in clinic, whether, trying to implement some multidisciplinary approaches during the various care of patients, hospitalized patients, outpatient pay clinic visits.

I think I would start screening my patients more, and I would talk about I would have these conversations with them just to create a safe space to share, and to make sure that they realize that even though it's a lung predominant disease, it has effects on other functions.

And it has multiple comorbidities that we're not very familiar with and we don't talk often about.

I love that, George.

Thank you for for sharing that.

And, yeah, right with these chronic lung conditions, as you said, mental health is definitely important.

And, you know, you you nicely noted, you know, how can we expand from a multidisciplinary approach?

And I know sometimes social workers, mental health coordinators, are parts of chronic lung disease teams.

And I think one thing I'm doing in in clinic when I see CF patients too, because this is also prevalent in that population, and when I get to work with trainees, you know, I was like, yes.

My my initial questions may be focusing on lung, lung symptoms, looking at lung function.

I'll do extrapulmonary manifestations, but I told them I always end the day looking, at mental health and making sure that that gets incorporated into my day to day practice.

And to Chris, to your point, though, right, we can if we recognize that there may be additional assistance or if there's concern for for mental health, how to make sure that we are able to refer in those settings.

So we can identify a problem, but we need to be able to have a a plan going forward if we do feel that, someone needs any type of follow-up.

So I I love that kind of just practical approach that we can start doing, ourselves and then working with our multidisciplinary teams.

But, Georgie, pick four fantastic articles, I think really impactful, you know, from our initial one, cutting edge anti inflammatory drugs, to registries reframing outcomes, and the overlooked burden of mental health.

So thank you so much for the work, George, that you did on this.

And, Chris, as always, I know Dave and I really look forward to these collaborations and would just love if you wouldn't mind reminding listeners on how they may be able to work with you on a future journal club going forward.

Thanks.

Yeah.

So the the main focus of journal club, in within BMJ Thorax is to highlight four research articles from roughly the last twelve months, some high impact journals, just as George has done today.

And, they tend to focus on one topic.

So today, bronchiectasis, it could be a different area like sleep medicine, asthma, COPD, lung cancer, etcetera.

And if people are interested in contributing to that, they can, send me an email.

My email address is christopher.tamble@ouh.nhs.uk, and I'm sure we can put a link to that.

So please do get in touch if you're interested in taking part, and, I'll tell you more details.

Definitely.

Highly encourage it.

If you need some, suggestions or coming up, definitely reach out to Monty and I.

We're happy to to help and direct you over to Chris.

Thank you, George and Chris, for coming on and for your time, and and thank you all for listening.

This episode was written, produced, edited by myself and Christina Montemayor, music's original music by Eric Rogers, and we'll see you next time.