Increased prevalence of chronic obstructive pulmonary disease in a general population

Dynamic changes in quality of life in older patients with chronic obstructive pulmonary disease: a 7-year follow up

PURPOSES

Chronic obstructive pulmonary disease (COPD) is a major cause of the rapid decline of health-related quality of life (HRQoL), associated with accelerated frailty in older populations. This study aimed to analyse the long-term dynamic changes of HRQoL and the predictive factors for the rapid decline of HRQoL in older patients with COPD.

METHODS

Overall 244 patients with COPD, aged ≧ 65 years from one medical centre were enrolled between March 2012 and July 2020. Further, we prospectively assessed HRQoL scores with utility values, using EuroQol Five-Dimension (EQ-5D) questionnaires. Additionally, long-term dynamic changes in HRQoL were analysed using the Kernel smoothing method and examined the factors contributing to the deterioration of HRQoL using a linear mixed effects model.

RESULTS

Older patients with COPD with forced expiration volume (FEV1) < 50% of prediction entered the phase of rapid and continuous decline of HRQoL ~ 2 years after enrolment, but patients with FEV1 ≥ 50% of prediction without rapidly declined HRQoL during 7 years follow up. Therefore, FEV1 < 50% of prediction is a novel predictor for the rapid decline of HRQoL. The course of rapidly declining HRQoL occurred, initially in the usual activities and pain/discomfort domains, followed by the morbidity, self-care, and depression/anxiety domains ~ 2 and 4 years after enrolment, respectively. The mixed effects model indicated that both FEV1 < 50% of prediction and a history of severe acute exacerbation (SAE) requiring hospitalisation were contributing factors for deterioration in HRQoL .

CONCLUSIONS

Both FEV1 < 50% of prediction and exacerbations requiring hospitalisation were contributing factors for the deterioration of HRQoL in long-term follow up. Additionally, FEV1 < 50% of prediction was a novel predictor for patients entering the phase of rapid decline of HRQoL.

Characteristics of Inhaler Technique in COPD Patients in a Specialized Center in Armenia, Colombia: A Cross-Sectional Study

Purpose

The aim of this research was to evaluate the technique of using inhaled drugs in patients with a confirmed history of COPD and describe errors in inhaler technique.

Patients and Methods

Descriptive cross-sectional study was conducted in patients with a history of COPD using inhalation therapy, attending pulmonology consultation between August 2020 and April 2021 in Armenia, Colombia. A non-probabilistic sample of 80 adult participants was calculated, and the inhalation technique was evaluated (depending on the device used) using a scale validated for Colombia. Descriptive analysis of the qualitative variables was performed using frequencies and percentages. The Chi-Square test and Fisher's exact test (in corresponding cases) were used to look for association relationships between categorical variables.

Results

A total of 80 participants were evaluated, of which 66.3% (n = 53) were male, and 32.5% were older than 80 years. Clinically, 30.0% (n = 24) were classified as Modified Medical Research Council Dyspnea Scale (mMRC) grade 3, and 51.2% (n = 41) had at least one exacerbation per year. The main comorbidity was hypertension (40.3%). Pressurized metered-dose inhalers with spacer were the most used device at 22.7% (n = 39). Incorrect technique (at least one error in the steps of the inhalation technique used) was found in 48.7%. The most frequent error among all the techniques was the failure to perform pre-inspiratory exhalation. No significant differences were observed between the development of the technique and the characteristics of the participants.

Conclusion

Nearly half of the patients who use inhalation devices make errors in the technique. Patient education and training of healthcare personnel represent a fundamental pillar in mitigating the incorrect use of these devices.

Period and cohort effects: consequences on spirometric lung function in Norway during the 20th century

Background and aim

Several factors can influence measured lung function over time. The aim of this study was to investigate period and cohort effects on spirometric measures in a large general population sample in Norway during the 20th century, using Global Lung Function Initiative (GLI-2012) equations as a reference.

Methods

36 466 subjects (born 1894-1969) from four cross-sectional surveys conducted between 1965 and 1999 were included, with harmonised data on smoking habits, respiratory symptoms, lung diseases, education and spirometry. Changes in forced expiratory volume in 1 s (FEV₁) and forced vital capacity (FVC) z-scores in healthy subjects across surveys were explored to investigate period effects. Linear mixed-effects models of FEV₁ and FVC z-scores on birth cohort, with survey as random effect, were used to investigate cohort effects, both in subjects of the total population and in healthy ones.

Results

Relatively higher FEV₁ and FVC z-scores in healthy subjects were found in the first survey (1965-1970) compared to the more recent ones (1988-1999), suggesting period effects. FEV₁ and FVC z-scores increased significantly with birth cohort from 1894 to 1935, after adjustment for covariates. A more stable trend of FEV₁ and FVC z-scores with birth cohort was evidenced for subjects born more recently (1945-1969).

Conclusions

An increase of lung function with year of birth was observed in Norwegian subjects during the first half of the 20th century. The impact of period effects on lung function decreased from 1965 to 1999.

Airway Obstruction in Primary Care Patients: Need for Implementing Spirometry Use

(1) Background: To detect early airway obstruction in an adult primary care setting. (2) Methods: Seventeen general practitioners (GP) were involved. A total of 912 patients consulting their GPs over 40 years were recruited: 583 of them (323M) agreed to perform/undergo all the procedures: respiratory questionnaire, mMRC questionnaire, and spirometry. We identified four subgroups: physician COPD patients; physician asthma patients; asthma-COPD overlap syndrome patients; and no respiratory diagnosis subjects, on the basis of physician diagnosis. For screening purposes, an FEV1/FVC < 70% was considered a marker of airway obstruction (AO). (3) Results: Prevalence rates of COPD, A, and ACOS were 12.5%, 7.8%, and 3.6%, respectively. In the overall sample 16.3% showed airway obstruction: 26% mild, 56% moderate, 17% severe, and 1% very severe. In obstructed subjects, those reporting neither respiratory symptoms nor a physician’s respiratory diagnosis were 60% level I; 43% level II; 44% level III; and none level IV. Wheezing (p < 0.001), sputum (p = 0.01), older age (p < 0.0001), and male gender (p = 0.002) were the best predictors of airway obstruction. (4) Conclusions: A high prevalence of AO was found. In AO we found a high prevalence of subjects without respiratory symptoms or respiratory chronic diagnosis. Airway obstruction was predicted by the presence of wheezing, sputum, older age, and male gender.

Prevalence of Pulmonary Embolism and Deep Venous Thromboembolism in Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

Background

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) increases the risk of pulmonary embolism (PE) and deep venous thrombosis (DVT). AECOPD combined with PE and DVT poses challenges for treatment and management. This necessitates prevention and management to estimate the overall prevalence of PE and DVT among patients with AECOPD and to identify the risk factors.

Methods

We searched the PubMed, Embase, and Cochrane Library databases from their inception to January 9, 2021 and extracted the data from the included studies. The risk of bias was assessed for each study. We separately calculated the prevalence of PE and DVT in patients with AECOPD. Subgroup analysis and meta-regression analyses were performed to determine the sources of heterogeneity. Furthermore, we assessed the publication bias.

Results

The meta-analysis included 20 studies involving 5,854 people. The overall prevalence of PE and DVT among patients with AECOPD was 11% (95% CI: 0.06–0.17) and 9% (95% CI: 0.06–0.12), respectively. Subgroup analysis demonstrated that the prevalence of PE among patients with AECOPD was 12, 2, 7, and 16% in the European, South-East Asia, Western Pacific, and Eastern Mediterranean regions, respectively, and the DVT was 10, 9, 9, and 4%, respectively. The prevalence of PE among patients with AECOPD aged ≥ 70 and <70 years old was 6 and 15%, respectively, and the DVT was 8 and 9%, respectively. The prevalence of PE among patients with AECOPD diagnosed within 48 h and other times (beyond 48 h or not mentioned) was 16 and 6%, respectively, and DVT was 10 and 7%, respectively.

Conclusion

The pooled prevalence of PE and DVT among patients with AECOPD was insignificantly different between the different age groups and the WHO regions. However, the early diagnosis was associated with a higher prevalence of PE. Clinicians and the public need to further improve the awareness of prevention and management for PE and DVT among patients with AECOPD.

Systematic Review Registration

PROSPERO, identifier CRD42021260827.

How is the organisational settings, content and availability of comprehensive multidisciplinary pulmonary rehabilitation for people with COPD in primary healthcare in Norway: a cross-sectional study

OBJECTIVE

To examine the organisational settings, content and availability of comprehensive multidisciplinary pulmonary rehabilitation (PR) programmes for people with chronic obstructive pulmonary disease (COPD) in primary healthcare in Norway.

DESIGN

This was a cross-sectional survey study examining the content, organisational settings and availability of comprehensive multidisciplinary PR for people with COPD.

SETTING AND PARTICIPANTS

When the survey was conducted, Norway had 436 municipalities/primary healthcare services who were invited to participate.

OUTCOME MEASURES

The main outcome was the question related to accessibility to a PR programme in primary healthcare. We also examined in what degree the single interventions which are a part of a PR programme were one of the municipalities services and if there were regional differences regarding PR.

RESULTS

Of the 436 municipalities, 158 answered the survey (36% response rate), and the survey covered for 45% of the total population in Norway. Five per cent of the responders reported having multidisciplinary PR for patients with COPD. The most frequently reported single interventions that can be a part of a multidisciplinary PR programme were reported as follows: group exercise training for all diagnoses (27%), reablement (25%) and home-care treatment by a physiotherapist and/or occupational therapist (24%). Southern-Eastern Norway had a significantly lower number of these interventions than Western Norway, Central Norway, and Northern Norway (p<0.001).

CONCLUSION

Only 5% of the Norwegian primary healthcare services (municipalities) had a multidisciplinary PR programme for patients with COPD. PR is the most important and cost-effective treatment within integrated care of patients with COPD. National strategies are therefore needed to increase the availability of PR for patients with COPD in Norwegian municipalities.

Large underreporting of COPD as cause of death-results from a population-based cohort study

BACKGROUND

In 2019, WHO estimated COPD to be the third leading cause of death in the world. However, COPD is probably underestimated as cause of death due to the well-known under-diagnosis.

AIM

To evaluate the proportion of and factors associated with COPD recorded as cause of death in a long-term follow-up of a population-based COPD cohort.

METHODS

The study population includes all individuals (n = 551) with COPD defined as chronic airway obstruction (post-bronchodilator FEV₁/FVC<0.70) + respiratory symptoms identified after re-examinations of four population-based cohorts. Mortality and underlying or contributing cause of death following ICD-10 classification were collected from the Swedish National Board of Health and Welfares register from date of examination in 2002-04 until 2016.

RESULTS

The study sample consisted of 32.3% GOLD 1, 55.9% GOLD 2, and 11.8% GOLD 3-4. The mean follow-up time was 10.3 (SD3.77) years and the cumulative mortality 45.0%. COPD (ICD-10 J43-J44) was recorded on 28.2% (n = 70) of the death certificates (11.1%, 25.7% and 57.1% by GOLD stage), whereof n = 35 had COPD recorded as underlying and n = 35 as contributing cause of death. To have COPD recorded as cause of death was independently associated with ex- and current smoking and a self-reported physician diagnosis of COPD, while male sex, overweight/obesity and higher FEV₁% of predicted associated with the absence.

CONCLUSIONS

COPD was largely underreported cause of death. Even among those with severe/very severe disease, COPD was only mentioned on 57.1% of the death certificates.

Clinical Characteristics of COPD Patients According to COPD Assessment Test (CAT) Score Level: Cross-Sectional Study

PURPOSE

The chronic obstructive pulmonary disease (COPD) assessment test (CAT) is widely used to assess the impact of COPD symptoms on health status. Whilst the CAT consists of eight different items, details on the distribution of each item are limited. This study aimed to investigate the distribution and clinical implication of each CAT item, stratified by CAT severity group, in stable COPD patients.

PATIENTS AND METHODS

This was a cross-sectional study at a single referral hospital in South Korea. Spirometry confirmed COPD patients with CAT measured at the first clinical visit were retrospectively identified. Patients were categorized into three groups: low (0 ≤ CAT < 10), medium (10 ≤ CAT < 20), and high (20 ≤ CAT ≤ 40) impact group. For the purpose of this analysis, the first four items (cough, sputum, chest tightness, and dyspnea) and the remaining four items (activities, confidence, sleep and energy) were also grouped as "pulmonary" and "extra-pulmonary", respectively.

RESULTS

A total of 815 patients were included, and mean (SD) forced expiratory volume in 1 s (FEV1) was 62.8 (17.4) % pred. Among them, 300 patients (36.8%) were in the high impact group and had a greater exacerbation history and lower lung function. The proportion of "extra-pulmonary" items score was greater in patients with higher total CAT scores, with the activity and confidence items showing higher scores.

CONCLUSION

In our study, in addition to dyspnea, activity limitation is a particular problem in individual patients with higher CAT total scores, for which physicians need to pay more attention. Our study suggests that whilst CAT total score captures the overall impact of COPD, each item of the CAT contains potentially useful information in understanding the patient's symptom burden.

Decreased COPD prevalence in Sweden after decades of decrease in smoking

BACKGROUND

COPD has increased in prevalence worldwide over several decades until the first decade after the millennium shift. Evidence from a few recent population studies indicate that the prevalence may be levelling or even decreasing in some areas in Europe. Since the 1970s, a substantial and ongoing decrease in smoking prevalence has been observed in several European countries including Sweden. The aim of the current study was to estimate the prevalence, characteristics and risk factors for COPD in the Swedish general population. A further aim was to estimate the prevalence trend of COPD in Northern Sweden from 1994 to 2009.

METHODS

Two large random population samples were invited to spirometry with bronchodilator testing and structured interviews in 2009-2012, one in south-western and one in northern Sweden, n = 1839 participants in total. The results from northern Sweden were compared to a study performed 15 years earlier in the same area and age-span. The diagnosis of COPD required both chronic airway obstruction (CAO) and the presence of respiratory symptoms, in line with the GOLD documents since 2017. CAO was defined as post-bronchodilator FEV1/FVC < 0.70, with sensitivity analyses based on the FEV1/FVC < lower limit of normal (LLN) criterion.

RESULTS

Based on the fixed ratio definition, the prevalence of COPD was 7.0% (men 8.3%; women 5.8%) in 2009-2012. The prevalence of moderate to severe (GOLD ≥ 2) COPD was 3.5%. The LLN based results were about 30% lower. Smoking, occupational exposures, and older age were risk factors for COPD, whereof smoking was the most dominating risk factor. In northern Sweden the prevalence of COPD, particularly moderate to severe COPD, decreased significantly from 1994 to 2009, and the decrease followed a decrease in smoking.

CONCLUSIONS

The prevalence of COPD has decreased in Sweden, and the prevalence of moderate to severe COPD was particularly low. The decrease follows a major decrease in smoking prevalence over several decades, but smoking remained the dominating risk factor for COPD.

Irritable bowel syndrome increases the risk of chronic obstructive pulmonary disease: A retrospective cohort study

Both inflammation and infection are associated with the development of irritable bowel syndrome (IBS) and chronic obstructive pulmonary disease (COPD). The purpose of this study is to further elucidate the association between IBS and COPD through a retrospective cohort study. We enrolled IBS patients diagnosed between 2000 and 2011 with follow-up for at least one year. The non-IBS patients as comparison group were selected with 1:3 matching by propensity score. Statistical analysis was utilized to assess the differences in characteristic distribution, and to compare the cumulative incidence of COPD between the IBS and non-IBS cohorts. We selected 14,021 IBS patients and 42,068 non-IBS patients for comparison. The IBS patients exhibited a significant risk to develop COPD compared with non-IBS patients. Additionally, the cumulative incidence rate of COPD in the IBS cohort increased significantly during the follow-up period of more than ten years, compared to the non-IBS cohort, based on the Kaplan-Meier analysis. The risk of COPD was also significantly decreased in those patients with more than eighteen IBS-related clinical visits. This retrospective cohort study demonstrates the significantly increased risk of COPD in patients with IBS. Therefore, early inspection and prevention of COPD is essential for patients with IBS.

Global Burden of Chronic Respiratory Diseases

Background: Noncommunicable diseases (NCDs) and chronic respiratory diseases (CRDs) are the main causes of mortality and morbidity worldwide. Methods: The main evidences about the NCDs and CRDs burden and related risk factors, from updated international reports and results of original researches, were collected and described in this review. Results: Most recent evidence is available from the Global Burden of Diseases Study (GBD) 2017 reports. There were 3.2 million deaths due to chronic obstructive pulmonary disease (COPD) and 495,000 deaths due to asthma. COPD was the seventh leading cause of years of life lost (YLLs). Overall, prevalent cases of CRDs were 545 million: about 50% for COPD and 50% for asthma. Incident cases of CRDs were 62 million, mostly due to asthma (69%) and COPD (29%). COPD accounted for 81.6 million disability-adjusted life years, asthma for 22.8 million. COPD prevalence of 9.1% has been found in a recent general population sample of North-Eastern Italy, while in Central Italy a 25-year follow-up of a general population sample has shown an increased prevalence of COPD and asthma up to 6.8% and 7.8%, respectively. In Central Italy, a COPD incidence of 8% and an asthma incidence of 3.2% have been found in adult subjects at an 18-year follow-up. Among the risk factors, a relevant role is played by smoking and high body mass index for asthma, while smoking, particulate matter pollution, ambient ozone pollution, occupational exposure to particulate matter, gases and fumes, as well as second-hand smoke, play an important role for COPD. Forecasting the YLLs by 2040 indicates a rising toll from several NCDs due to population growth and aging, with COPD expected to reach the fourth leading cause. Conclusions: Several recent studies and international reports highlighted the huge global health burden of CRDs and other major NCDs, pointing out the need for implementing international collaborations to fight this epidemic trend.

Influence of Previous-Year Physical Activity on the Cognition of COPD Older Patients During Exacerbation

BACKGROUND

Growing evidence demonstrates the negative health impact of physical inactivity. Our aim was to examine the influence of previous-year physical activity (PA) on the cognition of chronic obstructive pulmonary disease (COPD) patients during exacerbation.

METHODS

Observational study. One hundred and fifty-one patients with COPD exacerbation were recruited over a period of 3 years and divided in 2 groups according to their previous activity level. Sociodemographic, anthropometric, and clinical variables were collected. Our main outcome measures were previous-year PA level, measured using the Modified Baecke Physical Activity Questionnaire and cognitive status measured using the Montreal Cognitive Assessment.

RESULTS

The cognitive variables that exhibited significant differences (P < .05) according to PA level were the visuoconstructional skills subscore, attention subscore, language subscore, orientation subscore, and Montreal Cognitive Assessment total score, with worse results in the sedentary group. Based on the relationships between total scores, the Baecke score was positively correlated with the Montreal Cognitive Assessment total score (r = .457).

CONCLUSIONS

The cognitive status of COPD patients during an exacerbation is related to previous-year PA level. Previous-year PA level should be taken into consideration when patients with a COPD exacerbation are evaluated.

Impact of changing GOLD guidelines (2007-2011-2017) on assignment of a COPD patient to disease severity category

INTRODUCTION

The international standard for the recognition and treatment of chronic obstructive pulmonary disease (COPD) is guided by a regularly updated set of criteria developed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD).

AIM

To investigate the impact of updated COPD management guidelines from 2007 to 2017 (GOLD 2007, GOLD 2011 and GOLD 2017) on the assignment of patients into individual therapeutic groups, examining both individual and population dimensions.

MATERIAL AND METHODS

Each of 500 randomly chosen primary care physicians in Poland provided information on 10 individual COPD patients (disease history, clinical status, treatment and pharmacotherapy). This data was used to simulate the consequences of the implementation of the GOLD 2007, 2011 and 2017 guidelines.

RESULTS

A group of 298 physicians of 500 approached provided information on 2597 patients (64.2% males) aged 29-96 (61.6 ±11.1 years). Based on GOLD 2007 guidelines, most patients (56.7%) presented a severe stage of COPD. GOLD 2011 updates would significantly increase the proportion of patients with the most severe stage of disease, and this group would be predominantly classified as moderate or severe in GOLD 2007. The implementation of GOLD 2017 guidelines would result in a significant migration of patients towards the lightest (category A) form of the disease.

CONCLUSIONS

Updates to the GOLD 2007 COPD guidelines for GOLD 2011 and 2017 would have a significant impact on the classification of patients for particular therapeutic groups. As a result of the migration of patients to particular therapeutic groups, the pharmacological treatment would also change.

Demographic, Clinical and Management Characteristics of Newly Diagnosed COPD Patients in Turkey: A Real-Life Study

Purpose

In order to determine the clinical and sociodemographic characteristics of newly diagnosed treatment-naïve asthma and COPD patients in Turkey, a multicenter study in 2012 was initiated . We aimed to investigate the characteristics and therapies of COPD patients in the original study in more detail.

Patients and Methods

This nation-wide, multicentric, non-interventional, prospective, real-life observational cohort study was conducted in 122 centers. The newly diagnosed patients were not receiving any treatment before the recruitment. Their general characteristics, the combined GOLD 2011 COPD categories and exacerbation histories were noted. The patients were followed up with 3 voluntary visits for 1 year. Their adherence to the inhaled treatment according to GOLD 2011 was evaluated during follow-up visits.

Results

The study included 776 COPD patients. Their mean age was 59.4±9.1 years, and 11.9% of the patients were female. 35.1% of the patients were in the GOLD 2011 C and D category. 12.6% are frequent exacerbators, and 52.8% had at least one comorbid condition. 71.8% overtreatment rate was detected. Their attendance rates for three follow-up visits became 55.9%, 32.9% and 18.7%, respectively. The adherence rate to the treatment was measured as 81.9%.

Conclusion

Although these patients were diagnosed for the first time, the GOLD C and D categories and frequent exacerbator phenotype were found at a high rate. They were usually prescribed an overtreatment regimen. We think that newly diagnosed COPD patients should be evaluated carefully, and best effort should be made to treat these patients in accordance with the recommendations of the major COPD guidelines.

Increase in Airway Obstruction between 1993 and 2012 in Switzerland. An Observational Study

Rationale: Most studies determining the prevalence of airway obstruction are limited to short time periods.Objectives: Because temporal trends of obstruction in populations are largely unknown, we determined the prevalence of airway obstruction over 20 years in yearly general population samples in Switzerland between 1993 and 2012.Methods: We analyzed data of 85,789 participants aged 35 years and older who provided spirometric measurements as part of the LuftiBus lung function campaign. We linked data from the 2003-2012 period to the Swiss National Cohort to adjust for annual population differences. Spirometry was performed without bronchodilation, according to American Thoracic Society guidelines. We used Global Lung Initiative (GLI) and Hankinson reference equations to identify obstruction.Results: Obstruction prevalence increased between 1993 and 2012 from 6.1% (95% confidence interval [CI], 5.5 to 6.7) to 15.6% (95% CI, 13.8 to 17.3) based on GLI estimates and from 5.3% (95% CI, 4.7 to 5.9) to 15.4% (95% CI, 13.6 to 17.1) based on Hankinson estimates. When adjusted for participant demographics, air pollutant and occupational exposures, altitude, and season, the prevalence ratios of obstruction were 1.54 (95% CI, 1.22 to 1.93) and 1.65 (95% CI, 1.33 to 2.04) for GLI- and Hankinson-defined airway obstruction, respectively, for 2012 compared with 2003.Conclusions: Though prebronchodilator measurements likely overestimate the prevalence of airway obstruction in absolute terms compared with post-bronchodilator measurements, we found an increase in airway obstruction prevalence. Even with adjustment for several well-known risk factors for obstruction to make the populations across the years more comparable, we still saw a statistically significant increase in prevalence over this time period.

Gender differences among Swedish COPD patients: results from the ARCTIC, a real-world retrospective cohort study

The present study aimed to generate real-world evidence regarding gender differences among chronic obstructive pulmonary disease (COPD) patients, especially as regards the diagnosis and outcomes in order to identify areas for improvement and management and optimize the associated healthcare resource allocation. ARCTIC is a large, real-world, retrospective cohort study conducted in Swedish COPD patients and a matched reference population from 52 primary care centers in 2000–2014. The incidence of COPD, prevalence of asthma and other comorbidities, risk of exacerbations, mortality rate, COPD drug prescriptions, and healthcare resource utilization were analyzed. In total, 17,479 patients with COPD were included in the study. During the study period, COPD was more frequent among women (53.8%) and women with COPD experienced more exacerbations vs. men (6.66 vs. 4.66). However, the overall mortality rate was higher in men compared with women (45% vs. 38%), but no difference for mortality due to COPD was seen between genders over the study period. Women seemed to have a greater susceptibility to asthma, fractures, osteoporosis, rheumatoid arthritis, rhinitis, depression, and anxiety, but appeared less likely to have diabetes, kidney diseases, and cardiovascular diseases. Furthermore, women had a greater risk of COPD-related hospitalization and were likely to receive a significantly higher number of COPD drug prescriptions compared with men. These results support the need to reduce disease burden among women with COPD and highlight the role of healthcare professionals in primary care who should consider all these parameters in order to properly diagnose and treat women with COPD.

Exposure to second-hand tobacco smoke and respiratory symptoms in non-smoking adults: cross-sectional data from the general population of Telemark, Norway

Background

In Norway, data on the association between second-hand tobacco smoke (SHS) exposure at home and respiratory symptoms in adults are limited.

Methods

We assessed the association between self-reported exposure to SHS and the prevalence of respiratory symptoms among never-smokers aged 16 to 50 years from the general population who were included in a cross-sectional population-based study in Telemark County, Norway. Logistic regression analysis was used to estimate the odds ratios of symptoms among 8850 never-smokers who provided an affirmative response to questions regarding SHS; 504 (5.7%) of these reported that they lived in a home with daily or occasional indoor smoking.

Results

Productive cough and nocturnal dyspnoea were statistically associated with daily SHS exposure (ORs 1.5 [95% CI 1.04–2.0] and 1.8 [1.2–2.7], respectively). In analyses stratified by gender, nocturnal dyspnoea was associated with SHS among women (OR 1.8 [1.1–3.1]), but not among men (OR 0.93 [0.49–1.8]). Symptoms were not associated with occasional SHS exposure in the entire group, but infrequent exposure among men only was associated with increased prevalence of chronic cough; (OR 1.6; [1.04–2.6]) and was negatively associated with wheeze; (OR 0.44 [0.21–0.92)].

Conclusions

Daily SHS exposure in private homes was associated with productive cough and nocturnal dyspnoea. Our results suggest that preventive measures may be needed to reduce the respiratory effects of SHS at home.

Trial registration

ClinicalTrials.gov Identifier: NCT02073708 Registered February 27. 2014.

Obstructive and restrictive pulmonary dysfunction in long-term lymphoma survivors after high-dose therapy with autologous stem cell transplantation

BACKGROUND

Obstructive and restrictive dysfunction in long-term lymphoma survivors (LSs) after high-dose therapy with autologous stem-cell transplantation (HDT-ASCT) has not been addressed systematically previously.

MATERIAL AND METHODS

LSs treated in Norway 1987-2008 with HDT-ASCT who performed spirometry, measurement of static lung volumes and echocardiography 2012-2014 at either Oslo or St. Olavs University Hospitals was eligible. Smoking data were recorded by questionnaire. Treatment data were collected from medical records or hospital databases. Factors associated with obstructive and restrictive impairments (dichotomous outcomes) were examined by Poisson regression. Linear regression with the margins post-estimation command was used to derive adjusted mean values of forced expiratory volume in 1 s (FEV₁). We used the normative reference data recommended by the European Respiratory Society for calculating percent predicted values.

RESULTS

A total of 226 LSs were studied, of whom 11.5 and 5.8% had obstructive and restrictive impairment, respectively. For women and men, mean FEV₁ was 2.31 and 3.34 l corresponding to 11.4%- and 11.1%-points below that predicted from norms, respectively. In multivariable regression analyses, cumulative doxorubicin dose (400-775 mg/m²) and current smoking were associated with increased risk of obstructive impairment, and chest RT (>13-66 Gy) was associated with increased risk of restrictive impairment. Currently smoking LSs within the highest doxorubicin category (400-775 mg/m²), had the lowest adjusted mean FEV₁.

CONCLUSIONS

Despite intensive cancer treatment, our analysis showed modest reductions in obstructive parameters among long-term LSs after HDT-ASCT compared to normative reference data. To limit obstructive impairments in LSs after HDT-ASCT, we suggest that targeted smoking-cessation advice is directed towards patients who have received high cumulative doses of doxorubicin.

The Role of Fixed-Dose Dual Bronchodilator Therapy in Treating COPD

The incidence of chronic obstructive pulmonary disease (COPD) is rising in the United States, and the disease represents a significant source of morbidity and mortality. Primary care providers face many challenges in COPD diagnosis and treatment, as different clinical phenotypes require personalized treatment approaches. Patient adherence and inhaler technique also contribute to treatment outcomes. Around 48% of primary care providers are unaware of guidelines and recommendations for COPD diagnosis and treatment, which may lead to misdiagnosis or undertreatment of COPD symptoms. Inadequately treated COPD can impair patients' quality of life and ability to perform everyday activities. Long-acting bronchodilator therapy is the cornerstone treatment for patients with COPD; combinations of bronchodilators of different pharmacological classes have shown improved efficacy vs monotherapy. We review the rationale behind fixed-dose dual bronchodilator therapy, evidence for the 4 currently Food and Drug Administration-approved long-acting anticholinergic bronchodilators/long-acting β₂-agonists fixed combinations, patient suitability for the available inhaler devices, and practical guidance to optimize personalized care for patients with COPD.

The relationship between pulmonary function and suicidal ideation in Korean adults: a nationwide survey

Controversy surrounds the association between lung function and mental health in the general population, and previous reported results were confounded by the effect of other chronic illnesses. This study aimed to investigate whether reduced lung function was related to mental health issues, taking into consideration the relevant potential confounders. We used data from the 2008-2013 Korean National Health and Nutrition Examination Survey to examine the relationship between lung function and three mental issues (recognized stress, depressive mood, and suicidal ideation) among 22,068 Korean adults. A multiple logistic regression with adjustment for potential covariates including chronic illnesses revealed that a .5-L decrement of forced vital capacity increased the risk for suicidal ideation in both genders, but there was no significant association with recognized stress or depressive mood. We found an inverse relationship between lung function and suicidal ideation in the Korean general population.

Prevalence and trend of COPD from 1995-1997 to 2006-2008: The HUNT study, Norway

BACKGROUND

COPD is a major cause of morbidity and mortality across the world and new estimates of prevalence and trend are of great importance. We aimed to estimate the prevalence and trend of COPD from 1995-1997 to 2006-2008 in Norwegian adults ≥40 years from the Nord-Trøndelag Health Study.

MATERIAL AND METHODS

COPD was assessed using a fixed-ratio and lower limit of normal (LLN) criteria. Pre-bronchodilator spirometry was performed during 1995-1997 (n = 7158) and 2006-2008 (n = 8788). The prevalence of COPD was weighted using the inverse probability of selection and predicted probability of response.

RESULTS

The prevalence of pre-bronchodilator COPD was 16.7% in 1995-1997 and 14.8% in 2006-2008 using fixed-ratio criteria, and 10.4% in 1995-1997 and 7.3% in 2006-2008 using LLN criteria. The prevalence of LLN COPD was higher among men (13.0% in 1995-1997, 7.7% in 2006-2008) than women (8.0% in 1995-1997, 6.9% in 2006-2008). From 1995-1997 to 2006-2008, the prevalence decreased among men but remained relatively stable among women. Over the 11-year period, the cumulative incidence of pre-bronchodilator COPD using LLN criteria was 3.3% and 2.7% among men and women respectively. The prevalence of self-reported asthma and respiratory symptoms increased.

CONCLUSIONS

The prevalence declined in men but not in women from 1995-1997 to 2006-2008, and was consistently higher among men than women.

Missed diagnosis and overtreatment of COPD among smoking primary care population in Central Greece: old problems persist

Background

The diagnosis of COPD is not always consistent with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy in daily clinical practice, especially in primary care. This study aimed to estimate the overall COPD prevalence and severity, to identify differences between newly and previously diagnosed patients, and to evaluate the potential COPD overtreatment in a smoking population attending a primary care spirometry surveillance program.

Methods

A study was conducted in 10 primary health care centers of Central Greece during a 7-month period. Eligible participants were aged ≥40 years and were either current smokers or exsmokers.

Results

A total of 186 subjects were included (68% males, mean age 62.3±12.6 years, mean life-time tobacco exposure 50 pack-years). COPD prevalence was 17.8%, identified to be higher in elderly males. Forty-two percent of the COPD group were newly diagnosed patients, who were of younger age, current smokers, presented with less dyspnea and better health status, and mainly appeared with mild-to-moderate disease. Interestingly, 61.4% of non-COPD and 85.7% of newly diagnosed COPD individuals had been using inhaled medication under primary care provider's prescription without ever undergoing spirometry or further evaluation by a pulmonologist; thus, the phenomena of COPD overdiagnosis and missed diagnosis came into the spotlight. Moreover, only 26.3% of known COPD patients were properly medicated according to GOLD guidelines, while half of them were inappropriately treated with triple inhaled therapy.

Conclusion

We reported a significant prevalence of COPD in smoking population attending this spirometry program. A remarkable proportion of COPD patients were undiagnosed and made case finding worthwhile. Underutilization of spirometry in the diagnosis and management of COPD as well as general practitioners' nonadherence to the GOLD treatment guidelines was confirmed by our data. These findings highlight the need for a major overhaul and culture change in primary care settings of Central Greece.

2017 Global Initiative for Chronic Obstructive Lung Disease reclassifies half of COPD subjects to lower risk group

Background

Unlike the 2014 guidelines, the 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines have removed lung function from the risk assessment algorithm of patients with COPD. The aim of this investigation was to analyze the proportion of subjects who would change to a lower risk group when applying GOLD²⁰¹⁷ and determine if they exhibit different characteristics in terms of inflammation, symptoms and comorbidity compared to the subjects who would remain in a high-risk group.

Subjects and methods

A total of 571 subjects with physician-diagnosed and spirometry-verified COPD were included in the present study. The data consisted of measurements of lung function, inflammatory markers, together with questionnaires that covered comorbidities, COPD symptoms and medication.

Results

From group C, 53% of the subjects would be reclassified to the lower risk group A, and from group D, 47% of the subjects would be reclassified to the lower risk group B when using GOLD²⁰¹⁷ instead of GOLD²⁰¹⁴. Compared to the subjects who would remain in group D, those who would change to group B were more often men (56% vs 72%); of an older age, mean (SD), 71 (8) years vs 68 (7) years; had more primary care contact (54% vs 33%); had lower levels of blood neutrophils, geometrical mean (95% CI), 5.3 (5.0, 5.7) vs 4.6 (4.3, 4.9); reported less anxiety/depression (20% vs 34%); experienced less asthma (29% vs 46%) and had fewer symptoms according to the COPD assessment test, 16 (5) vs 21 (7). All p-values were <0.05.

Conclusion

The removal of spirometry from risk assessment in GOLD²⁰¹⁷ would lead to the reclassification of approximately half of the subjects in the risk groups C and D to the lower risk groups A and B. There are differences in age, gender, health care contacts, inflammation, comorbidity and symptom burden among those changing from group D to group B. The effects of reclassification and changes in eventual treatment for disease control and symptom burden need further investigation.

Geographical distribution of COPD prevalence in Europe, estimated by an inverse distance weighting interpolation technique

Existing data on COPD prevalence are limited or totally lacking in many regions of Europe. The geographic information system inverse distance weighted (IDW) interpolation technique has proved to be an effective tool in spatial distribution estimation of epidemiological variables, when real data are few and widely separated. Therefore, in order to represent cartographically the prevalence of COPD in Europe, an IDW interpolation mapping was performed. The point prevalence data provided by 62 studies from 19 countries (21 from 5 Northern European countries, 11 from 3 Western European countries, 14 from 5 Central European countries, and 16 from 6 Southern European countries) were identified using validated spirometric criteria. Despite the lack of data in many areas (including all regions of the eastern part of the continent), the IDW mapping predicted the COPD prevalence in the whole territory, even in extensive areas lacking real data. Although the quality of the data obtained from some studies may have some limitations related to different confounding factors, this methodology may be a suitable tool for obtaining epidemiological estimates that can enable us to better address this major public health problem.

Impact of inhalation therapy on the incidence of carious lesions in patients with asthma and COPD

Objective:

The aim of this study was to investigate the incidence of carious lesions, the amount of salivary flow rate and pH value in patients with asthma and chronic obstructive pulmonary diseases (COPD), using inhalation therapy. The obtained results were compared with the results of adult healthy subjects, forming a control group.

Material and Methods:

The study included 80 participants aging between 18 and 65 years. The experimental group (EG) was comprised of 40 participants, previously diagnosed with asthma or COPD undergoing inhalation therapy for more than five years. The control group (CG), comprised of 40 participants, mirrored the same age and gender status of the EG. Dental status was determined by decayed, missing, and filled teeth (DMFT index). Quantity and pH value of saliva were determined in the laboratory.

Results:

In the EG, the mean value of the salivary flow rate and pH value were statistically significantly lower than in the CG (p<0.001). Patients in the EG had a higher value of DMFT index when compared with the CG, although the difference was not statistically significant (p=0.199). Mean number of decayed teeth, as well as missing teeth, in the EG was statistically significantly higher than in the CG (p<0.001). Mean number of filled teeth in the EG was statistically significantly lower than in the CG (p<0.001).

Conclusion:

It was found that patients undergoing inhalation therapy face increasing risk of dental caries due to the lower salivary flow rate and pH value along with the inhalation therapy. They should receive intensive preventive care, including oral hygiene instruction and dietary advice.

Call to action: improving primary care for women with COPD

In this perspective-based article, which is based on findings from a comprehensive literature search, we discuss the significant and growing burden of chronic obstructive pulmonary disease in women worldwide. Chronic obstructive pulmonary disease now affects both men and women almost equally. Despite this, there remains an outdated perception of chronic obstructive pulmonary disease as a male-dominated disease. Primary care physicians play a central role in overseeing the multidisciplinary care of women with chronic obstructive pulmonary disease. Many women with chronic obstructive pulmonary disease delay seeking medical assistance, due to fear of stigmatization or dismissing symptoms as a 'smoker's cough'. Improving awareness is important to encourage women with symptoms to seek advice earlier. Once women do seek help, primary care physicians need to have knowledge of the nuances of female chronic obstructive pulmonary disease disease presentation to avoid mis- or delayed diagnosis, both of which are more common in women with chronic obstructive pulmonary disease than men. Subsequent management should consider gender-specific issues, such as differential incidences of comorbid conditions, potentially higher symptom burden, and a higher risk of exacerbations. Chronic obstructive pulmonary disease treatment and smoking cessation management should be specifically tailored to the individual woman and reviewed regularly to optimize patient outcomes. Finally, education should be an integral part of managing chronic obstructive pulmonary disease in women as it will help to empower them to take control of their disease.

The effect of inhaled corticosteroids on bone mineral density measured by quantitative ultrasonography in an older population

INTRODUCTION

Prolonged use of systemic corticosteroids leads to reduced bone mineral density and osteoporosis, in turn increasing the risk of minimal trauma fractures with their associated morbidity and mortality in elderly populations. However, the effect of inhaled corticosteroids on bone mineral density has been debated in the medical literature.

OBJECTIVES

We aimed to determine the effect of inhaled corticosteroids on bone mineral density measured using calcaneal quantitative ultrasonography in a cohort of older Australians.

METHODS

Data was collected from the Hunter Community Study, a longitudinal cohort of Australians aged 55-85. Simple and multiple linear regression methods were used to test the cross-sectional association between inhaled corticosteroids and calcaneal bone mineral density measured with quantitative ultrasound at baseline. A causal diagram was used to determine the minimally sufficient number of co-variates necessary to determine the unconfounded effect of inhaled corticosteroids on bone mineral density; these included gender, body mass index, smoking, asthma, alcohol use, age, physical activity, and diet.

RESULTS

There were 152 (6.8%) patients on inhaled corticosteroids and 2098 (93%) controls. Simple and multiple linear regression methods showed a non-significant effect of inhaled steroids on BMD with slight decrease of BMD -0.010 g/cm² (95% CI -0.042 to 0.022, P = .55) and -0.013 g/cm² (95% CI -0.062 to 0.036, P = .61) respectively. Age, gender, body mass index, and smoking were stronger predictors of BMD.

CONCLUSIONS

No statistically significant relationship was detected between the use of inhaled corticosteroids and reduced bone mineral density in this observational study of a cohort of older Australians.

Global and regional estimates of COPD prevalence: Systematic review and meta-analysis

Background

The burden of chronic obstructive pulmonary disease (COPD) across many world regions is high. We aim to estimate COPD prevalence and number of disease cases for the years 1990 and 2010 across world regions based on the best available evidence in publicly accessible scientific databases.

Methods

We conducted a systematic search of Medline, EMBASE and Global Health for original, population–based studies providing spirometry–based prevalence rates of COPD across the world from January 1990 to December 2014. Random effects meta–analysis was conducted on extracted crude prevalence rates of COPD, with overall summaries of the meta–estimates (and confidence intervals) reported separately for World Health Organization (WHO) regions, the World Bank's income categories and settings (urban and rural). We developed a meta–regression epidemiological model that we used to estimate the prevalence of COPD in people aged 30 years or more.

Findings

Our search returned 37 472 publications. A total of 123 studies based on a spirometry–defined prevalence were retained for the review. From the meta–regression epidemiological model, we estimated about 227.3 million COPD cases in the year 1990 among people aged 30 years or more, corresponding to a global prevalence of 10.7% (95% confidence interval (CI) 7.3%–14.0%) in this age group. The number of COPD cases increased to 384 million in 2010, with a global prevalence of 11.7% (8.4%–15.0%). This increase of 68.9% was mainly driven by global demographic changes. Across WHO regions, the highest prevalence was estimated in the Americas (13.3% in 1990 and 15.2% in 2010), and the lowest in South East Asia (7.9% in 1990 and 9.7% in 2010). The percentage increase in COPD cases between 1990 and 2010 was the highest in the Eastern Mediterranean region (118.7%), followed by the African region (102.1%), while the European region recorded the lowest increase (22.5%). In 1990, we estimated about 120.9 million COPD cases among urban dwellers (prevalence of 13.2%) and 106.3 million cases among rural dwellers (prevalence of 8.8%). In 2010, there were more than 230 million COPD cases among urban dwellers (prevalence of 13.6%) and 153.7 million among rural dwellers (prevalence of 9.7%). The overall prevalence in men aged 30 years or more was 14.3% (95% CI 13.3%–15.3%) compared to 7.6% (95% CI 7.0%–8.2%) in women.

Conclusions

Our findings suggest a high and growing prevalence of COPD, both globally and regionally. There is a paucity of studies in Africa, South East Asia and the Eastern Mediterranean region. There is a need for governments, policy makers and international organizations to consider strengthening collaborations to address COPD globally.

Informing management on the future structure of hospital care: an extrapolation of trends in demand and costs in lung diseases

OBJECTIVE

The planning of health care management benefits from understanding future trends in demand and costs. In the case of lung diseases in the national German hospital market, we therefore analyze the current structure of care, and forecast future trends in key process indicators.

METHODS

We use standardized, patient-level, activity-based costing from a national cost calculation data set of respiratory cases, representing 11.9-14.1 % of all cases in the major diagnostic category "respiratory system" from 2006 to 2012. To forecast hospital admissions, length of stay (LOS), and costs, the best adjusted models out of possible autoregressive integrated moving average models and exponential smoothing models are used.

RESULTS

The number of cases is predicted to increase substantially, from 1.1 million in 2006 to 1.5 million in 2018 (+2.7 % each year). LOS is expected to decrease from 7.9 to 6.1 days, and overall costs to increase from 2.7 to 4.5 billion euros (+4.3 % each year). Except for lung cancer (-2.3 % each year), costs for all respiratory disease areas increase: surgical interventions +9.2 % each year, COPD +3.9 %, bronchitis and asthma +1.7 %, infections +2.0 %, respiratory failure +2.6 %, and other diagnoses +8.5 % each year. The share of costs of surgical interventions in all costs of respiratory cases increases from 17.8 % in 2006 to 30.8 % in 2018.

CONCLUSIONS

Overall costs are expected to increase particularly because of an increasing share of expensive surgical interventions and rare diseases, and because of higher intensive care, operating room, and diagnostics and therapy costs.

Global and regional estimates of COPD prevalence: Systematic review and meta-analysis

BACKGROUND

The burden of chronic obstructive pulmonary disease (COPD) across many world regions is high. We aim to estimate COPD prevalence and number of disease cases for the years 1990 and 2010 across world regions based on the best available evidence in publicly accessible scientific databases.

METHODS

We conducted a systematic search of Medline, EMBASE and Global Health for original, population-based studies providing spirometry-based prevalence rates of COPD across the world from January 1990 to December 2014. Random effects meta-analysis was conducted on extracted crude prevalence rates of COPD, with overall summaries of the meta-estimates (and confidence intervals) reported separately for World Health Organization (WHO) regions, the World Bank's income categories and settings (urban and rural). We developed a meta-regression epidemiological model that we used to estimate the prevalence of COPD in people aged 30 years or more.

FINDINGS

Our search returned 37 472 publications. A total of 123 studies based on a spirometry-defined prevalence were retained for the review. From the meta-regression epidemiological model, we estimated about 227.3 million COPD cases in the year 1990 among people aged 30 years or more, corresponding to a global prevalence of 10.7% (95% confidence interval (CI) 7.3%-14.0%) in this age group. The number of COPD cases increased to 384 million in 2010, with a global prevalence of 11.7% (8.4%-15.0%). This increase of 68.9% was mainly driven by global demographic changes. Across WHO regions, the highest prevalence was estimated in the Americas (13.3% in 1990 and 15.2% in 2010), and the lowest in South East Asia (7.9% in 1990 and 9.7% in 2010). The percentage increase in COPD cases between 1990 and 2010 was the highest in the Eastern Mediterranean region (118.7%), followed by the African region (102.1%), while the European region recorded the lowest increase (22.5%). In 1990, we estimated about 120.9 million COPD cases among urban dwellers (prevalence of 13.2%) and 106.3 million cases among rural dwellers (prevalence of 8.8%). In 2010, there were more than 230 million COPD cases among urban dwellers (prevalence of 13.6%) and 153.7 million among rural dwellers (prevalence of 9.7%). The overall prevalence in men aged 30 years or more was 14.3% (95% CI 13.3%-15.3%) compared to 7.6% (95% CI 7.0%-8.2%) in women.

CONCLUSIONS

Our findings suggest a high and growing prevalence of COPD, both globally and regionally. There is a paucity of studies in Africa, South East Asia and the Eastern Mediterranean region. There is a need for governments, policy makers and international organizations to consider strengthening collaborations to address COPD globally.

Respiratory symptoms/diseases prevalence is still increasing: a 25-yr population study

BACKGROUND

Few epidemiological surveys on general population samples estimated changes in prevalence of respiratory symptoms/diseases over a long time interval; our study aims to quantify the temporal changes in the prevalence rates of asthma, allergic rhinitis and Chronic Obstructive Pulmonary Disease (COPD) after 25 years from baseline.

METHODS

A general population sample participated in 3 cross-sectional surveys carried out in Central Italy (Pisa) in 1985-88 (n = 3865), 1991-93 (n = 2841), 2009-11 (n = 1620). 2276 (47%) subjects participated in at least 1 survey, 1723 (35.5%) in at least 2 surveys and 849 (17.5%) in all the 3 surveys. All subjects filled in a standardized questionnaire about health status and risk factors; a sub-sample performed spirometry. Chi-square test was used to compare adjusted prevalence rates of respiratory symptoms/diseases and descriptive characteristics among the surveys. Generalised estimating equations (GEE) were used to analyze the association between respiratory symptoms/diseases and risk factors.

RESULTS

There was an increasing trend in prevalence rates of all respiratory symptoms/diseases throughout the surveys: current asthma attacks (1st-3rd survey prevalence: 3.4-7.2%), allergic rhinitis (16.2-37.4%), usual phlegm (8.7-19.5%) and COPD (2.1-6.8%) more than doubled. The GEE model confirmed these increasing trends, indicating higher risk of having respiratory symptoms/diseases in the second and third surveys.

CONCLUSIONS

While asthma and allergic rhinitis increasing trends were confirmed, with respect to other international studies, also a COPD increasing prevalence rates was shown.

Characteristics of prevalent and new COPD cases in Greece: the GOLDEN study

Background

Greece has one of the highest rates of smoking and chronic obstructive pulmonary disease (COPD) in Europe.

Aim

The study aimed to record both the disease characteristics among a sample of Greek COPD patients and the nationwide rates of newly diagnosed COPD cases.

Methods

In this noninterventional, epidemiological cross-sectional study, a representative nationwide sample of 45 respiratory centers provided data on the following: 1) the demographic and clinical characteristics of COPD patients and 2) newly diagnosed COPD cases monitored over a period of 6 months by each physician.

Results

Data from 6,125 COPD patients were collected. Advanced age (median age: 68 years), male predominance (71.3%), largely overweight status with median body mass index (BMI) =27.5 kg/m², high percentage of current and ex-smokers (89.8%), and presence of comorbidities (81.9%) were evident in the sample. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 criteria, majority of the COPD patients had moderate or severe airflow limitation (61%). Severity of airflow limitation was significantly associated with older age, male sex, obesity, ex-smoking status, and presence of comorbidity (all P-values <0.001). A total of 61.3% of the patients received medication, mostly bronchodilators (64.4%) and fixed-dose combinations of long-acting β₂-agonists and inhaled corticosteroids (39.9%), while 35.9% reported taking medication on demand. The majority (81.1%) of patients reported a preference for fewer inhalations of their bronchodilator therapy. Based on the mixed-effect Poisson model, the rate of newly diagnosed COPD cases was estimated to be 18.2% (95% confidence interval: 14.9–22.3) per pulmonologist/3 months. Of those newly diagnosed, the majority of patients had mild or moderate airflow limitation (78.2%).

Conclusion

The Greek Obstructive Lung Disease Epidemiology and health ecoNomics study reflected the real-life profile of COPD patients and provided evidence on the profile of new COPD cases in Greece. Various demographic factors were delineated, which can assist in designing more effective diagnostic and management strategies for COPD in Greece.

Respiratory Health in Cleaners in Northern Europe: Is Susceptibility Established in Early Life?

RATIONALE

There is some evidence that maternal smoking increases susceptibility to personal smoking's detrimental effects. One might question whether early life disadvantage might influence susceptibility to occupational exposure.

OBJECTIVES

In this cross-sectional study we investigated respiratory symptoms, asthma and self-reported chronic obstructive pulmonary disease (COPD) as related to working as a cleaner in Northern European populations, and whether early life factors influenced susceptibility to occupational cleaning's unhealthy effects.

METHODS

The RHINE III questionnaire study assessed occupational cleaning in 13,499 participants. Associations with respiratory symptoms, asthma and self-reported COPD were analysed with multiple logistic regressions, adjusting for sex, age, smoking, educational level, parent´s educational level, BMI and participating centre. Interaction of occupational cleaning with early life disadvantage (maternal smoking, severe respiratory infection <5 years, born during winter months, maternal age at birth >35 years) was investigated.

MAIN RESULTS

Among 2138 ever-cleaners the risks of wheeze (OR 1.4, 95% CI 1.3-1.6), adult-onset asthma (1.5 [1.2-1.8]) and self-reported COPD (1.7 [1.3-2.2]) were increased. The risk increased with years in occupational cleaning (adult-onset asthma: ≤1 year 0.9 [0.7-1.3]; 1-4 years 1.5 [1.1-2.0]; ≥4 years 1.6 [1.2-2.1]). The association of wheeze with cleaning activity ≥4 years was significantly stronger for those with early life disadvantage than in those without (1.8 [1.5-2.3] vs. 1.3 [0.96-1.8]; pinteraction 0.035).

CONCLUSIONS

Occupational cleaners had increased risk of asthma and self-reported COPD. Respiratory symptom risk was particularly increased in persons with factors suggestive of early life disadvantage. We hypothesize that early life disadvantage may increase airway vulnerability to harmful exposure from cleaning agents later in life.

Subjects with COPD and productive cough have an increased risk for exacerbations and death

BACKGROUND

Chronic bronchitis is related to worse general health status, exacerbations and mortality among subjects with COPD. Also less longstanding cough and phlegm may be related to worse prognosis in COPD but this has rarely been evaluated in population-based studies.

AIM

To evaluate the relationship between productive cough, exacerbations and mortality among subjects with and without COPD.

METHOD

All subjects with COPD (n = 993) were identified together with sex- and age matched reference subjects without obstructive lung function impairment from four population-based cohorts in 2002-04. Baseline spirometry and structured interview including data on exacerbations last 12 months were used in this study (n = 1986) together with mortality data collected until February 2012.

RESULTS

Productive cough was more common in COPD than non-COPD (42.8 vs. 23.5%, p < 0.001), more common in men than women, but associated to exacerbations in both sexes. COPD-subjects with productive cough had the highest risk for exacerbations in both sexes and they had a significantly increased risk for death (HR 1.48, 95% CI 1.13-1.94) also when adjusted for sex, age, BMI, smoking habits and heart disease.

CONCLUSION

Productive cough was common and increased the risk for exacerbations in both sexes, in both COPD and non-COPD. COPD-subjects with productive cough had the highest risk for exacerbations and a significantly higher risk for death also after adjustment for common risk factors.

Productivity losses in chronic obstructive pulmonary disease: a population-based survey

Objectives

We aimed to estimate incremental productivity losses (sick leave and disability) of spirometry-defined chronic obstructive pulmonary disease (COPD) in a population-based sample and in hospital-recruited patients with COPD. Furthermore, we examined predictors of productivity losses by multivariate analyses.

Methods

We performed four quarterly telephone interviews of 53 and 107 population-based patients with COPD and controls, as well as 102 hospital-recruited patients with COPD below retirement age. Information was gathered regarding annual productivity loss, exacerbations of respiratory symptoms and comorbidities. Incremental productivity losses were estimated by multivariate quantile median regression according to the human capital approach, adjusting for sex, age, smoking habits, education and lung function. Main effect variables were COPD/control status, number of comorbidities and exacerbations of respiratory symptoms.

Results

Altogether 55%, 87% and 31% of population-based COPD cases, controls and hospital patients, respectively, had a paid job at baseline. The annual incremental productivity losses were 5.8 (95% CI 1.4 to 10.1) and 330.6 (95% CI 327.8 to 333.3) days, comparing population-recruited and hospital-recruited patients with COPD to controls, respectively. There were significantly higher productivity losses associated with female sex and less education. Additional adjustments for comorbidities, exacerbations and FEV₁% predicted explained all productivity losses in the population-based sample, as well as nearly 40% of the productivity losses in hospital-recruited patients.

Conclusions

Annual incremental productivity losses were more than 50 times higher in hospital-recruited patients with COPD than that of population-recruited patients with COPD. To ensure a precise estimation of societal burden, studies on patients with COPD should be population-based.

Observational study to characterise 24-hour COPD symptoms and their relationship with patient-reported outcomes: results from the ASSESS study

BACKGROUND

Few studies have investigated the 24-hour symptom profile in patients with COPD or how symptoms during the 24-hour day are inter-related. This observational study assessed the prevalence, severity and relationship between night-time, early morning and daytime COPD symptoms and explored the relationship between 24-hour symptoms and other patient-reported outcomes.

METHODS

The study enrolled patients with stable COPD in clinical practice. Baseline night-time, early morning and daytime symptoms (symptom questionnaire), severity of airflow obstruction (FEV1), dyspnoea (modified Medical Research Council Dyspnoea Scale), health status (COPD Assessment Test), anxiety and depression levels (Hospital Anxiety and Depression Scale), sleep quality (COPD and Asthma Sleep Impact Scale) and physical activity level (sedentary, moderately active or active) were recorded.

RESULTS

The full analysis set included 727 patients: 65.8% male, mean ± standard deviation age 67.2 ± 8.8 years, % predicted FEV1 52.8 ± 20.5%. In each part of the 24-hour day, >60% of patients reported experiencing ≥1 symptom in the week before baseline. Symptoms were more common in the early morning and daytime versus night-time (81.4%, 82.7% and 63.0%, respectively). Symptom severity was comparable for each period assessed. Overall, in the week before baseline, 56.7% of patients had symptoms throughout the whole 24-hour day (3 parts of the day); 79.9% had symptoms in ≥2 parts of the 24-hour day. Symptoms during each part of the day were inter-related, irrespective of disease severity (all p < 0.001). Early morning and daytime symptoms were associated with the severity of airflow obstruction (p < 0.05 for both). Night-time, early morning and daytime symptoms were all associated with worse dyspnoea, health status and sleep quality, and higher anxiety and depression levels (all p < 0.001 versus patients without symptoms in each corresponding period). In each part of the 24-hour day, there was also an association between symptoms and a patient's physical activity level (p < 0.05 for each period).

CONCLUSIONS

More than half of patients experienced COPD symptoms throughout the whole 24-hour day. There was a significant relationship between night-time, early morning and daytime symptoms. In each period, symptoms were associated with worse patient-reported outcomes, suggesting that improving 24-hour symptoms should be an important consideration in the management of COPD.

Clinical characteristics and prognostic significance of chronic obstructive pulmonary disease in patients with atrial fibrillation: results from a multicenter atrial fibrillation registry study

OBJECTIVES

Atrial fibrillation (AF) and chronic obstructive pulmonary disease (COPD) are 2 common morbidities and often coexist. Studies have shown that COPD is a risk factor for cardiovascular disease, but the characteristics in patients with COPD and AF, as well as the impact of COPD on the outcomes of AF were lacking. The aim of present study was to analyze the clinical characteristics and to evaluate the association of COPD with 1-year outcomes in patients with AF.

DESIGN

Longitudinal observational study.

PARTICIPANTS

A total of 1975 consecutive patients with AF were registered. Patients were divided into COPD group and non-COPD group according to whether AF coexisted with COPD.

MEASUREMENTS

Outcome measures included all-cause mortality, stroke, and major adverse events (MAE) during 1-year follow-up.

RESULTS

A group of 227 (11.5%) patients had concomitant COPD. Compared with non-COPD patients, patients with COPD were older and tended to have other coexisting cardiovascular morbidities, and had a significantly higher percentage of smoking history. Anticoagulation with warfarin was adopted by only a few patients both with and without COPD. During 1-year follow-up, the all-cause mortality and major adverse event rate in the COPD group were significantly higher than that of non-COPD group (26.9% vs 12.3%, P < .001 and 25.6% vs 19.1%, P = .027, respectively), whereas the incidence of stroke in the 2 groups was comparable (7.9% vs 7.4%, P = .788). Moreover, the cause-specific mortality between the 2 groups was comparable. After multivariate adjustments, COPD was still an independent risk factor for both 1-year all-cause mortality [hazard rate (HR) = 1.491, 95% confidence interval (CI) 1.110-2.002, P = .008] and cardiovascular mortality (HR = 1.595, 95% CI 1.071-2.376, P = .022), but not a risk factor for stroke (HR = 0.879, 95% CI 0.527-1.464, P = .620).

CONCLUSIONS

Anticoagulation treatment is inadequate in patients with AF and COPD. The presence of COPD in patients with AF is an independent risk factor for 1-year all-cause mortality and cardiovascular mortality but not a risk factor for stroke.

Re-admissions to hospital and patient satisfaction among patients with chronic obstructive pulmonary disease after telemedicine video consultation - a retrospective pilot study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a major cause of acute hospital admissions. The main object of our study was to evaluate the effects of telemedicine video-consultation (TVC) on the frequency of hospital re-admissions due to COPD exacerbations. Our secondary aim was to assess the impact of TVC on the length of re-admission stays within 6 and 12 months follow up after TVC. Patient satisfaction was also evaluated.

METHODS

The study was a retrospective observational study of COPD patients who after hospital discharge or during outpatient treatment for acute COPD exacerbations, were monitored for 2 weeks by TVC at home by a specialist nurse at the hospital during a pilot project period. Retrospectively, we compared the frequencies (chi-square test) and durations of hospital re-admissions (paired t-test) due to COPD exacerbations within 6 and 12 months follow up after TVC to comparable events 6 and 12 months prior to TVC.

RESULTS

Among 99 patients followed for 6 months after TVC, 56 were followed for totally 12 months. The number of patients re-admitted and the number of re-admissions due to COPD exacerbations were not reduced within 6 or 12 months post-TVC, as compared to 6 and 12 months pre-TVC.The mean length of re-admission stays within 12 months post-TVC was markedly reduced as compared to pre-TVC. Patients hospitalised the last 6 and 12 months pre-TVC, had significantly shorter re-admission stays, p = 0.033 and p = 0.001, respectively. Patient satisfaction was high.

CONCLUSION

Despite the failure to demonstrate reduced frequency of re-admissions within 6 and 12 months post-TVC, the re-admission length within 12 months post-TVC was markedly reduced as compared to pre-TVC. The patient satisfaction was high. Future prospective, randomised, controlled trials must be performed before TVC can be recommended in COPD management.

Coronary artery disease concomitant with chronic obstructive pulmonary disease

BACKGROUND

Numerous epidemiologic studies have linked the presence of chronic obstructive pulmonary disease (COPD) to coronary artery disease (CAD). However, prevalence, pathological processes, clinical manifestations and therapy are still debated, as progress towards uncovering the link between these two disorders has been hindered by the complex nature of multimorbidity.

METHODS

Articles targeting CAD in patients with COPD were identified from the searches of MEDLINE and EMBASE databases in July 2013. Three authors reviewed available evidence, focusing on the latest development on disease prevalence, pathogenesis, clinical manifestations and therapeutic strategies. Both clinical trial and previous reviews have been included in this work.

RESULTS

The most accredited hypothesis asserts that the main common risk factors, that is, cigarette smoke and ageing, elicit a chronic low-grade systemic inflammatory response, which affects both cardiovascular endothelial cells and airways/lung parenchyma. The development of CAD in patients with COPD potentiates the morbidity of COPD, leading to increased hospitalizations, mortality and health costs. Moreover, correct diagnosis is challenging and therapies are not clearly defined.

CONCLUSIONS

Evidence from recently published articles highlights the importance of multimorbidity in patient management and future research. Moreover, many authors emphasize the importance of low-grade systemic inflammation as a common pathological mechanism and a possible future therapeutic target.

Young, African American adults with asthma: what matters to them?

BACKGROUND

Asthma is a common chronic condition that shows significant health disparities among minority populations. Little research has focused on the management needs and preferences of young African American adults with asthma, a population undergoing dramatic life changes as they transition from adolescence to adulthood.

OBJECTIVE

To understand the experiences and perspectives of young African American adults managing their asthma.

METHODS

Focus groups were conducted with African American adults (n = 34) 18 to 30 years old with a physician diagnosis of asthma. Focus group sessions were audiotaped, transcribed verbatim, and coded using constant comparative analysis.

RESULTS

Six major domains were identified and some of the salient themes included changes in asthma management needs with the onset of adulthood, career limitations owing to asthma, childcare interference with asthma regimen adherence, and difficulties with medication cost owing to lapses in insurance coverage. Participants also reported feeling discouraged when interacting with physicians as it related to their asthma care; yet ageism and racism were not perceived. Despite poor medication regimen compliance, participants were overwhelmingly interested in participating in asthma self-management programs and had strong preferences that such programs be tailored specifically to young adults with special consideration of the cultural experience of young African Americans with asthma.

CONCLUSION

Young African American adults have specific barriers to optimal asthma care and distinctive ideas for self-management programs. It is important for the asthma care provider to identify and address these population- and age-specific barriers to improve asthma outcomes and decrease health care disparities.