Chronic obstructive pulmonary disease: current burden and future projections

Acute Exacerbation of Chronic Obstructive Pulmonary Disease in Oldest Adults: Predictors of In-Hospital Mortality and Need for Post-acute Care

OBJECTIVES

Older age is associated with higher risk of death during acute exacerbations of chronic obstructive pulmonary disease (AE-COPD). Older patients hospitalized for AE-COPD often require post-acute care after acute phase. The aim of this study was to evaluate components of a comprehensive geriatric assessment and clinical/laboratory parameters, in order to find predictors of in-hospital mortality and need for post-acute care in patients aged 80 and older hospitalized for AE-COPD.

DESIGN

Prospective observational study.

SETTING

Hospital assessment.

PARTICIPANTS

121 patients consecutively admitted to an internal medicine and geriatrics department for AE-COPD.

MEASURES

Activities of Daily Living (ADL) Hierarchy scale, Geriatric Index of Comorbidity, cognitive impairment, and clinical and laboratory parameters were collected.

RESULTS

Mean age: 87.0 ± 4.9 years; male: 54.5%. In-hospital mortality (18.2% of patients) was significantly associated with functional disability, high comorbidity, cognitive impairment, anemia, older age, lower albumin, higher N-terminal pro-B-type natriuretic peptide (NT-proBNP) and white blood cell levels, oral corticosteroids taken before admission, and no angiotensin-converting enzyme inhibitors or angiotensin receptor blockers taken before admission. In a stepwise logistic regression, functional dependence (P = .006), cognitive impairment (P = .038), and oral corticosteroids therapy before hospitalization (P = .035) were independently associated with a higher risk of in-hospital mortality. Among laboratory parameters, only NT-proBNP remained significantly associated with in-hospital mortality (P = .026). The need for post-acute care (18.2% of survivors) was associated with older age, higher admission Pco₂, greater comorbidity, and cognitive impairment. In a stepwise logistic regression, only cognitive impairment (P = .016) and ln_Pco₂ (P = .056) confirmed their association with the need for post-acute care.

CONCLUSIONS/IMPLICATIONS

Preadmission functional dependence, cognitive impairment, and corticosteroid use, plus elevated NT-proBNP at admission are risk factors for mortality during an AE-COPD in the oldest old. Therefore, medical providers should consider these, as well as the patient's advance directives, in planning hospital care. Furthermore, providers should arrange especially careful posthospitalization monitoring and frequent follow-up of individuals with cognitive impairment and baseline hypercapnia.

Comparative Efficacy of Budesonide/Formoterol with Budesonide, Formoterol or Placebo for Stable Chronic Obstructive Pulmonary Disease: A Meta-Analysis

BACKGROUND The 2018 Global Initiative for Chronic Obstructive Lung Disease publication suggested that the combination of bronchodilator therapy of inhaled glucocorticoid/long-acting β₂ adrenoceptor agonist is more effective in improving pulmonary function and health status in the treatment of patients with acute exacerbations than the individual components; however, it is not known whether this also the case for stable chronic obstructive pulmonary disease (COPD). The purpose of this meta-analysis was to evaluate the effectiveness of budesonide/formoterol in the maintenance and relief therapy of patients with stable COPD. MATERIAL AND METHODS An electronic search of the literature in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials was undertaken to identify published randomized controlled trials (RCTs) of ≥12 weeks duration comparing the budesonide/formoterol, with budesonide, formoterol, or placebo in the treatment of patients with stable COPD. The identified RCTs were reviewed. The mean difference (MD) with corresponding 95% confidence interval (CI) was used to pool the results. RESULTS Seven high quality studies with RCTs met the inclusion criteria for meta-analysis. Compared with budesonide alone, the combination therapy of budesonide/formoterol showed significant improvement in the following spirometric indices: pre-dose forced expiratory volume in 1 second (FEV₁) (SMD: 0.26, 95% CI: 0.18, 0.34; P=0.000). In addition, versus formoterol alone, budesonide/formoterol was associated with a significant increase in pre-dose FEV₁ (SMD: 0.12, 95% CI: 0.07, 0.17; P=0.000). A similar pattern was also evident in the comparison to placebo, where budesonide/formoterol yielded greater increase in pre-dose FEV₁ (SMD: 0.24, 95% CI: 0.18, 0.30; P=0.000). Moreover, compared with other controls, the combination of budesonide-formoterol significantly improved morning peak expiratory flow and evening peak expiratory flow, significantly reduced the total score of St. George's Respiratory Questionnaire. CONCLUSIONS For stable COPD patients, compared with controls (monocomponents or placebo), budesonide/formoterol improved pulmonary function and health status. Future larger long-term RCTs are warranted to assess the beneficial clinical efficacy of budesonide/formoterol in COPD patients.

Predictive factors for exacerbation and re-exacerbation in chronic obstructive pulmonary disease: an extension of the Cox model to analyze data from the Swiss COPD cohort

Background

The Swiss COPD cohort was established in 2006 to collect data in a primary care setting. The objective of this study was to evaluate possible predictive factors for exacerbation and re-exacerbation.

Methods

In order to predict exacerbation until the next visit based on the knowledge of exacerbation since the last visit, a multistate model described by Therneau and Grambsch was performed.

Results

Data of 1,247 patients (60.4% males, 46.6% current smokers) were analyzed, 268 (21.5%) did not fulfill spirometric diagnostic criteria for COPD. Data of 748 patients (63% males, 44.1% current smokers) were available for model analysis. In order to predict exacerbation an extended Cox Model was performed. Mean FEV₁/FVC-ratio was 53.1% (±11.5), with a majority of patients in COPD GOLD classes 2 or 3. Hospitalization for any reason (HR1.7; P = 0.04) and pronounced dyspnea (HR for mMRC grade four 3.0; P < 0.001) at most recent visit as well as prescription of short-acting bronchodilators (HR1.7; P < 0.001), inhaled (HR1.2; P = 0.005) or systemic corticosteroids (HR1.8; P = 0.015) were significantly associated with exacerbation when having had no exacerbation at most recent visit. Higher FEV₁/FVC (HR0.9; P = 0.008) and higher FEV₁ values (HR0.9; P = 0.001) were protective. When already having had an exacerbation at the most recent visit, pronounced dyspnea (HR for mMRC grade 4 1.9; P = 0.026) and cerebrovascular insult (HR2.1; P = 0.003) were significantly associated with re-exacerbation. Physical activity (HR0.6; P = 0.031) and treatment with long-acting anticholinergics (HR0.7; P = 0.044) seemed to play a significant protective role. In a best subset model for exacerbation, higher FEV₁ significantly reduced and occurrence of sputum increased the probability of exacerbation. In the same model for re-exacerbation, coronary heart disease increased and hospitalization at most recent visit seemed to reduce the risk for re-exacerbation.

Conclusion

Our data confirmed well-established risk factors for exacerbations whilst analyzing their predictive association with exacerbation and re-exacerbation. This study confirmed the importance of spirometry in primary care, not only for diagnosis but also as a risk evaluation for possible future exacerbations.

Trial registration

Our study got approval by local ethical committee in 2006 (EK Nr. 170/06) and was registered retrospectively on ClinicalTrials.gov (NCT02065921, 19^th of February 2014).

Chronic obstructive pulmonary disease and lung cancer: inter-relationships

PURPOSE OF REVIEW

Chronic obstructive pulmonary disease (COPD) is a well established risk factor for lung cancer. Newer studies reveal a myriad of other mechanisms, some proven and some putative, which may contribute to their association.

RECENT FINDINGS

There is an ever-growing bundle of evidence that suggests a close association between persistent chronic inflammation and lung cancer. A few potential targets of genetic susceptibility locus for COPD and lung cancer have been suggested. Better characterization of immune dysregulation and identification of signaling pathways may assist the development of strategies to reduce risk of developing lung cancer in patients with COPD. Current lung cancer screening strategies may exclude some patients at high risk of having lung cancer. Prospective studies indicate that a screening criterion that includes variables reflecting the severity of COPD may increase the sensitivity of the screening program and reduce 'over-diagnosis bias' of indolent lung cancers. Examples of such variables include the emphysema score generated from computed tomography scans and diffusion capacity for carbon monoxide derived from lung function tests.

SUMMARY

A better understanding of the inter-relationship between lung cancer pathogenesis and COPD has been described recently. Improving lung cancer screening strategies by incorporating markers of COPD severity has recently been proposed.

Lung inflammation and disease: A perspective on microbial homeostasis and metabolism

It is now well appreciated that the human microbiome plays a significant role in a number of processes in the body, significantly affecting its metabolic, inflammatory, and immune homeostasis. Recent research has revealed that almost every mucosal surface in the human body is associated with a resident commensal microbiome of its own. While the gut microbiome and its role in regulation of host metabolism along with its alteration in a disease state has been well studied, there is a lacuna in understanding the resident microbiota of other mucosal surfaces. Among these, the scientific information on the role of lung microbiota in pulmonary diseases is currently severely limited. Historically, lungs have been considered to be sterile and lung diseases have only been studied in the context of bacterial pathogenesis. Recently however, studies have revealed a resilient microbiome in the upper and lower respiratory tracts and there is increased evidence on its central role in respiratory diseases. Knowledge of lung microbiome and its metabolic fallout (local and systemic) is still in its nascent stages and attracting immense interest in recent times. In this review, we will provide a perspective on lung-associated metabolic disorders defined for lung diseases (e.g., chronic obstructive pulmonary disease, asthma, and respiratory depression due to infection) and correlate it with lung microbial perturbation. Such perturbations may be due to altered biochemical or metabolic stress as well. Finally, we will draw evidence from microbiome and classical microbiology literature to demonstrate how specific lung morbidities associate with specific metabolic characteristics of the disease, and with the role of microbiome in this context. © 2018 IUBMB Life, 71(1):152-165, 2019.

Cost of Severe Chronic Obstructive Pulmonary Disease Exacerbations in a High Burden Region in North India

Background:

Data on costs of acute exacerbations of COPD (AECOPD) in low-income countries are sparse. We conducted a prospective survey to assess direct and indirect costs of severe AECOPD in a tertiary care setting in a high prevalence area of North India.

Methods:

We conducted face-to-face surveys using a semi-structured questionnaire among a convenience sample of 129 consenting patients admitted with AECOPD. Data were collected on out-of-pocket costs of hospitalization, consultation, medications, diagnostics, transportation, lodging, and missed work days for self and their attendants. Out-of-pocket costs were supplemented with World Health Organization-CHOICE estimates. Missed work-days were valued on per capita national income (Indian Rupees [INR] 68,748, US$1,145.8). Median total cost per exacerbation episode was INR 44,390 (Inter-quartile range [IQR]: INR 33,354–63,642; US$739.8, IQR: 555.9–1060.7). Hospital costs constituted the largest component of the costs (71%) followed by other costs directly borne by the patient himself (29%), medicine costs (14%), transportation charges (2%) and diagnostic tests (3%). Indirect costs to caregivers (median INR 1,544, IQR: INR 0–17,370 INR; US$25.7, IQR: US$0–289.5), calculated as financial loss due to missed work days, accounted for 4% of the total cost. Expenses were covered by family members in all but 11 patients.

Conclusions:

AECOPD in India are associated with substantial costs and strategies to reduce the burden of disease such as smoking cessation, influenza and pneumococcal vaccination, etc should be aggressively pursued.

Effects of Scutellaria baicalensis Extract on Cigarette Smoke-Induced Airway Inflammation in a Murine Model of Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD), including pulmonary emphysema and chronic bronchitis as well as structural and inflammatory changes in small airways, is insensitive to corticosteroid therapies. This study aimed to evaluate the effects of Scutellaria baicalensis root extract (SB_E) in a mouse model of COPD. The COPD mouse model was produced by challenging C57BL/6 mice with a cigarette smoke extract and lipopolysaccharide (LPS). SB_E significantly decreased the neutrophil counts in blood and bronchoalveolar lavage fluid (BALF), and the production of tumor necrosis factor (TNF)-α, interleukin (IL)-17A, macrophage inflammatory protein 2 (MIP2), and chemokine (C-X-C motif) ligand 1 (CXCL-1) in BALF, and TNF-α mRNA expression in lung tissue. The histological lung injury was also alleviated by treatment with SB_E. Thus, SB_E effectively inhibited airway inflammation by regulating the expression of inflammatory cytokines by blocking MIP2 and CXCL-1 secretion. Therefore, S. baicalensis may be a potential therapeutic agent for COPD.

Should vitamin D be routinely checked for all chronic obstructive pulmonary disease patients?

Aims and Objectives:

This study aimed to compare the vitamin D levels between chronic obstructive pulmonary disease (COPD) patients and healthy controls and to describe the correlation between vitamin D levels and lung functions.

Methods:

Fifty COPD patients (cases) and 30 healthy volunteers (controls) were recruited and their serum vitamin D level was measured together with lung function (forced vital capacity and forced expiratory volume in 1 s [FEV1]) by spirometry. vitamin D was categorized as ≤20 nmol/l: deficient, 21–50 nmol/l: inadequate, and ≥51 nmol/l as sufficient.

Results:

In this case–control cross-sectional study, lower vitamin D levels were associated with lower lung function in both cases as well as controls, the effect being more pronounced in cases. Mean FEV1 at vitamin D ≤20 nmol/l (0.98 ± 0.40 vs. controls 1.93 ± 0.24 with P = 0.006), mean FEV1 at vitamin D 21–50 nmol/l (1.55 ± 0.54 vs. 2.20 ± 0.31 with P = 0.000), and mean FEV1 at vitamin D ≥51 nmol/l (2.06 ± 0.54 vs. 2.20 ± 0.31 with P = 0.002). Moreover, the severity of predicted postbronchodilator FEV1% was also much lower among COPD cohort versus healthy volunteers (mean FEV1%: cases 47.88 ± 14.22 vs. controls 58.76 ± 15.05 with P = 0.002).

Conclusions:

Importantly, lung function in both the groups was affected by decreased vitamin D level; decrease in FEV1 was more pronounced among COPD patients compared to controls showing more expiratory airflow limitation. Vitamin D levels are associated with changes in lung function in cases of COPD as well as healthy controls. Larger studies to confirm the association in Indian context are required and routine assessment of vitamin D may be undertaken to obviate the effects of low vitmain D level on lung function.

Office-Based Sedation/General Anesthesia for COPD Patients, Part II

The safe treatment of patients with chronic obstructive pulmonary disease (COPD) in dental office office-based settings can be quite complex without a current understanding of the etiology, course, severity, and current treatment modalities of the disease. The additional concerns of providing sedation and/or general anesthesia to patients with COPD in settings outside of a hospital demand thorough investigation of individual patient presentation and realistic development of planned treatment that patients suffering from this respiratory condition can tolerate. Along with other co-morbidities, such as advanced age and potential significant cardiovascular compromise, the dental practitioner providing sedation or general anesthesia must tailor any treatment plan to address multiple organ systems and mitigate risks of precipitating acute respiratory failure from inadequate pain and/or anxiety control. Part I of this article covered the epidemiology, etiology, and pathophysiology of COPD. Patient considerations in the preoperative period were also reviewed. Part II will cover which patients are acceptable for sedation/general anesthesia in the dental office-based setting as well as sedation/general anesthesia techniques that may be considered. Postoperative care will also be reviewed.

Physical signs in patients with chronic obstructive pulmonary disease

We reviewed the various physical signs of chronic obstructive pulmonary disease, their pathogenesis, and clinical importance. We searched PubMed, EMBASE, and the CINAHL from inception to March 2018. We used the following search terms: chronic obstructive pulmonary disease, physical examination, purse-lip breathing, breath sound intensity, forced expiratory time, abdominal paradox, Hoover's sign, barrel-shaped chest, accessory muscle use, etc. All types of studies were chosen. Globally, history taking and clinical examination of the patients is on the wane. One reason can be a significant development in the field of medical technology, resulting in overreliance on sophisticated diagnostic machines, investigative procedures, and medical tests as first-line modalities of patient's management. In resource-constrained countries, detailed history taking and physical examination should be emphasized as one of the important modalities in patient's diagnosis and management. Declining bedside skills and clinical aptitude among the physician is indeed a concern nowadays. Physical diagnosis of chronic obstructive pulmonary disease (COPD) is the quickest and reliable modalities that can lead to early diagnosis and management of COPD patients. Bedside elicitation of physical signs should always be the starting point for any diagnosis and therapeutic approach.

Protective Effect of Hydroxysafflor Yellow A on Inflammatory Injury in Chronic Obstructive Pulmonary Disease Rats

OBJECTIVE

To investigate the attenuating effect of Hydroxysafflor yellow A (HSYA) on inflammatory injury in chronic obstructive pulmonary disease (COPD).

METHODS

Rats were randomly assigned to 7 groups according to body weight including normal control group, HSYA blank group (76.8 mg/kg), COPD group, COPD+HSYA (30, 48, 76.8 mg/kg) groups and COPD+dexamethasone (2 mg/kg), 10 in each group. Passive cigarette smoke and intratracheal instillation of lipopolysaccharides were used to establish a COPD model in rats. Hematoxylin and eosin staining of lung tissue sections was used, real-time polymerase chain reaction (PCR) was used to assay mRNA levels of some cytokines in lung tissues, the cytokines in bronchoalveolar lavage fluid (BALF) were measured by enzyme-linked immunosorbent assay (ELISA), Western blot analysis was used to determine phosphorylated p38 mitogen-activated protein kinase (MAPK) levels in lung tissues, and nuclear factor-κB (NF-κB) p65 protein levels in lung tissues were detected by immunohistochemistry.

RESULTS

Lung alveolar septa destruction, alveolus fusion, inflammatory cell infiltration, and bronchiole exudation were observed. These pathological changes were alleviated in the COPD+HSYA group. The mRNA expression of inflammatory factors were significantly increased in lung tissues from COPD rats (all P<0.01) and were inhibited by HSYA. Levels of inflammatory cytokines in BALF of COPD rats were significantly increased (all P<0.01) which were inhibited by HSYA (all P<0.01, 48, 76.8 mg/kg). The levels of p38 MAPK phosphorylation and p65 in lung tissues of COPD rats were significantly increased (all P<0.01) and were suppressed by HSYA (all P<0.01, 48, 76.8 mg/kg).

CONCLUSIONS

HSYA could alleviate inflammatory cell infiltration and other pathological changes in the lungs of COPD rats. HSYA inhibited inflammatory cytokine expression, and increase phosphorylation of p38 MAPK and NF-κB p65 in the lungs of COPD rats. The protective mechanism of HSYA to inhibit COPD inflammation might be by attenuating NF-κB and p38MAPK signal transduction.

Pharmacological interventions for the treatment of depression in chronic obstructive pulmonary disease

BACKGROUND

Studies report that up to 80% of individuals with chronic obstructive pulmonary disease (COPD) may struggle with symptoms of depression. However, this major comorbidity in COPD is rarely managed effectively. A number of recent studies indicate that left untreated, COPD-related depression is associated with worse quality of life, worse compliance with COPD treatment plan, increased exacerbations, hospital admissions, and healthcare costs when compared to individuals with COPD without depression. Regrettably, COPD practice guidelines do not provide conclusive treatment recommendations for the use of antidepressants in patients with COPD, and base their guidelines on findings from trials in the general population. This may be problematic, as there is an elevated risk of respiratory issues associated with antidepressant treatment and COPD. Evaluating effectiveness and safety of pharmacological interventions specifically for patients with COPD and depression was therefore paramount.

OBJECTIVES

To assess the effectiveness and safety of pharmacological interventions for the treatment of depression in patients with COPD.

SEARCH METHODS

The last search was performed on 26 November 2018. We initially searched the following databases via the Specialised Trials Registers of the Cochrane Airways and Common Mental Disorders Groups (to June 2016): MEDLINE, Embase, PsycINFO, CINAHL, AMED, and the Cochrane Library trials register (CENTRAL). Searches from June 2016 to November 2018 were performed directly on Ovid MEDLINE, Embase, PsycINFO and the Cochrane Library (Issue 11, 2018). We searched ClinicalTrials.gov, the ISRCTN registry, and the World Health Organization International Clinical Trials Registry Platform to 26 November 2018. We searched the grey literature databases to identify studies not indexed in major databases and the reference lists of studies initially identified for full-text screening.

SELECTION CRITERIA

All published and unpublished randomised controlled trials (RCTs) comparing the efficacy of pharmacological interventions with no intervention, placebo or co-intervention in adults with diagnosed COPD and depression were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed articles identified by the search for eligibility. Our primary outcomes were change in depressive symptoms and adverse events. The secondary outcomes were: change in quality of life, change in dyspnoea, change in forced expiratory volume in one second (FEV1), change in exercise tolerance, change in hospital utilisation (length of stay and readmission rates), and cost-effectiveness. For continuous outcomes, we calculated the pooled mean difference (MD) or standardised mean difference (SMD) with 95% confidence interval (CI) as appropriate. For dichotomous outcomes, we calculated the pooled odds ratio (OR) and corresponding 95% CI using a random-effects model. We assessed the quality of evidence using the GRADE framework.

MAIN RESULTS

Of the 1125 records screened for eligibility, four RCTs (N = 201 participants), and one on-going study, met the inclusion criteria. Two classes of antidepressants were investigated in two separate comparisons with placebo: a tricyclic antidepressant (TCA) and selective serotonin reuptake inhibitors (SSRIs).TCA versus placeboOnly one RCT (N = 30 participants) provided results for this comparison.Primary outcomesThe TCA (nortriptyline) reduced depressive symptoms post-treatment compared to placebo (MD -10.20, 95% CI -16.75 to -3.65; P = 0.007; very low-quality evidence), as measured by the Hamilton Depression Rating Scale (HAM-D). Three participants withdrew from the trial due to adverse events related to the tested antidepressant (dry mouth, sedation, orthostatic hypotension).Secondary outcomesThe overall results post-treatment indicated that nortriptyline was not effective in improving the quality of life of individuals with COPD, as measured by the Sickness Impact Profile (MD -2.80, 95% CI -11.02 to 5.42; P = 0.50; very low-quality evidence).The results for the change in dyspnoea for the domains examined (e.g. dyspnoea scores for 'most day-to-day activities') post-treatment showed no improvement in the intervention group (MD 9.80, 95% CI -6.20 to 25.80; P = 0.23; very low-quality evidence).No data were reported for change in FEV1, change in exercise tolerance, change in hospital utilisation, or cost-effectiveness. The TCA study provided short-term results, with the last follow-up data collection at 12 weeks.The quality of the evidence for all the outcomes evaluated was very low due to a small sample size, imprecision, attrition, and selection and reporting bias.SSRIs versus placeboThree RCTs (N = 171 participants) provided results for this comparison.Primary outcomesThe pooled results for two studies showed no difference for the change in depressive symptoms post-intervention (SMD 0.75, 95% CI -1.14 to 2.64; 148 participants; 2 studies; P = 0.44; very low-quality evidence). High heterogeneity was observed (I² = 95%), limiting the reliability of these findings.While it was not possible to meta-analyse the total adverse events rates across the studies, it was possible to combine the results for two medication-specific adverse effects: nausea and dizziness. There were no significant post-treatment group differences for nausea (OR 2.32, 95% CI 0.66 to 8.12; 171 participants; 3 studies; P = 0.19; very low-quality evidence) or dizziness (OR 0.61, 95% CI 0.09 to 4.06; 143 participants; 2 studies; P = 0.61; very low-quality evidence).Secondary outcomesThe pooled analysis of two trials reporting data for the change in quality of life did not show improvement post-treatment in the intervention group compared to placebo (SMD 1.17, 95% CI -0.80 to 3.15; 148 participants; 2 studies; P = 0.25; very low-quality evidence).There was no difference between groups in change in FEV1 post-treatment (MD 0.01, 95% CI -0.03 to 0.05; 148 participants; 2 studies; P = 0.60; low-quality evidence). However, two trials reported improvement in exercise tolerance in the SSRI group versus the placebo group (MD 13.88, 95% CI 11.73 to 16.03; 148 participants; 2 studies; P < 0.001; very low-quality evidence).The trials included in this comparison did not report data related to the change in dyspnoea, hospital utilisation rates, or cost-effectiveness.

AUTHORS' CONCLUSIONS

There is insufficient evidence to make definitive statements about the efficacy or safety of antidepressants for treating COPD-related depression. New RCTs are needed; with better methodological quality and more accurate reporting of the methods used. Moreover, longer-term follow-up data collection is needed, including outcomes such as adverse events, hospital utilisation and cost-effectiveness.

Time-series hyperpolarized xenon-129 MRI of lobar lung ventilation of COPD in comparison to V/Q-SPECT/CT and CT

Purpose

To derive lobar ventilation in patients with chronic obstructive pulmonary disease (COPD) using a rapid time-series hyperpolarized xenon-129 (HPX) magnetic resonance imaging (MRI) technique and compare this to ventilation/perfusion single-photon emission computed tomography (V/Q-SPECT), correlating the results with high-resolution computed tomography (CT) and pulmonary function tests (PFTs).

Materials and methods

Twelve COPD subjects (GOLD stages I–IV) participated in this study and underwent HPX-MRI, V/Q-SPECT/CT, high-resolution CT, and PFTs. HPX-MRI was performed using a novel time-series spiral k-space sampling approach. Relative percentage ventilations were calculated for individual lobe for comparison to the relative SPECT lobar ventilation and perfusion. The absolute HPX-MRI percentage ventilation in each lobe was compared to the absolute CT percentage emphysema score calculated using a signal threshold method. Pearson’s correlation and linear regression tests were performed to compare each imaging modality.

Results

Strong correlations were found between the relative lobar percentage ventilation with HPX-MRI and percentage ventilation SPECT (r = 0.644; p < 0.001) and percentage perfusion SPECT (r = 0.767; p < 0.001). The absolute CT percentage emphysema and HPX percentage ventilation correlation was also statistically significant (r = 0.695, p < 0.001). The whole lung HPX percentage ventilation correlated with the PFT measurements (FEV₁ with r = − 0.886, p < 0.001*, and FEV₁/FVC with r = − 0.861, p < 0.001*) better than the whole lung CT percentage emphysema score (FEV₁ with r = − 0.635, p = 0.027; and FEV₁/FVC with r = − 0.652, p = 0.021).

Conclusion

Lobar ventilation with HPX-MRI showed a strong correlation with lobar ventilation and perfusion measurements derived from SPECT/CT, and is better than the emphysema score obtained with high-resolution CT.

Key Points

• The ventilation hyperpolarized xenon-129 MRI correlates well with ventilation and perfusion with SPECT/CT with the advantage of higher temporal and spatial resolution.

• The hyperpolarized xenon-129 MRI correlates with the PFT measurements better than the high-resolution CT with the advantage of avoiding the use of ionizing radiation.

Electronic supplementary material

The online version of this article (10.1007/s00330-018-5888-y) contains supplementary material, which is available to authorized users.

Comparison of clinical efficacy between ultra-LABAs and ultra-LAMAs in COPD: a systemic review with meta-analysis of randomized controlled trials

Background

A single long-acting bronchodilator, ultra-long acting muscarinic antagonist (ultra-LAMA) or ultra-long acting β₂-agonist (ultra-LABA) is preferred for the initial treatment of patients with chronic obstructive pulmonary disease (COPD); however, there are few head-to-head comparative studies between the two. Here, a meta-analysis of randomized controlled trials was performed to compare the clinical efficacy between ultra-LABA and ultra-LAMA in patients with moderate-to-severe COPD.

Methods

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched (to March 1, 2017) to identify all published randomized controlled trials.

Results

Of the 12,906 articles found by searching the databases, we obtained data from 10,591 patients with COPD (LABA, n=5,058; LAMA, n=5,533) in seven published studies. Our results showed that COPD exacerbation were significantly lower in patients taking ultra-LAMA than those taking ultra-LABA (odds ratio =0.857, P=0.0008). However, no significant differences were observed between ultra-LAMA and ultra-LABA patients regarding improvement in trough forced expiratory volume in 1 s, the transitional dyspnea index, or St. George's Respiratory Questionnaire score.

Conclusions

This study suggests that COPD exacerbation occurred less often in patients taking an ultra-LAMA than in those taking an ultra-LABA with similar efficacy of lung function and quality of life.

Saikosaponin a Inhibits Cigarette Smoke-Induced Oxidant Stress and Inflammatory Responses by Activation of Nrf2

Saikosaponin a (SSa), a triterpenoid saponin, has numerous pharmacological properties, including anti-inflammatory and antioxidant effects. The purpose of this study was to investigate whether and how SSa protected against cigarette smoke (CS)-induced lung inflammation in mice. The mice were exposed to CS and SSa was administered by an intraperitoneal (i.p.) injection 1 h before CS treatment for 5 consecutive days. The results showed that SSa significantly inhibited CS-induced inflammatory cell infiltration, NO, TNF-α, and IL-1β production in BALF. SSa also inhibited CS-induced MPO and MDA contents in lung tissues. Furthermore, SSa significantly inhibited CS-induced NF-κB and upregulated the expression of Nrf2 and HO-1. In conclusion, these results support a therapeutic potential for SSa in CS-induced lung inflammation.

Forecasting life expectancy, years of life lost, and all-cause and cause-specific mortality for 250 causes of death: reference and alternative scenarios for 2016-40 for 195 countries and territories

BACKGROUND

Understanding potential trajectories in health and drivers of health is crucial to guiding long-term investments and policy implementation. Past work on forecasting has provided an incomplete landscape of future health scenarios, highlighting a need for a more robust modelling platform from which policy options and potential health trajectories can be assessed. This study provides a novel approach to modelling life expectancy, all-cause mortality and cause of death forecasts -and alternative future scenarios-for 250 causes of death from 2016 to 2040 in 195 countries and territories.

METHODS

We modelled 250 causes and cause groups organised by the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) hierarchical cause structure, using GBD 2016 estimates from 1990-2016, to generate predictions for 2017-40. Our modelling framework used data from the GBD 2016 study to systematically account for the relationships between risk factors and health outcomes for 79 independent drivers of health. We developed a three-component model of cause-specific mortality: a component due to changes in risk factors and select interventions; the underlying mortality rate for each cause that is a function of income per capita, educational attainment, and total fertility rate under 25 years and time; and an autoregressive integrated moving average model for unexplained changes correlated with time. We assessed the performance by fitting models with data from 1990-2006 and using these to forecast for 2007-16. Our final model used for generating forecasts and alternative scenarios was fitted to data from 1990-2016. We used this model for 195 countries and territories to generate a reference scenario or forecast through 2040 for each measure by location. Additionally, we generated better health and worse health scenarios based on the 85th and 15th percentiles, respectively, of annualised rates of change across location-years for all the GBD risk factors, income per person, educational attainment, select intervention coverage, and total fertility rate under 25 years in the past. We used the model to generate all-cause age-sex specific mortality, life expectancy, and years of life lost (YLLs) for 250 causes. Scenarios for fertility were also generated and used in a cohort component model to generate population scenarios. For each reference forecast, better health, and worse health scenarios, we generated estimates of mortality and YLLs attributable to each risk factor in the future.

FINDINGS

Globally, most independent drivers of health were forecast to improve by 2040, but 36 were forecast to worsen. As shown by the better health scenarios, greater progress might be possible, yet for some drivers such as high body-mass index (BMI), their toll will rise in the absence of intervention. We forecasted global life expectancy to increase by 4·4 years (95% UI 2·2 to 6·4) for men and 4·4 years (2·1 to 6·4) for women by 2040, but based on better and worse health scenarios, trajectories could range from a gain of 7·8 years (5·9 to 9·8) to a non-significant loss of 0·4 years (-2·8 to 2·2) for men, and an increase of 7·2 years (5·3 to 9·1) to essentially no change (0·1 years [-2·7 to 2·5]) for women. In 2040, Japan, Singapore, Spain, and Switzerland had a forecasted life expectancy exceeding 85 years for both sexes, and 59 countries including China were projected to surpass a life expectancy of 80 years by 2040. At the same time, Central African Republic, Lesotho, Somalia, and Zimbabwe had projected life expectancies below 65 years in 2040, indicating global disparities in survival are likely to persist if current trends hold. Forecasted YLLs showed a rising toll from several non-communicable diseases (NCDs), partly driven by population growth and ageing. Differences between the reference forecast and alternative scenarios were most striking for HIV/AIDS, for which a potential increase of 120·2% (95% UI 67·2-190·3) in YLLs (nearly 118 million) was projected globally from 2016-40 under the worse health scenario. Compared with 2016, NCDs were forecast to account for a greater proportion of YLLs in all GBD regions by 2040 (67·3% of YLLs [95% UI 61·9-72·3] globally); nonetheless, in many lower-income countries, communicable, maternal, neonatal, and nutritional (CMNN) diseases still accounted for a large share of YLLs in 2040 (eg, 53·5% of YLLs [95% UI 48·3-58·5] in Sub-Saharan Africa). There were large gaps for many health risks between the reference forecast and better health scenario for attributable YLLs. In most countries, metabolic risks amenable to health care (eg, high blood pressure and high plasma fasting glucose) and risks best targeted by population-level or intersectoral interventions (eg, tobacco, high BMI, and ambient particulate matter pollution) had some of the largest differences between reference and better health scenarios. The main exception was sub-Saharan Africa, where many risks associated with poverty and lower levels of development (eg, unsafe water and sanitation, household air pollution, and child malnutrition) were projected to still account for substantive disparities between reference and better health scenarios in 2040.

INTERPRETATION

With the present study, we provide a robust, flexible forecasting platform from which reference forecasts and alternative health scenarios can be explored in relation to a wide range of independent drivers of health. Our reference forecast points to overall improvements through 2040 in most countries, yet the range found across better and worse health scenarios renders a precarious vision of the future-a world with accelerating progress from technical innovation but with the potential for worsening health outcomes in the absence of deliberate policy action. For some causes of YLLs, large differences between the reference forecast and alternative scenarios reflect the opportunity to accelerate gains if countries move their trajectories toward better health scenarios-or alarming challenges if countries fall behind their reference forecasts. Generally, decision makers should plan for the likely continued shift toward NCDs and target resources toward the modifiable risks that drive substantial premature mortality. If such modifiable risks are prioritised today, there is opportunity to reduce avoidable mortality in the future. However, CMNN causes and related risks will remain the predominant health priority among lower-income countries. Based on our 2040 worse health scenario, there is a real risk of HIV mortality rebounding if countries lose momentum against the HIV epidemic, jeopardising decades of progress against the disease. Continued technical innovation and increased health spending, including development assistance for health targeted to the world's poorest people, are likely to remain vital components to charting a future where all populations can live full, healthy lives.

FUNDING

Bill & Melinda Gates Foundation.

Correlation of chronic obstructive pulmonary disease assessment test and clinical chronic obstructive pulmonary disease questionnaire score with BODE index in patients of stable chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) has a major impact on health status in accordance with disease severity. It is usually assessed by the various quality of life questionnaires.

OBJECTIVES

The aim of this study is to assess the disease severity and health status in stable patients of COPD using COPD assessment test (CAT) and clinical COPD questionnaire (CCQ) scores and to correlate with BODE index and its components.

METHODS

One hundred patients of stable COPD were subjected to CAT, CCQ irrespective of the stage of COPD during their visit. BODE index was also calculated.

RESULTS

COPD severity status assessed using forced expiratory volume 1% (FeV1%) predicted values correlated significantly with individual scores (CAT and FeV1%; r = -0.67; P < 0.001 and CCQ and FeV1%; r = 0.61; P < 0.001). CAT and CCQ score also correlated significantly (r = 0.84, P < 0.001) and both with the BODE index (r = 0.80; CAT and r = 0.66; CCQ, P < 0.01). Individual components of BODE index significantly correlated with CAT and CCQ scores.

CONCLUSIONS

The CAT and CCQ have similar psychometric as well physical properties to assess the health status of COPD patients and can be used as a reliable scientific research tool and can be used in clinical practise to study the disease state and plan an appropriate treatment plan. The BODE index which is more objective, correlated well.

Racial differences in comorbidity profile among patients with chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is often accompanied by multiple comorbidities, which are associated with an increased risk of exacerbation, a poor health-related quality of life, and high mortality. However, differences in comorbidity profile by race and ethnicity in COPD patients have not been fully elucidated.

METHODS

Participants aged 40 to 79 years with spirometry-defined COPD from the U.S. National Health and Nutrition Examination Survey (NHANES) (2007-2012) and from the Korea NHANES (2007-2015) were analyzed to compare the prevalence of comorbidities by race and ethnicity group. Comorbidities were defined using questionnaire data, physical exams, and laboratory tests.

RESULTS

Non-Hispanic Whites had the highest prevalence of dyslipidemia (65.5%), myocardial infarction (6.2%), osteoarthritis (40.1%), and osteoporosis (13.6%), while non-Hispanic Blacks had the highest prevalence of asthma (24.0%), hypertension (70.2%), stroke (7.3%), diabetes mellitus (DM) (23.3%), anemia (16.4%), and rheumatoid arthritis (11.9%). Compared to non-Hispanic Whites, non-Hispanic Blacks had a significantly higher prevalence of hypertension, stroke, DM, anemia, and rheumatoid arthritis after adjusting for age, sex, body mass index, and smoking status, while Hispanics had a significantly higher prevalence of DM and anemia, and Koreans had significantly lower prevalences of all comorbidities except stroke, DM, and anemia.

CONCLUSIONS

COPD-related comorbidities varied significantly by race and ethnicity, and different strategies may be required for the optimal management of COPD and its comorbidities in different race and ethnicity groups.

Revised (2018) COPD Clinical Practice Guideline of the Korean Academy of Tuberculosis and Respiratory Disease: A Summary

Chronic obstructive pulmonary disease (COPD) results in high morbidity and mortality among patients nationally and globally. The Korean clinical practice guideline for COPD was revised in 2018. The guideline was drafted by the members of the Korean Academy of Tuberculosis and Respiratory Diseases as well as the participating members of the Health Insurance Review and Assessment Service, Korean Physicians' Association, and Korea Respiration Trouble Association. The revised guideline encompasses a wide range of topics, including the epidemiology, diagnosis, assessment, monitoring, management, exacerbation, and comorbidities of COPD in Korea. We performed systematic reviews assisted by an expert in meta-analysis to draft a guideline on COPD management. We expect this guideline to facilitate the treatment of patients with respiratory conditions by physicians as well other health care professionals and government personnel in South Korea.

Quantitative assessment of pulmonary vascular alterations in chronic obstructive lung disease: Associations with pulmonary function test and survival in the KOLD cohort

PURPOSE

Despite the high prevalence of pulmonary vascular alterations and their substantial impact on chronic obstructive pulmonary disease (COPD), tools for the direct in vivo assessment of pulmonary vascular alterations remain limited. Thus, the purpose of this study was to automatically extract pulmonary vessels from volumetric chest CT and evaluate the associations between the derived quantitative pulmonary vessel features and clinical parameters, including survival, in COPD patients.

METHODS

This study included 344 adult COPD patients. Pulmonary vessels were automatically extracted from volumetric chest CT data. Quantitative pulmonary vessel features were obtained from various lung surface areas (LSAs), which are theoretical surface areas drawn at different depths from the pleural borders. The total number of vessels (N_total) and number of vessels with vessel area (VA) less than 5 mm² (N_<5mm) were counted as both robust values and as values per 10 cm² of LSA (N_total/LSA; N_<5mm/LSA). The average VA (VA_mean) and percentage of measured VA in the corresponding LSA (%VA) were measured. Associations between quantitative pulmonary vessel features and clinical parameters, including survival and the pulmonary function test (PFT), were evaluated.

RESULTS

The pulmonary vessels were automatically extracted with 100% technical success. Cox regression analysis showed N_total/LSA, N_<5mm/LSA, VA_mean, and %VA to be significant predictors of survival (hazard ratio (HR), 0.80, 0.75, 0.70, 0.49, respectively). Patients classified into high-risk groups by %VA_18mm (cut-off = 3.258), chosen because it demonstrated the strongest statistical influence on survival in a univariate Cox analysis, were associated with worse overall survival before (HR, 4.83; p < 0.001) and after adjustment for patient age and BMI (HR, 2.18; p = 0.014). Of the quantitative pulmonary vessel features, N_total/LSA, N_<5mm/LSA, and %VA were correlated with FEV₁, FEV₁/FVC, and DLCO in all LSAs. The strongest correlation with PFTs was noted at LSA_9mm for both N_total (FEV₁, r = 0.33; FEV₁/FVC, r = 0.51) and N_<5mm (FEV₁, r = 0.35; FEV₁/FVC, r = 0.52). For %VA, the association was most evident at LSA_18mm (FEV₁, r = 0.27; FEV₁/FVC, r = 0.47). Significant moderate to strong correlations were consistently observed between the extent of emphysema and quantitative pulmonary vessel features (r = 0.44-0.66; all p < 0.001).

CONCLUSIONS

The automated extraction of pulmonary vessels and their quantitative assessment are technically feasible. Various quantitative pulmonary vessel features demonstrated significant relationships with survival and PFT in COPD patients. Of the various quantitative features, the percentage of total VA measured at 18 mm depth from the pleural surface (%VA_18mm) and the number of small vessels counted per 10 cm² of LSA at 9 mm depth from the pleural surface (N_<5mm/LSA_9mm) had the strongest predictability for the clinical parameters.

Discovery of natural flavonoids as activators of Nrf2-mediated defense system: Structure-activity relationship and inhibition of intracellular oxidative insults

Continuous overproduction of reactive oxygen species (ROS), termed as oxidative stress, plays a crucial role in the onset and progression of many human diseases. Activation of nuclear transcription factor erythroid 2-related factor (Nrf2) by small molecules could eliminate ROS, and thus block the pathogenesis of oxidative stress-induced diseases. In this study, a natural flavonoid library was established and tested for their potential Nrf2 inducing effects. Based on QR inducing effect of flavonoids, their structure-activity relationship (SAR) on Nrf2 induction was summarized, and twenty flavonoids were firstly identified to be potential activators of Nrf2-mediated defensive response. Then, 7-O-methylbiochanin A (7-MBA) was further investigated for its capability on the Nrf2 activation and prevention against oxidative insults in human lung epithelial cells. Further studies indicated that 7-MBA activated Nrf2 signaling pathway and protected human lung epithelial Beas-2B cells against sodium arsenite [As(III)]-induced cytotoxicity in an Nrf2-dependent manner. Activation of Nrf2 by 7-MBA upregulated intracellular antioxidant capacity, which was produced by enhancement of Nrf2 stabilization, blockage of Nrf2 ubiquitination, as well as Nrf2 phosphorylation by mitogen-activated protein kinase (MAPK), protein kinase C (PKC), protein kinase R-like endoplasmic reticulum kinase (PERK), and phosphatidylinositol-4,5-bisphosphate 3-kinase (PI3K). Taken together, 7-MBA is a novel isoflavone-type Nrf2 activator displaying potential preventive effect against oxidative damages in human lung epithelial cells.

Chronic obstructive pulmonary disease with short-acting inhaled pharmacotherapy increases the risk of prostate cancer: A two-stage database approach

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) are at a higher risk of many types of cancer. However, specific investigation of the risk of prostate cancer and the influence of COPD pharmacotherapy in patients with COPD is lacking. This study investigated the risk and influence of COPD pharmacotherapy on risk of prostate cancer in patients with COPD.

METHODS

This retrospective cohort study used data from Taiwan's Longitudinal Health Insurance Database 2005 (LHID2005). The study cohort comprised COPD patients who received treatment between 2004 and 2008, and who were identified from the LHID2005. The control cohort comprised patients without COPD and was matched to the study cohort by age and sex. Two-stage propensity score calibration with the National Health Interview Survey 2005 was performed to obtain the missing confounders of smoking, alcohol drinking, and body mass index in the LHID. The hazard ratio (HR) and adjusted HR were estimated. Moreover, the influence of inhaled medications and other related medication on the risk of prostate cancer was analyzed by Cox proportional hazard regression.

RESULTS

The COPD cohort comprised 12,774 patients, and the control cohort comprised 38,322 patients (1:3). The incidence of prostate cancer was 633 per 100,000 person-years in the COPD cohort and 361 per 100,000 person-years in the control cohort. The propensity score calibration-adjusted HR was 1.62 (95% CI, 1.40-1.87, p < 0.001) in the COPD cohort. Further analysis revealed that the adjusted HR for the risk of prostate cancer was 1.61 (95% CI, 1.19-2.16, p = 0.002) in patients with COPD who used short-acting muscarinic antagonists (SAMAs) and 1.89 (95% CI, 1.40-2.54, p < 0.001) in patients with COPD who used short-acting beta-agonists (SABAs). COPD patients had lower risk of prostate cancer when using statin (HR = 0.63, 95% CI, 0.45-0.89, p = 0.010) or aspirin (HR = 0.55, 95% CI, 0.35-0.85, p = 0.008).

CONCLUSION

Patients with COPD are at a higher risk of prostate cancer, particularly those using SAMAs or SABAs. This finding suggests that inflammation control may be an effective strategy for decreasing the risk of prostate cancer.

Prevalence of undiagnosed COPD in male patients with coronary artery disease: a cross-sectional study in Jordan

Purpose

COPD and coronary artery disease (CAD) are common chronic diseases with shared risk factors. COPD continues to be largely underdiagnosed and undertreated. We aimed to describe the prevalence and predictors of undiagnosed COPD in Jordanian men with CAD.

Patients and methods

In a cross-sectional study conducted at a referral center in Jordan, male patients who underwent coronary angiography for suspected CAD and reported ≥10 pack-year of cigarette smoking were recruited. Pre- and post-bronchodilator spirometry was undertaken for all participants, and COPD was defined as post-bronchodilator FEV₁/FVC <70%. The finding of ≥50% coronary luminal narrowing confirmed the presence of CAD.

Results

Spirometry was undertaken for 376 men with mean age of 56.02±10.55 years, and 72.6% were active cigarettes smokers with a mean pack-year of 55.89±34.25. A CAD diagnosis was confirmed in 300 (79.8%) men. Spirometric criteria for COPD were met in 76 (15.7%) patients, of whom 91.5% were not previously diagnosed. COPD-related symptoms were common: chronic cough (44.4%), dyspnea (66.2%), and wheezes (27.9%). COPD was more common in patients with (18.0%) compared to patients without (6.6%) CAD (P=0.014). Multivariate logistic regression showed that the risk of COPD was higher in patients with CAD (OR 3.16, 95% CI, 1.10–9.09, P=0.033) and in those with chronic bronchitis (OR 13.07, 95% CI, 6.69–25.52, P<0.001).

Conclusion

There was a high prevalence of COPD among male patients with CAD and most were underdiagnosed despite having respiratory symptoms. Male smokers with CAD and respiratory symptoms should be evaluated for airflow limitation and the presence of COPD.

The impact of dyspnea and threat of dyspnea on error processing

Dyspnea (breathlessness) is a threatening and aversive bodily sensation and a major symptom of various diseases. It has been suggested to impair several aspects of functioning in affected patients, but experimental proof for this assumption is widely absent. Error processing is an important domain of functioning and has intensively been studied using electrophysiological measures. Specifically, the error-related negativity (ERN) has been suggested to reflect early performance monitoring and error detection, while the error positivity (Pe) has been linked to subsequent error awareness. So far, little is known about the effects of anticipated or perceived dyspnea on error processing. Therefore, in 49 healthy participants, we studied the effects of experimentally induced dyspnea and threat of dyspnea on the ERN/Pe and behavioral task performance. Participants performed the arrowhead version of the flanker task during three experimental conditions: an unloaded baseline condition, a dyspnea condition, and a threat of dyspnea condition. Dyspnea was induced by breathing through inspiratory resistive loads, while high-density EEG was continuously measured. No differences in task performance (reaction times, error rates) and ERN mean amplitudes were found between conditions. However, mean amplitudes for the Pe differed between conditions with smaller Pe amplitudes during threat of dyspnea compared to baseline and dyspnea conditions, with the latter two conditions showing no difference. These results may suggest that threat of dyspnea, but not dyspnea itself, reduces error awareness, while both seem to have no impact on early error processing and related behavioral performance.

Mobile health applications in self-management of patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis of their efficacy

Background

Mobile health applications are increasingly used in patients with Chronic Obstructive Pulmonary Disease (COPD) to improve their self-management, nonetheless, without firm evidence of their efficacy. This meta-analysis was aimed to assess the efficacy of mobile health applications in supporting self-management as an intervention to reduce hospital admission rates and average days of hospitalization, etc.

Methods

PubMed, Web of Science (SCI), Cochrane Library, and Embase were searched for relevant articles published before November 14th, 2017. A total of 6 reports with randomized controlled trials (RCTs) were finally included in this meta-analysis.

Results

Patients using mobile phone applications may have a lower risk for hospital admissions than those in the usual care group (risk ratio (RR) = 0.73, 95% CI [0.52, 1.04]). However, there was no significant difference in reducing the average days of hospitalization.

Conclusion

Self-management with mobile phone applications could reduce hospital admissions of patients with COPD.

Effects of the Chinese herb formula Yufeining on stable chronic obstructive pulmonary disease: A randomized, double-blind, placebo-controlled trial

BACKGROUND

A Chinese herb formula Yufeining (YFN) has showed promise in the treatment of stable chronic obstructive pulmonary disease (COPD), less is known that the impact of YFN in combination with standard Western treatments on lung inflammation. This study evaluated the safety and efficacy of YFN as a treatment for stable COPD and as an anti-inflammatory agent.

METHODS

Sixty patients with stable COPD were randomly assigned to two treatment groups (YFN treatment, N = 30; placebo treatment, N = 30). Both groups received inhaled steroids and bronchodilators during an 8-week intervention, and patient status was assessed at 8 weeks later and 4 months after treatment. The primary outcome included clinical efficacy. The secondary outcomes involved CAT score, mMRC grade, six-minute walking distance (6MWD). IL-8, TNF-α, IL-17A, LTB4, TGF-β1 and CRP were also detection in peripheral serum, as well as adverse reaction conditions.

RESULTS

The YFN group demonstrated a significant improvement in clinical efficacy (compare 89.3% to 63.3% in the placebo group; P < 0.05). CAT scores and mMRC grades significantly decreased (P < 0.05, P < 0.01), and 6MWD significantly increased (P<0.05), after YFN treatment. The levels of IL-8, TNF-α, LTB4 and CRP decreased significantly after 8 weeks of treatment compared to baseline levels in both groups. Only in the YFN treatment group, the levels of IL-17A decreased significantly after treatment compared to baseline levels (P < 0.05). No changes were observed inTGF-β1 from pre-to post-treatment in either group (P > 0.05). Serum levels of IL-8, TNF-α, IL-17A, LTB4 and CRP decreased significantly after YFN treatment compared to the placebo group (P < 0.05).

CONCLUSION

A combinatorial treatment approach with YFN, inhaled steroids and bronchodilators produced a clinically effective treatment for stable COPD, leading to a significant decrease in circulating inflammatory mediators. The study appeared YFN was safety.

CLINICAL TRIAL REGISTRATION NUMBER

No. ChiCTR-IOR-17013577.

Spirometric Values of Greek People and Comparison with ECSC and GLI Values in COPD People

Background:

During the past few years, the use of criteria introduced by Global Initiative for Chronic Obstructive Lung Disease (GOLD) is recommended for the diagnosis and classification of Chronic Obstructive Pulmonary Disease(COPD),taking into account the values of a Forced Expiratory Volume In 1 second (FEV1) and a Forced Expiratory Volume In 1 second (FEV1) to Forced Vital Capacity (FVC) ratio. In Europe, the reference values of the European Coal and Steel Community (ECSC), that were originally developed in 1993 are still used.

Aim of the Study:

The study aimed to carry out measurement of spirometric values in a healthy, non smoking Greek population, development of local equations and comparison with ECSC and Global Lung Initiative(GLI) equations, in order to see if there is a need for separate ones in everyday use.

Methods:

Normal predicted values for FEV1 and FEV1/FVC% were obtained from a group of 500 healthy subjects, aged 18-89 years. In addition, a group of 124 COPD patients, with no other comorbidities was studied. Patients were classified according to GOLD criteria in four groups with ECSC, GLI predicted values or with our own predicted values.

Results:

The statistical analysis has revealed that there is no significant difference among the three sets of predicted values and no statistical difference was detected among the classification of COPD patients.

Conclusion:

It is shown that the 3 sets of predicted values are almost identical, despite the fact that they have been collected from different study populations.Αccording to the study, there is no need in recalculating values for Greek population.

Proteases and Their Inhibitors in Chronic Obstructive Pulmonary Disease

In the context of respiratory disease, chronic obstructive pulmonary disease (COPD) is the leading cause of mortality worldwide. Despite much development in the area of drug development, currently there are no effective medicines available for the treatment of this disease. An imbalance in the protease: Antiprotease ratio in the COPD lung remains an important aspect of COPD pathophysiology and several studies have shown the efficacy of antiprotease therapy in both in vitro and in vivo COPD models. However more in-depth studies will be required to validate the efficacy of lead drug molecules targeting these proteases. This review discusses the current status of protease-directed drugs used for treating COPD and explores the future prospects of utilizing the potential of antiprotease-based therapeutics as a treatment for this disease.

Mind⁻Body (Baduanjin) Exercise Prescription for Chronic Obstructive Pulmonary Disease: A Systematic Review with Meta-Analysis

Baduanjin exercise is a traditional Chinese health Qigong routine created by an ancient physician for health promotion. Its mild-to-moderate exercise intensity is suitable for individuals with medical conditions. Recently, a large number of trials have been conducted to investigate the effects of Baduanjin exercise in patients with chronic obstructive pulmonary disease (COPD). It remains to be determined whether Baduanjin exercise prescription is beneficial for the management of COPD patients. Thus, we conducted a systematic review to objectively evaluate the existing literature on this topic. We searched six databases (PubMed, Web of Science, Cochrane Library, Scopus, China National Knowledge Infrastructure, and Wanfang) from inception until early May 2018. The adapted Physical Therapy Evidence Database (PEDro) scale was used for study quality assessment of all randomized controlled trials (RCTs). Based on 95% confidence interval (CI), the pooled effect size (Hedge's g) of exercise capability (6-Minute Walking Test, 6-MWT), lung function parameters (forced expiratory volume in one second, FEV₁; forced volume vital capacity, FVC; FEV₁/FVC ratio), and quality of life were calculated based on the random-effects model. Twenty RCTs (n = 1975 COPD patients) were included in this review, with sum scores of the adapted PEDro scale between 5 and 9. Study results of the meta-analysis indicate that Baduanjin is effective in improving exercise capability (Hedge's g = 0.69, CI 0.44 to 0.94, p < 0.001, I² = 66%), FEV₁ (Hedge's g = 0.47, CI 0.22 to 0.73, p < 0.001, I² = 68.01%), FEV₁% (Hedge's g = 0.38, CI 0.21 to 0.56, p < 0.001, I² = 54.74%), FVC (Hedge's g = 0.39, CI 0.22 to 0.56, p < 0.001, I² = 14.57%), FEV₁/FVC (Hedge's g = 0.5, CI 0.33 to 0.68, p < 0.001, I² = 53.49%), and the quality of life of COPD patients (Hedge's g = -0.45, CI -0.77 to -0.12, p < 0.05, I² = 77.02%), as compared to control groups. Baduanjin exercise as an adjunctive treatment may potentially improve exercise capability and pulmonary function of COPD patients as well as quality of life. Baduanjin exercise could be tentatively prescribed for COPD in combination with the conventional rehabilitation program to quicken the process of recovery. To confirm the positive effects of Baduanjin exercise for COPD patients, future researchers need to consider our suggestions mentioned in this article.

Administrative databases and clinical governance: The case of COPD

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. However, COPD is still underdiagnosed, undertreated, and not sufficiently prevented. Health administrative databases provide a powerful way of studying COPD in the population.

METHODS

This retrospective study used administrative data, collected during 2011 and 2012, retrieved from 3 Italian local health authorities (LHAs).

RESULTS

The analysis through administrative databases allowed firstly to identify patients with COPD receiving services by the 3 LHAs: The estimated average is ~3% of the population aged ≥40 years. Furthermore, it was also possible to stratify patients by investigating the health consumption in hospitalization for COPD and use of respiratory drugs. In all 3 LHA patients with moderate COPD were the majority of the population with COPD. Finally, it was possible to distinguish patients who made an appropriate use of SABA (76% of the total), patients who had a potentially inappropriate use (20%), and those with an overuse of SABA (4%).

CONCLUSION

The use of SABA consumption patterns can be a reliable proxy variable to detect subgroups who may necessitate therapy revision. Health administrative databases seem beneficial for planning health care interventions, including the COPD field. They are robust information systems subjected to regular data quality controls remaining the prevalent data source, reliable because of the amount of data and the population coverage, especially in countries with a National Health Service System.

The prevalence of chronic airflow obstruction in three cities in the Nordic-Baltic region

BACK GROUND

Chronic airflow obstruction (CAO) is the primary characteristic of Chronic obstructive pulmonary disease (COPD) but is also seen in chronic asthma.

OBJECTIVE

To compare the prevalence of CAO and possible risk factors between Tartu in Estonia, Reykjavik in Iceland and Uppsala in Sweden.

METHODS

All participants underwent spirometry testing of forced expiratory volume in 1 s (FEV₁) and forced vital capacity (FVC) before and after bronchodilation. CAO was defined as post-bronchodilator FEV₁/FVC below lower limit of normal. Information on respiratory diseases and smoking status, was obtained through questionnaires administered by trained interviewers.

RESULTS

1037 men and 956 women participated in the study. The prevalence of CAO was lower in women in Tartu compared to the other centres (4.9% vs. 13.4 and 8.7% in Reykjavik and Uppsala, respectively, p = 0.002) while no difference was found for men. A similar picture was seen for the proportion of participants that had smoked 10 pack years or more which was much lower in Tartu for women than in Reykjavik and Uppsala, respectively (13.2% vs. 33.7 and 29.2%, p < 0.001). (Fig. 1). Of the participants with CAO the majority (57-67%) did not have a previous diagnosis of asthma or COPD.

CONCLUSION

The prevalence of CAO was lower in Estonian women than in women from Iceland and Sweden. The reason for this was probably that the Estonian women had smoked less than the female participants from Iceland and Sweden. The majority of those with CAO do not have a diagnosed lung disease.

Single inhaler triple therapy with extrafine beclomethasone, formoterol, and glycopyrronium for the treatment of chronic obstructive pulmonary disease

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) management focuses on the alleviation of symptoms and prevention of exacerbations. Inhaled long acting bronchodilators and inhaled corticosteroids (ICS) are the main classes of treatment for COPD. Triple therapy with a long acting beta₂-agonist (LABA), long acting muscarinic antagonist (LAMA), and ICS is commonly prescribed for symptomatic COPD patients experiencing regular exacerbations. Triple therapy is usually administered using separate inhalers; there is little clinical trial evidence of an effect on exacerbation prevention with this approach. Areas covered: This evaluation reviews the single inhaler extrafine combination containing beclometasone diproprionate (BDP), formoterol fumarate (FF), and glycopyrronium bromide (GB) which has been developed as a simplified triple regime. BDP/FF/GB significantly reduced exacerbation rates in three clinical trials (1-year duration) compared against LAMA monotherapy (20% exacerbation reduction), ICS/LABA combination (23% exacerbation reduction), and LAMA/LABA combination (15% exacerbation reduction). Expert opinion: The practical benefits of single inhaler triple therapy in the real world have not been studied. However, the robust clinical trial evidence that BDP/FF/GB reduces exacerbations compared to double combination treatments and LAMA monotherapy cements triple therapy positioning as an escalation step in COPD management pathways.

Short-term benefit of smoking cessation along with glycopirronium on lung function and respiratory symptoms in mild COPD patients: a retrospective study

INTRODUCTION

Tobacco smoke is the leading cause of chronic obstructive pulmonary disease (COPD). Smoking cessation can change the natural history of COPD, as we know from the GOLD guidelines. Little is known about the short-term clinical and functional effects of smoking cessation treatment combined with anti-muscarinic bronchodilators.

OBJECTIVE

To determine whether quitting smoking, obtained by smoking cessation treatment combined with the use of a new long-acting muscarinic antagonist bronchodilator (LAMA), can improve lung function tests and respiratory symptoms more than the use of LAMA alone.

METHODS

We evaluated, in a retrospective analysis, the functional and clinical data, collected in one year, of 120 patients who were current smokers affected by mild COPD and who quit smoking using smoking cessation treatment combined with glycopirronium. We compared them with a group of 80 patients with mild COPD undergoing the same treatment but who did not quit smoking. All patients underwent functional and clinical tests at baseline and at a third-month check.

MEASUREMENTS AND MAIN RESULTS

The two groups were homogeneous in terms of demographic data without significant differences. All patients used varenicline for smoking cessation. They all performed the following tests: a spirometry with detection of resistances, the 6 min walking test, haemogasanalysis, the exhaled CO test, the COPD assessment test (CAT) and finally the modified Medical Research Council test (mMRC). A significant improvement in the functional tests at the third-month check was found in both groups-quitters and non-quitters. However, a notable increase in the examined parameters was registered in the group of patients who quit smoking, in particular, we observed a significant increase at the third-month check of the parameter forced expiratory volume in 1 s (FEV1) of more than 200 ml with p < 0.001. A comparison between quitters and non-quitters revealed a major benefit derived from smoking cessation in terms of functional changes and symptom relief. In particular, not only FEV1 but also forced expiratory flow at 25%-75% of vital capacity (FEF 25-75) (p < 0.01) and CAT (p < 0.001) were found to be significantly improved in patients who quit than in patients who did not at the check time point.

CONCLUSIONS

Smoking cessation treatment obtained by varenicline was confirmed as a crucial therapeutic option, especially when combined with bronchodilator in mild COPD. Patients who quit smoking could already benefit from both treatments in the short term, improving lung function and respiratory symptoms and therefore improving their quality of life.

Chronic bronchitis and airflow obstruction is associated with household cooking fuel use among never-smoking women: a community-based cross-sectional study in Odisha, India

BACKGROUND

The use of solid biomass as cooking fuel could be a potential risk factor for chronic bronchitis (CB) and airflow obstruction (AFO) among never-smoking women. The disease burden in India among women is generally underestimated due to limited population-based epidemiological investigations. The aim of the study was to determine the prevalence of CB and AFO among never-smoking women, and its association with household cooking fuel use.

METHODS

We conducted a community-based cross-sectional study with a representative study sample (N = 1120) in Odisha, India during 2013-14. Study participants, never-smoking women aged 18-49 years, were recruited randomly from the population census. Trained community health volunteers administered a validated questionnaire that aligned with the standards of the Burden of Obstructive Lung Disease (BOLD) initiative and conducted spirometry. Prevalence estimates of CB (defined as "cough with productive of sputum for at least 3 months of the year for at least 2 years") and AFO (pre-bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) < 0.7) was estimated. Indoor PM2.5 exposure data were collected from a subset of 130 of the total 1120 homes in the study settings. Multivariable regression models were used to estimate the associated risk factors.

RESULTS

Prevalence of CB and AFO were 7.3 and 22.4% respectively among the study participants. Of the study participants, 31% used exclusive liquefied petroleum gas, 18% used mixed fuel and 51% exclusively used solid biomass fuel for household cooking. In adjusted analysis, both CB (odds ratio 1·96, 95% CI: 1.06-3.64; p = 0·031) and AFO (OR 5.55, 95% CI: 3.51-8.78; p < 0·001) were found to be associated with cooking with solid biomass fuel. Interquartile range increases in PM2.5 was associated with significantly lower FEV1/FVC ratio.

CONCLUSIONS

The study highlights that the estimates of population burden of CB and AFO are much higher than shown in previous epidemiological studies, and that cooking fuel type and time spent on cooking were associated with increased chronic bronchitis as well as decreased lung function as measured by FEV1/FCV ratios. To most accurately understand the current burden of disease and most effectively prevent an escalation in the future disease burden, further epidemiological investigations are warranted.

Xeroderma Pigmentosum Group C Deficiency Alters Cigarette Smoke DNA Damage Cell Fate and Accelerates Emphysema Development

Cigarette smoke (CS) exposure is a major risk factor for the development of emphysema, a common disease characterized by loss of cells comprising the lung parenchyma. The mechanisms of cell injury leading to emphysema are not completely understood but are thought to involve persistent cytotoxic or mutagenic DNA damage induced by CS. Using complementary cell culture and mouse models of CS exposure, we investigated the role of the DNA repair protein, xeroderma pigmentosum group C (XPC), on CS-induced DNA damage repair and emphysema. Expression of XPC was decreased in mouse lungs after chronic CS exposure and XPC knockdown in cultured human lung epithelial cells decreased their survival after CS exposure due to activation of the intrinsic apoptosis pathway. Similarly, cell autophagy and apoptosis were increased in XPC-deficient mouse lungs and were further increased by CS exposure. XPC deficiency was associated with structural and functional changes characteristic of emphysema, which were worsened by age, similar to levels observed with chronic CS exposure. Taken together, these findings suggest that repair of DNA damage by XPC plays an important and previously unrecognized role in the maintenance of alveolar structures. These findings support that loss of XPC, possibly due to chronic CS exposure, promotes emphysema development and further supports a link between DNA damage, impaired DNA repair, and development of emphysema.

Clinical and economic outcomes associated with the use of fluticasone propionate 250 mcg and salmeterol 50 mcg combination versus tiotropium bromide 18 mcg as initial maintenance treatment for chronic obstructive pulmonary disease in managed care

AIMS

To examine the clinical and economic outcomes associated with the use of long-acting bronchodilators for initial maintenance treatment of chronic obstructive pulmonary disease (COPD) by analyzing health insurance claims data in the US.

METHODS

A retrospective, observational, matched cohort study used health insurance claims data (January 2008 to June 2013) to assess COPD-related outcomes for subjects aged ≥40 years. Subjects were assigned to a study cohort according to the first observed prescription fill for a long-acting bronchodilator (fluticasone propionate 250 mcg/salmeterol 50 mcg [FSC] or tiotropium bromide 18 mcg [TIO]). The analysis period for each subject comprised a 1-year pre-index date and 1-year post-index date. Primary outcome measure was total COPD-related costs per-patient per-year (PPPY) during the follow-up period. Secondary outcome measures included COPD-related exacerbations and the components of COPD-related costs.

RESULTS

Overall, 24,040 subjects were identified; the analysis sample consisted of 19,090 subjects (9,545 per cohort) with no significant differences between cohorts. Mean COPD-related total costs PPPY were numerically lower among the FSC cohort; however, the difference was not statistically significant ($2,224 [±4,108] vs $2,352 [±3,721], p = .057). There was no difference between cohorts for COPD-related medical costs (p = .894). COPD-related pharmacy costs were significantly, yet modestly, lower in the FSC cohort compared with the TIO cohort ($1,160 [±1,106] vs 1,275 [±1,110], p < .001). There were no statistically significant differences in the rate or number of exacerbations between the matched cohorts.

LIMITATIONS

While propensity scoring achieved balance in baseline characteristics, some residual confounding unobserved in the database may be present.

CONCLUSIONS

Few clinical and economic differences between subjects initiating maintenance therapy with FSC or TIO were observed.

Gender-specific estimates of COPD prevalence: a systematic review and meta-analysis

Rationale

COPD has been perceived as being a disease of older men. However, >7 million women are estimated to live with COPD in the USA alone. Despite a growing body of literature suggesting an increasing burden of COPD in women, the evidence is limited.

Objectives

To assess and synthesize the available evidence among population-based epidemiologic studies and calculate the global prevalence of COPD in men and women.

Materials and methods

A systematic review and meta-analysis reporting gender-specific prevalence of COPD was undertaken. Gender-specific prevalence estimates were abstracted from relevant studies. Associated patient characteristics as well as custom variables pertaining to the diagnostic method and other important epidemiologic covariates were also collected. A Bayesian random-effects meta-analysis was performed investigating gender-specific prevalence of COPD stratified by age, geography, calendar time, study setting, diagnostic method, and disease severity.

Measurements and main results

Among 194 eligible studies, summary prevalence was 9.23% (95% credible interval [CrI]: 8.16%-10.36%) in men and 6.16% (95% CrI: 5.41%-6.95%) in women. Gender prevalences varied widely by the World Health Organization Global Burden of Disease subregions, with the highest female prevalence found in North America (8.07% vs 7.30%) and in participants in urban settings (13.03% vs 8.34%). Meta-regression indicated that age ≥40 and bronchodilator testing contributed most significantly to heterogeneity of prevalence estimates across studies.

Conclusion

We conducted the largest ever systematic review and meta-analysis of global prevalence of COPD and the first large gender-specific review. These results will increase awareness of COPD as a critical woman's health issue.

Death-specific rate due to asthma and chronic obstructive pulmonary disease in Iran

BACKGROUND AND OBJECTIVE

Asthma and chronic obstructive pulmonary disease (COPD) could be considered as a major health problem in industrialized and developing countries. This study was designed to analyze the trends of mortality from asthma and COPD at national and subnational levels in Iran based on National Death Registry, from 2001 to 2015.

MATERIALS AND METHODS

We used Death Registration System (DRS) as the basic source of data. Death Registration System data were available from 1995 to 2010 in Iran's Ministry of Health. Although, Tehran and Isfahan, 2 most populated cities in Iran, had independent death registry systems in their cemeteries, by combining their data we achieved more comprehensive and representative data on death among Iranian people. We addressed incompleteness and misclassification of death registry system using demographic and statistical methods. We also employed spatio-temporal and Gaussian process regression to extrapolate and interpolate mortality rates for the missing data.

RESULTS

Age-standardized asthma mortality rate was 7.2 (5.6-9.2) in females and 8.8 (6.9-11.1) in males at the national level in 2015. Age-standardized COPD mortality rates in females and males, respectively, were 8.46 (6.6-10.9) and 12.38 (9.8-15.6) during the studied years. A reduction in age-standardized asthma mortality was observed during the period of study. In addition, the trend of COPD mortality was increasing.

CONCLUSIONS

It seems that mortality rate attributable to COPD has risen during the past 15 years in Iran. It could have increased because of increased exposure of people to related risk factors such as air pollution which is a common problem in larger cities and border provinces.

The discovery and development of aclidinium bromide for the treatment of chronic obstructive pulmonary disease

INTRODUCTION

Bronchodilators, including long-acting muscarinic receptor antagonists (LAMAs), are a mainstay of the pharmacological treatment of chronic obstructive pulmonary disease (COPD). LAMAs act as bronchodilators principally by antagonizing airway smooth muscle cells M₃ muscarinic receptors. Aclidinium bromide is a twice-daily LAMA which was developed to improve on the efficacy and/or safety of previous LAMAs. Area covered: Herein, the authors present the pharmacotherapeutic role of aclidinium in COPD and point out unmet need in this research area. The following aspects are covered: a) the discovery and medicinal chemistry of aclidinium bromide; b) an overview of the market; c) its mechanism of action; d) its pharmacokinetic/pharmacodynamic profile derived from pre-clinical studies; e) the clinical studies which led to its licensing; f) the evidence from meta-analyses; g) the aclidinium/formoterol fixed dose combination for COPD and h) priorities in this area of research. Expert opinion: Aclidinium bromide has the pharmacological properties, safety and efficacy profile and inhaler characteristics which makes it a valuable therapeutic option for pharmacological management of patients with COPD. Due to its rapid biotransformation into inactive metabolites, aclidinium is potentially one of the safest LAMAs. Further head-to-head randomized clinical trials are required to define efficacy and safety of aclidinium when compared to once-daily LAMAs. The clinical relevance of airway anti-remodeling effects of aclidinium has to be defined.

Spirituality, Illness Unpredictability, and Math Anxiety Effects on Negative Affect and Affect-Management Coping for Individuals Diagnosed with Alpha-1 Antitrypsin Deficiency

A growing number of genetic tests are included in diagnostic protocols associated with many common conditions. A positive diagnosis associated with the presence of some gene versions in many instances predicts a range of possible outcomes, and the uncertainty linked to such results contributes to the need to understand varied responses and plan strategic communication. Uncertainty in illness theory (UIT; Mishel, 1988, 1990) guided the investigation of efforts to feel in control and hopeful regarding genetic testing and diagnosis for alpha-1 antitrypsin deficiency (AATD). Participants included 137 individuals with AATD recruited from the Alpha-1 Research Registry who were surveyed about their subjective numeracy, anxiety about math, spirituality, perceptions of illness unpredictability, negative affect regarding genetic testing, and coping strategies about a diagnosis. Results revealed that experiencing more fear and worry contributed both directly and indirectly to affect-management coping strategies, operating through individual perceptions of illness unpredictability. The inability to predict the symptoms and course of events related to a genetic illness and anxiety regarding math heightened fear and worry. Spirituality lessened both illness unpredictability and negative affective responses to a diagnosis. Results affirm the importance of clinician and counselor efforts to incorporate attention to patient spirituality. They also illustrate the complexity associated with strategic efforts to plan communication about the different versions of a gene's effects on well-being, when some versions align with mild health effects and others with severe effects.

Burden of disease associated with asthma among the adult general population of five Middle Eastern countries: Results of the SNAPSHOT program

BACKGROUND

Asthma affects millions worldwide resulting in a significant disease burden. However, data on asthma burden from the Middle East is limited. This analysis describes the asthma burden in Egypt, Turkey and a Gulf cluster (Kuwait, Saudi Arabia and United Arab Emirates) as part of the SNAPSHOT program.

METHODS

SNAPSHOT was an observational, cross-sectional program carried out by telephone in a random sample of the adult general population of the five above mentioned countries. Quotas were defined per country demographics. Subjects were considered to have asthma if they fulfilled the screening criteria, based on the global Asthma Insights and Reality studies. Data collected included demographics, physician consultations, and asthma control (measured by the Asthma Control Test; ACT). Quality of life was assessed using the EuroQol Five-Dimension questionnaire (EQ-5D); and limitations to daily activities using the modified Sheehan Disability Scale (SDS).

RESULTS

939 subjects answered questions related to asthma burden. Overall, 367 (44.2%) reported uncontrolled asthma (ACT≤19), and reported significantly lower EQ-5D-3L utility values (0.6 ± 0.4) and EQ-VAS scores (60.7 ± 24.2) compared to controlled subjects (0.8 ± 0.3 and 75.3 ± 19.8 respectively) (p < 0.0001). A significantly higher proportion with uncontrolled asthma also reported experiencing impact on activities of daily living compared to subjects with controlled asthma (p < 0.0001). Overall, 355 (37.8%) asthma subjects were followed by a physician. However, most visits were unscheduled (695;78.0%).

CONCLUSION

Uncontrolled asthma imposes a significant burden in these Middle Eastern countries resulting in increased frequency of healthcare use, lower quality of life, and a higher impact on daily life compared to controlled asthma.

Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Current guidelines recommend that patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) should be treated with systemic corticosteroid for seven to 14 days. Intermittent systemic corticosteroid use is cumulatively associated with adverse effects such as osteoporosis, hyperglycaemia and muscle weakness. Shorter treatment could reduce adverse effects.

OBJECTIVES

To compare the efficacy of short-duration (seven or fewer days) and conventional longer-duration (longer than seven days) systemic corticosteroid treatment of adults with acute exacerbations of COPD.

SEARCH METHODS

Searches were carried out using the Cochrane Airways Group Specialised Register of Trials, MEDLINE and CENTRAL (Cochrane Central Register of Controlled Trials) and ongoing trials registers up to March 2017.

SELECTION CRITERIA

Randomised controlled trials comparing different durations of systemic corticosteroid defined as short (i.e. seven or fewer days) or longer (i.e. longer than seven days). Other interventions-bronchodilators and antibiotics-were standardised. Studies with participants requiring assisted ventilation were excluded.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by The Cochrane Collaboration.

MAIN RESULTS

Eight studies with 582 participants met the inclusion criteria, of which five studies conducted in hospitals with 519 participants (range 28 to 296) contributed to the meta-analysis. Mean ages of study participants were 65 to 73 years, the proportion of male participants varied (58% to 84%) and COPD was classified as severe or very severe. Corticosteroid treatment was given at equivalent daily doses for three to seven days for short-duration treatment and for 10 to 15 days for longer-duration treatment. Five studies administered oral prednisolone (30 mg in four, tapered in one), and two studies provided intravenous corticosteroid treatment. Studies contributing to the meta-analysis were at low risk of selection, performance, detection and attrition bias. In four studies we did not find a difference in risk of treatment failure between short-duration and longer-duration systemic corticosteroid treatment (n = 457; odds ratio (OR) 0.72, 95% confidence interval (CI) 0.36 to 1.46)), which was equivalent to 22 fewer per 1000 for short-duration treatment (95% CI 51 fewer to 34 more). No difference in risk of relapse (a new event) was observed between short-duration and longer-duration systemic corticosteroid treatment (n = 457; OR 1.04, 95% CI 0.70 to 1.56), which was equivalent to nine fewer per 1000 for short-duration treatment (95% CI 68 fewer to 100 more). Time to the next COPD exacerbation did not differ in one large study that was powered to detect non-inferiority and compared five days versus 14 days of systemic corticosteroid treatment (n = 311; hazard ratio 0.95, 95% CI 0.66 to 1.37). In five studies no difference in the likelihood of an adverse event was found between short-duration and longer-duration systemic corticosteroid treatment (n = 503; OR 0.89, 95% CI 0.46 to 1.69, or nine fewer per 1000 (95% CI 44 fewer to 51 more)). Length of hospital stay (n = 421; mean difference (MD) -0.61 days, 95% CI -1.51 to 0.28) and lung function at the end of treatment (n = 185; MD FEV1 -0.04 L; 95% CI -0.19 to 0.10) did not differ between short-duration and longer-duration treatment.

AUTHORS' CONCLUSIONS

Information from a new large study has increased our confidence that five days of oral corticosteroids is likely to be sufficient for treatment of adults with acute exacerbations of COPD, and this review suggests that the likelihood is low that shorter courses of systemic corticosteroids (of around five days) lead to worse outcomes than are seen with longer (10 to 14 days) courses. We graded most available evidence as moderate in quality because of imprecision; further research may have an important impact on our confidence in the estimates of effect or may change the estimates. The studies in this review did not include people with mild or moderate COPD; further studies comparing short-duration systemic corticosteroid versus conventional longer-duration systemic corticosteroid for treatment of adults with acute exacerbations of COPD are required.