Analysis of longitudinal changes in the psychological status of patients with asthma

Significant relationships between the psychological status and poor asthma outcomes are often reported. However, most of these studies are cross-sectional and none have evaluated how the psychological status progresses over time during the management of asthma patients. Therefore, we examined the longitudinal changes in the psychological status of asthma patients, and compared them with changes in other clinical measurements. Eighty-seven outpatients with stable asthma after 6 months of treatment were enrolled in this study. The psychological status was evaluated using the Hospital Anxiety and Depression Scale (HADS), the health status using the Asthma Quality of Life Questionnaire (AQLQ) and the St. George's Respiratory Questionnaire (SGRQ). The patient's pulmonary function, peak expiratory flow values and airway hyperresponsiveness were measured at entry and every year thereafter over a 5-year period. Using mixed effects models to estimate the slopes, the HADS anxiety and depression scores did not change significantly over time (p=0.71 and 0.72, respectively). The changes in the HADS scores correlated noticeably with changes in the AQLQ and SGRQ scores, but not with changes in the physiological measurements. The baseline HADS anxiety and depression scores were significantly correlated to the subsequent annual changes in each measurement. The psychological status remained clinically stable over the 5-year study period in patients with stable asthma. Changes in the psychological status were significantly correlated to changes in the health status. The baseline HADS scores were a useful indicator in detecting patients who would show subsequent deterioration in their psychological status.

Longitudinal deteriorations in patient reported outcomes in patients with COPD

Goals of effective management of patients with chronic obstructive pulmonary disease (COPD) include relieving their symptoms and improving their health status. We examined how such patient reported outcomes would change longitudinally in comparison to physiological outcomes in COPD. One hundred thirty-seven male outpatients with stable COPD were recruited for the study. The subjects health status was evaluated using the St. George's Respiratory Questionnaire (SGRQ) and the Chronic Respiratory Disease Questionnaire (CRQ). Their dyspnoea using the modified Medical Research Council (MRC) scale and their psychological status using the Hospital Anxiety and Depression Scale (HADS) were assessed upon entry and every 6 months thereafter over a 5-year period. Pulmonary function and exercise capacity as evaluated by peak oxygen uptake (VO2) on progressive cycle ergometry were also followed over the same time. Using mixed effects models to estimate the slopes for the changes, scores on the SGRQ, the CRQ, the MRC and the HADS worsened in a statistically significant manner over time. However, changes only weakly correlated with changes in forced expiratory volume in 1s (FEV(1)) and peak (VO2). We demonstrated that although changes in pulmonary function and exercise capacity are well known in patients with COPD, patient reported outcomes such as health status, dyspnoea and psychological status also deteriorated significantly over time. In addition, deteriorations in patient reported outcomes only weakly correlated to changes in physiological indices. To capture the overall deterioration of COPD from the subjective viewpoints of the patients, patient reported outcomes should be followed separately from physiological outcomes.

Dyspnoea with activities of daily living versus peak dyspnoea during exercise in male patients with COPD

Dyspnoea measurements in chronic obstructive pulmonary disease (COPD) can be broadly divided into two categories: those that assess breathlessness during exercise, and those that assess breathlessness during daily activities. We investigated the relationships between dyspnoea at the end of exercise and during daily activities with clinical measurements and mortality in COPD patients. We examined 143 male outpatients with moderate to very severe COPD. The peak Borg score at the end of progressive cycle ergometry was used for the assessment of peak dyspnoea rating during exercise, and the Baseline Dyspnea Index (BDI) score was used for dyspnoea with activities of daily living. Relationships between these dyspnoea ratings with other clinical measurements of pulmonary function, exercise indices, health status and psychological status were then investigated. In addition, their relationship with the 5-year mortality of COPD patients was also analyzed to examine their predictive ability. Although the BDI score was significantly correlated with airflow limitation, diffusing capacity, exercise indices, health status and psychological status, the Borg score at the end of exercise had non-existent or only weak correlations with them. The BDI score was strongly significantly correlated with mortality, whereas the Borg score was not. Dyspnoea during daily activities was more significantly correlated with objective and subjective measurements of COPD than dyspnoea at the end of exercise. In addition, the former was more predictive of mortality. Dyspnoea with activities of daily living is considered to be a better measurement for evaluating the disease severity of COPD than peak dyspnoea during exercise.

Matrix metalloproteinase-9 promoter polymorphism associated with upper lung dominant emphysema

RATIONALE

Matrix metalloproteinase 9 (MMP-9) has proteolytic activity against connective tissue proteins and appears to play an important role in the development of chronic obstructive pulmonary disease (COPD). The functional polymorphism of MMP-9 (C-1562T) is considered as one of the candidate genes in the susceptibility to COPD.

OBJECTIVES

To determine if MMP-9 (C-1562T) is related to the development of COPD in the Japanese population and whether it is associated with development of pulmonary emphysema assessed by high-resolution computed tomographic (HRCT) parameters.

METHODS

MMP-9 (C-1562T) genotypes of 84 patients with COPD and 85 healthy smokers (control subjects) were determined by the restriction fragment length polymorphism method. We investigated the relationship between the genotypes using automatically analyzed HRCT parameters, such as percentage of low attenuation area (LAA%) and average computed tomography (CT) value density (Hounsfield units; mean CTv) in upper, middle, and lower lung fields in all patients with COPD.

MEASUREMENTS AND MAIN RESULTS

There was no difference in polymorphism of MMP-9 (C-1562T) between patients with COPD and control subjects. In the HRCT study, patients with COPD with a T allele (C/T or T/T) showed larger LAA% (95% confidence interval of difference, 0.5-18.7; p = 0.04), and smaller mean CTv (confidence interval, -34.3 to -1.0; p = 0.04) in the upper lung compared with patients without T alleles (C/C). However, pulmonary function tests showed no difference between the two patient groups. Patients with a T allele showed a decrease in LAA% and an increase in mean CTv from upper to lower lung fields (p = 0.006 and p = 0.002, respectively).

CONCLUSIONS

Polymorphism of MMP-9 (C-1562T) was associated with upper lung dominant emphysema in patients with COPD.

Exercise Capacity Deterioration in Patients With COPD

BACKGROUND

Although exercise capacity is an important outcome measure in patients with COPD, its longitudinal course has not been analyzed in comparison to the change in pulmonary function.

PURPOSES

To examine how exercise capacity would deteriorate over time in patients with COPD, and what factors would contribute to it.

METHODS

A total of 137 male outpatients with moderate-to-very-severe COPD were examined. The average age was 69.0 +/- 6.6 years (+/- SD), and the mean postbronchodilator FEV(1) was 45.9 +/- 15.4% predicted. Progressive cycle ergometry and pulmonary function testing were performed at entry, and every 6 months thereafter over 5 years. Due to the presence of missing data, a mixed-effect model analysis was then used to estimate the longitudinal changes in various clinical parameters.

RESULTS

Peak oxygen uptake (Vo(2)), peak minute ventilation (Ve), and peak tidal volume (Vt) during exercise declined significantly over time (p < 0.0001), which was no less rapid than the deterioration in FEV(1). The mean decline rates for peak Vo(2) were 32 +/- 60 mL/min/yr and 0.5 +/- 1.0 mL/min/kg/yr. Multiple regression analysis revealed that the changes in peak Ve, peak Vt, and peak respiratory rates were significant predictors for the change in peak Vo(2).

CONCLUSION

We demonstrated clear evidence of measurable and progressive deterioration in exercise capacity in COPD patients, which was no less rapid than the decline in airflow limitation. Dynamic ventilatory constraints during exercise also deteriorated over time, which most significantly contributed to this exercise capacity deterioration. In addition to pulmonary function, the longitudinal follow-up of exercise capacity is important not to miss the overall deterioration in COPD.

Longitudinal changes in patient vs. physician-based outcome measures did not significantly correlate in asthma

BACKGROUND AND OBJECTIVE

Although improving health status is one important aim in managing asthmatic patients, few studies have evaluated their health status longitudinally. Therefore, we examined longitudinal changes in health status of asthma patients, and compared them with changes in physiological measures.

METHODS

Eighty-seven outpatients with stable asthma after 6 months of treatment were recruited. Health status using the Asthma Quality of Life Questionnaire (AQLQ) and the St. George's Respiratory Questionnaire (SGRQ), pulmonary function, peak expiratory flow (PEF) values, and airway hyperresponsiveness (AHR) were evaluated at entry and every year over a 5-year period.

RESULTS

Using mixed effects models to estimate the slopes, the overall AQLQ score declined statistically at a mean rate of 0.06 units/year (P=.0091). However, this decline did not reach a clinically significant level at 5 years. The total SGRQ score did not change significantly (P=.54). Although the forced expiratory volume in 1 sec declined at a mean rate of 53 mL/year, the PEF variability and AHR improved significantly.

CONCLUSION

Health status was clinically stable over the 5-year study period in patients with asthma, which contrasted with the changes in the physiological outcome measures. As a patient centered outcome measure, health status should be followed separately.

Possible maximal change in the SF-36 of outpatients with chronic obstructive pulmonary disease and asthma

The purpose of the present study was to investigate the responsiveness of the Short Form-36 (SF-36) in patients with chronic obstructive pulmonary disease (COPD) and asthma. We studied patients with COPD and asthma who attended our outpatient clinic. In the first cross-sectional study, we compared the differences in the SF-36 scores between pretreatment patients (152 with COPD and 174 with asthma) who visited the clinic for the first time and in-treatment patients (123 with COPD and 151 with asthma) who had received treatment for > 6 months. The differences in each scale of the SF-36 ranged from 6.9 to 14.4 in COPD patients and from 7.0 to 28.3 in asthma patients. In the second longitudinal study, patients who visited for the first time were enrolled, and the initial, and, 3-, 6-, and 12-month evaluations of the SF-36 were studied. A total of 136 COPD patients and 136 asthma patients were enrolled consecutively, and 100 patients with COPD and 66 patients with asthma completed the year-long examinations. In COPD patients, except for bodily pain, the scores in all scales of the SF-36 improved significantly during the first 3 or 6 months. In patients with asthma, all scale scores of the SF-36 improved significantly during the first 3 months. Maximal changes in the SF-36 scores were observed at 6 or 12 months. Longitudinal maximal changes in each scale approached or exceeded the possible maximal changes, which were derived from the differences in the scores between pretreatment patients and in-treatment patients in the first cross-sectional study. Improvements in the SF-36 scores showed moderate to strong negative correlations with their baseline scores in patients with COPD and asthma. In conclusion, the SF-36 shows sufficient responsiveness in the assessment of the health status of patients with COPD and asthma, but these responses are strongly influenced by their baseline values.

Longitudinal Changes in Health Status Using the Chronic Respiratory Disease Questionnaire and Pulmonary Function in Patients with Stable Chronic Obstructive Pulmonary Disease

Long-term changes in health status have been less evaluated in patients with chronic obstructive pulmonary disease (COPD), in comparison to the changes in forced expiratory volume in 1 s (FEV1). Accordingly, we examined the clinical course of health status as well as pulmonary function in COPD patients, and investigated the relationship between the change in health status and the change in pulmonary function in a 3-year longitudinal study involving 224 patients with COPD. Health status using the Chronic Respiratory Disease Questionnaire (CRQ) and pulmonary function were measured at baseline and every six months over three years. We used the random effects model for the slopes to estimate the longitudinal changes. A total of 147 patients completed the 3-year study. The dyspnoea, fatigue, and emotional function domains of the CRQ declined slowly but significantly over 3 years (p = 0.001, 0.003, and 0.004, respectively) with a mean decline rate of 0.08/year. This means that it would take about 6 years to reach the minimal important change of 0.5 on the CRQ. The mean decline in post-bronchodilator FEV1 was 60 ml/year. None of the changes in any of the domains of the CRQ were significantly correlated with the changes in pulmonary function. We have found that, in comparison to the decline in pulmonary function, health status evaluated by the CRQ declined significantly but very slowly in three of four domains over three years in patients with COPD. Furthermore, we have demonstrated that there was no significant relationship between the change in health status and the change in pulmonary function.

Exercise responses during endurance testing at different intensities in patients with COPD

Endurance time on submaximal exercise tests is a sensitive measure in detecting changes after medical intervention and is used as an outcome in clinical trials, although there has been little discussion regarding the appropriate intensity. Therefore, we investigated whether there were differences in exercise responses between endurance tests at high versus moderate intensity, and analyzed which test was more appropriate. Thirty-seven patients with chronic obstructive pulmonary disease participated in the study. They performed cycle endurance tests at high and moderate submaximal workloads representing 80% and 60% of the maximum work rate reached on progressive cycle ergometry, respectively. Each type of exercise test was performed after inhaling salbutamol 400 microg, ipratropium bromide 80 microg or an identical placebo. Endurance time on the 80% endurance test was much shorter than on the 60% endurance test. The coefficients of variation for the endurance time were lower on the 80% test. Statistically significant improvements in the endurance time after bronchodilators in comparison to placebo were found only on the 80% test. When using the endurance time as an outcome, the high intensity endurance test is preferable to the moderate intensity endurance test, as the high intensity test demonstrated shorter exercise time, less variability and higher sensitivity.

Health-related quality of life in stable asthma: what are remaining quality of life problems in patients with well-controlled asthma?

We purposed to examine the distribution of the disturbances in the health-related quality of life (HRQoL) and to determine the relationship between HRQoL and various clinical parameters in patients with well-controlled asthma according to the guidelines. We enrolled 162 patients with stable asthma, and 113 were defined as well-controlled. HRQoL was measured by the Living with Asthma Questionnaire (LWAQ), the St. George's Respiratory Questionnaire (SGRQ), and the short-form 36 health survey questionnaire (SF-36), dyspnea by the Medical Research Council (MRC), and psychological status by the Hospital Anxiety and Depression Scale (HADS). In both stable and well-controlled patients, the frequency distributions showed that the scores on the Avoidance, Distress, and Preoccupation constructs on the LWAQ were widely distributed, whereas the scores on the Vitality and General Health scales on the SF-36 were normally distributed. In patients with well-controlled asthma, the HADS had mild to moderate correlations with all questionnaires. Multiple regression analysis showed that the Anxiety, the MRC scale and the treatment steps accounted for 44% of the variance in the Avoidance on the LWAQ. These results suggest that domains of psychological well-being may continue to be affected even though the asthma patients are well-controlled by guideline criteria.

A comparison of two simple measures to evaluate the health status of asthmatics: the Asthma Bother Profile and the Airways Questionnaire 20

Simple and concise measures for health status are desirable in clinical practice. The Asthma Bother Profile (ABP), which consists of 23 items, has been developed to assess how much asthma bothers patients. The Airways Questionnaire 20 (AQ20) is a simple instrument which consists of 20 items. The purpose of this study was to investigate how the ABP and AQ20 evaluate the health status of patients with asthma. A total of 166 patients with chronic asthma (age: 48 +/- 16 yr, 77 males) completed pulmonary function testing, measurement of airway hyperresponsiveness, dyspnea rating, assessments of their anxiety and depression (HADS; Hospital Anxiety and Depression Scale), and assessments of their health status. The health status was assessed using the ABP, AQ20, the short-form 36 health survey questionnaire (SF-36), the Living With Asthma Questionnaire (LWAQ) and the Asthma Quality of Life Questionnaire (AQLQ). The Japanese version of the ABP included only 15 'bother' items out of the original 23 items due to cultural differences. The scores on the ABP were widely distributed, whereas the scores on the AQ20 were skewed towards the milder end of the scale. The ABP had a strong correlation with the Avoidance and Distress constructs on the LWAQ, and Anxiety and Depression on the HADS (Rs = 0.56 to approximately 0.79), and its strongest correlation with the General Health (Rs = -0.64) scale among the 8 subscales on the SF-36. The AQ20 had a less significant correlation with the LWAQ, AQLQ, and SF-36 than the ABP. The ABP and AQ20 were short and simple to complete, and both measures could easily be used in clinical practice. The ABP can evaluate patients more specifically with respect to distress and bother than the AQ20.

Risk and Severity of COPD Is Associated With the Group-Specific Component of Serum Globulin 1F Allele

BACKGROUND

The finding that only 15 to 20% of cigarette smokers acquire COPD suggests that there is a genetic predisposition to the disease. Genetic polymorphism of the group-specific component of serum globulin (Gc-globulin), also known as vitamin-D-binding protein, is considered one of the candidates for the susceptibility to COPD. However, the role of Gc-globulin polymorphism in the development of COPD remains inconclusive.

STUDY OBJECTIVE

s: To determine whether Gc-globulin gene polymorphism plays a role in the development of COPD in the Japanese population, and whether it is associated with the physiologic deterioration in COPD, and its radiologically detectable correlates.

DESIGN

Association study.

SUBJECTS AND METHODS

One hundred three patients with COPD and 88 healthy smokers sampled from the Japanese population were genotyped for Gc-globulin by the restriction fragment-length polymorphism method. Based on the results of the genotyping, we investigated the relationship between Gc-globulin polymorphism and a physiologic/radiologic indicator of lung function, namely, the annual decline of FEV(1) (dFEV(1)) in 86 patients with COPD and 21 healthy smokers. Additionally, high-resolution CT parameters such as low-attenuation area percentage (LAA%) and average CT number (mean CT score) were measured in 85 patients with COPD.

RESULTS

There was an increased proportion of Gc*1F homozygotes in the patients with COPD (32%) compared with the healthy smokers (17%) [p = 0.01; odds ratio, 2.3; 95% confidence interval, 1.2 to 4.6]. Patients with COPD and the Gc*1F allele showed a larger dFEV(1) (p = 0.01), higher frequency with LAA% > 60% (p = 0.01), and lower mean CT score than patients without this allele (p = 0.03).

CONCLUSION

Gc-globulin polymorphism is significantly associated with susceptibility to COPD, and also with the severity of the disease.

Development and psychometric analysis of the Japanese version of the Nottingham Health Profile: cross-cultural adaptation

OBJECTIVE

To adapt the Nottingham Health Profile (NHP) for Japanese and to describe the results of the assessment of its psychometric properties.

METHODS

Assessments included test-retest reliability over approximately a 2-week interval, internal consistency and construct validity in 133 patients with COPD.

RESULTS

The distribution of scores indicated that most of the NHP sections exhibited a floor effect, although this is greatly reduced with the NHP-Distress scale. The test-retest reliability was above 0.8 for all sections when patients reporting any change in their health status rating were excluded. Cronbach's alpha coefficients reflected the number of items contained in each section. The internal consistency of the emotional reactions section at one timepoint and the physical mobility section at both timepoints were lower than expected to be higher. All sections except the pain section could be used to distinguish patients who reported their health status to be good or fair from those who rated it to be poor or very poor.

CONCLUSION

The adaptation of the NHP for Japanese was successful. Most sections showed reasonable test-retest reliability, indicating that they produced acceptable levels of random measurement error. The internal consistency of the sections was confirmed, although the alpha values of the emotional reactions and physical mobility sections were lower than might be expected for scales of their length. Different sections of the Japanese NHP were shown to have known group validity.

Optimal cutoff level of breath carbon monoxide for assessing smoking status in patients with asthma and COPD

STUDY OBJECTIVES

To assess the optimal cutoff level of breath CO concentration to distinguish actual smokers from nonsmokers among patients with asthma and COPD.

SETTING

Kyoto University Hospital outpatient clinic.

SUBJECTS AND METHODS

Three hundred thirty-one consecutive outpatients (161 with asthma and 170 with COPD) were examined cross-sectionally by self-reported smoking status, breath CO monitoring, and serum cotinine concentration. Actual smoking status was verified by serum cotinine concentration.

RESULTS

Mean serum cotinine concentrations of never smokers, former smokers, and current smokers with asthma were 6.0 +/- 5.2 ng/mL, 12.1 +/- 25.0 ng/mL, and 198.3 +/- 181.7 ng/mL, respectively (+/- SD). Mean serum cotinine concentrations of former smokers and current smokers with COPD were 23.2 +/- 69.2 ng/mL and 191.1 +/- 109.8 ng/mL, respectively. Mean breath CO levels of never smokers, former smokers, and current smokers with asthma were 6.1 +/- 2.4 ppm, 7.7 +/- 3.2 ppm, and 19.9 +/- 17.3 ppm, respectively. Mean breath CO levels of former smokers and current smokers with COPD were 7.7 +/- 4.3 ppm and 13.5 +/- 6.5 ppm, respectively. The optimal cutoff level of breath CO to discriminate between actual smokers and nonsmokers was 10 ppm in patients with asthma and 11 ppm in patients with COPD, giving 85.0% and 73.1% sensitivity, and 85.8% and 84.7% specificity, respectively.

CONCLUSION

The optimal cutoff level of breath CO to assess actual smoking status was 10 ppm in patients with stable asthma and 11 ppm in patients with stable COPD. In patients with asthma and COPD, breath CO levels were potentially influenced by underlying airway inflammation, suggesting misclassification in the assessment of smoking status by breath CO.

A comparison of the responsiveness of different generic health status measures in patients with asthma

Generic health status has been recommended to be measured separately from disease-specific health status, because they can yield complementary information. In particular, generic health status can provide comprehensive health ratings across various disorders. However, the weakness with generic measures is that they may be less responsive to clinical changes than disease-specific ones. Therefore, when using generic health status as an endpoint in clinical trials, the instrument to be used is a problem with respect to responsiveness. In the present study, we investigated and compared the responsiveness of health status measures during asthma treatment using three different generic instruments: the Medical Outcomes Study Short Form 36-items Health Survey (SF-36), the Nottingham Health Profile (NHP) and the EQ5D (EuroQoL), as well as one disease-specific instrument, the Asthma Quality of Life Questionnaire (AQLQ). Fifty-four new patients with asthma who consulted our clinic were recruited. The health status measurements were performed on the initial visit, and at 3 and 6 months. All subscales of the SF-36 showed a significant improvement during the first 6 months. Each dimension of the EQ5D showed stronger ceiling effects than the SF-36. With respect to the responsiveness indices, the SF-36 was regarded as more responsive than the NHP or EQ5D utility. The changes in the SF-36 had a weak to moderate correlation with the changes in the AQLQ. In conclusion, the SF-36 had a higher responsiveness for asthma as a generic measure than the NHP or EQ5D, and evaluated different aspects from the AQLQ. The SF-36 can be used effectively in asthma clinical trials.

A comparison of the effects of salbutamol and ipratropium bromide on exercise endurance in patients with COPD

STUDY OBJECTIVE

Inhaled bronchodilators are the first-line pharmacotherapy against COPD. The purpose of the present study was to investigate the effects of beta(2)-agonists and anticholinergic agents on the exercise capacity of patients with COPD.

METHODS

A total of 67 stable patients with COPD were recruited at the Kyoto University Hospital. After inhaling 400 micro g salbutamol, 80 micro g ipratropium bromide, or an identical placebo in a randomized, double-blind, crossover fashion, the patients performed cycle endurance tests at a constant workload of 80% of the maximum work rate reached on progressive cycle ergometry, and the endurance time was recorded.

RESULTS

Both salbutamol and ipratropium bromide significantly improved the endurance time by 29 s (15%; p < 0.001) and 27 s (14%; p < 0.001), respectively, in comparison with the placebo. However, there was no statistically significant difference between them (p = 0.71). The dyspnea ratios were also similarly reduced by both bronchodilators. The difference in the endurance time between therapy with salbutamol and placebo was significantly, but moderately, related to the difference between therapy with ipratropium bromide and placebo. In addition, there were no relationships, or only weakly significant relationships, between the change in FEV(1) and the change in the endurance time, the highest oxygen uptake, and the highest minute ventilation for both salbutamol and ipratropium bromide.

CONCLUSIONS

Therapy with both salbutamol and ipratropium bromide improved exercise capacity, as evaluated by the endurance time, and reduced dyspnea similarly in patients with COPD. In addition, the effects of the different bronchodilators on exercise capacity varied within individuals, and a complex mechanism may be responsible for the different effects of these two bronchodilators on exercise capacity vs airflow limitation. These results support the conclusion that both types of inhaled bronchodilators can be used as first-line drugs for the treatment of stable patients with COPD.

Change in generic and disease-specific health-related quality of life during a one-year period in patients with newly detected chronic obstructive pulmonary disease

BACKGROUND

Although the health-related quality of life (HRQoL) in patients with chronic obstructive pulmonary disease (COPD) has been assessed by generic or disease-specific HRQoL measures, the responsiveness of the generic HRQoL measures is generally weak.

OBJECTIVES

To investigate the responses generated by generic and disease-specific HRQoL questionnaires, we prospectively followed the clinical course of patients with newly detected COPD after the initiation of treatment.

METHODS

A prospective, longitudinal study with a 1-year follow-up was designed. The forced expiratory volume in 1 s (FEV(1)), forced vital capacity (FVC), the Nottingham Health Profile (NHP) as a generic HRQoL measure, and the Chronic Respiratory Disease Questionnaire (CRQ) as a disease-specific HRQoL measure were measured at baseline and at 3, 6, and 12 months after the initiation of standard treatment.

RESULTS

Eighty-two patients completed the study. The FEV(1), FVC, and NHP and CRQ scores improved significantly during the first 3 months (p < 0.05). During the last 6 months, although the FEV(1) declined (p < 0.05), the HRQoL assessed by the NHP and CRQ remained elevated. Except for the score on the social isolation section of the NHP at 12 months, all HRQoL scores at 6 and 12 months were significantly improved compared to baseline (p < 0.05).

CONCLUSION

In new patients with COPD, the NHP as well as the CRQ was able to detect changes in the HRQoL associated with effective medical interventions. The influence of the changes in airflow limitation on the HRQoL was weak.

Analysis of the factors related to mortality in chronic obstructive pulmonary disease: role of exercise capacity and health status

In this study, we analyzed the relationships of exercise capacity and health status to mortality in patients with chronic obstructive pulmonary disease (COPD). We recruited 150 male outpatients with stable COPD with a mean postbronchodilator FEV1 at 47.4% of predicted. Their pulmonary function, progressive cycle ergometry, and health status using the Chronic Respiratory Disease Questionnaire, the St. George's Respiratory Questionnaire (SGRQ), and the Breathing Problems Questionnaire were measured at entry. Among 144 patients who were available for the 5-year follow-up, 31 had died. Univariate Cox proportional hazards analysis revealed that the SGRQ total score and the Breathing Problems Questionnaire were significantly correlated with mortality; however, with the Chronic Respiratory Disease Questionnaire, the total score was not significantly correlated. Multivariate Cox proportional hazards analysis revealed that the peak oxygen uptake and the SGRQ total score were both predictive of mortality, independent of FEV1 and age. Stepwise Cox proportional hazards analysis revealed that the peak oxygen uptake was the most significant predictor of mortality. We found that exercise capacity and health status were significantly correlated with mortality, although different health status measures had different abilities to predict mortality. These results will have a potentially great impact on the multidimensional evaluation of disease severity in COPD.

Longitudinal changes in airflow limitation and airway hyperresponsiveness in patients with stable asthma

BACKGROUND

There are few long-term studies of the effects of treatment on the natural course of asthma.

OBJECTIVE

To investigate the longitudinal changes in airflow limitation and airway hyperresponsiveness (AHR) in asthma.

METHODS

We recruited 81 outpatients (never smokers) with stable asthma from the Kyoto University Hospital. They were evaluated for pulmonary function and AHR, expressed by forced expiratory volume in 1 second (FEV1) and the provocation dose that caused a 20% fall in FEV1 (PD20-FEV1), respectively, at entry and every 6 months over 3 years. We used random effects models to estimate the slopes of these changes, and then evaluated the relationship between these changes and their predictive factors.

RESULTS

Using random effects models, the percentage of the predicted FEV1 (%FEV1) declined significantly but slightly at a mean rate of 0.5%/year (P = 0.002; 95% confidence interval, 0.3 to 0.8). The mean decline rate of FEV1 was 34 mL/year. However, Log(PD20-FEV1) showed significant improvement at a mean rate of 0.088 cumulative units/year (P < 0.001; 95% confidence interval, 0.053 to 0.122). Multiple regression analysis showed that the baseline values of %FEV1 and Log(PD20-FEV1) were the most significant predictive factors for their subsequent changes, respectively.

CONCLUSIONS

In stable asthmatic patients treated according to international guidelines, airflow limitation progressed at a nearly normal rate over 3 years. However, AHR continued to improve despite its ceiling effects. Multiple regression analysis revealed a significant negative relationship between the initial values and the subsequent changes in airflow limitation and AHR, respectively.

Health status measured with the CRQ does not predict mortality in COPD

One purpose of measuring health status is to predict future outcomes. The aim of this study was to investigate the ability of health status derived from the Chronic Respiratory Disease Questionnaire (CRQ) to predict mortality in chronic obstructive pulmonary disease (COPD). One-hundred and forty-three patients with COPD were recruited. Health status, using the CRQ, and pulmonary function were measured at entry. Mortality after 7 yrs was then assessed. Univariate and multivariate Cox proportional hazards analyses were performed to predict those factors related to mortality. Of all the patients, 13 could not be followed up and 40 had died. The survival rate was 69% at 7 yrs. Univariate regression analyses revealed that the dyspnoea and emotional function domains and the total score of the CRQ were weakly but significantly correlated with mortality from all causes. However, multivariate regression analyses revealed that age and forced expiratory volume in one second were the strongest predictors of mortality, and health status was not a significant factor. Although there was a weak but significant relationship between health status and subsequent mortality in chronic obstructive pulmonary disease, it was not significant after an adjustment for age and pulmonary function. Mortality cannot be predicted from Chronic Respiratory Disease Questionnaire scores.

Comparison of the responsiveness of different disease-specific health status measures in patients with asthma

BACKGROUND

Disease-specific health status measures are characterized by higher responsiveness than generic measures and may be preferred in clinical trials. However, comparisons of responsiveness between various disease-specific measures have rarely been performed in asthma studies.

STUDY OBJECTIVE

We investigated and compared the responsiveness of health status scores in asthmatic patients during treatment using three different disease-specific measures: the Juniper Asthma Quality of Life Questionnaire (AQLQ), the Living with Asthma Questionnaire (LWAQ), and the Airways Questionnaire 20 (AQ20).

METHODS

We attempted to follow up 170 patients with newly diagnosed asthma over a 6-month period. Patients underwent treatment with inhaled corticosteroids in accordance with the guideline. A health status evaluation using three disease-specific measures, and pulmonary function tests were performed on the initial visit, and at 3 months and 6 months. The effect size and the standardized response mean were used as responsiveness indexes.

RESULTS

A total of 109 patients completed the 6-month follow-up and were then analyzed. All health status scores and FEV(1) measures improved during the first 3 months (p < 0.001). The total of the AQLQ scores showed high responsiveness indexes ranging from 1.28 to 1.46 between baseline and 3 months, and baseline and 6 months. Spearman correlation coefficients were smaller between the change in FEV(1) and the change in the LWAQ. Although the AQ20 also demonstrated high responsiveness, a ceiling effect was indicated.

CONCLUSIONS

The AQLQ was the most responsive measure during asthma treatment. The relationship between the change in airflow limitation and the change in the LWAQ was weaker compared to the AQLQ and the AQ20. Although the AQ20 was also responsive and its simplicity is favorable, the ceiling effect should be considered when using it.

Relationship between different indices of exercise capacity and clinical measures in patients with chronic obstructive pulmonary disease

PURPOSE

The purpose of this study was to make comparisons between different types of exercise tests used in chronic obstructive pulmonary disease (COPD) to better interpret the results and to select the most suitable testing procedure. Therefore, we evaluated the relationship between exercise capacity and other clinical measures and their relative contributions to exercise capacity in patients with COPD.

METHOD

We studied 36 patients with stable COPD. All patients underwent baseline pulmonary function testing. Dyspnea during activities of daily living was assessed with the Oxygen Cost Diagram (OCD). The Hospital Anxiety and Depression Scale and the St George's Respiratory Questionnaire were used to assess psychologic status and health-related quality of life, respectively. All patients performed the 6-minute walking test, progressive cycle ergometry, and the cycle endurance test.

RESULTS

Each exercise capacity result correlated significantly with pulmonary function, the OCD, and the Activity and Total scores of the St George's Respiratory Questionnaire. Multiple regression analyses revealed that the OCD was an important predictor of exercise capacity, especially for the walking test. Diffusing capacity was also a significant predictor on progressive cycle ergometry. Body mass index was the most significant predictor of the endurance time.

CONCLUSION

The 3 different exercise tests had similar characteristics in relation to pulmonary function, dyspnea, and health-related quality of life in patients with COPD. However, some differences were found in the aspects they evaluated.

Dyspnea is a better predictor of 5-year survival than airway obstruction in patients with COPD

BACKGROUND

FEV(1) is regarded as the most significant correlate of survival in COPD and is used as a measure of disease severity in the staging of COPD. Recently, however, the categorization of patients with COPD on the basis of the level of dyspnea has similarly been reported to be useful in the prediction of health-related quality of life and improvement in exercise performance after pulmonary rehabilitation.

STUDY OBJECTIVES

We compared the effects of the level of dyspnea and disease severity, as evaluated by airway obstruction, on the 5-year survival rate of patients with COPD.

DESIGN AND METHODS

A total of 227 patients with COPD were enrolled in a 5-year, prospective, multicenter study in the Kansai area of Japan, involving 20 divisions of respiratory medicine from various university and city hospitals.

RESULTS

After 5 years, 183 patients were available for the follow-up examination (follow-up rate, 81%). The 5-year cumulative survival rate among patients with COPD was 73%. The effect of disease staging, based on the American Thoracic Society (ATS) guideline as evaluated by the percentage of predicted FEV(1), on the 5-year survival rate was not significant (p = 0.08). However, the level of dyspnea was significantly correlated to the 5-year survival rate (p < 0.001). The Cox proportional hazards model revealed that the level of dyspnea had a more significant effect on survival than disease severity based on FEV(1).

CONCLUSIONS

The categorization of patients with COPD on the basis of the level of dyspnea was more discriminating than staging of disease severity using the ATS guideline with respect to 5-year survival. Dyspnea should be included as one of the variables, in addition to airway obstruction, for evaluating patients with COPD in terms of mortality.

Changes in indices of airway hyperresponsiveness during one year of treatment with inhaled corticosteroids in patients with asthma

We analyzed the changes in indices of airway hyperresponsiveness, including hypersensitivity and hyperreactivity, during one year of treatment with inhaled corticosteroids. We then investigated on which of them the inhaled corticosteroids had a primary effect. Fifty outpatients with asthma were recruited and treated with inhaled beclomethasone dipropionate. They underwent bronchoprovocation tests on the initial visit and at 3, 6, and 12 months. The dose of methacholine required to produce a 20% fall in the forced expiratory volume in 1 second (PD20-FEV1) was measured to evaluate airway hypersensitivity. A relatively novel index, the percent change in the forced vital capacity (deltaFVC%) at the PD20-FEV1, was assessed as a marker of airway hyperreactivity. PD20-FEV1 and deltaFVC% were assumed to indicate the horizontal shift of the dose-response curve and the vertical change in the maximal response plateau, respectively. Log(PD20-FEV1) and deltaFVC% continued to improve throughout the year (p < 0.001 and p = 0.002, respectively). Log(PD20-FEV1) improved significantly at the 3-month evaluation (p < 0.001), and deltaFVC% improved at the 6-month evaluation (p = 0.012). Log(PD20-FEV1) had no or weak relationships with deltaFVC% at all evaluation points. In conclusion, inhaled corticosteroids continued not only to reverse the leftward shift of the curve, but also to restore the plateau. Furthermore, their effect was reflected primarily by the former rather than the latter: They should be followed separately to examine how much airway inflammation is reduced.

Additive effects of prednisolone and beclomethasone dipropionate in patients with stable chronic obstructive pulmonary disease

It remains unclear whether inhaled corticosteroids can produce the maximum benefits of corticosteroids in patients with chronic obstructive pulmonary disease (COPD). To assess the additive effects of 30 mg/day prednisolone to high-dose, inhaled beclomethasone dipropionate (BDP), we conducted a randomised double-blind, placebo-controlled cross-over trial. The study population consisted of 21 men with stable COPD. The mean age of the patients was 69.1 +/- 6.8 years, and FEV(1)was 0.86 +/- 0.28 l. Seventeen out of the 21 patients (81%) were considered susceptible to steroids in a previous trial (FEV(1)increased at least 15% from baseline after receiving 14 days of 30 mg/day prednisolone). All of the patients had been on 1600 microg/day BDP for more than 3 months. Spirometry was performed before the entry, and at the end of 3-week placebo and prednisolone periods. The peak expiratory flow (PEF), symptoms, and Guyatt's Chronic Respiratory Disease Questionnaire (CRQ) as a disease specific health-related quality of life over the last seven days of each period were also evaluated. Although a marginal increase in PEF was found during the prednisolone period, no significant differences in FEV(1), FVC, symptoms or CRQ scores were observed between the two treatment periods. We conclude that the therapeutic effects of steroid therapy may be achieved by the long-term use of high-dose, inhaled corticosteroid in some patients with stable COPD.