Prevalence, pathogenesis, and causes of chronic cough

Effect of the treatment of iron deficiency anemia on chronic drug-resistant cough: a rare case report

BACKGROUND

A persistent difficult-to-treat cough can be exhausting. Iron is an essential element that plays an important role in regulating the production of pro-inflammatory cytokines, and its deficiency may potentiate airway inflammation and dysfunction. There is a paucity of data regarding a link between iron deficiency (ID) and idiopathic cough.

OBJECTIVES

In this study, a case of persistent non-productive cough, which was unresponsive to targeted treatment approaches but responsive to iron therapy, is reported.

METHODS

A 53-year-old woman came to a medical clinic with complaints of a chronic and progressive non-productive cough. She underwent a complete clinical and paraclinical evaluation.

RESULTS

Her vital signs were stable and no abnormalities were found on the physical examination. The results of the spirometry and chest radiography were unremarkable. The laboratory test indicated hypochromic microcytic anemia, with a hemoglobin value of 9.6 g/dL. Her cough was resolved after treatment of iron-deficiency anemia with an oral nutraceutical capsule containing 28 mg of elemental iron (as ferrous bis-glycinate) plus folic acid, vitamin B12, and vitamin C, once daily for six months.

CONCLUSION

In the case of unexplained chronic cough, resistant to targeted therapies, investigation and treatment of ID may contribute to the resolution of cough.

Increased postoperative complications after laparoscopic gastrectomy in patients with preserved ratio impaired spirometry

BACKGROUND

Preserved ratio impaired spirometry (PRISm), defined as decreased forced expiratory volume in the first second in the setting of normal ratio, is associated with an increased risk of respiratory disease and systemic comorbidities. Unlike severe obstructive pulmonary disease, little is known about the impact of PRISm on short-term outcomes in patients undergoing laparoscopic gastrectomy (LG) and its association with small airway dysfunction (SAD).

METHODS

This study enrolled 830 patients who underwent preoperative spirometry and LG between January 2021 and August 2023. Of these, 228 patients were excluded. Participants were categorized into 3 groups based on their baseline lung function, and postoperative outcomes were subsequently analyzed. Potential associations between postoperative outcomes and various clinical variables were examined using univariate and multivariate analyses.

RESULTS

PRISm was identified in 16.6% of the patients, whereas SAD was present in 20.4%. The incidence of postoperative pulmonary complications (PPCs) was notably higher in the SAD group (20.3% vs 9.8%, P = .002) and the PRISm group (28.0% vs 9.8%, P < .001) than the normal group. Among the 3 groups, pneumonia was the most frequently observed PPC. Multivariate analysis revealed that both SAD (odds ratio [OR], 2.34; 95% CI, 1.30-4.22; P = .005) and PRISm (OR, 3.26; 95% CI, 1.80-5.90; P < .001) independently constituted significant risk factors associated with the occurrence of PPCs. Univariate analysis showed that female was a possible risk factor for PPCs in PRISm group.

CONCLUSION

Our study showed that PRISm and SAD were associated with the increased PPCs in patients undergoing LG for gastric cancer.

Epidemiology and Healthcare Service Utilization among Adults with Chronic Cough

Background and objective: Chronic cough (CC) is a prevalent yet underexplored medical condition, with limited real-world data regarding its healthcare burden. This study investigates the epidemiology, associated comorbidities, and healthcare service utilization among patients with CC. Methods: In this retrospective cohort study, adult patients with at least 3 physician diagnoses of cough over a period spanning a minimum of 8 weeks and a maximum of 12 months anytime between 2009 and 2018, were defined as patients with CC (PwCC). The reference group were adults without cough matched in a 1:1 ratio for age, sex, and place of residence. Results: The study included 91,757 PwCC, reflecting a prevalence of 5.5%. Of those, 59,296 patients (mean [SD] age, 53.9 [16.8] years; 59.6% females) were first diagnosed with CC during the study period, representing a 10-year incidence rate of 3.26% (95%CI: 3.24-3.29%). Diseases associated with the highest OR for CC included lung cancer (OR = 3.32; 95%CI: 2.90-4.25), whooping cough (OR = 3.04; 95%CI: 2.70-3.60), and respiratory infections (OR = 2.81; 95%CI: 2.74-2.88). Furthermore, PwCC demonstrated increased healthcare service utilization, leading to a higher adjusted annual estimated mean cost (USD 4038 vs. USD 1833, p < 0.001). Conclusions: Chronic cough emerges as a relatively prevalent complaint within community care, exerting a considerable economic burden. This study underscores the need for heightened awareness, comprehensive management strategies, and resource allocation to address the multifaceted challenges associated with chronic cough.

Pharmacists' clinical decision making when responding to a self-medication request for a cough in a developing country

BACKGROUND

Some studies have reported that community pharmacies in developing countries, including Indonesia, provided sub-optimal advice when handling patient's self-medication request for cough. The reasons behind such advice, therefore, need to be investigated.

OBJECTIVES

To describe Indonesian pharmacists' clinical decision making when handling self-medication cases for a cough.

METHODS

An open-ended questionnaire consisting of two cough clinical vignettes (case 1: cough due to asthma worsening and case 2: cough as a symptom of common cold) were developed. Pharmacists were interviewed to provide recommendations and reasons for their recommendations for these scenarios. Content analysis was used to analyse participants' statements for the two scenarios. The number of participants who provided appropriate recommendations and reasons were then counted.

RESULTS

A total of 245 community pharmacists participated in the study. In the case of cough due to asthma worsening, recommending a product because the product was indicated to help with the symptoms was the most common recommendation and stated reason (40%). Appropriate recommendation (direct medical referral) with appropriate reasoning (indicating warning symptoms and/or making a symptom diagnosis) was provided by 25% participants. In the case of cough as a symptom of common cold, recommending products to help with the symptoms was also the most common recommendation and stated reason (53%). Appropriate recommendations (recommending product) with appropriate reasoning (providing product to treat the symptoms and/or indicating no warning symptoms and/or making a symptom diagnosis) was provided by 81% participants.

CONCLUSION

The ability of Indonesian community pharmacists to provide appropriate recommendations for cough self-medication requests is dependent on whether triage is required. The inability of most community pharmacists to differentiate between major and minor conditions may lead to serious health implications for patients and therefore educational interventions should be undertaken to improve community pharmacists' differential diagnostic skills for triage.

Impulse oscillometry in the diagnosis of cough variant asthma in children

BACKGROUND

Cough variant asthma (CVA) is one of the most common causes of chronic cough in children worldwide. The diagnosis of CVA in children remains challenging. This study aimed to assess the diagnostic utility of impulse oscillometry (IOS) pulmonary function in children with CVA.

METHODS

This study included children aged 4 to 12 years diagnosed with CVA who underwent IOS pulmonary function and bronchodilation (BD) tests. A control group of healthy children was matched. Pre- and post-BD IOS parameters were recorded and presented as mean ± standard deviation or median. Receiver operating characteristic (ROC) curves were plotted, and the area under the curve (AUC) was calculated to evaluate the discriminatory potential of the IOS parameters for diagnosing CVA.

RESULTS

A total of 180 patients with CVA and 65 control subjects were included. The baseline IOS parameters in the CVA group, except X5%pred, were significantly greater compared to the control group. After inhalation of salbutamol sulfate, all IOS parameters improved significantly in the CVA group. However, Z5%pred, R5%pred, and R20%pred remained greater in the CVA group compared to the control group. The improvement rates of IOS parameters in the CVA group significantly surpassed those in the control group. The ROC curve results for pre-BD IOS parameters and the improvement rate during the BD test showed that the combinations of pre-Z5%pred+△Z5% and pre-R5%pred+△R5% achieved the highest AUC value of 0.920 and 0.898, respectively. The AUC values of these combined parameters surpassed those of individual ones.

CONCLUSIONS

This study highlights that children with CVA exhibit greater IOS parameters compared to healthy children. The changes in IOS parameters during the BD test provided valuable diagnostic information for CVA, and the combination of various parameters can help pediatricians accurately identify CVA in children.

The Impact of Medical Comorbidities on Cough Improvement Following Superior Laryngeal Block

INTRODUCTION

Chronic refractory cough is defined as cough lasting greater than 8 weeks and with an unclear etiology. Blockade of the internal branch superior laryngeal nerve (iSLN) has been shown to be safe and effective in the treatment of chronic cough. It remains unknown, however, if underlying comorbidities impact patient response to iSLN blockade.

METHODS

A total of 44 patients aged 18 years and older were seen at our institution's Laryngology clinics between 2019 and 2022 and treated with iSLN blockade. Patient demographics, comorbidities, and pre- and post-treatment cough severity index (CSI) scores were collected from electronic medical records. Two-tailed independent T tests were used to compare CSI scores between groups with and without 4 underlying comorbidities: GERD, pulmonary history, smoking history, and evidence of vocal fold paresis or asymmetry on stroboscopy.

RESULTS

Patients with a history of GERD or smoking and those with evidence of glottic insufficiency had similar improvements in CSI compared to those who did not (22.5 ± 26.4 vs 45.0 ± 47.1, P = .36; 32.7 ± 27.8 vs 29.0 ± 38, P = .85; 41.3 ± 18.8 vs 27.2 ± 37.7, P = .195). Patients with underlying pulmonary conditions had a significantly reduced response to iSLN blockade than did patients without underlying disease (9.85 ± 15.0 vs 47.4 ± 38.1, P = .028).

CONCLUSION

Underlying lung pathology may contribute to decreased iSLN blockade efficacy in the treatment of chronic refractory cough from laryngeal hypersensitivity and its treatment is likely necessary for optimal symptom reduction. Characterizing patient comorbidity profiles can help guide patient counseling on expected treatment efficacy.

Prevalence and causes of chronic cough in Japan

BACKGROUND

Chronic cough is one of the most common symptoms of respiratory diseases and can adversely affect patients' quality of life and interfere with social activities, resulting in a significant social burden. A survey is required to elucidate the frequency and treatment effect of chronic cough. However, clinical studies that cover all of Japan have not yet been conducted.

METHODS

Patients who presented with a cough that lasted longer than 8 weeks and visited the respiratory clinics or hospitals affiliated with the Japan Cough Society during the 2-year study period were registered.

RESULTS

A total of 379 patients were enrolled, and those who did not meet the definition of chronic cough were excluded. A total of 334 patients were analyzed: 201 patients had a single cause, and 113 patients had two or more causes. The main causative diseases were cough variant asthma in 92 patients, sinobronchial syndrome (SBS) in 36 patients, atopic cough in 31 patients, and gastroesophageal reflux (GER)-associated cough in 10 patients. The time required to treat undiagnosed patients and those with SBS was significantly longer and the treatment success rate for GER-associated cough was considerably poor.

CONCLUSIONS

We confirmed that the main causes of chronic cough were cough variant asthma, SBS, atopic cough, and their complications. We also showed that complicated GER-associated cough was more likely to become refractory. This is the first nationwide study in Japan of the causes and treatment effects of chronic cough.

Leveraging AI and Machine Learning to Develop and Evaluate a Contextualized User-Friendly Cough Audio Classifier for Detecting Respiratory Diseases: Protocol for a Diagnostic Study in Rural Tanzania

BACKGROUND

Respiratory diseases, including active tuberculosis (TB), asthma, and chronic obstructive pulmonary disease (COPD), constitute substantial global health challenges, necessitating timely and accurate diagnosis for effective treatment and management.

OBJECTIVE

This research seeks to develop and evaluate a noninvasive user-friendly artificial intelligence (AI)-powered cough audio classifier for detecting these respiratory conditions in rural Tanzania.

METHODS

This is a nonexperimental cross-sectional research with the primary objective of collection and analysis of cough sounds from patients with active TB, asthma, and COPD in outpatient clinics to generate and evaluate a noninvasive cough audio classifier. Specialized cough sound recording devices, designed to be nonintrusive and user-friendly, will facilitate the collection of diverse cough sound samples from patients attending outpatient clinics in 20 health care facilities in the Shinyanga region. The collected cough sound data will undergo rigorous analysis, using advanced AI signal processing and machine learning techniques. By comparing acoustic features and patterns associated with TB, asthma, and COPD, a robust algorithm capable of automated disease discrimination will be generated facilitating the development of a smartphone-based cough sound classifier. The classifier will be evaluated against the calculated reference standards including clinical assessments, sputum smear, GeneXpert, chest x-ray, culture and sensitivity, spirometry and peak expiratory flow, and sensitivity and predictive values.

RESULTS

This research represents a vital step toward enhancing the diagnostic capabilities available in outpatient clinics, with the potential to revolutionize the field of respiratory disease diagnosis. Findings from the 4 phases of the study will be presented as descriptions supported by relevant images, tables, and figures. The anticipated outcome of this research is the creation of a reliable, noninvasive diagnostic cough classifier that empowers health care professionals and patients themselves to identify and differentiate these respiratory diseases based on cough sound patterns.

CONCLUSIONS

Cough sound classifiers use advanced technology for early detection and management of respiratory conditions, offering a less invasive and more efficient alternative to traditional diagnostics. This technology promises to ease public health burdens, improve patient outcomes, and enhance health care access in under-resourced areas, potentially transforming respiratory disease management globally.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/54388.

ERS International Congress 2023: highlights from the Airway Diseases Assembly

In this review, early career and senior members of Assembly 5 (Airway Diseases, Asthma, COPD and Chronic Cough) present key recent findings pertinent to airway diseases that were presented during the European Respiratory Society International Congress 2023 in Milan, Italy, with a particular focus on asthma, COPD, chronic cough and bronchiectasis. During the congress, an increased number of symposia, workshops and abstract presentations were organised. In total, 739 abstracts were submitted for Assembly 5 and the majority of these were presented by early career members. These data highlight the increased interest in this group of respiratory diseases.

Prevalence and burden of chronic cough in France

Background

Chronic cough is a common condition that is associated with lower health-related quality of life and greater healthcare resource use. There are limited data on the prevalence, population characteristics and burden of chronic cough in France.

Methods

This was a cross-sectional study based on responses from French adult residents to the 2020 National Health and Wellness Survey. Respondents with chronic cough were compared to 1:3 propensity score-matched controls without chronic cough.

Results

The weighted lifetime and 12-month prevalence of chronic cough were estimated as 7.5% and 4.8%, respectively. Respondents with chronic cough reported significantly worse perceived health than matched controls, with lower mean±sd scores of 46.68±9.28 versus 50.42±8.26 on the physical health component and 40.32±9.87 versus 44.32± 9.69 on the mental health component of the Medical Outcomes Study 12-item Short Form Survey Version 2 survey (p<0.001 for both comparisons). Respondents with chronic cough also had higher rates of moderate-to-severe forms of anxiety (24.4% versus 12.4%) and depression (36.4% versus 20.2%); higher rates of multiple forms of sleep disturbance; greater impairment of work productivity (38.2% versus 25.5%) and other activities (41.8% versus 28.2%; p<0.001 for all comparisons). Respondents with chronic cough also had higher rates of all-cause healthcare resource use including emergency room visits, hospitalisation, and overall and specialist healthcare provider visits compared to controls (p<0.001 for all comparisons).

Conclusion

Chronic cough is a common condition in France that is associated with lower health-related quality of life and greater healthcare resource utilisation.

Postnasal drip and chronic cough in patients with chronic rhinitis treated with temperature-controlled radiofrequency neurolysis

OBJECTIVE

To evaluate the contribution of postnasal drip (PND) and chronic cough (CC) to symptoms of patients with chronic rhinitis treated with temperature-controlled radiofrequency (TCRF) neurolysis of the posterior nasal nerve (PNN), and correlate PND and CC scores with components of the reflective total nasal symptom score (rTNSS).

METHODS

Pooled data from three prospective studies: two single-arm studies and the index active treatment arm of a randomized controlled trial. Adult patients with baseline rTNSS ≥6 were treated with TCRF neurolysis at nonoverlapping regions of the PNN. PND and CC symptoms were evaluated on a 0 (none) to 3 (severe) scale.

RESULTS

Data from 228 patients (57.9% women, 42.1% men) were included. The mean baseline rTNSS was 8.1 (95% confidence interval [CI], 7.8-8.3), which decreased to 3.2 (95% CI, 2.9-3.5) at 6 months. At baseline, 97.4% of patients had PND and 80.3% had CC. Median baseline PND and CC symptom scores were 3 (interquartile range [IQR], 2-3) and 2 (IQR, 1-2), respectively. At 6 months, this decreased to 1 (IQR, 0-2) and 0 (IQR, 0-1), respectively, showing significant improvement from baseline (both p < 0.001). Spearman correlation coefficients with components of rTNSS (rhinorrhea, congestion, itching, sneezing) were 0.16 to 0.22 for CC and 0.19 to 0.46 for PND, indicating only a weak to moderate correlation.

CONCLUSION

PND and CC contribute to the symptomatology of chronic rhinitis and are significantly improved after TCRF neurolysis of the PNN. The inclusion of PND and CC symptoms in a chronic rhinitis assessment instrument could provide important additional information for the characterization of the disease state and outcomes after any therapeutic treatment.

Safety and Pharmacokinetics of HRS-2261, a P2X3 Receptor Antagonist, in Healthy Subjects: A Randomized, Double-Blind, Placebo-Controlled Phase 1 Study

BACKGROUND

P2X3 receptor antagonists hold promising potential as a therapeutic option for patients with refractory or unexplained chronic cough, a condition lacking approved therapies. This study assessed the safety, tolerability, and pharmacokinetics (PK) of HRS-2261, a novel selective P2X3 receptor antagonist, in healthy subjects.

METHODS

This randomized, double-blinded, placebo-controlled phase 1 trial of HRS-2261 consisted of three phases: the single ascending dose (SAD) study phase, the food-effect study phase, and the multiple ascending dose (MAD) study phase. In the SAD phase, healthy subjects were randomly assigned to receive a single oral dose of HRS-2261 (25, 100, 200, 400, 800, and 1200 mg) or placebo. Subjects in the 200 mg group of the SAD phase progressed directly to the food-effect phase following safety evaluation. In the MAD phase, healthy subjects were randomized to receive HRS-2261 (50, 200, and 400 mg) or placebo twice daily for 14 consecutive days. The primary endpoints were safety and tolerability.

RESULTS

A total of 62 and 30 subjects were enrolled in the SAD and MAD phases, respectively, with 12 subjects from the SAD phase transitioning to the food-effect phase. The incidence and severity of adverse events (AEs) were not dose dependent, and most AEs were mild except for one moderate AE (epididymitis, which was not related to treatment) in the 400 mg group. Dysgeusia was reported in nine subjects, including two from the SAD phase, one from the food-effect phase, and six from the MAD phase. The median Tmax and geometric mean t1/2 were 0.9-2.0 h and 4.1-8.5 h in the SAD, and 2.0-2.7 h and 4.6-5.0 h on day 14 in the MAD, respectively. Drug exposures in the SAD and MAD phases were both less than dose proportional. The accumulation of the drug was slight with repeated twice-daily dosing. Food-effect study results showed that food intake did not affect the plasma exposure of HRS-2261.

CONCLUSIONS

HRS-2261 demonstrated good tolerability, with a low incidence of dysgeusia. The PK profile was favorable. This study supports further development of HRS-2261 as a potential P2X3 receptor antagonist for chronic cough.

TRIAL REGISTRATION NUMBER

Clinical trials.gov, identifier: NCT05274516. Trial registration date: March 10, 2022.

Research status of east Asian traditional medicine treatment for chronic cough: A scoping review

BACKGROUND

When patients continue to experience cough despite conventional treatment, East Asian traditional medicine (EATM) including herbal medicine and/or acupuncture has been frequently used. Previous systematic reviews of EATM treatment for chronic cough have been conducted mainly on herbal medicine, targeting patients with conditions that cause cough. In clinical practice, EATM interventions are not limited to herbal medicine, and considering that chronic cough is often caused by two or more conditions or unspecific causes, a comprehensive investigation is clinically relevant. We examined the current research status of EATM for chronic cough.

METHODS

Based on Arksey and O'Malley's scoping review methodological framework, a total of six English, Chinese, Korean, and Japanese electronic databases were searched on August 2022. Any clinical studies on EATM targeting chronic cough patients (regardless of their cause) were included.

RESULTS

Among 474 included studies, the study designs were mainly randomized controlled trials (72.4%), and the population was evenly distributed between children and adults. The cause of cough was not reported in most studies (56.1%). The common cause of cough was upper airway cough syndrome and post-respiratory infection (9.5%, each), followed by mixed cause (7.6%), nonspecific cause (5.9%), and gastroesophageal reflux disease (4.0%). EATM was conducted for a mean of 19.1 days, and herbal medicine was the most common (80.6%). Conventional medication was frequently used as a control (81.2%). For outcomes, the total effective rate was the most frequently utilized (94.3%), followed by cough severity (53.8%). EATM treatment showed positive outcomes in most studies.

CONCLUSIONS

In future EATM studies, it is necessary to either specify the cause of chronic cough or to report that the study was targeting nonspecific chronic cough. In addition, high-quality studies assessing the efficacy of EATM with placebo control treatment should be conducted, using validated evaluation tools.

Profiles of Cough and Associated Risk Factors in Nonhospitalized Individuals With SARS-CoV-2 Omicron Variant Infection: Cross-Sectional Online Survey in China

BACKGROUND

Cough is a common symptom during and after COVID-19 infection; however, few studies have described the cough profiles of COVID-19.

OBJECTIVE

The aim of this study was to investigate the prevalence, severity, and associated risk factors of severe and persistent cough in individuals with COVID-19 during the latest wave of the Omicron variant in China.

METHODS

In this nationwide cross-sectional study, we collected information of the characteristics of cough from individuals with infection of the SARS-CoV-2 Omicron variant using an online questionnaire sent between December 31, 2022, and January 11, 2023.

RESULTS

There were 11,718 (n=7978, 68.1% female) nonhospitalized responders, with a median age of 37 (IQR 30-47) years who responded at a median of 16 (IQR 12-20) days from infection onset to the time of the survey. Cough was the most common symptom, occurring in 91.7% of participants, followed by fever, fatigue, and nasal congestion (68.8%-87.4%). The median cough visual analog scale (VAS) score was 70 (IQR 50-80) mm. Being female (odds ratio [OR] 1.31, 95% CI 1.20-1.43), having a COVID-19 vaccination history (OR 1.71, 95% CI 1.37-2.12), current smoking (OR 0.48, 95% CI 0.41-0.58), chronic cough (OR 2.04, 95% CI 1.69-2.45), coronary heart disease (OR 1.71, 95% CI 1.17-2.52), asthma (OR 1.22, 95% CI 1.02-1.46), and gastroesophageal reflux disease (GERD) (OR 1.21, 95% CI 1.01-1.45) were independent factors for severe cough (VAS>70, 37.4%). Among all respondents, 35.0% indicated having a productive cough, which was associated with risk factors of being female (OR 1.44, 95% CI 1.31-1.57), having asthma (OR 1.84, 95% CI 1.52-2.22), chronic cough (OR 1.44, 95% CI 1.19-1.74), and GERD (OR 1.22, 95% CI 1.01-1.47). Persistent cough (>3 weeks) occurred in 13.0% of individuals, which was associated with the risk factors of having diabetes (OR 2.24, 95% CI 1.30-3.85), asthma (OR 1.70, 95% CI 1.11-2.62), and chronic cough (OR 1.97, 95% CI 1.32-2.94).

CONCLUSIONS

Cough is the most common symptom in nonhospitalized individuals with Omicron SARS-CoV-2 variant infection. Being female, having asthma, chronic cough, GERD, coronary heart disease, diabetes, and a COVID-19 vaccination history emerged as independent factors associated with severe cough, productive cough, and persistent cough.

Association of novel adult cough subclasses with clinical characteristics and lung function across six decades of life in a prospective, community-based cohort in Australia: an analysis of the Tasmanian Longitudinal Health Study (TAHS)

BACKGROUND

Cough is a common yet heterogeneous condition. Little is known about the characteristics and course of cough in general populations. We aimed to investigate cough subclasses, their characteristics from childhood across six decades of life, and potential treatable traits in a community-based cohort.

METHODS

For our analysis of the Tasmanian Longitudinal Health Study (TAHS), a prospective, community-based cohort study that began on Feb 23, 1968, and has so far followed up participants in Tasmania, Australia, at intervals of 10 years from a mean age of 7 years to a mean age of 53 years, we used data collected as part of the TAHS to distinguish cough subclasses among current coughers at age 53 years. For this analysis, participants who answered Yes to at least one cough-related question via self-report questionnaire were defined as current coughers and included in a latent class analysis of cough symptoms; participants who answered No to all nine cough-related questions were defined as non-coughers and excluded from this analysis. Two groups of longitudinal features were assessed from age 7 years to age 53 years: previously established longitudinal trajectories of FEV1, forced vital capacity [FVC], FEV1/FVC ratio, asthma, and allergies-identified via group-based trajectory analysis or latent class analysis-and symptoms at different timepoints, including asthma, current productive cough, ever chronic productive cough, current smoking, and second-hand smoking.

FINDINGS

Of 8583 participants included at baseline in the TAHS, 6128 (71·4%) were traced and invited to participate in a follow-up between Sept 3, 2012, and Nov 8, 2016; 3609 (58·9%) of these 6128 returned the cough questionnaire. The mean age of participants in this analysis was 53 years (SD 1·0). 2213 (61·3%) of 3609 participants were defined as current coughers and 1396 (38·7%) were categorised as non-coughers and excluded from the latent class analysis. 1148 (51·9%) of 2213 participants in this analysis were female and 1065 (48·1%) were male. Six distinct cough subclasses were identified: 206 (9·3%) of 2213 participants had minimal cough, 1189 (53·7%) had cough with colds only, 305 (13·8%) had cough with allergies, 213 (9·6%) had intermittent productive cough, 147 (6·6%) had chronic dry cough, and 153 (6·9%) had chronic productive cough. Compared with people with minimal cough, and in contrast to other cough subclasses, people in the chronic productive cough and intermittent productive cough subclasses had worse lung function trajectories (FEV1 persistent low trajectory 2·9%, 6·4%, and 16·1%; p=0·0011, p<0·0001; FEV1/FVC early low-rapid decline trajectory 2·9%, 12·1%, and 13·0%; p=0·012, p=0·0007) and a higher prevalence of cough (age 53 years 0·0%, 32·4% [26·1-38·7], and 50·3% [42·5-58·2]) and asthma (age 53 years 6·3% [3·7-10·6], 26·9% [21·3-33·3], and 41·7% [24·1-49·7]) from age 7 years to age 53 years.

INTERPRETATION

We identified potential treatable traits for six cough subclasses (eg, asthma, allergies, and active and passive smoking for productive cough). The required management of productive cough in primary care (eg, routine spirometry) might differ from that of dry cough if our findings are supported by other studies. Future population-based studies could apply our framework to address the heterogeneity and complexity of cough in the community.

FUNDING

The National Health and Medical Research Council of Australia, The University of Melbourne, Clifford Craig Medical Research Trust of Tasmania, Victorian Asthma Foundation, Queensland Asthma Foundation, Tasmanian Asthma Foundation, The Royal Hobart Hospital Research Foundation, the Helen MacPherson Smith Trust, GlaxoSmithKline, and the China Scholarship Council.

Association of chronic cough with exposure to polycyclic aromatic hydrocarbons in the US population

Polycyclic aromatic hydrocarbons (PAHs) are environmental pollutants formed during the incomplete combustion of organic substances, such as coal and oil. PAHs exposure is known to increase the incidence of respiratory diseases; however, limited research has focused on their impact on chronic cough. In this study, we utilized data from the National Health and Nutritional Examination Surveys (NHANES) from 2003 to 2012. Chronic cough was defined as 'coughing most days for three consecutive months or more'. Employing survey-weighted multivariate logistic regression models, we identified positive associations between all six PAHs metabolites (1-NAP, 2-NAP, 3-FLU, 2-FLU, 1-PHE, and 1-PYR) found in urine and the presence of chronic cough. Furthermore, results from restricted cubic spline modeling revealed a nonlinear relationship between urinary levels of 1-NAP, 2-NAP, 3-FLU, 2-FLU, and 1-PYR and the risk of chronic cough. Co-exposure modeling unveiled the combined effects of multiple exposures and the relative contributions of each PAHs. Notably, co-exposure to PAHs was positively associated with an increased risk of chronic cough, where 2-FLU emerged as the primary contributor to this association. These findings were particularly pronounced in individuals with high cotinine exposure (≥0.05 ng/mL). In conclusion, this study presents epidemiological evidence linking PAHs exposure to an elevated risk of chronic cough. Further prospective investigations are warranted to corroborate these findings.

Identifying unique spectral fingerprints in cough sounds for diagnosing respiratory ailments

Coughing, a prevalent symptom of many illnesses, including COVID-19, has led researchers to explore the potential of cough sound signals for cost-effective disease diagnosis. Traditional diagnostic methods, which can be expensive and require specialized personnel, contrast with the more accessible smartphone analysis of coughs. Typically, coughs are classified as wet or dry based on their phase duration. However, the utilization of acoustic analysis for diagnostic purposes is not widespread. Our study examined cough sounds from 1183 COVID-19-positive patients and compared them with 341 non-COVID-19 cough samples, as well as analyzing distinctions between pneumonia and asthma-related coughs. After rigorous optimization across frequency ranges, specific frequency bands were found to correlate with each respiratory ailment. Statistical separability tests validated these findings, and machine learning algorithms, including linear discriminant analysis and k-nearest neighbors classifiers, were employed to confirm the presence of distinct frequency bands in the cough signal power spectrum associated with particular diseases. The identification of these acoustic signatures in cough sounds holds the potential to transform the classification and diagnosis of respiratory diseases, offering an affordable and widely accessible healthcare tool.

Ethnobotanical study of traditional medicinal plants used by the local people in Habru District, North Wollo Zone, Ethiopia

BACKGROUND

Ethiopia is a country located in the Horn of Africa, which combines richness in plant resources and cultures of human plant use. The people of Habru District of North Wollo Zone (Amhara Region, Ethiopia) have a long history of use of plant resources for various purposes including in traditional herbal remedy preparation and use. However, the district has not been adequately studied for its ethnobotanical resources and the associated knowledge. This study focused on human medicinal plants and their traditional uses in Habru District. The objective of the study was to document and analyze the plant species used by the local communities to treat human ailments along with the associated traditional knowledge and practices.

METHODOLOGY

The study was carried out in Habru District from June 2021 to December 2022. Ethnobotanical data were collected using semi-structured interviews, guided field walks, 13 focus group discussions (one at the district level and 12 at the kebele/subdistrict level) and market surveys. A total of 388 informants (250 males and 138 females) were selected from all 13 kebeles within Habru District using systematic random sampling, and 42 key informants were purposively selected. Descriptive statistics, preference ranking, direct matrix ranking, informant consensus factor and fidelity level were applied for data analysis.

RESULTS

The results provide insights into the medicinal plant diversity within Habru District, where 134 plant species in 110 genera and 54 families were documented, including 2 endemics, highlighting the district's significance in biodiversity conservation and healthcare delivery. Disease prevalence analysis showed that gastrointestinal and parasitic ailments (ICF = 0.85), febrile diseases (ICF = 0.84), and culture-related conditions exhibit high informant consensus factors. Remedy preparation involves various plant parts, predominantly leaves (47.3%), followed by roots (22.1%), fruits (7.0%), and seeds (5.8%). Freshly harvested plant parts were frequently used (58.2%), while 24.7% involved both dried and fresh parts. Oral application (47.3%) and topical use (31.8%) are the major routes of remedy administration. The marketability of medicinal plants was evident, with 16.4% of the species reported as marketable, including Terminalia brownii Fresen. Myrtus communis L., Ruta chalepensis L., Olea europaea L. subsp. cuspidata (Wall. & G.Don) Cif., Allium sativum L. and Capsicum annuum L. Multipurpose plants such as Solanum somalense Franchet. (91.3% FL), Ocimum lamiifolium Hochst. ex. Benth. (88.9% FL), and Verbascum sinaiticum Benth. (85.7% FL) exhibited notable healing potentials.

CONCLUSION

The current study underscores the intricate relationship between the local community and medicinal plants, emphasizing the importance of biodiversity conservation and health care and acknowledging the dynamic interplay between cultural heritage and ecosystem health. The results contribute to the development of sustainable conservation strategies, healthcare practices and the preservation of traditional knowledge, and highlight the interdependence of human societies and their natural environments. Community-based conservation initiatives with active participation of local communities are desirable for the conservation and sustainable use of medicinal plant species and their habitats. Raising public awareness about the sustainable harvesting and utilization of marketed medicinal plants (e.g., Terminalia brownii Fresen.) that are under threat is also important to ensure their availability for future generations and contribution to socioeconomic development.

Prevalence of Anxiety as a Variable in Treatment Outcomes for Individuals With Chronic Refractory Cough

PURPOSE

Anxiety is a mental state characterized by an intense sense of tension, worry, or apprehension relative to something adverse that might happen in the future. Anxiety is a known comorbidity in cough patients, yet its prevalence among those with chronic refractory cough (CRC) is unknown. Anxiety is not typically assessed during evaluation for CRC, but treatments for CRC such as neuromodulators and behavioral cough suppression therapy (BCST) may potentially attenuate anxiety. This preliminary study investigates the potential prevalence of anxiety in CRC and its possible role in treatment outcomes.

METHOD

CRC patients seen in a specialty clinic at the University of Utah or the University of Montana completed the Leicester Cough Questionnaire (LCQ) pre- and post-BCST treatment. Participants were dichotomized into positive anxiety screen (PAS) and negative anxiety screen (NAS) groups based on presence or absence of documented anxiety within electronic medical records at the University of Utah and based on a Generalized Anxiety Disorder-7 score > 5 at the University of Montana.

RESULTS

Of the 86 total participants, 37 (43%) were in the PAS group (29 females, Mage = 56 ± 13) and 49 (57%) were in the NAS group (36 females, Mage = 64 ± 14). Eighty-nine percent of CRC participants with a PAS reported a clinically meaningful improvement in LCQ total score following treatment compared to 65% of NAS participants. Furthermore, mean pre- to posttreatment change scores on the LCQ were significantly greater within the PAS group (p = .002, Cohen's d = 0.7, indicating a moderate to large effect size).

CONCLUSION

This preliminary study suggests that (a) anxiety may be prevalent among those with CRC and (b) those patients who screen positive for anxiety report greater benefit from BCST.

Patient's experiences of coughing after lung cancer surgery: A multicenter qualitative study

PURPOSE

Cough is one of the most common symptoms after lung cancer surgery, which seriously affects the quality of life. Little research has been conducted on patient's experiences of cough following lung surgery. This study aimed to elucidate the experience of coughing after lung cancer surgery from the patient's perspective regarding symptoms and their impacts on daily life, as well as triggers and dealing strategies.

METHODS

Between June 2023 and July 2023, we conducted semi-structured interviews with patients from outpatient clinics of two hospitals who were pathologically diagnosed with lung cancer and experienced cough after surgery through convenience sampling. The interview recordings were transcribed and analyzed by two researchers. The traditional content analysis and thematic analysis were used to identify the common codes, subthemes, and themes.

RESULTS

A total of 28 participants were interviewed. The mean age of the participants was 55.21 years (range: 36-75 years), and 21 participants were female. Most patients (75%) were interviewed within 6 months of surgery. We identified five themes (accompanying symptoms, incentives, effects, solution, and information sources) and 12 subthemes (local symptoms, systemic symptoms, personal factors, external factors, emotion, relationship with others, reduced quality of life, medical measures, nonmedical measures, no measures, relatives and friends, and the Internet). Patients with lung cancer may experience various cough symptoms after surgery, which a variety of internal and external factors can trigger. The coughing imposes a double burden on the physical and psychological due to the negative emotions it provokes.

CONCLUSION

We generated a concept framework of cough after lung cancer surgery, providing a basis for further development of measurement tools from the patients' perspective. The lack of knowledge related to coughing highlights the need for adequate and timely health education and professional medical care.

Effectiveness of sublingual immunotherapy in pediatric cedar pollinosis: A real-world database study

BACKGROUND

Pediatric allergic rhinitis (AR), including cedar pollinosis (CP), is increasing in Japan. We investigated the effects of sublingual immunotherapy (SLIT), which has limited studies of its effectiveness in real-world settings, on children with CP.

METHODS

This retrospective cohort study used a claim database in 2018-2021. Children aged ≤15 years with CP records in 2019 were eligible and were followed up through 2021. We included 2962 CP children undergoing SLIT and 547 who were not. The medication score was used to evaluate SLIT effectiveness in the cedar pollen dispersal season each year. Adverse events and the occurrence of allergic diseases were also evaluated.

RESULTS

Medication score was higher in the SLIT group during the index period but lower in 2021 compared to the non-SLIT group (mean ± standard deviation: 5.17 ± 2.39 and 4.74 ± 2.38 in 2019, 3.13 ± 2.30 and 3.55 ± 2.48 in 2021, respectively). The adjusted mean difference between groups from 2019 to 2021 was -0.62 (95% confidence interval: -0.86 to -0.39, p < .0001), and the medication score was reduced in the SLIT group (risk ratio: 1.2: 1.1 to 1.3). The occurrence of adverse events involving abdominal disorders (adjusted odds ratio [aOR]: 0.64: 0.51 to 0.81), asthma exacerbation (aOR: 0.37: 0.24 to 0.57), and allergic diseases involving hay fever unrelated to CP (aOR: 0.60: 0.45 to 0.80) or asthma (aOR: 0.71: 0.58 to 0.86) was lower in the SLIT group.

CONCLUSION

In children with CP, SLIT is effective, well tolerated, and could decrease the occurrence of other allergic diseases.

Patient's experiences of coughing after lung cancer surgery: A multicenter qualitative study

Purpose

Cough is one of the most common symptoms after lung cancer surgery, which seriously affects the quality of life. Little research has been conducted on patient's experiences of cough following lung surgery. This study aimed to elucidate the experience of coughing after lung cancer surgery from the patient's perspective regarding symptoms and their impacts on daily life, as well as triggers and dealing strategies.

Methods

Between June 2023 and July 2023, we conducted semi‐structured interviews with patients from outpatient clinics of two hospitals who were pathologically diagnosed with lung cancer and experienced cough after surgery through convenience sampling. The interview recordings were transcribed and analyzed by two researchers. The traditional content analysis and thematic analysis were used to identify the common codes, subthemes, and themes.

Results

A total of 28 participants were interviewed. The mean age of the participants was 55.21 years (range: 36–75 years), and 21 participants were female. Most patients (75%) were interviewed within 6 months of surgery. We identified five themes (accompanying symptoms, incentives, effects, solution, and information sources) and 12 subthemes (local symptoms, systemic symptoms, personal factors, external factors, emotion, relationship with others, reduced quality of life, medical measures, nonmedical measures, no measures, relatives and friends, and the Internet). Patients with lung cancer may experience various cough symptoms after surgery, which a variety of internal and external factors can trigger. The coughing imposes a double burden on the physical and psychological due to the negative emotions it provokes.

Conclusion

We generated a concept framework of cough after lung cancer surgery, providing a basis for further development of measurement tools from the patients' perspective. The lack of knowledge related to coughing highlights the need for adequate and timely health education and professional medical care.

Chronic Refractory Cough: Long-Term Outcomes Following Cough Suppression Therapy

OBJECTIVE

This study aimed to determine the long-term outcomes of patients with chronic refractory cough (CRC) following treatment for cough suppression therapy (CST). Currently, there is a lack of objective data regarding the long-term outcome of behavioral treatment for CRC.

METHODS

From the charts of 106 adult patients diagnosed with CRC, 24 patients were identified as having long-term data at least 3 months post-CST in the form of otolaryngologic examination, Voice Handicap Index-10 (VHI-10), and Cough Severity Index (CSI) scores. Patients underwent otolaryngologic evaluation and completed the VHI-10 and CSI assessments during pretreatment, posttreatment, and long-term follow-up visits. Patients were also divided into two groups based on their number of comorbidities.

RESULTS

Twenty of the 24 patients had significant reduction in cough severity after completing CST (P < 0.001). A significant difference was also found in CSI scores from pretherapy to the long-term follow-up visits (P = 0.001). No significant difference was found in CSI scores from posttherapy to long-term follow-up visits (P = 0.93). No significant difference was found in VHI-10 scores over time (P = 0.83). No correlation was found between changes in cough and voice severity and number of comorbidities at the tested level.

CONCLUSIONS

Findings of no significant change in CRC over the long term compared to posttherapy measures suggest that patients were able to maintain improvement in cough over the long term despite various comorbidities. The current results suggest that CST represents a satisfactory approach to treating CRC and provides patients with an ongoing tool to maintain reduced cough severity. No significant correlations between number of comorbidities and mean CSI or VHI-10 scores were found over the long term.

Practical multidisciplinary framework for the assessment and management of patients with unexplained chronic aerodigestive symptoms

OBJECTIVE

Patients experiencing unexplained chronic throat symptoms (UCTS) are frequently referred to gastroenterology and otolaryngology outpatient departments for investigation. Often despite extensive investigations, an identifiable structural abnormality to account for the symptoms is not found. The objective of this article is to provide a concise appraisal of the evidence-base for current approaches to the assessment and management of UCTS, their clinical outcomes, and related healthcare utilisation.

DESIGN

This multidisciplinary review critically examines the current understanding of aetiological theories and pathophysiological drivers in UCTS and summarises the evidence base underpinning various diagnostic and management approaches.

RESULTS

The evidence gathered from the review suggests that single-specialty approaches to UCTS inadequately capture the substantial heterogeneity and pervasive overlaps among clinical features and biopsychosocial factors and suggests a more unified approach is needed.

CONCLUSION

Drawing on contemporary insights from the gastrointestinal literature for disorders of gut-brain interaction, this article proposes a refreshed interdisciplinary approach characterised by a positive diagnosis framework and patient-centred therapeutic model. The overarching aim of this approach is to improve patient outcomes and foster collaborative research efforts.

Cough and sputum in long COVID are associated with severe acute COVID-19: a Japanese cohort study

BACKGROUND

Multiple prolonged symptoms are observed in patients who recover from acute coronavirus disease 2019 (COVID-19), defined as long COVID. Cough and sputum are presented by patients with long COVID during the acute and post-acute phases. This study aimed to identify specific risk factors for cough and sputum in patients with long COVID.

METHODS

Hospitalized patients with COVID-19 aged 18 years were enrolled in a multicenter cohort study at 26 medical institutions. Clinical data during hospitalization and patient-reported outcomes after discharge were collected from medical records, paper-based questionnaires, and smartphone apps.

RESULTS

At the 3-, 6-, and 12-month follow-ups, there were no differences in the incidence rates of wet and dry coughs. In contrast, the proportion of patients presenting sputum without coughing increased over time compared to those with sputum and coughing. Univariate analyses of cough and sputum at all follow-up visits identified intermittent mandatory ventilation (IMV), smoking, and older age as risk factors for prolonged symptoms. At the 12-month follow-up, persistent cough and sputum were associated with the characteristics of severe COVID-19 based on imaging findings, renal and liver dysfunction, pulmonary thromboembolism, and higher serum levels of LDH, KL-6, and HbA1C. The Kaplan-Meier curves showed that the severity of acute COVID-19 infection was correlated with prolonged cough and sputum production. Multivariable logistic regression analysis showed that IMV ventilator management were independent risk factors for prolonged cough and sputum at 12 months.

CONCLUSIONS

In a Japanese population with long COVID, prolonged cough and sputum production were closely associated with severe COVID-19. These findings emphasize that a preventive approach including appropriate vaccination and contact precaution and further development of therapeutic drugs for COVID-19 are highly recommended for patients with risk factors for severe infection to avoid persistent respiratory symptoms.

The Efficacy of Superior Laryngeal Nerve Block for Neurogenic Cough: A Placebo-Controlled Trial

OBJECTIVES

Chronic cough is a common and debilitating problem. The objective of this study is to assess the efficacy and safety of superior laryngeal nerve (SLN) block for neurogenic cough through a placebo-controlled, prospective trial.

METHODS

Patients were recruited in an outpatient tertiary care center. Inclusion criteria included a history consistent with neurogenic cough and age ≥ 18. Exclusion criteria included patients with untreated other etiologies of chronic cough (i.e., uncontrolled reflux) and current neuromodulating medication use. Patients were randomized into the treatment (1-2 mL of a 1:1 triamcinolone 40 mg: 1% lidocaine with 1:200,000 epinephrines) or placebo (saline) group and received two unilateral injections at approximately 2-week intervals. Outcomes were measured primarily by the Leicester Cough Questionnaire (LCQ) and a patient symptom log including a visual analog scale of cough severity.

RESULTS

17 patients completed the study, including 10 in the treatment group and seven in the placebo group. Eight (80%) patients in the treatment group reported improvement with at least one of the injections, whereas only 1 (14.3%) patient reported improvement in the placebo group (p < 0.0001). Average total LCQ scores increased in the treatment group from 10.09 to 13.15 (p = 0.03), with the most change occurring in the social domain. There was no statistically significant change in LCQ scores for the placebo group. There were no serious adverse events.

CONCLUSION

An SLN block is a safe and efficacious procedure for the treatment of neurogenic cough. Further studies are needed to optimize treatment protocol and assess long-term follow-up of patient outcomes.

LEVEL OF EVIDENCE

2 Laryngoscope, 133:3068-3074, 2023.

Analysis of COVID-19 Resulting Cough Using Formants and Automatic Speech Recognition System

As part of our contributions to researches on the ongoing COVID-19 pandemic worldwide, we have studied the cough changes to the infected people based on the Hidden Markov Model (HMM) speech recognition classification, formants frequency and pitch analysis. In this paper, An HMM-based cough recognition system was implemented with 5 HMM states, 8 Gaussian Mixture Distributions (GMMs) and 13 dimensions of the basic Mel-Frequency Cepstral Coefficients (MFCC) with 39 dimensions of the overall feature vector. A comparison between formants frequency and pitch extracted values is realized based on the cough of COVID-19 infected people and healthy ones to confirm our cough recognition system results. The experimental results present that the difference between the recognition rates of infected and non-infected people is 6.7%. Whereas, the formant analysis variation based on the cough of infected and non-infected people is clearly observed with F1, F3, and F4 and lower for F0 and F2.

Altered functional connectivity of the nucleus tractus solitarii in patients with chronic cough after lung surgery: an rs-fMRI study

BACKGROUND

To explore the altered functional connectivity (FC) of the nucleus tractus solitarii (NTS) in patients with chronic cough after lung surgery using resting-state functional magnetic resonance imaging (rs-fMRI), and the association between abnormal FC and clinical scale scores.

METHODS

A total of 22 patients with chronic cough after lung surgery and 22 healthy controls were included. Visual analog scale (VAS), Mandarin Chinese version of the Leicester Cough Questionnaire (LCQ-MC), and Hamilton anxiety rating scale (HAMA) scores were assessed, and rs-fMRI data were collected. The FC analysis was performed using the NTS as the seed point, and FC values with all voxels in the whole brain were calculated. A two-sample t-test was used to compare FC differences between the two groups. The FC values of brain regions with differences were extracted and correlated with clinical scale scores.

RESULTS

In comparison to healthy controls, FC values in the NTS and anterior cingulate cortex(ACC) were reduced in patients with chronic cough after lung surgery (GRF correction, p-voxel < 0.005, p-cluster < 0.05) which were positively correlated with LCQ-MC scores (r = 0.534, p = 0.011), but with VAS (r = -0.500, p = 0.018), HAMA (r = -0.713, p < 0.001) scores were negatively correlated.

CONCLUSIONS

Reduced FC of the NTS with ACC may be associated with cough hypersensitivity and may contribute to anxiety in patients with chronic cough after lung surgery.

Xiaoqinglong decoction suppresses childhood cough variant asthma and inhibited the body inflammatory response by regulating IL-6/STAT3 signalling pathway

Xiaoqinglong decoction (XQLD) is widely used clinically in the treatment of childhood cough variant asthma (CVA). However, its potential mechanism is still unknown. In the present study, the authors investigate the biological network and signalling pathway of XQLD in treatment of childhood CVA using network pharmacology-based analysis and experimental validation. By using the Bioinformatics Analysis Tool Molecular Mechanism of Traditional Chinese Medicine (BATMAN-TCM) database, the authors confirmed the correlation between XQLD and asthma, and the authors screened 1338 potential target genes of Mahuang and Guizhi, the most active herbs in XQLD. By overlapping "Childhood asthma-related genes" of DisGeNET database, the authors identified 58 intersecting genes of Childhood asthma and 1338 target genes of Mahuang and Guizhi. The intersecting genes were used to construct the protein-to-protein interaction and performed Gene Ontology (GO) functional and the Kyoto Encyclopedia of Genes and Genomes pathway enrichment analyses. Gene Ontology enrichment analysis demonstrated 359 Biological Process terms, 16 Cellular Component terms, and 26 Molecular Function terms. Meantime, 75 terms of Kyoto Encyclopedia of Genes and Genomes signalling pathway were involved in enrichment analysis. These candidates showed a significant correlation with inflammatory response and positive regulation of tyrosine phosphorylation of STAT protein. In addition, XQLD treatment significantly upregulated serum interferon-γ expression, and downregulated serum interlukin-6 expression of CVA mice. XQLD treatment significantly inhibited phosphorylation of STAT3 in bronchial-lung tissues. Our data suggest that XQLD effectively alleviated bronchial-lung tissue damage in CVA mice and inhibited the body inflammatory response by regulating interlukin-6/STAT3 signalling pathway.

Screening COVID-19 by Swaasa AI platform using cough sounds: a cross-sectional study

The Advent of Artificial Intelligence (AI) has led to the use of auditory data for detecting various diseases, including COVID-19. SARS-CoV-2 infection has claimed more than six million lives to date and therefore, needs a robust screening technique to control the disease spread. In the present study we created and validated the Swaasa AI platform, which uses the signature cough sound and symptoms presented by patients to screen and prioritize COVID-19 patients. We collected cough data from 234 COVID-19 suspects to validate our Convolutional Neural Network (CNN) architecture and Feedforward Artificial Neural Network (FFANN) (tabular features) based algorithm. The final output from both models was combined to predict the likelihood of having the disease. During the clinical validation phase, our model showed a 75.54% accuracy rate in detecting the likely presence of COVID-19, with 95.45% sensitivity and 73.46% specificity. We conducted pilot testing on 183 presumptive COVID subjects, of which 58 were truly COVID-19 positive, resulting in a Positive Predictive Value of 70.73%. Due to the high cost and technical expertise required for currently available rapid screening methods, there is a need for a cost-effective and remote monitoring tool that can serve as a preliminary screening method for potential COVID-19 subjects. Therefore, Swaasa would be highly beneficial in detecting the disease and could have a significant impact in reducing its spread.

Efficacy, Safety and Economic Evaluation of Wolbigachul-Tang for Chronic Cough Due to Upper Airway Cough Syndrome (UACS): A Study Protocol for Randomized, Double-Blind, Active-Comparator Controlled, Parallel, Exploratory Clinical Trial

Upper airway cough syndrome (UACS) is a common cause of chronic cough characterized by upper airway symptoms, including nasal discharge and throat discomfort. Empirical treatments for UASC-induced chronic cough, such as first-generation antihistamines, have been used; however, the long-term use of these medicines has adverse effects. Therefore, we evaluate the efficacy, safety, and economic feasibility of Wolbigachul-tang (WBGCT), an herbal medication for UASC-induced chronic cough. This is a randomized, double-blind, active-comparator-controlled, parallel, and exploratory clinical trial. Thirty patients with UASC-induced chronic cough will be recruited and randomly allocated to the WBGCT and control groups in a 1:1 allocation ratio. The investigational medicine will be administered three times per day for 2 weeks (3 g of WBGCT at a time). The primary outcome measure is the cough symptom score measured at screening, before starting the trial, and after 2 and 4 weeks. Secondary outcome measures include the cough visual analog scale, nasal discharge score, questionnaire of clinical symptoms of cough and sputum, Leicester cough questionnaire-Korean version, integrative medicine outcome scale, integrative medicine patient satisfaction scale, and 5-level EuroQol 5-dimensional questionnaire, which will be assessed before starting the trial and after 2 and 4 weeks. This study aims to investigate the efficacy, safety, and economic feasibility of WBGCT in the treatment of chronic cough. Therefore, the results of this trial provide evidence for the application of WBGCT in the treatment of UACS-induced chronic cough.

Burden of refractory and unexplained chronic cough on patients' lives: a cohort study

Background

Chronic cough (cough lasting for ≥8 weeks) can lead to significant impairment in quality of life (QoL). Using patient-reported outcomes, this cohort study assessed the perceived impact of chronic cough on QoL and everyday life in patients from outpatient hospital clinics with refractory chronic cough (RCC) or unexplained chronic cough (UCC).

Methods

This was a multicentre, non-interventional survey study. Cough severity was assessed on a 0-100 mm Visual Analogue Scale (VAS). Frequency, intensity and disruptiveness of cough were assessed using an adaptation of the Cough Severity Diary. The impact of cough on QoL was assessed using the Leicester Cough Questionnaire (LCQ). The physical impact of cough and associated impact on everyday life activities were explored using purpose-designed questions.

Results

191 patients responded to the survey; 121 (63.4%) had RCC and 149 were women (78.0%). Mean score on the cough severity VAS was 62.9 mm. Mean LCQ total score of 11.9 indicated reduced QoL. Cough impaired patients' everyday life, including the inability to speak fluently (58.0% of patients) and feeling tired/drained (46.6%). Women perceived poorer chronic cough-related QoL than men, as reflected by lower LCQ scores, and greater impairment of physical health, including cough-related stress urinary incontinence, and psychological health.

Conclusions

Patients with RCC/UCC experience a significant burden in their everyday life, including impaired QoL, and perceive a negative impact on physical and psychological health and everyday activities, affecting work, relationships and leisure activities. The impact appears to be greater in women than men for several of the aspects studied.

Identification of cough-variant asthma phenotypes based on clinical and pathophysiologic data

BACKGROUND

Cough-variant asthma (CVA) may respond differently to antiasthmatic treatment. There are limited data on the heterogeneity of CVA.

OBJECTIVE

We aimed to classify patients with CVA using cluster analysis based on clinicophysiologic parameters and to unveil the underlying molecular pathways of these phenotypes with transcriptomic data of sputum cells.

METHODS

We applied k-mean clustering to 342 newly physician-diagnosed patients with CVA from a prospective multicenter observational cohort using 10 prespecified baseline clinical and pathophysiologic variables. The clusters were compared according to clinical features, treatment response, and sputum transcriptomic data.

RESULTS

Three stable CVA clusters were identified. Cluster 1 (n = 176) was characterized by female predominance, late onset, normal lung function, and a low proportion of complete resolution of cough (60.8%) after antiasthmatic treatment. Patients in cluster 2 (n = 105) presented with young, nocturnal cough, atopy, high type 2 inflammation, and a high proportion of complete resolution of cough (73.3%) with a highly upregulated coexpression gene network that related to type 2 immunity. Patients in cluster 3 (n = 61) had high body mass index, long disease duration, family history of asthma, low lung function, and low proportion of complete resolution of cough (54.1%). TH17 immunity and type 2 immunity coexpression gene networks were both upregulated in clusters 1 and 3.

CONCLUSION

Three clusters of CVA were identified with different clinical, pathophysiologic, and transcriptomic features and responses to antiasthmatics treatment, which may improve our understanding of pathogenesis and help clinicians develop individualized cough treatment in asthma.

Diagnostic accuracy of blood eosinophils in comparison to other common biomarkers for identifying sputum eosinophilia in patients with chronic cough

Background

Sputum eosinophilia is a treatable trait for chronic cough. It is currently not clear whether the blood eosinophil counts could be used to identify sputum eosinophilia in patients with chronic cough. This study aimed to evaluate the diagnostic accuracy of blood eosinophils in comparison to other common type 2 biomarkers for identifying sputum eosinophilia in patients with chronic cough.

Methods

In this prospective study, a total of 658 patients with chronic cough were enrolled. Induced-sputum test, routine blood test, total immunoglobulin E (TIgE), and fractional exhaled nitric oxide (FeNO) level were measured. The percentage of sputum eosinophils (Eos%) ≥ 2.5% was defined as sputum eosinophilia. The area under the curve (AUC) of blood eosinophil counts, TIgE, and FeNO alone or in combination for predicting sputum eosinophilia were analyzed.

Results

The AUC of blood eosinophil counts for predicting sputum eosinophilia in chronic cough patients was moderate [0.826 (0.767-0.885)], as compared to that of FeNO [0.784 (0.720-0.849), P = 0.280] and TIgE [0.686 (0.613-0.760), P = 0.001]. When combining blood eosinophil counts and FeNO for detecting sputum eosinophilia, a significantly larger AUC [0.868 (0.814-0.923), with a sensitivity of 84.2% and a specificity of 82.8%] was yielded, as compared to each single marker alone (all P < 0.05).

Conclusions

Blood eosinophil counts have a moderate diagnostic value for identifying sputum eosinophilia in patients with chronic cough, while a combination of blood eosinophil counts and FeNO measurement can provide additional predictive value.

TRP (transient receptor potential) ion channel family: structures, biological functions and therapeutic interventions for diseases

Transient receptor potential (TRP) channels are sensors for a variety of cellular and environmental signals. Mammals express a total of 28 different TRP channel proteins, which can be divided into seven subfamilies based on amino acid sequence homology: TRPA (Ankyrin), TRPC (Canonical), TRPM (Melastatin), TRPML (Mucolipin), TRPN (NO-mechano-potential, NOMP), TRPP (Polycystin), TRPV (Vanilloid). They are a class of ion channels found in numerous tissues and cell types and are permeable to a wide range of cations such as Ca²⁺, Mg²⁺, Na⁺, K⁺, and others. TRP channels are responsible for various sensory responses including heat, cold, pain, stress, vision and taste and can be activated by a number of stimuli. Their predominantly location on the cell surface, their interaction with numerous physiological signaling pathways, and the unique crystal structure of TRP channels make TRPs attractive drug targets and implicate them in the treatment of a wide range of diseases. Here, we review the history of TRP channel discovery, summarize the structures and functions of the TRP ion channel family, and highlight the current understanding of the role of TRP channels in the pathogenesis of human disease. Most importantly, we describe TRP channel-related drug discovery, therapeutic interventions for diseases and the limitations of targeting TRP channels in potential clinical applications.

Cough and cough hypersensitivity as treatable traits of asthma

Cough is a common and troublesome symptom in people with asthma and is often associated with poorer asthma control and exacerbations. Apart from asthma, other causes or comorbidities might underlie cough in asthma, such as rhinosinusitis and bronchiectasis. Eosinophilic inflammation and bronchoconstriction can lead to an acute episode of cough or worsen chronic cough. Cough hypersensitivity with laryngeal paraesthesia, allotussia, and hypertussia might underlie the cough of asthma through augmented sensory nerve excitability of upper-airway vagal sensory nerves. Cough associated with bronchoconstriction and type 2 inflammation should respond to inhaled corticosteroids and long-acting β-adrenoceptor agonist therapy. For cough hypersensitivity in adults, speech and language therapy and neuromodulators (eg, gabapentin) could be considered. In children, there is no consistent association of asthma with cough sensitivity or between cough and asthma severity. Further research is needed to realise the potential of cough as a measure of asthma control, to understand the mechanisms of cough in asthma, and to develop safe, effective treatments and a precision-medicine approach to the management of cough in asthma in children and adults.

Zi-Su-Zi decoction improves airway hyperresponsiveness in cough-variant asthma rat model through PI3K/AKT1/mTOR, JAK2/STAT3 and HIF-1α/NF-κB signaling pathways

ETHNOPHARMACOLOGICAL RELEVANCE

Cough-variant asthma (CVA) is one of the most common causes of chronic cough. Its pathogenesis is closely related to chronic airway inflammation and airway hyperresponsiveness. CVA belongs to the category of "wind cough" in Traditional Chinese medicine (TCM). Zi-Su-Zi decoction (ZSD) is a Chinese herbal formula that is clinically used for the treatment of cough and asthma, especially CVA. However, the mechanism of action remains unclear.

AIM OF THE STUDY

In this study, we aimed to explore the potential mechanism by which ZSD improves CVA airway hyperresponsiveness.

MATERIALS AND METHODS

The targets of ZSD in CVA were studied using a Network pharmacology. The main chemical components of ZSD were detected and analyzed using ultra-high-pressure liquid chromatography (UHPLC-MS/MS). In animal experiments, the rat model of CVA was established using Ovalbumin (OVA)/Aluminum hydroxide (AL(OH)3) sensitization. Moreover, the experiment also evaluated cough symptoms, percentage of eosinophils (EOS%), pulmonary function tests, histopathological sections, blood cytokine levels, mRNA and protein levels.

RESULTS

The results showed that Network pharmacology suggested 276 targets of ZSD and CVA and found that ZSD treatment with CVA was closely related to the phosphoinositide 3-kinase (PI3K)/protein kinase B (AKT) signaling pathway. UHPLC-MS/MS revealed that ZSD contained 52 main chemical components. Compared with the model group, the cough symptoms of the rats in the different ZSD concentration groups were relieved, the EOS% index was lowered, and body weight was increased. HE staining showed that ZSD reduced airway inflammation, edema and hyperplasia, thereby improving the pathological structure of lung tissue, and the effect of high-dose ZSD was especially significant. Our most important finding was that ZSD blocked the entry of hypoxia-inducible factor-1α (HIF-1α), signal transducer and activator of transcription-3 (STAT3) and nuclear factor kappa-B (NF-κB) into the nucleus by interfering with PI3K/AKT1/mechanistic target of rapamycin (mTOR), and janus kinase 2 (JAK2) signaling factors. Consequently, inhibiting the release of cytokines and immunoglobulin-E, thereby reducing airway hyperresponsiveness (AHR) and partially reverses airway remodeling.

CONCLUSIONS

This study showed that ZSD can improve airway hyperresponsiveness and partially reverse airway remodeling by inhibiting the PI3K/AKT1/mTOR, JAK2/STAT3 and HIF-1α/NF-κB signaling pathways. Therefore, ZSD is an effective prescription for the treatment of CVA.

Characteristics and Management of Patients with Refractory or Unexplained Chronic Cough in Outpatient Hospital Clinics in Spain: A Retrospective Multicenter Study

PURPOSE

Chronic cough (cough that persists for ≥ 8 weeks) can cause a range of physical symptoms and psychosocial effects that significantly impair patients' quality of life. Refractory chronic cough (RCC) and unexplained chronic cough (UCC) are challenging to diagnose and manage, with substantial economic implications for healthcare systems.

METHODS

This retrospective multicenter non-interventional study aimed to characterize the profile and health resource consumption of patients with RCC or UCC who attended outpatient clinics at Spanish hospitals. Data were collected from medical records of patients with RCC or UCC for up to 3 years before study inclusion.

RESULTS

The patient cohort (n = 196) was representative of the chronic cough population (77.6% female, mean age 58.5 years). Two-thirds of patients (n = 126) had RCC. The most frequently visited doctors were pulmonologists (93.4% of patients) and primary care physicians (78.6%), with a mean of 5 visits per patient over three years' observation. The most common diagnostic tests were chest x-ray (83.7%) and spirometry with bronchodilation (77.0%). The most commonly prescribed treatments were proton pump inhibitors (79.6%) and respiratory medications (87.8%). Antibiotics were prescribed empirically to 56 (28.6%) patients. Differences between RCC or UCC groups related mainly to approaches used to manage cough-associated conditions (gastroesophageal reflux disease, asthma) in patients with RCC.

CONCLUSION

RCC and UCC are responsible for high health resource utilization in Spanish hospitals. Specific treatments targeting the pathological processes driving chronic cough may provide opportunities to reduce the associated burden for patients and healthcare systems.

Cough desensitization treatment for patients with refractory chronic cough: results of a second pilot randomized control trial

OBJECTIVE

The purpose of this study was to collect pilot efficacy data on a novel treatment for refractory chronic cough (RCC), which we call cough desensitization treatment (CDT).

DESIGN AND METHODS

In this parallel cohort, sham-controlled, randomized controlled trial, 21 adults with RCC were randomly assigned to 12 sessions of either CDT (progressive doses of aerosolized capsaicin while behaviorally suppressing cough; n = 11) or a sham treatment (repeated exposure to aerosolized saline; n = 9). The Leicester Cough Questionnaire (LCQ) was the primary outcome measure. Perceived cough severity with a visual analogue scale and cough challenge testing (for measuring cough-reflex sensitivity) were secondary outcome measures. Data were analyzed with mixed effects linear regression and follow-up contrasts.

RESULTS

Results on all measures favored CDT. Excluding one sham participant, whose baseline LCQ scores were deemed unreliable, mean change in LCQ at 3-weeks post treatment was 6.35 and 2.17 in the CDT and sham groups, respectively. There was moderate to strong evidence of a greater improvement in the CDT group in total LCQ score (p = .058) and LCQ Psychological domain (p = .026) and Physical domain (p = .045) scores. Strong evidence was found for a greater reduction in urge-to-cough during CCT in the CDT group (p = .037) and marginal for a reduction in the capsaicin cough-reflex sensitivity (p = .094). There was weak evidence of a greater reduction in cough severity in the CDT group (p = .103).

DISCUSSION

Although the study is limited due to the small sample size, the data provide additional evidence supporting further research on CDT. CDT resulted in a greater change in the primary efficacy measure (LCQ) than both pharmaceutical and behavioral treatments currently found in the literature.

TRIAL REGISTRATION

This trial (NCT05226299) was registered on Clinicaltrials.gov on 07/02/2022.

A Chronic Cough and Something More: An Unusual Presentation of Hepatocellular Carcinoma

Liver cancer is one of the main contributors to cancer-related death and is the fifth most frequent cancer worldwide. Hepatocellular carcinoma (HCC), the most common of liver cancers, is most frequently diagnosed incidentally during routine imaging in high-risk patients with cirrhosis. However, patients with advanced disease may present with upper abdominal pain, early satiety, weight loss, and a palpable upper abdominal mass. We describe a case of HCC in a 69-year-old male presenting exclusively with an intractable cough, which improved after transarterial chemoembolization-raising awareness of the importance of having a systematic and physiopathology-based approach to chronic cough to have an adequate diagnosis and treatment.

Development and clinical validation of Swaasa AI platform for screening and prioritization of pulmonary TB

Acoustic signal analysis has been employed in various medical devices. However, studies involving cough sound analysis to screen the potential pulmonary tuberculosis (PTB) suspects are very few. The main objective of this cross-sectional validation study was to develop and validate the Swaasa AI platform to screen and prioritize at risk patients for PTB based on the signature cough sound as well as symptomatic information provided by the subjects. The voluntary cough sound data was collected at Andhra Medical College-India. An Algorithm based on multimodal convolutional neural network architecture and feedforward artificial neural network (tabular features) was built and validated on a total of 567 subjects, comprising 278 positive and 289 negative PTB cases. The output from these two models was combined to detect the likely presence (positive cases) of PTB. In the clinical validation phase, the AI-model was found to be 86.82% accurate in detecting the likely presence of PTB with 90.36% sensitivity and 84.67% specificity. The pilot testing of model was conducted at a peripheral health care centre, RHC Simhachalam-India on 65 presumptive PTB cases. Out of which, 15 subjects truly turned out to be PTB positive with a positive predictive value of 75%. The validation results obtained from the model are quite encouraging. This platform has the potential to fulfil the unmet need of a cost-effective PTB screening method. It works remotely, presents instantaneous results, and does not require a highly trained operator. Therefore, it could be implemented in various inaccessible, resource-poor parts of the world.

Membranous Vocal Fold Lesions in Patients With Chronic Cough: A Case Series

OBJECTIVES

Trauma related to chronic cough and forceful glottal closure has been associated with lesions of the vocal process; however, there is limited description of cough leading to membranous vocal fold lesions. We present a series of mid-membranous vocal fold lesions in a cohort of patients with chronic cough, with a proposed mechanism of lesion formation.

METHODS

Patients treated for chronic cough with membranous vocal fold lesions affecting phonation were identified. Presentation, diagnosis, treatment strategies (behavioral, medical, and surgical), patient-reported outcome measures (PROMs), and videostroboscopy were reviewed.

RESULTS

Five patients are included (four females, one male, aged 56±16 years). Mean cough duration was 2.6±3.5 years. All patients were on acid suppressive medications for existing gastroesophageal reflux disease (GERD) prior to referral. All lesions were identified at the mid-membranous vocal folds and morphologically encompassed a wound healing spectrum between ulceration and/or granulation tissue (granuloma) formation. Patients were treated in an interdisciplinary fashion with behavioral cough suppression therapy, superior laryngeal nerve block, and neuromodulators. Three had persistent lesions requiring procedural intervention (one office-based steroid injection and two surgical excisions). At the completion of treatment, all five patients had improvement in Cough Severity Index with an average decrease of 15.2±4.8. All but one patient had improvement in their Voice Handicap Index-10 with an average decrease of 13.2±11.1. One patient undergoing surgical intervention was noted to have a persistent lesion on follow-up.

CONCLUSION

Mid-membranous vocal fold lesions in patients with chronic cough are uncommon. When they do occur, they represent epithelial change arising in context of shear injury and are distinct from phonotraumatic lesions in the lamina propria. An interdisciplinary approach including behavioral cough suppression therapy, neuromodulators, superior laryngeal nerve block, and acid suppression are reasonable for initial management, reserving surgical intervention for refractory lesions once the inciting source of injury has been controlled.

[Chronic cough]

Coughing is an important protective reflex of the respiratory tract and primarily serves clearance of the bronchial system. It is also an exceptionally common symptom in outpatient care that can be an expression of a variety of diseases. Coughing duration of longer than 8 weeks is referred to as chronic cough. A structured, often interdisciplinary diagnostic process is essential. The aim here is to identify causal treatment options, avoiding overdiagnosis and simultaneously not overlooking severe illness. This article discusses current diagnostic procedures, important differential diagnoses and possible treatment options.

Can clinical characteristics differentiate patients with unexplained chronic cough from patients with asthma and COPD?

Background: Chronic cough is reported in up to 20% of the adult population and often persists despite medical treatment with currently available therapies. Many clinical conditions, including asthma and chronic obstructive pulmonary disease (COPD), must be excluded before making a Unexplained chronic cough diagnosis. Methods: The primary objective was to use a large hospital dataset to compare clinical features of patients with a primary diagnosis of UCC with those with asthma or COPD without a primary diagnosis of UCC to help clinicians differentiate between these conditions more readily. Data were collected for all hospitalization and outpatient medical encounters for each patient between November 2013 and December 2018. Information included demographics, encounter dates, medications prescribed at every encounter for chronic cough, lung function testing, and hematologic parameters. Asthma and COPD were combined into one group to ensure there was no overlap with UCC and due to limitations of International Classification of Diseases coding to confirm an asthma(A)/COPD diagnosis. Results: Female gender represented 70% of encounters for UCC versus 61.8% for asthma/COPD (p < 0.0001); the mean age was 56.9 years for UCC versus 50.1 years for A/COPD (p < 0.0001). The number of patients on cough medications and the cough medication frequency were significantly higher in the UCC versus A/COPD group (p < 0.0001). UCC versus A/COPD patients had a total of eight versus three cough-related encounters over the study duration (i.e., 5 years) (<0.0001). The average interval between successive encounters was less for UCC (114 days) versus the A/COPD (288 days) group. Gender-adjusted Forced expiratory volume in the first second of exhalation/Forced vital capacity (FEV₁/FVC) ratios, residual volume%, and Diffusion capacity for carbon monoxide (DLCO%) were significantly higher in UCC versus A/COPD, whereas the response to bronchodilators of FEV₁, FVC and residual volumes were significantly greater in A/COPD patients. Conclusions: Clinical characteristics differentiating UCC from A/COPD could accelerate recognition of UCC diagnosis especially in the subspecialty setting where patients with these disorders are referred.

Efficacy and tolerability of zinc acetate for treatment of chronic refractory cough: pilot randomised futility trial

Background

Cough is the most reported symptom in the United States, with chronic refractory cough representing significant morbidity to patients. Zinc acetate may have beneficial effects in the cough reflex pathway. We sought to assess the safety and efficacy of zinc acetate in the management of chronic refractory cough.

Study design and methods

This was a randomised, placebo-controlled, parallel-design pilot trial of individuals with chronic refractory cough. The effects of 6 weeks of zinc acetate versus placebo on quality of life and symptoms as measured by the Cough Quality-of-Life Questionnaire (CQLQ), Leicester Cough Questionnaire (LCQ), cough visual analogue score (C-VAS) and Global Assessment of Change in Cough (GACC) scores were evaluated. A futility analysis plan with a one-sided 80% confidence interval was used to compare treatment effect to published minimum clinically important differences (MCID) for each outcome.

Results

34 participants, 17 in each group, were enrolled and randomised. Participants were primarily white females with moderate-severe cough. Participants assigned to zinc acetate had a significant increase in serum zinc levels after 6 weeks, while those assigned to placebo did not. Both groups showed improvement in CQLQ, LCQ, C-VAS and GACC scores, but the treatment effects of zinc acetate versus placebo were small with confidence intervals that did not include the MCIDs.

Interpretation

We observed no benefit of zinc therapy over placebo on cough symptoms or quality of life and conclude that larger trials of zinc for chronic cough are not warranted.

Herbal Medicine Maekmundong-Tang on Patients with Nonspecific Chronic Cough: Study Protocol for a Double-Blind, Randomized Controlled Clinical Trial

As the treatment of nonspecific chronic cough with conventional medications that treat cough according to the cause is limited, Maekmundong-tang (comprising Liriopis seu Ophiopogonis Tuber, Pinelliae Tuber, Oryzae Semen, Zizyphi Fructus, Ginseng Radix, and Glycyrrhizae Radix et Rhizoma) has been used empirically in the clinical setting of East Asian traditional medicine. This study is the first to explore the feasibility, preliminary effect, safety, and cost-effectiveness of Maekmundong-tang for nonspecific chronic cough. This study protocol is that of a double-blind, randomized, active-controlled, parallel-group clinical trial for comparing Maekmundong-tang with Saengmaek-san (comprising Liriopis seu Ophiopogonis Tuber, Ginseng Radix, and Schisandrae Fructus), a Korean national health insurance-covered herbal medicine for cough. A total of 30 nonspecific chronic cough patients will participate and receive the assigned herbal medicine for 6 weeks, and clinical parameters will be assessed at weeks 0 (baseline), 3 (midterm assessment), 6 (primary endpoint), 9, and 24 (follow-up). Study feasibility outcomes, including recruitment, adherence, and completion rates, will be assessed. Preliminary effects on cough severity, frequency, and quality of life will be evaluated using outcome measures, such as the Cough Symptom Score, Cough Visual Analog Scale, and the Leicester Cough Questionnaire. Adverse events and laboratory tests will be monitored for safety evaluation, and exploratory economic evaluations will be conducted. The results will provide evidence of Maekmundong-tang in the treatment of nonspecific chronic cough.

The role of smoking and alcohol in mediating the effect of gastroesophageal reflux disease on lung cancer: A Mendelian randomization study

Observational studies have suggested a positive association between gastroesophageal reflux disease and lung cancer, but due to the existence of confounders, it remains undetermined whether gastroesophageal reflux disease (GERD) has a causal association with lung cancer. Therefore, Mendelian randomization (MR) analyses were applied to investigate the relationship between the two conditions. Two-sample Mendelian randomization analysis was utilized with summary genetic data from the European Bioinformatics Institute (602,604 individuals) and International Lung Cancer Consortium, which provides information on lung cancer and its histological subgroups. Furthermore, we used two-step Mendelian randomization and multivariable Mendelian randomization to estimate whether smoking initiation (311,629 cases and 321,173 controls) and alcohol intake frequency (n = 462,346) mediate any effect of gastroesophageal reflux disease on lung cancer risk. The Mendelian randomization analyses indicated that gastroesophageal reflux disease was associated with and significantly increased the risk of lung cancer (OR_IVW = 1.35, 95% CI = 1.18-1.54; p = 1.36 × 10^-5). Smoking initiation and alcohol intake frequency mediated 35% and 3% of the total effect of gastroesophageal reflux disease on lung cancer, respectively. The combined effect of these two factors accounted for 60% of the total effect. In conclusion, gastroesophageal reflux disease is associated with an increased risk of lung cancer, and interventions to reduce smoking and alcohol intake may reduce the incidence of lung cancer.