Global Initiative on Obstructive Lung Disease (GOLD) classification of lung disease and mortality: findings from the Atherosclerosis Risk in Communities (ARIC) study

Mortality risk in patients with preserved ratio impaired spirometry: assessing the role of physical activity

BACKGROUND

While all-cause mortality is reportedly increased in preserved ratio impaired spirometry (PRISm), no remedial efforts have been suggested.

AIM

To study the ability of physical activity (PA) on reducing the morality increased in PRISm patients.

DESIGN

We prospectively enrolled a cohort of Taiwanese adults from 1994 to 2018 in a health surveillance program.

METHODS

Mortality risks of those who were inactive were compared against those meeting the current recommendation of 150 min/week of PA. Cox proportional hazards models were used for hazard ratios and life table method was for estimating loss of life expectancy.

RESULTS

A total of 461 183 adults were enrolled. Among them, one-seventh of the cohort (65 832 or 14.3%) had PRISm, and 53.1% were inactive. Those who were inactive with PRISm had 28% increased mortality from all-cause, 45% from cardiovascular diseases (CVDs) and 67% from respiratory disease, with a 3-year reduction in life expectancy (males, 3.72 and females, 2.93). In PRISm patients who met the exercise recommendation, excess mortality was reduced by two-third, both all-cause (from 28% to 9%) and CVD (from 45% to 15%).

CONCLUSION

PRISm involves a large portion of general population (14.3%) and shortens life expectancy by 3 years. More than half of the subjects were physically inactive, and adherence to 150 min/week of PA was associated with a two-third reduction of excess mortality from all cause and from CVD. Recommending PA among those with PRISm might be highly beneficial, although exercise alone may not eliminate all risks associated with PRISm.

Implications of Cardiopulmonary Risk for the Management of COPD: A Narrative Review

Chronic obstructive pulmonary disease (COPD) constitutes a major global health burden and is the third leading cause of death worldwide. A high proportion of patients with COPD have cardiovascular disease, but there is also evidence that COPD is a risk factor for adverse outcomes in cardiovascular disease. Patients with COPD frequently die of respiratory and cardiovascular causes, yet the identification and management of cardiopulmonary risk remain suboptimal owing to limited awareness and clinical intervention. Acute exacerbations punctuate the progression of COPD in many patients, reducing lung function and increasing the risk of subsequent exacerbations and cardiovascular events that may lead to early death. This narrative review defines and summarises the principles of COPD-associated cardiopulmonary risk, and examines respiratory interventions currently available to modify this risk, as well as providing expert opinion on future approaches to addressing cardiopulmonary risk.

Mortality prevention as the centre of COPD management

COPD is a major healthcare problem and cause of mortality worldwide. COPD patients at increased mortality risk are those who are more symptomatic, have lower lung function and lower diffusing capacity of the lung for carbon monoxide, decreased exercise capacity, belong to the emphysematous phenotype and those who have concomitant bronchiectasis. Mortality risk seems to be greater in patients who experience COPD exacerbations and in those who suffer from concomitant cardiovascular and/or metabolic diseases. To predict the risk of death in COPD patients, several composite scores have been created using different parameters. In previous years, large studies (also called mega-trials) have evaluated the efficacy of different therapies on COPD mortality, but until recently only nonpharmaceutical interventions have proven to be effective. However, recent studies on fixed combinations of triple therapy (long-acting β-agonists, long-acting muscarinic antagonists and inhaled corticosteroids) have provided encouraging results, showing for the first time a reduction in mortality compared to dual therapies. The aim of the present review is to summarise available data regarding mortality risk in COPD patients and to describe pharmacological therapies that have shown effectiveness in reducing mortality.

Chronic obstructive pulmonary disease (COPD) and COPD-like phenotypes

Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease. Historically, two COPD phenotypes have been described: chronic bronchitis and emphysema. Although these phenotypes may provide additional characterization of the pathophysiology of the disease, they are not extensive enough to reflect the heterogeneity of COPD and do not provide granular categorization that indicates specific treatment, perhaps with the exception of adding inhaled glucocorticoids (ICS) in patients with chronic bronchitis. In this review, we describe COPD phenotypes that provide prognostication and/or indicate specific treatment. We also describe COPD-like phenotypes that do not necessarily meet the current diagnostic criteria for COPD but provide additional prognostication and may be the targets for future clinical trials.

A Holistic Approach to Cardiometabolic and Infectious Health in the General Population of Reunion Island: The REUNION Study

INTRODUCTION

Reunion Island is a French overseas department in the South West Indian Ocean with a unique multi-ethnic population. Cardiovascular diseases are the most common chronic conditions with higher prevalences of hypertension and diabetes compared to mainland France. Moreover, Reunion Island is particularly exposed to vector-borne diseases such as chikungunya and dengue. Our objective is to describe the prevalence of cardiometabolic and infectious diseases in Reunion Island and explore causal mechanisms linking these diseases.

METHODS

The REUNION study is an ongoing French prospective study. From January 2022, 2,000 consenting participants (18-68 years old) are being recruited from the general population according to polling lists and random generation of cellphone number. Baseline examination consists of (i) general health examination, assessment of cardiovascular risk factors, markers of subclinical atherosclerosis, bronchial obstruction, neuropathic and autonomic dysfunction, (ii) questionnaires to determine sociodemographic characteristics, diet, exposure to vector-borne diseases, mental health and cognitive functions, social inequalities in health and ethnic origins, (iii) biological sampling for determination of cardiovascular risk factors, seroprevalence of infectious diseases, innovative lipid biomarkers, advanced omics, composition of intestinal, periodontal and skin microbiota, and biobanking.

CONCLUSIONS

The REUNION study should provide new insights into the prevalence of cardiometabolic and infectious diseases, as well as their potential associations through the examination of various environmental pathways and a wide range of health aspects.

Impact of COPD on mortality: An 8-year observational retrospective healthcare claims database cohort study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality. Here we present a large observational study on the association of COPD and exacerbations with mortality (AvoidEx Mortality).

METHODS

A real-world, observational cohort study with longitudinal analyses of German healthcare claims data in patients ≥40 years of age with a COPD diagnosis from 2011 to 2018 (n = 250,723) was conducted. Patients entered the cohort (index date) upon the first COPD diagnosis. To assess the impact of COPD on all-cause death, a propensity score-matched control group of non-COPD patients was constructed. The number and severity of exacerbations during a 12-month pre-index period were used to form subgroups. For each exacerbation subgroup the exacerbations during 12 months prior to death were analysed.

RESULTS

COPD increases the all-cause mortality risk by almost 60% (HR 1.57 (95% CI 1.55-1.59)) in comparison to matched non-COPD controls, when controlling for other baseline covariates. The cumulative risk of death after 8 years was highest in patients with a history of more than one moderate or severe exacerbation. Among all deceased COPD patients, 17.2% had experienced a severe, and 34.8% a moderate exacerbation, within 3 months preceding death. Despite increasing exacerbation rates towards death, more than the half of patients were not receiving any recommended pharmacological COPD therapy in the year before death.

CONCLUSION

Our study illustrates the impact of COPD on mortality risk and highlights the need for consequent COPD management comprising exacerbation assessment and treatment.

All-cause and cause-specific mortality by spirometric pattern and sex - a population-based cohort study

BACKGROUND

Chronic airway obstruction (CAO) and restrictive spirometry pattern (RSP) are associated with mortality, but sex-specific patterns of all-cause and specific causes of death have hardly been evaluated.

OBJECTIVES

To study the possible sex-dependent differences of all-cause mortality and patterns of cause-specific mortality among men and women with CAO and RSP, respectively, to that of normal lung function (NLF).

DESIGN

Population-based prospective cohort study.

METHODS

Individuals with CAO [FEV1/vital capacity (VC) < 0.70], RSP [FEV1/VC ⩾ 0.70 and forced vital capacity (FVC) < 80% predicted] and NLF (FEV1/VC ⩾ 0.70 and FVC ⩾ 80% predicted) were identified within the Obstructive Lung Disease in Northern Sweden (OLIN) studies in 2002-2004. Mortality data were collected through April 2016, totally covering 19,000 patient-years. Cox regression and Fine-Gray regression accounting for competing risks were utilized to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) adjusted for age, body mass index, sex, smoking habits and pack-years.

RESULTS

The adjusted hazard for all-cause mortality was higher in CAO and RSP than in NLF (HR, 95% CI; 1.69, 1.31-2.02 and 1.24, 1.06-1.71), and the higher hazards were driven by males. CAO had a higher hazard of respiratory and cardiovascular death than NLF (2.68, 1.05-6.82 and 1.40, 1.04-1.90). The hazard of respiratory death was significant in women (3.41, 1.05-11.07) while the hazard of cardiovascular death was significant in men (1.49, 1.01-2.22). In RSP, the higher hazard for respiratory death remained after adjustment (2.68, 1.05-6.82) but not for cardiovascular death (1.11, 0.74-1.66), with a similar pattern in both sexes.

CONCLUSION

The higher hazard for all-cause mortality in CAO and RSP than in NLF was male driven. CAO was associated with respiratory death in women and cardiovascular death in men, while RSP is associated with respiratory death, similarly in both sexes.

Relationship between depression severity and respiratory symptoms in US adults: A national cross-sectional study

OBJECTIVE

The relationship between depression severity and cough, wheeze and exertional dyspnoea is unclear. The aim of this study was to explore this relationship.

METHODS

We used weighted logistic regression analysis and fitted curves to explore the relationship between depression severity and respiratory symptoms. In addition, we examined the relationship between depression and COPD and asthma. Stratified analyses were used to analyse specific populations.

RESULTS

We weighted 10,142 subjects to reflect the entire US population. Using the population without depression as a reference, the risk of cough and asthma in the severely depressed population was 3.32 times (OR 3.324, 95% CI 1.567-7.050) and 2.84 times (OR 2.842, 95% CI 1.521-5.311) higher than that in the population without depressive symptoms, and the risk of asthma and COPD was 2.4 times and 2.6 times (OR 2.410, 95% CI 1.371-4.236; OR 2.566, 95% CI 1.236-4.921). In subgroup analyses, the correlation between depression scores and prevalence of cough and wheeze was corrected for gender level. In addition, smoking status and marital status were interaction factors between depression score and prevalence of cough. The prevalence of exertional dyspnoea by depression score was influenced by CVD.

CONCLUSIONS

Depression severity was associated with respiratory symptoms, asthma, and COPD. Gender corrected the correlation between depression and cough and asthma, and depressive state was an independent risk factor for asthma and COPD. This finding provides new ideas for the management of respiratory symptoms and diseases.

[Magnetic resonance imaging of the lung : State of the art]

Due to the low proton density of the lung parenchyma and the rapid signal decay at the air-tissue interfaces, for a long time the lungs were difficult to access using magnetic resonance imaging (MRI); however, technical advances could address most of these obstacles. Pulmonary alterations associated with tissue proliferation ("plus pathologies"), can now be detected with high diagnostic accuracy because of the locally increased proton density. Compared to computed tomography (CT), MRI provides a comprehensive range of functional imaging procedures (respiratory mechanics, perfusion and ventilation). In addition, as a radiation-free noninvasive examination modality, it enables repeated examinations for assessment of the course or monitoring of the effects of treatment, even in children. This article discusses the technical aspects, gives suggestions for protocols and explains the role of MRI of the lungs in the routine assessment of various diseases.

Mortality risk reduction with budesonide/glycopyrrolate/formoterol fumarate versus fluticasone furoate/umeclidinium/vilanterol in COPD: a matching-adjusted indirect comparison based on ETHOS and IMPACT

OBJECTIVE

Chronic obstructive pulmonary disease (COPD) is a leading cause of death worldwide. While two approved fixed-dose inhaled corticosteroid/long-acting muscarinic antagonist (LAMA)/long-acting β2-agonist (LABA) triple therapies reduce all-cause mortality (ACM) versus dual LAMA/LABA therapy in patients with COPD, head-to-head studies have not compared the effects of these therapies on ACM. We compared ACM in adults with moderate-to-very severe COPD receiving budesonide/glycopyrrolate/formoterol fumarate (BGF) in ETHOS versus fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) in IMPACT using a matching-adjusted indirect comparison (MAIC).

METHODS

A systematic literature review identified two studies (ETHOS [NCT02465567]; IMPACT [NCT02164513]) of ≥52 weeks reporting ACM as an efficacy endpoint in patients receiving triple therapy. As ETHOS and IMPACT lack a common comparator, an unanchored MAIC compared ACM between licensed doses of BGF (320/18/9.6 μg) from ETHOS and FF/UMEC/VI (100/62.5/25 μg) from IMPACT in patients with moderate-to-very severe COPD. Using on- and off-treatment data from the final retrieved datasets of the intention-to-treat populations, BGF data were adjusted according to aggregate FF/UMEC/VI data using 11 baseline covariates; a supplementary unadjusted indirect treatment comparison was also conducted. P-values for these post-hoc analyses are not adjusted for Type I error.

RESULTS

ACM over 52 weeks was statistically significantly reduced by 39% for BGF versus FF/UMEC/VI in the MAIC (hazard ratio [HR] [95% CI]: 0.61 [0.38, 0.95], p = 0.030) and unadjusted analysis (HR [95% CI]: 0.61 [0.41, 0.92], p = 0.019).

CONCLUSION

In this MAIC, which adjusted for population heterogeneity between ETHOS and IMPACT, ACM was significantly reduced with BGF versus FF/UMEC/VI in patients with moderate-to-very severe COPD.

Association of spirometric restriction with mortality in the silicotics: a cohort study

BACKGROUND

Restrictive spirometry pattern (RSP), defined as reduced forced vital capacity (FVC) in absence of airflow obstruction (AFO), is associated with increased risk of mortality in general population. However, evidence in the patients with silicosis is limited. This study was aimed to investigate the relationship between RSP and the risk of death in a silicotic cohort.

METHOD

This retrospective cohort study used data from the Pneumoconiosis Clinic, Hong Kong Department of Health that containing 4315 patients aged 18-80 years and diagnosed with silicosis during 1981-2019, with a follow-up till 31 December 2019. Spirometry was carried out at the diagnostic examination of silicosis. Lung function categories were classified as normal spirometry (FEV1/FVC ≥ 0.7, FVC ≥ 80% predicted), RSP only (FEV1/FVC ≥ 0.7, FVC < 80% predicted), AFO only (FEV1/FVC < 0.7, FVC ≥ 80% predicted), and RSP&AFO mixed (FEV1/FVC < 0.7, FVC < 80% predicted). The hazard ratio (HR) and 95% confidence intervals (95% CI) were computed using a Cox proportional hazards model adjusting for age, body mass index, history of tuberculosis, smoking status, pack-years, and radiographic characteristics of silicotic nodules.

RESULTS

Among the 4315 patients enrolled in the study, the prevalence of RSP was 24.1% (n = 1038), including 11.0% (n = 473) with RSP only and 13.1% (n = 565) with mixed RSP and AFO. During the follow-up period, a total of 2399 (55.6%) deaths were observed. Compared with the silicotics with normal spirometry, those with RSP only had significantly increased risk of all-cause mortality (HR = 1.63, 95% CI 1.44-1.85) and respiratory-related mortality (HR = 1.56, 95% CI 1.31-1.85). Notably, a higher risk of mortality was observed in silicotics with mixed ventilatory defects of both RSP and AFO (all-cause mortality: HR = 2.22, 95% CI 1.95-2.52; respiratory-related mortality: HR = 2.59, 95% CI 2.18-3.07) than in those with RSP only.

CONCLUSION

RSP is significantly associated with increased risk of all-cause and respiratory-related mortality in the silicotics, and patients with mixed restrictive and obstructive ventilatory defect have higher risk of mortality than those with single RSP or AFO. These findings emphasize the importance of recognizing RSP in the occupational settings, especially for the silicotic patients with mixed ventilatory defect.

Mortality in non-exacerbating COPD: a longitudinal analysis of UK primary care data

INTRODUCTION

Non-exacerbating patients with chronic obstructive pulmonary disease (COPD) are a less studied phenotype. We investigated clinical characteristics, mortality rates and causes of death among non-exacerbating compared with exacerbating patients with COPD.

METHODS

We used data from the Clinical Practice Research Datalink, Hospital Episode Statistics and Office for National Statistics between 1 January 2004 and 31 December 2018. Ever smokers with a COPD diagnosis with minimum 3 years of baseline information were included. We compared overall using Cox regression and cause-specific mortality rates using competing risk analysis, adjusted for age, sex, deprivation, smoking status, body mass index, GOLD stage and comorbidities. Causes of death were identified using International Classification of Diseases-10 codes.

RESULTS

Among 67 516 patients, 17.3% did not exacerbate during the 3-year baseline period. Mean follow-up was 4 years. Non-exacerbators were more likely to be male (63.3% vs 52.4%, p<0.001) and less often had a history of asthma (33.9% vs 43.6%, p<0.001) or FEV1<50% predicted (23.7 vs 31.8%) compared with exacerbators. Adjusted HR for overall mortality in non-exacerbators compared with exacerbators was 0.62 (95% CI 0.56 to 0.70) in the first year of follow-up and 0.87 (95% CI 0.83 to 0.91) thereafter. Non-exacerbating patients with COPD died less of respiratory causes than exacerbators (29.2% vs 40.3%) and more of malignancies (29.4% vs 23.4%) and cardiovascular diseases (26.2% vs 22.9%). HRs for malignant and circulatory causes of death were increased after the first year of follow-up.

DISCUSSION

In this primary care cohort, non-exacerbators showed distinct clinical characteristics and lower mortality rates. Non-exacerbators were equally likely to die of respiratory, malignant or cardiovascular diseases.

Association between chronic obstructive pulmonary disease and cardiovascular disease in adults aged 40 years and above: data from NHANES 2013-2018

BACKGROUND

Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) are two major age-related diseases prevalent in the elderly. However, it is unclear whether there is a higher prevalence of one or more CVDs in COPD patients compared to those without COPD, and the magnitude of this increased prevalence.

METHODS

This population-based cross-sectional study was conducted using data from the National Health and Nutrition Examination Survey (NHANES) 2013-2018 among American adults aged 40 years and above. Multivariable logistic regression models (including unadjusted model, minimally adjusted model, and fully adjusted model) were conducted to investigate the association between COPD and the prevalence of one or more CVDs, including coronary heart disease, heart failure, angina pectoris, heart attack, diabetes, and stroke.

RESULTS

This study included 11,425 participants, consisting of 661 participants with COPD and 10,764 participants without COPD. COPD patients had a significantly higher prevalence of CVD than those without COPD (59.6% vs. 28.4%). After adjusting for covariates, COPD was significantly associated with the prevalence of one CVD (OR = 2.2, 95% CI = 1.6-3.0, p < 0.001), two or more CVDs (OR = 3.3, 95% CI = 2.2-5.0, p < 0.001), and three or more CVDs (OR = 4.3, 95% CI = 2.9-6.5, p < 0.001).

CONCLUSIONS

Patients with COPD have a higher prevalence of one or more CVDs compared with those without COPD. Our findings highlight the importance of CVD prevention and management in patients with COPD.

Exploring Current Concepts and Challenges in the Identification and Management of Early-Stage COPD

The need to improve health outcomes, as well as disease prognosis, has led clinicians and researchers to propose new ways of identifying COPD in its earliest forms. This initiative is based on the hypothesis that an earlier intervention would have a greater prognostic impact. However, the operational definition of a patient in the initial stages of the disease is complex, and there is still no unanimously accepted definition. GOLD has recently proposed different concepts to identify COPD in its early stages, such as COPD in young people or COPD with mild functional impairment. In addition, GOLD proposes two other concepts, called pre-COPD (symptomatic non-obstructive patients) and PRISm (preserved ratio with impaired spirometry), which aim to identify the patient at risk of developing this chronic airflow obstruction. However, despite the attractiveness of these concepts, none have been taken up universally by the medical community. A universally accepted identification of how to define COPD in its early stages is necessary as a preliminary step in order to design clinical trials to find out the best way to treat these patients. This review deals with these concepts of COPD at the onset of the disease, highlighting their importance and the problems involved in identifying them as therapeutic targets in real clinical practice.

Mortality and readmission risk for hospitalised patients with acute exacerbation of COPD with and without spirometric obstruction: a longitudinal observational study in China

OBJECTIVE

To compare the clinical features and outcomes in patients with pre-chronic obstructive pulmonary disease (COPD) and COPD hospitalised for confirmed or suspected acute exacerbation of COPD (AECOPD).

DESIGN

A multicentre, longitudinal observational cohort study.

SETTING

Data were obtained from the AECOPD Inpatient Registry Study in China.

PARTICIPANTS

5896 patients hospitalised for AECOPD between 2017 and 2021.

OUTCOMES

Patients were divided into the COPD (n=5201) and pre-COPD (n=695) groups according to the lung function test results. The outcomes of interest included all-cause, respiratory disease-related and cardiovascular disease-related deaths as well as readmissions within 30 days and 12 months after discharge. Cumulative incidence functions were used to estimate the risk of cause-specific mortality and readmission. Multivariate hazard function models were used to determine the association between lung function and outcomes.

RESULTS

There were significant between-group differences in the symptoms at admission and medication use during hospitalisation. However, there was no significant between-group difference in the 30-day all-cause mortality (0.00 vs 2.23/1000 person-month (pm), p=0.6110) and readmission (33.52 vs 30.64/1000 pm, p=0.7175). Likewise, the 30-day and 12-month cause-specific outcomes were not significantly different between groups (30-day readmission with acute exacerbation (AE): 26.07 vs 25.11/1000 pm; 12-month all-cause mortality: 0.20 vs 0.93/1000 pm; all-cause readmission: 11.49 vs 13.75/1000 pm; readmission with AE: 9.15 vs 11.64/1000 pm, p>0.05 for all comparisons). Cumulative incidence curves revealed no significant between-group differences in the 30-day and 12-month prognosis (p>0.05). Multivariate analysis revealed no significant association of lung function categories with 30-day and 12-month mortality or readmission (p>0.05 for all effect estimations).

CONCLUSIONS

Patients with pre-COPD have mild symptoms and similar risks for mortality and readmission during follow-up as patients with COPD. Patients with pre-COPD should receive optimal therapies before the occurrence of irreversible damage.

Cardiovascular Diseases in COPD: From Diagnosis and Prevalence to Therapy

Chronic obstructive pulmonary disease (COPD) is considered one of the leading causes of mortality. Cardiovascular comorbidities are diagnosed often in COPD patients, not only because of the common risk factors these two diseases share, but also because of the systemic inflammation which characterizes COPD and has deleterious effects in the cardiovascular system. The comorbid cardiovascular diseases in COPD result in several difficulties in the holistic treatment of these patients and affect outcomes such as morbidity and mortality. Several studies have reported that mortality from cardiovascular causes is common among COPD patients, while the risk for acute cardiovascular events increases during COPD exacerbations and remains high for a long time even after recovery. In this review, we focus on the prevalence of cardiovascular comorbidities in COPD patients, presenting the evidence regarding the interaction of the pathophysiological pathways which characterize each disease. Furthermore, we summarize information regarding the effects of cardiovascular treatment on COPD outcomes and vice versa. Finally, we present the current evidence regarding the impact of cardiovascular comorbidities on exacerbations, quality of life and survival of COPD patients.

Association between long-term exposure to ambient particulate matter and pulmonary function among men and women in typical areas of South and North China

Background

Studies comparing the effects of different sizes and concentrations of ambient particulate matter (PM) on pulmonary function in different regions and sexes remain sparse.

Objectives

To investigate the associations of different sizes and levels of long-term ambient PM exposure with pulmonary function among people of different sexes in typical areas of South and North China.

Methods

In 2021, a total of 1,592 participants aged 20-73 years were recruited to participate in the pulmonary function test from the baseline survey of the Diverse Life-Course Cohort (DLCC) in typical areas of Guangdong Province and Hebei Province. The three-year (2018-2020) average ambient PM concentrations were assessed from the ChinaHighPM₁ dataset, ChinaHighPM_2.5 dataset and ChinaHighPM₁₀ dataset. Mean differences in pulmonary function were used in multilevel models for different regions and sexes.

Results

We discovered significant associations of ambient PM exposure with reduced forced vital capacity (FVC) and increased forced expiratory volume in 1 s/forced vital capacity ratio (FEV₁/FVC) among men and lower levels of FEV₁ and FVC among women, such that a 5-μg/m³ concentration increase in PM₁, PM_2.5, and PM₁₀ was associated with decreases in FVC of 122.1 ml (95% confidence interval (CI): 30.8, 213.4), 54.6 ml (95% CI: 15.8, 93.3) and 42.9 ml (95% CI: 12.7, 73.1) and increases in FEV₁/FVC of 2.2% (95% CI: 0.6, 3.9), 1.1% (95% CI: 0.4, 1.9) and 0.9% (95% CI: 0.3, 1.5) among men and decreases in FEV₁ of 51.1 ml (95% CI: 9.7, 92.4), 21.6 ml (95% CI: 4.3, 38.9) and 16.7 ml (95% CI: 3.3, 30.1) and in FVC of 77.8 ml (95% CI: 10.0, 145.6), 38.7 ml (95% CI: 9.0, 68.5) and 31.1 ml (95% CI: 8.1, 54.1) among women in Hebei Province. There was no association between ambient PM and pulmonary function in Guangdong Province.

Conclusion

Long-term exposure to different sizes and concentrations of ambient PM were associated with FEV₁ and FVC among men and women differently. The impact of ambient PM on FVC should be of greater concerned.

Restrictive spirometry pattern among construction trade workers

BACKGROUND

Spirometry-based studies of occupational lung disease have mostly focused on obstructive or mixed obstructive/restrictive outcomes. We wanted to determine if restrictive spirometry pattern (RSP) is associated with occupation and increased mortality.

METHODS

Study participants included 18,145 workers with demographic and smoking data and repeatable spirometry. The mortality analysis cohort included 15,445 workers with known vital status and cause of death through December 31, 2016. Stratified analyses explored RSP prevalence by demographic and clinical variables and trade. Log-binomial regression models explored RSP risk factors while controlling for important confounders such as smoking, obesity, and comorbidities. Cox regression models explored mortality risk by spirometry category.

RESULTS

Prevalence of RSP was very high (28.6%). Mortality hazard ratios for RSP were 1.50 for all causes, 1.86 for cardiovascular diseases, 2.31 for respiratory diseases, and 1.66 for lung cancer. All construction trades except painters, machinists, and roofers had significantly elevated risk for RSP compared to our internal reference group. RSP was significantly associated with both parenchymal and pleural changes seen by chest X-ray.

CONCLUSIONS

Construction trade workers are at significantly increased risk for RSP independent of obesity. Individuals with RSP are at increased risk for all-cause mortality as well as mortality attributable to respiratory diseases, cardiovascular diseases, and lung cancer. RSP deserves greater attention in occupational medicine and epidemiology.

Pulmonary Function Tests as a Biomarker in Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia Patients Treated With Somatostatin Analogues

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) describes an indolent, under-recognised and poorly understood pulmonary condition with fewer than 200 reported cases across the literature. Currently, cases are diagnosed following a biopsy of the primary lesion, with treatment options centring on symptomatic benefit as opposed to targeting the underlying aetiology. Classically, DIPNECH lesions have been described as slow growing and benign, but with growing awareness of the condition, reports of metastatic disease with significant symptomatic burden have been reported. However, effectively addressing the subset of DIPNECH patients with greater metastatic potential remains an unmet clinical need. Due to the similarities between DIPNECH and carcinoid patients, several centres have considered using somatostatin analogues to not only help symptomatically but also to initiate tumour regression. However, to date, there are limited biomarkers to help evaluate the benefit of such options. In this review, we consider the use of pulmonary function tests (PFTs) to help quantify the benefit of somatostatin analogues. Although much of the evidence stems from small single-centre studies, the use of PFTs within the treatment pathway for both localised and metastatic DIPNECH represents a meaningful improvement from subjective monitoring of disease.

Tongxinluo enhances the effect of atorvastatin on the treatment of atherosclerosis with chronic obstructive pulmonary disease by maintaining the pulmonary microvascular barrier

Atherosclerosis (AS) is a common comorbidity of chronic obstructive pulmonary disease (COPD), and systemic inflammation is an important mechanism of COPD with AS. Tongxinluo (TXL) improves the function of vascular endothelial cells. We aimed to prove that impairment of pulmonary microvascular barrier function is involved in COPD-mediated aggravation of AS and investigate whether TXL enhances the effect of Ato (atorvastatin) on COPD with AS by protecting pulmonary microvascular endothelial barrier function. In vivo, a COPD with atherosclerotic apolipoprotein E knockout (AS ApoE^-/-) mouse model was established by cigarette smoke combined with a high-fat diet. The animals were administered TXL, Ato, and TXL + Ato once a day for 20 weeks. Lung function, lung microvascular permeability, lung inflammation, systemic inflammation, serum lipid levels, atheromatous plaque formation, and endothelial damage biomarkers were measured. In vitro, human pulmonary microvascular endothelial cells (HPMECs) were pretreated with TXL and incubated with cigarette smoke extract to establish the model. The permeability of the endothelial monolayer, inflammatory cytokines, endothelial damage biomarkers, and tight junction (Tj) proteins were determined. Cigarette smoking significantly exacerbated the high-fat diet-induced pulmonary function decline, pulmonary microvascular endothelial barrier dysfunction, inflammation, and atherosclerotic plaques. These changes were reversed by TXL-Ato; the combination was more effective than Ato alone. Furthermore, TXL protected the HPMEC barrier and inhibited inflammation in HPMECs. COPD aggravates AS, possibly through the destruction of pulmonary microvascular barrier function; thus, lung inflammation triggers systemic inflammation. In treating COPD with AS, TXL enhances the antiatherosclerotic effect of Ato, protecting the pulmonary microvascular barrier.

Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations: strengths and concerns for future needs

Chronic Obstructive Pulmonary Disease (COPD) is already the third leading cause of death worldwide and simultaneously a major cause of morbidity and mortality. Global initiative for Chronic Obstructive Lung Disease (also known as GOLD) committee, has been created in 1997 to increase the awareness regarding the burden of COPD. GOLD recommendations have been contributing to diagnosis, management and therapy of COPD since 2001. Through these years, by reviewing published articles, GOLD aimed to provide state-of-the-art information not only for pulmonologists, but also for non-respiratory physicians, and to encourage research on COPD. From 2011, GOLD annual reports have changed the way of COPD evaluation from based entirely on spirometric parameters to more clinical indices, such as the assessment of symptoms and dyspnea alongside with exacerbations. Moreover, according to recent developments in pathophysiology of COPD, there is a trend in identifying new pre-clinical stages, contributing to prevention and early COPD treatment. In the field of therapeutic algorithms, changes turn to a more personalized approach. However, it is not clear in what extent this personalized disease management would be feasible and the real challenge for current recommendations is to include more patient characteristics such as co-morbidities and multidimensional scores in disease evaluation.

Analysis of the Effect of Mindfulness Behavior Intervention Combined with Progressive Breathing Training on Pulmonary Function Rehabilitation in Patients with Chronic Obstructive Pulmonary Disease

Purpose

Studies have shown that 50%-70% of patients with chronic obstructive pulmonary disease (COPD) have fatigue in addition to respiratory symptoms, so relieving respiratory symptoms and reducing fatigue are the main treatment objectives for COPD patients. This study focuses on the effect of positive behavioral intervention combined with progressive breathing training on pulmonary function rehabilitation in patients with COPD.

Methods

86 patients who underwent COPD treatment in our hospital between August 2020 and December 2021 were selected as study subjects and were divided into control (n = 43) and study groups (n = 43) using the random number table method. Patients in the control group were given conventional care, treatment, and health guidance, while patients in the study group were given positive behavioral intervention combined with progressive breathing training on this basis. Patients in both groups were compared on the basis of Multidimensional Fatigue Inventory 20 (MFI-20) score, the Medical Coping Questionnaire (MCMQ score), the Massive Attentional Awareness Scale (MAAS) score, and pulmonary function indicators (including the percentage of forced expiratory volume one second (FEV1%), peak expiratory flow (PEF), forced vital capacity (FVC), and 6-min walk distance (6MWD)) and quality of life (MCMQ) scores before and after 12 weeks of intervention.

Results

After 12 weeks of intervention, the study group had higher MFI-20 scores (comprehensive fatigue, physical fatigue, reduced activity, decreased power, and mental fatigue), confrontation scores on the MCMQ scale, MAAS scores (observation, description, nonjudgmental to intrinsic experience, nonresponsiveness to intrinsic experience, and perceived behavior), FEV1%, PEF, FVC, and 6MWD levels than the control group (P < 0.05). The scores of avoidance and submission on the MCMQ scale, and all scores of quality of life (cough, expectoration, shortness of breath, chest tightness, housework, going out, sleep, and energy) were lower than those of the control group (P < 0.05).

Conclusion

Positive behavioral interventions combined with progressive breathing training have a strengthening effect on the clinical treatment of COPD patients. Positive behavioral interventions combined with progressive breathing training are simple to implement as individual self-regulation methods and can be practiced on their own after being familiar with certain methods and techniques, and long-term adherence helps individuals cope with the stimulation of adverse events. Trail Registration. The clinical registration number for this research is L2020083.

Impact of lung function impairment after allogeneic hematopoietic stem cell transplantation

Late-onset noninfectious pulmonary complications (LONIPC) are a major cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HSCT). However, the clinical impact of lung function deterioration itself in long-term adult survivors of HSCT remains to be fully investigated. This retrospective, longitudinal study aimed to investigate pulmonary function following HSCT in terms of its change and the clinical significance of its decline. We examined 167 patients who survived for at least 2 years without relapse. The median follow-up period was 10.3 years. A linear mixed-effects model showed that the slope of pulmonary function tests values, including percent vital capacity (%VC), percent forced expiratory volume in one second (%FEV₁), and FEV₁/forced VC ratio (FEV₁%), decreased over time. The cumulative incidence of newly obstructive and restrictive lung function impairment (LFI) at 10 years was 15.7% and 19.5%, respectively. Restrictive LFI was a significant, independent risk factor for overall survival (hazard ratio 7.11, P = 0.007) and non-relapse mortality (hazard ratio 12.19, P = 0.003). Our data demonstrated that lung function declined over time after HSCT and that the decline itself had a significant impact on survival regardless of LONIPC.

Association between Influenza and COVID-19 Viruses and the Risk of Atherosclerosis: Meta-Analysis Study and Systematic Review

There is a lot of evidence to suggest that patients infected with the COVID-19 and influenza viruses are at risk of atherosclerosis. Additionally, there are heterogeneous studies on the risk of arthrosclerosis in patients infected with the influenza and COVID-19 viruses. We conducted a case−control and cross-sectional study and examined the association between the risk of atherosclerosis, and influenza virus (IV-A and IV-B) and COVID-19 infections in this study. We searched for keywords such as influenza virus, COVID-19 and atherosclerosis in English and Persian in well-known databases such as PubMed, SID, Magiran and Google Scholar. In this study, we analyzed the information using a meta-analysis, the random effect model, the I2 index and STAT (version 11.2). The results from the analysis of ten studies on influenza virus and nine studies on COVID-19 reviewed individually (totaling 6428 samples for influenza virus infections and 10,785 samples for COVID-19 infections) demonstrated a risk of arthrosclerosis in patients with influenza and COVID-19 infections, with an OR (odds ratio) = 0.45 ((95% CI): 0.25 to 0.64) and an OR (odds ratio) = 1.04 ((95% CI): 0.82 to 1.26), respectively. The present study provides new insights into the risk of atherosclerosis in patients infected with the COVID-19 and influenza viruses. Therefore, it seems necessary to consider different strategies for managing and eradicating viral infections among individuals.

Pooled Cohort Probability Score for Subclinical Airflow Obstruction

Rationale: Early detection of chronic obstructive pulmonary disease (COPD) is a public health priority. Airflow obstruction is the single most important risk factor for adverse COPD outcomes, but spirometry is not routinely recommended for screening. Objectives: To describe the burden of subclinical airflow obstruction (SAO) and to develop a probability score for SAO to inform potential detection and prevention programs. Methods: Lung function and clinical data were harmonized and pooled across nine U.S. general population cohorts. Adults with respiratory symptoms, inhaler use, or prior diagnosis of COPD or asthma were excluded. A probability score for prevalent SAO (forced expiratory volume in 1 second/forced vital capacity < 0.70) was developed via hierarchical group-lasso regularization from clinical variables in strata of sex and smoking status, and its discriminative accuracy for SAO was assessed in the pooled cohort as well as in an external validation cohort (NHANES [National Health and Nutrition Examination Survey] 2011-2012). Incident hospitalizations and deaths due to COPD (respiratory events) were defined by adjudication or administrative criteria in four of nine cohorts. Results: Of 33,546 participants (mean age 52 yr, 54% female, 44% non-Hispanic White), 4,424 (13.2%) had prevalent SAO. The incidence of respiratory events (Nat-risk = 14,024) was threefold higher in participants with SAO versus those without (152 vs. 39 events/10,000 person-years). The probability score, which was based on six commonly available variables (age, sex, race and/or ethnicity, body mass index, smoking status, and smoking pack-years) was well calibrated and showed excellent discrimination in both the testing sample (C-statistic, 0.81; 95% confidence interval [CI], 0.80-0.82) and in NHANES (C-statistic, 0.83; 95% CI, 0.80-0.86). Among participants with predicted probabilities ⩾ 15%, 3.2 would need to undergo spirometry to detect one case of SAO. Conclusions: Adults with SAO demonstrate excess respiratory hospitalization and mortality. A probability score for SAO using commonly available clinical risk factors may be suitable for targeting screening and primary prevention strategies.

Burden of chronic obstructive pulmonary disease and its attributable risk factors in 204 countries and territories, 1990-2019: results from the Global Burden of Disease Study 2019

OBJECTIVE

To report the global, regional, and national burden of chronic obstructive pulmonary disease (COPD) and its attributable risk factors between 1990 and 2019, by age, sex, and sociodemographic index.

DESIGN

Systematic analysis.

DATA SOURCE

Global Burden of Disease Study 2019.

MAIN OUTCOME MEASURES

Data on the prevalence, deaths, and disability adjusted life years (DALYs) of COPD, and its attributable risk factors, were retrieved from the Global Burden of Disease 2019 project for 204 countries and territories, between 1990 and 2019. The counts and rates per 100 000 population, along with 95% uncertainty intervals, were presented for each estimate.

RESULTS

In 2019, 212.3 million prevalent cases of COPD were reported globally, with COPD accounting for 3.3 million deaths and 74.4 million DALYs. The global age standardised point prevalence, death, and DALY rates for COPD were 2638.2 (95% uncertainty intervals 2492.2 to 2796.1), 42.5 (37.6 to 46.3), and 926.1 (848.8 to 997.7) per 100 000 population, which were 8.7%, 41.7%, and 39.8% lower than in 1990, respectively. In 2019, Denmark (4299.5), Myanmar (3963.7), and Belgium (3927.7) had the highest age standardised point prevalence of COPD. Egypt (62.0%), Georgia (54.9%), and Nicaragua (51.6%) showed the largest increases in age standardised point prevalence across the study period. In 2019, Nepal (182.5) and Japan (7.4) had the highest and lowest age standardised death rates per 100 000, respectively, and Nepal (3318.4) and Barbados (177.7) had the highest and lowest age standardised DALY rates per 100 000, respectively. In men, the global DALY rate of COPD increased up to age 85-89 years and then decreased with advancing age, whereas for women the rate increased up to the oldest age group (≥95 years). Regionally, an overall reversed V shaped association was found between sociodemographic index and the age standardised DALY rate of COPD. Factors contributing most to the DALYs rates for COPD were smoking (46.0%), pollution from ambient particulate matter (20.7%), and occupational exposure to particulate matter, gases, and fumes (15.6%).

CONCLUSIONS

Despite the decreasing burden of COPD, this disease remains a major public health problem, especially in countries with a low sociodemographic index. Preventive programmes should focus on smoking cessation, improving air quality, and reducing occupational exposures to further reduce the burden of COPD.

Dual versus single long-acting bronchodilator use could raise acute coronary syndrome risk by over 50%: A population-based nested case-control study

BACKGROUND

Coronary heart disease occurs more frequently among patients with chronic obstructive pulmonary disease (COPD) compared to those without COPD. While some research suggests that long-acting bronchodilators might confer an additional risk of acute coronary syndrome (ACS), information from real-world clinical practice about the cardiovascular impact of using two versus one long-acting bronchodilator for COPD is limited. We undertook a population-based nested case-control study to estimate the risk of ACS in users of both a long-acting muscarinic antagonist (LAMA) and a long-acting beta2-agonist (LABA) relative to users of a LAMA.

METHODS

The study was based on the primary care PREDICT Cardiovascular Disease Cohort and linked data from regional laboratories and the New Zealand Ministry of Health's national data collections. The underlying cohort (n = 29,993) comprised patients aged 45-84 years, who initiated treatment with a LAMA and/or LABA for COPD between 1 February 2006 and 11 October 2016. 1490 ACS cases were matched to 13,550 controls by date of birth, sex, date of cohort entry (first long-acting bronchodilator dispensing), and COPD severity.

RESULTS

Relative to current use of LAMA therapy, current use of LAMA and LABA dual therapy was associated with a significantly higher risk of ACS (adjusted OR = 1.72; [95% CI: 1.28-2.31]).

CONCLUSION

Dual long-acting bronchodilator therapy, rather than LAMA mono-therapy, could increase the risk of ACS by more than 50%. This has important implications for decisions about the potential benefit/harm ratio of COPD treatment intensification, given the modest benefits of dual therapy.

Case-finding and improving patient outcomes for chronic obstructive pulmonary disease in primary care: the BLISS research programme including cluster RCT

Background

Chronic obstructive pulmonary disease is a major contributor to morbidity, mortality and health service costs but is vastly underdiagnosed. Evidence on screening and how best to approach this is not clear. There are also uncertainties around the natural history (prognosis) of chronic obstructive pulmonary disease and how it impacts on work performance.

Objectives

Work package 1: to evaluate alternative methods of screening for undiagnosed chronic obstructive pulmonary disease in primary care, with clinical effectiveness and cost-effectiveness analyses and an economic model of a routine screening programme. Work package 2: to recruit a primary care chronic obstructive pulmonary disease cohort, develop a prognostic model [Birmingham Lung Improvement StudieS (BLISS)] to predict risk of respiratory hospital admissions, validate an existing model to predict mortality risk, address some uncertainties about natural history and explore the potential for a home exercise intervention. Work package 3: to identify which factors are associated with employment, absenteeism, presenteeism (working while unwell) and evaluate the feasibility of offering formal occupational health assessment to improve work performance.

Design

Work package 1: a cluster randomised controlled trial with household-level randomised comparison of two alternative case-finding approaches in the intervention arm. Work package 2: cohort study – focus groups. Work package 3: subcohort – feasibility study.

Setting

Primary care settings in West Midlands, UK.

Participants

Work package 1: 74,818 people who have smoked aged 40–79 years without a previous chronic obstructive pulmonary disease diagnosis from 54 general practices. Work package 2: 741 patients with previously diagnosed chronic obstructive pulmonary disease from 71 practices and participants from the work package 1 randomised controlled trial. Twenty-six patients took part in focus groups. Work package 3: occupational subcohort with 248 patients in paid employment at baseline. Thirty-five patients took part in an occupational health intervention feasibility study.

Interventions

Work package 1: targeted case-finding – symptom screening questionnaire, administered opportunistically or additionally by post, followed by diagnostic post-bronchodilator spirometry. The comparator was routine care. Work package 2: twenty-three candidate variables selected from literature and expert reviews. Work package 3: sociodemographic, clinical and occupational characteristics; occupational health assessment and recommendations.

Main outcome measures

Work package 1: yield (screen-detected chronic obstructive pulmonary disease) and cost-effectiveness of case-finding; effectiveness of screening on respiratory hospitalisation and mortality after approximately 4 years. Work package 2: respiratory hospitalisation within 2 years, and barriers to and facilitators of physical activity. Work package 3: work performance – feasibility and acceptability of the occupational health intervention and study processes.

Results

Work package 1: targeted case-finding resulted in greater yield of previously undiagnosed chronic obstructive pulmonary disease than routine care at 1 year [n = 1278 (4%) vs. n = 337 (1%), respectively; adjusted odds ratio 7.45, 95% confidence interval 4.80 to 11.55], and a model-based estimate of a regular screening programme suggested an incremental cost-effectiveness ratio of £16,596 per additional quality-adjusted life-year gained. However, long-term follow-up of the trial showed that at ≈4 years there was no clear evidence that case-finding, compared with routine practice, was effective in reducing respiratory admissions (adjusted hazard ratio 1.04, 95% confidence interval 0.73 to1.47) or mortality (hazard ratio 1.15, 95% confidence interval 0.82 to 1.61). Work package 2: 2305 patients, comprising 1564 with previously diagnosed chronic obstructive pulmonary disease and 741 work package 1 participants (330 with and 411 without obstruction), were recruited. The BLISS prognostic model among cohort participants with confirmed airflow obstruction (n = 1894) included 6 of 23 candidate variables (i.e. age, Chronic Obstructive Pulmonary Disease Assessment Test score, 12-month respiratory admissions, body mass index, diabetes and forced expiratory volume in 1 second percentage predicted). After internal validation and adjustment (uniform shrinkage factor 0.87, 95% confidence interval 0.72 to 1.02), the model discriminated well in predicting 2-year respiratory hospital admissions (c-statistic 0.75, 95% confidence interval 0.72 to 0.79). In focus groups, physical activity engagement was related to self-efficacy and symptom severity. Work package 3: in the occupational subcohort, increasing dyspnoea and exposure to inhaled irritants were associated with lower work productivity at baseline. Longitudinally, increasing exacerbations and worsening symptoms, but not a decline in airflow obstruction, were associated with absenteeism and presenteeism. The acceptability of the occupational health intervention was low, leading to low uptake and low implementation of recommendations and making a full trial unfeasible.

Limitations

Work package 1: even with the most intensive approach, only 38% of patients responded to the case-finding invitation. Management of case-found patients with chronic obstructive pulmonary disease in primary care was generally poor, limiting interpretation of the long-term effectiveness of case-finding on clinical outcomes. Work package 2: the components of the BLISS model may not always be routinely available and calculation of the score requires a computerised system. Work package 3: relatively few cohort participants were in paid employment at baseline, limiting the interpretation of predictors of lower work productivity.

Conclusions

This programme has addressed some of the major uncertainties around screening for undiagnosed chronic obstructive pulmonary disease and has resulted in the development of a novel, accurate model for predicting respiratory hospitalisation in people with chronic obstructive pulmonary disease and the inception of a primary care chronic obstructive pulmonary disease cohort for longer-term follow-up. We have also identified factors that may affect work productivity in people with chronic obstructive pulmonary disease as potential targets for future intervention.

Future work

We plan to obtain data for longer-term follow-up of trial participants at 10 years. The BLISS model needs to be externally validated. Our primary care chronic obstructive pulmonary disease cohort is a unique resource for addressing further questions to better understand the prognosis of chronic obstructive pulmonary disease.

Trial registration

Current Controlled Trials ISRCTN14930255.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 13. See the NIHR Journals Library website for further project information.

Prediction of COPD by the single-breath nitrogen test and various respiratory symptoms

Early identification of subjects running an increased risk of contracting COPD enables focus on individual preventive measures. The slope of the alveolar plateau of the single-breath nitrogen washout test (N₂-slope) is a sensitive measure of small-airway dysfunction. However, its role remains unexplored in predicting hospital admission or death related to COPD, i.e. incident COPD events, in relation to the presence of various respiratory symptoms.

A random population sample of 625 men, aged 50 (n=218) or 60 years (n=407), was followed for 38 years for incident COPD events. At baseline, a questionnaire on respiratory symptoms and smoking habits was collected, spirometry and the single-breath nitrogen test were performed, and the N₂-slope was determined. Proportional hazard regression (Cox regression) analysis was used for the prediction model.

The N₂-slope improved the prediction of COPD events significantly beyond that of respiratory symptoms weighted all together and other covariates (hazard ratio 1.63, 95% CI 1.20–2.22; p<0.005), a prediction applicable to subjects without (p=0.001) and with (p<0.05) airway obstruction. Dyspnoea and wheezing were the most predictive symptoms. The combination of the N₂-slope and number of respiratory symptoms notably resulted in an effective prediction of incident COPD events even in nonobstructive subjects, as evidenced by a predicted incidence of ∼70% and ∼90% for a very steep N₂-slope combined with many respiratory symptoms in subject without and with airway obstruction, respectively.

The alveolar N₂-slope should be considered in the critical need for further research on early diagnosis of COPD.

The N₂ slope of the single-breath nitrogen test predicts incident COPD events as well as or better than respiratory symptoms among subjects without and with airway obstruction. Combining N₂ slope and symptoms results in effective prediction.https://bit.ly/3dYJdu1

Association of Ventilatory Disorders with Respiratory Symptoms, Physical Activity, and Quality of Life in Subjects with Prior Tuberculosis: A National Database Study in Korea

Tuberculosis (TB) survivors experience post-TB lung damage and ventilatory function disorders. However, the proportions of obstructive and restrictive ventilatory disorders as well as normal ventilation among subjects with prior TB are unknown. In addition, the impacts of ventilatory disorder and its severity on respiratory symptoms, physical activity limitations, and the quality of life in subjects with prior TB remain unclear. Subjects who participated in the Korean National Health and Nutritional Examination Survey 2007–2016 were enrolled in this study. We evaluated the impact of each ventilatory disorder and its severity on respiratory symptoms, physical activity limitations, and quality of life (measured by the EuroQoL five dimensions questionnaire [EQ-5D] index values) in subjects with prior TB. Among 1466 subjects with prior TB, 29% and 16% had obstructive ventilatory disorders and restrictive ventilatory disorders, respectively. Mild and moderate obstructive ventilatory disorders were not associated with respiratory symptoms, physical activity limitations, or EQ-5D index value compared with normal ventilation; however, severe obstructive ventilatory disorders were associated with more respiratory symptoms (adjusted odds ratio [aOR] = 13.62, 95% confidence interval [CI] = 4.64–39.99), more physical activity limitation (aOR = 218.58, 95% CI = 26.82–1781.12), and decreased EQ-5D index (adjusted coefficient = −0.06, 95% CI = (−0.12–−0.10) compared with normal ventilation. Mild restrictive ventilatory disorders were associated with more respiratory symptoms (aOR = 2.10, 95% CI = 1.07–4.14) compared with normal ventilation, while moderate (aOR = 5.71, 95% CI = 1.14–28.62) and severe restrictive ventilatory disorders (aOR = 9.17, 95% CI = 1.02–82.22) were associated with physical activity limitation compared with normal ventilation. In conclusion, among subjects with prior TB, 29% and 16% developed obstructive and restrictive ventilatory disorders, respectively. Severe obstructive ventilatory disorder was associated with more respiratory symptoms, more physical activity limitation, and poorer quality of life, while severe restrictive ventilatory disorder was associated with more physical activity limitations.

Management and outcomes of patients with chronic obstructive lung disease and lung cancer in a public healthcare system

Hypothesis

There is limited data on the care and outcomes of individuals with both chronic obstructive pulmonary disease (COPD) and lung cancer, particularly in advanced disease. We hypothesized such patients would receive less cancer treatment and have worse outcomes.

Methods

We analyzed administrative data from the province of Ontario including demographics, hospitalization records, physician billings, cancer diagnosis, and treatments. COPD was defined using the ICES-derived COPD cohort (1996–2014) with data from 2002 to 2014. Descriptive statistics and multivariable analyses were undertaken.

Results

Of 105 304 individuals with lung cancer, 43 375 (41%) had stage data and 36 738 (34.9%) had COPD. Those with COPD were likely to be younger, have a Charlson score ≤ 1, have lower income, to live rurally, and to have stage I/II lung cancer (29.8 vs 26.5%; all p<0.001). For the COPD population with stage I/II cancer, surgery and adjuvant chemotherapy were less likely (56.8 vs. 65.9% and 15.4 vs. 17.1%, respectively), while radiation was more likely (26.0 vs. 21.8%) (p all < 0.001). In the stage III/IV population, individuals with COPD received less chemotherapy (55.9 vs 64.4%) or radiation (42.5 vs 47.5%; all p<0.001). Inhaler and oxygen use was higher those with COPD, as were hospitalizations for respiratory infections and COPD exacerbations. On multivariable analysis, overall survival was worse among those with COPD (HR 1.20, 95% CI 1.19–1.22).

Conclusions

A co-diagnosis of COPD and lung cancer is associated with less curative treatment in early stage disease, less palliative treatment in late stage disease, and poorer outcomes.

Clinical and Prognostic Impact of Low Diffusing Capacity for Carbon Monoxide Values in Patients With Global Initiative for Obstructive Lung Disease I COPD

BACKGROUND

The Global Initiative for Obstructive Lung Disease (GOLD) does not promote diffusing capacity for carbon monoxide (Dlco) values in the evaluation of COPD. In GOLD spirometric stage I COPD patients, the clinical and prognostic impact of a low Dlco has not been explored.

RESEARCH QUESTION

Could a Dlco threshold help define an increased risk of death and a different clinical presentation in these patients?

STUDY DESIGN AND METHODS

GOLD stage I COPD patients (n = 360) were enrolled and followed over 109 ± 50 months. Age, sex, pack-years' history, BMI, dyspnea, lung function measurements, exercise capacity, BODE index, and history of exacerbations were recorded. A cutoff value for Dlco was identified for all-cause mortality and the clinical and physiological characteristics of patients above and below the threshold compared. Cox regression analysis explored the predictive power of that cutoff value for all-cause mortality.

RESULTS

A Dlco cutoff value of <60% predicted was associated with all-cause mortality (Dlco ≥ 60%: 9% vs Dlco < 60%: 23%, P = .01). At a same FEV₁% predicted and Charlson score, patients with Dlco < 60% had lower BMI, more dyspnea, lower inspiratory capacity (IC)/total lung capacity (TLC) ratio, lower 6-min walk distance (6MWD), and higher BODE. Cox multiple regression analysis confirmed that after adjusting for age, sex, pack-years history, smoking status, and BMI, a Dlco < 60% is associated with all-cause mortality (hazard ratio [HR], 95% CI = 3.37, 1.35-8.39; P = .009) INTERPRETATION: In GOLD I COPD patients, a Dlco < 60% predicted is associated with increased risk of death and worse clinical presentation. What the cause(s) of this association are and whether they can be treated need to be determined.

Impaired Respiratory Health and Life Course Transitions From Health to Chronic Lung Disease

Primary prevention and interception of chronic lung disease are essential in the effort to reduce the morbidity and mortality caused by respiratory conditions. In this review, we apply a life course approach that examines exposures across the life span to identify risk factors that are associated with not only chronic lung disease but also an intermediate phenotype between ideal lung health and lung disease, termed "impaired respiratory health." Notably, risk factors such as exposure to tobacco smoke and air pollution, as well as obesity and physical fitness, affect respiratory health across the life course by being associated with both abnormal lung growth and lung function decline. We then discuss the importance of disease interception and identifying those at highest risk of developing chronic lung disease. This work begins with understanding and detecting impaired respiratory health, and we review several promising molecular biomarkers, predictive symptoms, and early imaging findings that may lead to a better understanding of this intermediate phenotype.

Is the use of two versus one long-acting bronchodilator by patients with COPD associated with a higher risk of acute coronary syndrome in real-world clinical practice?

BACKGROUND

Cardiovascular comorbidity is common among patients with chronic obstructive pulmonary disease (COPD) and there is concern that long-acting bronchodilators (long-acting muscarinic antagonists (LAMAs) and long-acting beta₂ agonists (LABAs)) may further increase the risk of acute coronary events. Information about the impact of treatment intensification on acute coronary syndrome (ACS) risk in real-world settings is limited. We undertook a nationwide nested case-control study to estimate the risk of ACS in users of both a LAMA and a LABA relative to users of a LAMA.

METHODS

We used routinely collected national health and pharmaceutical dispensing data to establish a cohort of patients aged >45 years who initiated long-acting bronchodilator therapy for COPD between 1 February 2006 and 30 December 2013. Fatal and non-fatal ACS events during follow-up were identified using hospital discharge and mortality records. For each case we used risk set sampling to randomly select up to 10 controls, matched by date of birth, sex, date of cohort entry (first LAMA and/or LABA dispensing), and COPD severity.

RESULTS

From the cohort (n=83 417), we identified 5399 ACS cases during 281 292 person-years of follow-up. Compared with current use of LAMA therapy, current use of LAMA and LABA dual therapy was associated with a higher risk of ACS (OR 1.28 (95% CI 1.13 to 1.44)). The OR in an analysis restricted to fatal cases was 1.46 (95% CI 1.12 to 1.91).

CONCLUSION

In real-world clinical practice, use of two versus one long-acting bronchodilator by people with COPD is associated with a higher risk of ACS.

Preserved Ratio Impaired Spirometry in a Spirometry Database

BACKGROUND

Spirometry results can yield a diagnosis of normal air flow, air flow obstruction, or preserved ratio impaired spirometry (PRISm), defined as a reduced FEV₁ or FVC in the setting of preserved FEV₁/FVC. Previous studies have estimated the prevalence of PRISm to be 7-12%. Our objective was to examine the prevalence of PRISm in a spirometry database and to identify factors associated with PRISm.

METHODS

We performed a retrospective analysis of 21,870 spirometries; 1,616 were excluded because of missing data or extremes of age, height, or weight. We calculated the prevalence of PRISm in prebronchodilator and postbronchodilator pulmonary function tests. Subsequently, we calculated the prevalence of PRISm by various age, race, body mass index, and diagnosis categories, as well as by gender and smokers versus nonsmokers. Finally, in the subset of the cohort with FEV₁ < lower limit of normal, we performed a multivariable logistic regression analysis to identify factors associated with PRISm.

RESULTS

We identified 18,059 prebronchodilator spirometries, and 22.3% of these yielded a PRISm diagnosis. This prevalence remained stable in postbronchodilator spirometries (17.7%), after excluding earlier pulmonary function tests for subjects with multiple pulmonary function tests (20.7% in prebronchodilator and 24.3% in postbronchodilator), and when we limited the analysis to prebronchodilator spirometries that met American Thoracic Society criteria (20.6%). The PRISm prevalence was higher in subjects 45-60 y old (24.4%) and in males (23.7%) versus females (17.9%). The prevalence rose with body mass index and was higher for those with a referral diagnosis of restrictive lung disease (50%). PRISm prevalence was similar between races and smokers versus nonsmokers. In a multivariable analysis, higher % of predicted FEV₁ (odds ratio 1.51, 95% CI 1.42-1.60), body mass index (odds ratio 1.52, 95% CI 1.39-1.68), and restrictive lung disease (odds ratio 4.32, 95% CI 2.54-7.57) were associated with a diagnosis of PRISm. Smoking was inversely associated (odds ratio 0.55, 95% CI 0.46-0.65) with PRISm.

CONCLUSIONS

In a spirometry database at an academic medical center, the PRISm prevalence was 17-24%, which is higher than previously reported.

Long-term Health Outcomes Among Survivors Exposed to Sulfur Mustard in Iran

IMPORTANCE

The prevalence and severity of long-term health complications after exposure to sulfur mustard are unknown.

OBJECTIVE

To investigate the long-term health outcomes among survivors exposed to sulfur mustard during the Iran-Iraq War.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, late-onset health complications of 64 190 Iranian survivors exposed to sulfur mustard during the Iran-Iraq War from 1980 to 1988 were investigated using descriptive statistics. Data involving affected organs and symptom severity were extracted from the Veterans and Martyr Affair Foundation (VMAF) database from 1980 to 2019. Assessments were conducted across 3 groups depending on whether survivors were (1) evacuated and admitted (EA) to a hospital; (2) not evacuated or admitted (NEA) to a hospital; or (3) evacuation or admission status was not documented.

EXPOSURES

Analysis of chronic symptom severity following exposure to sulfur mustard.

MAIN OUTCOMES AND MEASURES

Mild, moderate, or severe rankings of symptoms in lungs, eyes, and skin of survivors exposed to sulfur mustard using data from the VMAF database.

RESULTS

Of 64 190 chemical survivors registered in the VMAF database, 60 861 met the inclusion criteria. Of the included survivors, 98.0% were male, and the mean (SD) age was 23.5 (7.7) years. Most survivors (53 675 [88.2%]) had no symptoms or mild lesions, and 7186 survivors (11.8%) had moderate or severe complications. Moderate to severe lung (6540 [10.7%]), eye (335 [0.6%]), or skin (725 [1.2%]) injuries were documented in the exposed population. The proportion of moderate plus severe late complications in eyes was 3 times as high in male survivors compared with female survivors (0.6% [95% CI, 0.53%-0.65%] vs 0.2% [95% CI, 0.09%-0.73%]; P < .001), whereas dermal complications were significantly more common in female survivors (3.9% [95% CI, 2.92%-5.11%] vs 1.14% [95% CI, 1.06%-1.23%]; P < .001). Mild lung lesions were more prevalent in the NEA group than in the EA group (73.9% [95% CI, 73.4%-74.4%] vs 11.0% [95% CI, 10.6%-11.3%]; P < .001). In the NEA group, 83.2% (n = 23 866) developed lung injuries that were mostly mild or moderate, whereas 77% (n = 24 766) of the EA group did not develop lung injuries (P < .001).

CONCLUSIONS AND RELEVANCE

The present study found sex differences in the frequencies of eye and skin complications following sulfur mustard exposure, and lung complications were more prevalent years after sulfur mustard exposure than soon after exposure. Mild lung lesions were observed more frequently among sulfur mustard-exposed survivors who had not been evacuated or hospitalized than among those who had been evacuated or hospitalized. These differences may be due to physiological response or dose of exposure. Close monitoring over an extended period may be required for detection of late pulmonary complications in individuals exposed to sulfur mustard.

Factors Associated with Exercise-Induced Desaturation in Patients with Chronic Obstructive Pulmonary Disease

Purpose

The 6-min walk test (6MWT) is a useful tool to assess the physiologic function in patients with chronic obstructive pulmonary disease (COPD). The recent study showed that patients with COPD with oxygen desaturation during the 6MWT had an increased risk of exacerbation and death compared with those without oxygen desaturation. This study aimed to explore the potential risk factors for exercise-induced desaturation (EID) in patients with COPD.

Patients and Methods

Adult patients with COPD were enrolled from the Chang Gung Research Database between January 2013 and January 2017. Age, sex, body mass index, underlying diseases, medications, and results of the pulmonary function tests and 6MWT were retrospectively collected and analyzed.

Results

Among 1768 patients with COPD, 932 (52.7%) had oxygen desaturation, and the other 836 (47.3%) had no desaturation during the 6MWT. The patients with EID had a shorter 6-min walk distance than those without desaturation (352.08±120.29 vs 426.56±112.56, p<0.0001). In the multivariate logistic regression analysis, older age, female sex, lower forced expiratory volume in 1 s, and comorbidity with atrial fibrillation (AF) were associated with oxygen desaturation during the 6MWT. Patients with EID had higher exacerbation frequency than those without desaturation in the 1-year follow-up period (0.59±1.50 vs 0.34±1.26, p<0.0001). Patients with COPD with AF also had a higher rate of exacerbation requiring emergency department visit or hospitalization in the 1-year follow-up.

Conclusion

This study demonstrates that older age, low FEV1, and female sex are risk factors for EID. Desaturation during 6MWT is related to frequent acute exacerbation of COPD in the 1-year follow-up.

Association between serum uric acid and spirometric pulmonary function in Korean adults: The 2016 Korea National Health and Nutrition Examination Survey

BACKGROUND

A limited number of epidemiological studies have investigated the association between serum uric acid and pulmonary function in the general population. However, the results have been inconclusive.

OBJECTIVES

This study was performed to investigate the association between serum uric acid and spirometric pulmonary function in general population.

METHODS

Among the 8,150 participants who participated in the 2016 Korea National Health and Nutrition Examination Survey, 2,901 participants were analyzed in this study. Subjects were divided into four groups according to forced vital capacity (FVC)% predicted or forced expiratory volume in 1 second (FEV1) % predicted quartiles. Participants in the lowest quartile of FVC % predicted and FEV1% predicted were compared to those in the remaining quartiles according to age, education level, household income, smoking status, alcohol consumption, aerobic exercise, obesity, hypertension, diabetes, renal impairment, serum uric acid, and hyperuricemia. Multivariable logistic regression analyses were used to calculate the odds ratio (OR) of hyperuricemia for participants in the lowest quartile of FVC% and FEV1 predicted, with above covariates.

RESULTS

In women, hyperuricemia was associated with lowest quartile of FVC% predicted (OR 1.71, 95% CI 1.06-2.75, p = 0.027) and FEV1 predicted (OR 1.70, 95% CI 1.06-2.74, p = 0.028) respectively, serving as above confounding variables. In men, hyperuricemia (OR 1.54, 95% CI 1.07-2.22, p = 0.021) was associated with the lowest quartile of FEV1% predicted, not FVC% predicted. According to median age, in women, age ≥ 56 years old with hyperuricemia was associated with lowest quartile of FVC% predicted (OR 1.85, 95% CI 1.04-3.28, p = 0.037) and FEV1% predicted (OR 1.99, 95% CI 1.11-3.75, p = 0.021), respectively. In men, age ≥ 56 years old with hyperuricemia was associated with lowest quartile of FEV1% predicted (OR 1.75, 95% CI 1.05-2.94, p = 0.033), not FCV% predicted.

CONCLUSIONS

Hyperuricemia was associated with lowest quartile of FEV1% or FVC% predicted in Korean general population. This correlation between hyperuricemia and low pulmonary function was more pronounced in women and older age.

Defining Chronic Mucus Hypersecretion Using the CAT in the SPIROMICS Cohort

Background

Chronic cough and phlegm are frequently reported chronic obstructive pulmonary disease (COPD) symptoms. Prior research classified chronic mucus hypersecretion (CMH) based on the presence of these symptoms for ≥3 months, called chronic bronchitis (CB) if respiratory infection symptoms were present for 1–2 years (Medical Research Council [MRC] definition). We explored whether the COPD Assessment Test (CAT), a simple measure developed for routine clinical use, captures CMH populations and outcomes similarly to MRC and St. George’s Respiratory Questionnaire (SGRQ) definitions.

Methods

We identified CMH in the SPIROMICS COPD cohort using (a) MRC definitions, (b) SGRQ questions for cough and phlegm (both as most/several days a week), and (c) CAT cough and phlegm questions. We determined optimal cut-points for CAT items and described exacerbation frequencies for different CMH definitions. Moderate exacerbations required a new prescription for antibiotics/oral corticosteroids or emergency department visit; severe exacerbations required hospitalization. Results were stratified by smoking status.

Results

In a population of 1431 participants (57% male; mean FEV₁% predicted 61%), 47% and 49% of evaluable participants had SGRQ- or CAT-defined CMH, respectively. A cut-point of ≥2 for cough and phlegm items defined CMH in CAT. Among SGRQ-CMH+ participants, 80% were also defined as CMH+ by the CAT. CMH+ participants were more likely to be current smokers. A higher exacerbation frequency was observed for presence of CMH+ versus CMH− in the year prior to baseline for all CMH definitions; this trend continued across 3 years of follow-up, regardless of smoking status.

Conclusion

Items from the CAT identified SGRQ-defined CMH, a frequent COPD trait that correlated with exacerbation frequency. The CAT is a short, simple questionnaire and a potentially valuable tool for telemedicine or real-world trials. CAT-based CMH is a novel approach for identifying clinically important characteristics in COPD that can be ascertained in these settings.

A perspective for chronic obstructive pulmonary disease (COPD) management: six key clinical questions to improve disease treatment

INTRODUCTION

In 2011, the GOLD recommendations for the treatment of Chronic Obstructive Pulmonary Disease (COPD) introduced new clinical elements to classify the severity of the disease and to guide pharmacological choice. For the first time in the GOLD documents, treatment decision was no longer guided only by pulmonary function, but by a more complex combination of pulmonary function and clinical aspects. The recent versions of the GOLD recommendations introduce new aspects for the clinicians and pose new question for the management of the disease. In addition, inflammatory biomarkers and blood eosinophil levels, have been considered to guide treatment selection.

AREA COVERED

The evolution of disease management proposed by the GOLD document opens several areas of debate. A series of roundtable discussions among respiratory physicians took place in Italy to address key clinical questions. Particularly, the role of lung function and the use of biomarkers, the adherence to international guidelines and the possibility to personalize the pharmacological approach in COPD patients have been discussed, summarized and analyzed.

EXPERT OPINION

The authors believe that the development of a precision medicine approach tailoring the specific treatment for each patient is the goal of COPD management and may be achieved by considering the phenotypic classification of COPD patients.

Intrabronchial stents in heterogenous emphysema: a highly selected material followed 5 years

Background

Endobronchial lung volume reduction (EBVR) with one-way valves introduced into the most diseased lobe of the lung is a non-invasive method to improve lung function in patients with severe heterogenous emphysema. The problem is to select the right patients for the procedure. Furthermore, the long-term effects have not been reported in most studies.

Methods

EBVR was performed in 35 patients with severely handicapping emphysema and with one radiologically clearly enlarged (at least 125%) target lung lobe and clearly visible and complete interlobar fissures on CT. Most of the successful survivors have then been followed for five years.

Results

Five (14%) were primary failures (defined as less than 15% increase of FEV_1sec) and 10 (28%) were secondary failures (the valves were coughed up or removed for some reason). In the 21 successful l patients, the improvement of FEV_1sec was in the mean 59%. Over the years, FEV_1sec gradually decreased but was still higher 5 years later than initially. Of the successful group, 76% were still alive after 5 years, while only 50% were in the refused or failed groups.

Conclusions

With careful selection of patients remarkably good results in lung function can be achieved, and these improvements will last for years though slowly decrease. In addition, the results indicate an improvement in survival with successful EBVR procedure.

Correlation of Inhaled Long-Acting Bronchodilators With Adverse Cardiovascular Outcomes in Patients With Stable COPD: A Bayesian Network Meta-Analysis of Randomized Controlled Trials

A majority of existing studies have focused on the efficacy of inhaled long-acting bronchodilators (ILABs), such as long-acting muscarinic antagonists (LAMAs) and long-acting β2-agonists (LABAs), and LABAs combined with LAMAs in treating chronic obstructive pulmonary disease (COPD). The current meta-analysis aimed to investigate the correlation of ILABs with specific cardiovascular adverse events (CAEs). Five electronic databases, including PubMed, Embase, Cochrane Library, Scopus, and Web of Science were systematically retrieved. Finally, 16 randomized controlled trials were enrolled into the current meta-analysis. Typically, the efficacy of 3 major classes of drugs (LABAs, LAMAs, and LABAs combined with LAMAs), and 7 specific drugs (including formoterol, glycopyrrolate, indacaterol, olodaterol, Salmeterol, tiotropium, and vilanterol) for 4 CAEs, including myocardial infarction, cardiac failure (CF), ischemic heart disease (IHD), and stroke in stable COPD patients, was examined. All the pooled results were analyzed through the odds ratios (ORs) with the corresponding 95% confidence intervals (CIs). The direct meta-analysis results suggested that LABAs could increase the risk of CF in patients with stable COPD compared with placebo controls (OR 1.70, 95% CI, 1.00-2.90). In addition, network meta-analysis results indicated that LAMAs combined with LABAs would result in an increased risk of CF in patients with stable COPD (OR 2.31, 95% CI, 1.10-5.09). According to the ILABs specific drug analysis, formoterol may potentially have protective effects on IHD compared with placebo controls (OR 0.45, 95% CI, 0.18-1.00). In conclusion, among these 3 kinds of ILABs, including LAMAs, LABAs, and LABAs/LAMAs, for stable COPD patients, LAMAs and LABAs are associated with the least possibility to induce myocardial infarction and stroke, respectively. However, the application of LABAs will probably increase the risk of CF; they should be used with caution for stable COPD patients with CF. In addition, in specific-drug analysis, the use of formoterol can reduce the risk of treatment-related IHD. Nevertheless, more studies on different drug doses are needed in the future to further validate this conclusion.

Association of Surgical Hospitalization with Brain Amyloid Deposition: The Atherosclerosis Risk in Communities-Positron Emission Tomography (ARIC-PET) Study

BACKGROUND

As more older adults undergo surgery, it is critical to understand the long-term effects of surgery on brain health, particularly in relation to the development of Alzheimer's disease. This study examined the association of surgical hospitalization with subsequent brain β-amyloid deposition in nondemented older adults.

METHODS

The Atherosclerosis Risk in Communities-Positron Emission Tomography (ARIC-PET) study is a prospective cohort study of 346 participants without dementia who underwent florbetapir PET imaging. Active surveillance of local hospitals and annual participant contact were used to gather hospitalization and surgical information (International Classification of Disease, Ninth Revision, Clinical Modification codes) over the preceding 24-yr period. Brain amyloid measured using florbetapir PET imaging was the primary outcome. Elevated amyloid was defined as a standardized uptake value ratio of more than 1.2.

RESULTS

Of the 313 participants included in this analysis (age at PET: 76.0 [SD 5.4]; 56% female), 72% had a prior hospitalization, and 50% had a prior surgical hospitalization. Elevated amyloid occurred in 87 of 156 (56%) participants with previous surgical hospitalization, compared with 45 of 87 (52%) participants who had no previous hospitalization. Participants with previous surgical hospitalizations did not show an increased odds of elevated brain amyloid (odds ratio, 1.32; 95% CI, 0.72 to 2.40; P = 0.370) after adjusting for confounders (primary analysis). Results were similar using the reference group of all participants without previous surgery (hospitalized and nonhospitalized; odds ratio, 1.58; 95% CI, 0.96 to 2.58; P = 0.070). In a prespecified secondary analysis, participants with previous surgical hospitalization did demonstrate increased odds of elevated amyloid when compared with participants hospitalized without surgery (odds ratio, 2.10; 95% CI, 1.09 to 4.05; P = 0.026). However, these results were attenuated and nonsignificant when alternative thresholds for amyloid-positive status were used.

CONCLUSIONS

The results do not support an association between surgical hospitalization and elevated brain amyloid.

Comparison of pre- and post-bronchodilator lung function as predictors of mortality: The HUNT Study

BACKGROUND AND OBJECTIVE

Post-bronchodilator (BD) lung function is recommended for the diagnosis of chronic obstructive pulmonary disease (COPD). However, often only pre-BD lung function is used in clinical practice or epidemiological studies. We aimed to compare the discrimination ability of pre-BD and post-BD lung function to predict all-cause mortality.

METHODS

Participants aged ≥40 years with airflow limitation (n = 2538) and COPD (n = 1262) in the second survey of the Nord-Trøndelag Health Study (HUNT2, 1995-1997) were followed up until 31 December 2015. Survival analysis and time-dependent area under the receiver operating characteristic curves (AUC) were used to compare the discrimination ability of pre-BD and post-BD lung function (percent-predicted forced expiratory volume in the first second (FEV1 ) (ppFEV1 ), FEV1 z-score, FEV1 quotient (FEV1 Q), modified Global Initiative for Chronic Obstructive Lung Disease (GOLD) categories or GOLD grades).

RESULTS

Among 2538 participants, 1387 died. The AUC for pre-BD and post-BD ppFEV1 to predict mortality were 60.8 and 61.8 (P = 0.005), respectively, at 20 years' follow-up. The corresponding AUC for FEV1 z-score were 58.5 and 60.4 (P < 0.001), for FEV1 Q were 68.7 and 70.1 (P = 0.002) and for modified GOLD categories were 62.3 and 64.5 (P < 0.001). Among participants with COPD, the AUC for pre-BD and post-BD ppFEV1 were 57.0 and 58.8 (P < 0.001), respectively. The corresponding AUC for FEV1 z-score were 53.1 and 55.8 (P < 0.001), for FEV1 Q were 63.6 and 65.1 (P = 0.037) and for GOLD grades were 56.0 and 57.0 (P = 0.268).

CONCLUSION

Mortality was better predicted by post-BD than by pre-BD lung function; however, they differed only by a small margin. The discrimination ability using GOLD grades among COPD participants was similar.