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Lüsebrink E, Gade N, Seifert P, Ceelen F, Veit T, Fohrer F, Hoffmann S, Höpler J, Binzenhöfer L, Roden D, Saleh I, Lanz H, Michel S, Schneider C, Irlbeck M, Tomasi R, Hatz R, Hausleiter J, Hagl C, Magnussen C, Meder B, Zimmer S, Luedike P, Schäfer A, Orban M, Milger K, Behr J, Massberg S, Kneidinger N. The role of coronary artery disease in lung transplantation: a propensity-matched analysis. Clin Res Cardiol 2024:10.1007/s00392-024-02445-y. [PMID: 38587564 DOI: 10.1007/s00392-024-02445-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/26/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND AND AIMS Candidate selection for lung transplantation (LuTx) is pivotal to ensure individual patient benefit as well as optimal donor organ allocation. The impact of coronary artery disease (CAD) on post-transplant outcomes remains controversial. We provide comprehensive data on the relevance of CAD for short- and long-term outcomes following LuTx and identify risk factors for mortality. METHODS We retrospectively analyzed all adult patients (≥ 18 years) undergoing primary and isolated LuTx between January 2000 and August 2021 at the LMU University Hospital transplant center. Using 1:1 propensity score matching, 98 corresponding pairs of LuTx patients with and without relevant CAD were identified. RESULTS Among 1,003 patients having undergone LuTx, 104 (10.4%) had relevant CAD at baseline. There were no significant differences in in-hospital mortality (8.2% vs. 8.2%, p > 0.999) as well as overall survival (HR 0.90, 95%CI [0.61, 1.32], p = 0.800) between matched CAD and non-CAD patients. Similarly, cardiovascular events such as myocardial infarction (7.1% CAD vs. 2.0% non-CAD, p = 0.170), revascularization by percutaneous coronary intervention (5.1% vs. 1.0%, p = 0.212), and stroke (2.0% vs. 6.1%, p = 0.279), did not differ statistically between both matched groups. 7.1% in the CAD group and 2.0% in the non-CAD group (p = 0.078) died from cardiovascular causes. Cox regression analysis identified age at transplantation (HR 1.02, 95%CI [1.01, 1.04], p < 0.001), elevated bilirubin (HR 1.33, 95%CI [1.15, 1.54], p < 0.001), obstructive lung disease (HR 1.43, 95%CI [1.01, 2.02], p = 0.041), decreased forced vital capacity (HR 0.99, 95%CI [0.99, 1.00], p = 0.042), necessity of reoperation (HR 3.51, 95%CI [2.97, 4.14], p < 0.001) and early transplantation time (HR 0.97, 95%CI [0.95, 0.99], p = 0.001) as risk factors for all-cause mortality, but not relevant CAD (HR 0.96, 95%CI [0.71, 1.29], p = 0.788). Double lung transplant was associated with lower all-cause mortality (HR 0.65, 95%CI [0.52, 0.80], p < 0.001), but higher in-hospital mortality (OR 2.04, 95%CI [1.04, 4.01], p = 0.039). CONCLUSION In this cohort, relevant CAD was not associated with worse outcomes and should therefore not be considered a contraindication for LuTx. Nonetheless, cardiovascular events in CAD patients highlight the necessity of control of cardiovascular risk factors and a structured cardiac follow-up.
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Affiliation(s)
- Enzo Lüsebrink
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany.
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany.
| | - Nils Gade
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Paula Seifert
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Felix Ceelen
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), LMU University Hospital, LMU Munich, Munich, Germany
| | - Tobias Veit
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), LMU University Hospital, LMU Munich, Munich, Germany
| | - Fabian Fohrer
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), LMU University Hospital, LMU Munich, Munich, Germany
| | - Sabine Hoffmann
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Julia Höpler
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Leonhard Binzenhöfer
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Daniel Roden
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Inas Saleh
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Hugo Lanz
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Sebastian Michel
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiac Surgery, LMU University Hospital, LMU Munich, Munich, Germany
| | - Christian Schneider
- Division for Thoracic Surgery, LMU University Hospital, LMU Munich, Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Roland Tomasi
- Department of Anesthesiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Rudolf Hatz
- Division for Thoracic Surgery, LMU University Hospital, LMU Munich, Munich, Germany
| | - Jörg Hausleiter
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Christian Hagl
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiac Surgery, LMU University Hospital, LMU Munich, Munich, Germany
| | - Christina Magnussen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Benjamin Meder
- Department of Cardiology, Angiology, and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
- DZHK (German Center for Cardiovascular Research), partner site Heidelberg, Heidelberg, Germany
| | - Sebastian Zimmer
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, University Hospital Essen, University Duisburg-Essen, West German Heart- and Vascular Center, Essen, Germany
| | - Andreas Schäfer
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Martin Orban
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Katrin Milger
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), LMU University Hospital, LMU Munich, Munich, Germany
| | - Jürgen Behr
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), LMU University Hospital, LMU Munich, Munich, Germany
| | - Steffen Massberg
- Department of Medicine I, LMU University Hospital, LMU Munich, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Nikolaus Kneidinger
- Department of Medicine V, Comprehensive Pneumology Center (CPC-M), German Center for Lung Research (DZL), LMU University Hospital, LMU Munich, Munich, Germany.
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Schabert V, Shah S, Holmgren U, Cabrera C. Prescribing pathways to triple therapy in patients with chronic obstructive pulmonary disease in the United States. Ther Adv Respir Dis 2021; 15:17534666211001018. [PMID: 33866875 PMCID: PMC8058794 DOI: 10.1177/17534666211001018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend triple therapy (TT) for chronic obstructive pulmonary disease (COPD) patients based on severity. TT utilization by severity is infrequently studied in real-world settings and may deviate significantly from current clinical recommendations. This study describes prescribing pathways to TT among patients with COPD in the United States. Methods: This study analyzed Geisinger Health System electronic medical records from 1 January 2004 to 30 November 2016. Two retrospective cohorts of COPD patients were included: (1) incident COPD, and (2) incident TT users. COPD treatment patterns, including time to TT, were summarized. Time to TT was estimated using Kaplan–Meier methods. Predictors of the relative hazard for TT among incident COPD patients were estimated using Cox proportional hazards regressions. Results: Incident COPD and TT cohorts included 57,141 and 8173 patients, respectively. TT was used by 9.6% of incident COPD patients. In the year before TT, 34.3% of incident TT patients received treatment combinations recommended before TT according to GOLD recommendations, which mainly included: long-acting muscarinic antagonists (LAMAs), long-acting beta agonists (LABAs) + LAMAs, and inhaled corticosteroids + LABAs. Among incident TT patients, median time from COPD diagnosis to TT exceeded 2 years. The hazard for TT over time was associated with lower forced expiratory volume in 1 s values, more frequent exacerbations, current/previous smoking, and comorbid lung conditions such as pulmonary vascular disease, acute respiratory failure, and lung cancer. About 15–20% of the incident TT patients stepped down to a one- or two-drug regimen. Median time to TT discontinuation or step-down were 2 and 9 months, respectively. Conclusion: The study has revealed discrepancies in the treatment of COPD patients between GOLD guidelines and actual clinical practices in the United States. Pathways to TT differed from recommended therapy regimes. Further studies are needed to understand barriers to the use of guideline-recommended TTs by healthcare providers. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
| | | | | | - Claudia Cabrera
- BioPharmaceuticals Medical, AstraZeneca, KC6 SE-431 83 Mölndal, Gothenburg, Sweden
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Sindaghatta Krishnarao C, Maheshwarappa M, Thippeswamy T, Siddaiah JB, Lokesh KS, Mahesh PA. Risk Factors Associated with Development of Pulmonary Arterial Hypertension and Corpulmonale in Patients with Chronic Obstructive Pulmonary Disease. CURRENT RESPIRATORY MEDICINE REVIEWS 2020. [DOI: 10.2174/1573398x15666191018151526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
Chronic Obstructive Pulmonary Disease is an important cause of morbidity
and mortality globally. The onset of pulmonary hypertension and corpulmonale is associated with
decreased survival in patients with COPD.
Objective:
To assess risk factors associated with the development of pulmonary hypertension and
corpulmonale and to identify high-risk phenotypes who may need early evaluation and intervention.
Methods:
Consecutive adult patients with COPD were evaluated for factors influencing the
development of pulmonary hypertension and corpulmonale which included symptomatology,
hospitalization in the previous year, MMRC dyspnea grade, SGRQ score, 6 minute walk test, ABG,
CRP, spirometry and echocardiography.
Results:
We found Pulmonary Hypertension in 36(30%) patients and 27(22.5%) had corpulmonale.
On multivariate analysis, we found PaO2 ≤75 mm Hg and six minute walk test <80% predicted to be
significantly associated with the development of Pulmonary hypertension and we found
hospitalization in the previous year to be significantly and independently associated with the
development of corpulmonale.
Conclusion:
We observed hospitalization in the previous year was an independent risk factor for the
development of corpulmonale and six-minute walk test <80% predicted, PaO2 <75 mm Hg were
independent risk factors for the development of pulmonary hypertension.
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Loh LC, Ong CK, Koo HJ, Lee SM, Lee JS, Oh YM, Seo JB, Lee SD. A novel CT-emphysema index/FEV 1 approach of phenotyping COPD to predict mortality. Int J Chron Obstruct Pulmon Dis 2018; 13:2543-2550. [PMID: 30174423 PMCID: PMC6110287 DOI: 10.2147/copd.s165898] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background COPD-associated mortality was examined using a novel approach of phenotyping COPD based on computed tomography (CT)-emphysema index from quantitative CT (QCT) and post-bronchodilator (BD) forced expiratory volume in 1 second (FEV1) in a local Malaysian cohort. Patients and methods Prospectively collected data of 112 eligible COPD subjects (mean age, 67 years; male, 93%; mean post-BD FEV1, 45.7%) was available for mortality analysis. Median follow-up time was 1,000 days (range, 60–1,400). QCT and clinicodemographic data were collected at study entry. Based on CT-emphysema index and post-BD FEV1% predicted, subjects were categorized into “emphysema-dominant,” “airway-dominant,” “mild mixed airway-emphysema,” and “severe mixed airway-emphysema” diseases. Results Sixteen patients (14.2%) died of COPD-associated causes. There were 29 (25.9%) “mild mixed,” 23 (20.5%) “airway-dominant,” 15 (13.4%) “emphysema-dominant,” and 45 (40.2%) “severe mixed” cases. “Mild mixed” disease was proportionately more in Global Initiative for Chronic Obstructive Lung Disease (GOLD) Group A, while “severe mixed” disease was proportionately more in GOLD Groups B and D. Kaplan–Meier survival estimates showed increased mortality risk with “severe mixed” disease (log rank test, p=0.03) but not with GOLD groups (p=0.08). Univariate Cox proportionate hazard analysis showed that age, body mass index, long-term oxygen therapy, FEV1, forced volume capacity, COPD Assessment Test score, modified Medical Research Council score, St Georges’ Respiratory Questionnaire score, CT-emphysema index, and “severe mixed” disease (vs “mild mixed” disease) were associated with mortality. Multivariate Cox analysis showed that age, body mass index, and COPD Assessment Test score remain independently associated with mortality. Conclusion “Severe mixed airway-emphysema” disease may predict COPD-associated mortality. Age, body mass index, and COPD Assessment Test score remain as key mortality risk factors in our cohort.
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Affiliation(s)
- Li-Cher Loh
- Department of Medicine, RCSI & UCD Malaysia Campus, Penang, Malaysia
| | - Choo-Khoon Ong
- Department of Medicine, RCSI & UCD Malaysia Campus, Penang, Malaysia
| | - Hyun-Jung Koo
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea,
| | - Sang Min Lee
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea,
| | - Jae-Seung Lee
- Department of Pulmonary and Critical Care Medicine, and Clinical Research Center for Chronic Obstructive Airway Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yeon-Mok Oh
- Department of Pulmonary and Critical Care Medicine, and Clinical Research Center for Chronic Obstructive Airway Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Joon-Beom Seo
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea,
| | - Sang-Do Lee
- Department of Pulmonary and Critical Care Medicine, and Clinical Research Center for Chronic Obstructive Airway Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Fathima M, Saini B, Foster JM, Armour CL. A mixed methods analysis of community pharmacists' perspectives on delivering COPD screening service to guide future implementation. Res Social Adm Pharm 2018; 15:662-672. [PMID: 30131254 DOI: 10.1016/j.sapharm.2018.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 07/12/2018] [Accepted: 08/13/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Studies have shown that COPD screening by community pharmacists is effective, but it is unknown if it can be successfully implemented in Australian pharmacies. OBJECTIVE We aimed to investigate the pharmacist-perceived barriers and facilitators to the implementation of a community pharmacy-based COPD screening service guided by implementation science methodology. METHODS Trained pharmacists participated in a 6 month longitudinal study designed and based on implementation science frameworks. Pharmacists completed feedback questionnaires pre-and post-study and participated in semi-structured telephone interviews about their experience of implementing the service, the training provided, their views on patient recruitment, their interactions with health professionals and patients, and their future recommendations for such a service. Interviews were recorded and transcribed verbatim, analysed thematically, and questionnaire and interview data were triangulated. RESULTS Of 20 pharmacists providing questionnaire data, 15 pharmacists (male 53%; age 39.8 ± 8.6yrs, rural 47%) participated in an interview. Questionnaire data revealed that pharmacists engaged positively with the service and reported that it was very useful for patients and for the profession. In-depth qualitative analysis revealed 6 main implementation themes: 1. Patient recruitment (pharmacists lacked patient recruitment skills), 2. Adaptation and entrepreneurship (protocol adaptation increased patient engagement), 3. Training and resource needs (face-to-face training was preferred for skill-based learning), 4. Lack of GP involvement (sub-optimal GP-pharmacist collaboration), 5. Factors related to the operation or full implementation phase (high professional satisfaction, need for remuneration) and 6. Suggestions for refining the screening service (raise public awareness about the service, provide service remuneration, use electronic methods to improve GP referral uptake). A number of effective adaptations to the service were reported by pharmacists, such as advertising, recruitment practices, patient inclusion criteria and inter-professional communication with GPs which would be beneficial to implementation. CONCLUSION This mixed methods study identified a number of key facilitators to service implementation and challenges such as difficulty with patient recruitment, low public awareness of pharmacy-based clinical services, remuneration, and sub-optimal GP-pharmacist collaboration. Working with stakeholders to identify and resolve challenges and to optimise the fit of the service for individual settings may lead to increasingly successful implementation of pharmacy-based service models.
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Affiliation(s)
- Mariam Fathima
- Woolcock Institute of Medical Research, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.
| | - Bandana Saini
- Woolcock Institute of Medical Research, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; Faculty of Pharmacy, University of Sydney, Sydney, New South Wales, Australia
| | - Juliet M Foster
- Woolcock Institute of Medical Research, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Carol L Armour
- Woolcock Institute of Medical Research, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; Central Sydney Area Health Service, Sydney, New South Wales, Australia
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Bereznicki B, Walters H, Walters J, Peterson G, Bereznicki L. Initial diagnosis and management of chronic obstructive pulmonary disease in Australia: views from the coal face. Intern Med J 2017; 47:807-813. [DOI: 10.1111/imj.13418] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 02/21/2017] [Accepted: 02/28/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Bonnie Bereznicki
- School of Medicine; University of Tasmania; Hobart Tasmania Australia
| | - Haydn Walters
- School of Medicine; University of Tasmania; Hobart Tasmania Australia
| | - Julia Walters
- School of Medicine; University of Tasmania; Hobart Tasmania Australia
| | - Gregory Peterson
- School of Medicine; University of Tasmania; Hobart Tasmania Australia
| | - Luke Bereznicki
- School of Medicine; University of Tasmania; Hobart Tasmania Australia
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Novosad SA, Henkle E, Schafer S, Hedberg K, Ku J, Siegel SAR, Choi D, Slatore CG, Winthrop KL. Mortality after Respiratory Isolation of Nontuberculous Mycobacteria. A Comparison of Patients Who Did and Did Not Meet Disease Criteria. Ann Am Thorac Soc 2017; 14:1112-1119. [PMID: 28387532 PMCID: PMC5566290 DOI: 10.1513/annalsats.201610-800oc] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 04/06/2017] [Indexed: 12/22/2022] Open
Abstract
RATIONALE The mortality of patients with respiratory tract isolates of nontuberculous mycobacteria (NTM) and their risk factors for death are not well described. OBJECTIVES To determine age-adjusted mortality rates for patients with respiratory NTM isolates and their causes of death and to examine whether American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) diagnostic criteria identify those at higher risk of death after NTM isolation. METHODS We linked vital records registries with a previously identified Oregon population-based cohort of patients with NTM respiratory isolation. We excluded patients with Mycobacterium gordonae (n = 33) and those who died (n = 21) at the time of first isolation. We calculated 5-year age-adjusted mortality rates. We used Kaplan-Meier and Cox proportional hazards analysis to examine the association of ATS/IDSA criteria and other risk factors with death. RESULTS Of 368 subjects with respiratory NTM isolates in 2005-2006, 316 were included in the survival analysis. Most (84%) of their cultures isolated Mycobacterium avium complex. 35.1% died in the 5 years following respiratory isolation. Five-year age-adjusted mortality rates were slightly higher for those meeting (28.7/1,000) versus not meeting (23.4/1,000) ATS/IDSA criteria. In multivariate analysis, older age (adjusted hazard ratio [aHR], 1.06; 95% confidence interval [CI], 1.04-1.07) and lung cancer (aHR, 2.77; 95% CI, 1.51-5.07) were associated with an increased risk of death. A trend was noted between meeting ATS/IDSA criteria and subsequent death (aHR, 1.37; 95% CI, 0.95-1.97). Among cases, male sex, older age, and immunosuppressive therapy use were independent risk factors for death. CONCLUSIONS In the State of Oregon, patients with NTM respiratory isolates have high mortality, regardless of whether they meet ATS/IDSA criteria for pulmonary NTM disease. Most patients die as a result of causes other than NTM infection.
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Affiliation(s)
| | | | - Sean Schafer
- Public Health Division, Oregon Health Authority, Portland, Oregon
| | - Katrina Hedberg
- Public Health Division, Oregon Health Authority, Portland, Oregon
| | - Jennifer Ku
- Division of Infectious Diseases, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Dongseok Choi
- School of Public Health, and
- Graduate School of Dentistry, Kyung Hee University, Seoul, Korea; and
| | - Christopher G. Slatore
- Division of Pulmonary & Critical Care Medicine, Department of Medicine
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
| | - Kevin L. Winthrop
- School of Public Health, and
- Division of Infectious Diseases, School of Medicine, Oregon Health & Science University, Portland, Oregon
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Lacasse Y, Bernard S, Sériès F, Nguyen VH, Bourbeau J, Aaron S, Maltais F. Multi-center, randomized, placebo-controlled trial of nocturnal oxygen therapy in chronic obstructive pulmonary disease: a study protocol for the INOX trial. BMC Pulm Med 2017; 17:8. [PMID: 28069009 PMCID: PMC5223547 DOI: 10.1186/s12890-016-0343-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 12/08/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Long-term oxygen therapy (LTOT) is the only component of the management of chronic obstructive pulmonary disease (COPD) that improves survival in patients with severe daytime hypoxemia. LTOT is usually provided by a stationary oxygen concentrator and is recommended to be used for at least 15-18 h a day. Several studies have demonstrated a deterioration in arterial blood gas pressures and oxygen saturation during sleep in patients with COPD, even in those not qualifying for LTOT. The suggestion has been made that the natural progression of COPD to its end stages of chronic pulmonary hypertension, severe hypoxemia, right heart failure, and death is dependent upon the severity of desaturation occurring during sleep. The primary objective of the International Nocturnal Oxygen (INOX) trial is to determine, in patients with COPD not qualifying for LTOT but who present significant nocturnal arterial oxygen desaturation, whether nocturnal oxygen provided for a period of 3 years decreases mortality or delay the prescription of LTOT. METHODS The INOX trial is a 3-year, multi-center, placebo-controlled, randomized trial of nocturnal oxygen therapy added to usual care. Eligible patients are those with a diagnosis of COPD supported by a history of past smoking and obstructive disease who fulfill our definition of significant nocturnal oxygen desaturation (i.e., ≥ 30% of the recording time with transcutaneous arterial oxygen saturation < 90% on either of two consecutive recordings). Patients allocated in the control group receive room air delivered by a concentrator modified to deliver 21% oxygen. The comparison is double blind. The primary outcome is a composite of mortality from all cause or requirement for LTOT. Secondary outcomes include quality of life and utility measures, costs from a societal perspective and compliance with oxygen therapy. The follow-up period is intended to last at least 3 years. DISCUSSION The benefits of LTOT have been demonstrated whereas those of nocturnal oxygen therapy alone have not. The INOX trial will likely determine whether supplemental oxygen during sleep is effective in reducing mortality, delaying the need for LTOT and improving health-related quality of life in patients with COPD who desaturate overnight. TRIAL REGISTRATION Current Controlled Trials ISRCTN50085100 ; ClinicalTrials.gov NCT01044628 (date of registration: January 6, 2010).
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Affiliation(s)
- Yves Lacasse
- Centre de recherche, Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), 2725 Chemin Ste-Foy, Québec, Québec, G1V 4G5, Canada.
| | - Sarah Bernard
- Centre de recherche, Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), 2725 Chemin Ste-Foy, Québec, Québec, G1V 4G5, Canada
| | - Frédéric Sériès
- Centre de recherche, Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), 2725 Chemin Ste-Foy, Québec, Québec, G1V 4G5, Canada
| | - Van Hung Nguyen
- Centre de recherche, Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), 2725 Chemin Ste-Foy, Québec, Québec, G1V 4G5, Canada
| | - Jean Bourbeau
- Institut thoracique de Montréal, 3650 rue St-Urbain, Montréal, Québec, H2X 2P4, Canada
| | - Shawn Aaron
- The Ottawa Hospital - General Campus, Mailbox 211, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - François Maltais
- Centre de recherche, Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), 2725 Chemin Ste-Foy, Québec, Québec, G1V 4G5, Canada
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Altinoz H, Adiguzel N, Salturk C, Gungor G, Mocin O, Berk Takir H, Kargin F, Balci M, Dikensoy O, Karakurt Z. Obesity might be a good prognosis factor for COPD patients using domiciliary noninvasive mechanical ventilation. Int J Chron Obstruct Pulmon Dis 2016; 11:1895-901. [PMID: 27578969 PMCID: PMC4998020 DOI: 10.2147/copd.s108813] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Cachexia is known to be a deteriorating factor for survival of patients with chronic obstructive pulmonary disease (COPD), but data related to obesity are limited. We observed that obese patients with COPD prescribed long-term noninvasive mechanical ventilation (NIMV) had better survival rate compared to nonobese patients. Therefore, we conducted a retrospective observational cohort study. Archives of Thoracic Diseases Training Hospital were sought between 2008 and 2013. All the subjects were prescribed domiciliary NIMV for chronic respiratory failure secondary to COPD. Subjects were grouped according to their body mass index (BMI). The first group consisted of subjects with BMI between 20 and 30 kg/m2, and the second group consisted of subjects with BMI >30 kg/m2. Data obtained at the first month’s visit for the following parameters were recorded: age, sex, comorbid diseases, smoking history, pulmonary function test, 6-minute walk test (6-MWT), and arterial blood gas analysis. Hospital admissions were recorded before and after the domiciliary NIMV usage. Mortality rate was searched from the electronic database. Overall, 118 subjects were enrolled. Thirty-eight subjects had BMI between 20 and 30 kg/m2, while 80 subjects had BMI >30 kg/m2. The mean age was 65.8±9.4 years, and 81% were male. The median follow-up time was 26 months and mortality rates were 32% and 34% for obese and nonobese subjects (P=0.67). Improvement in 6-MWT was protective against mortality. In conclusion, survival of obese patients with COPD using domiciliary NIMV was found to be better than those of nonobese patients, and the improvement in 6-MWT in such patients was found to be related to a better survival.
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Affiliation(s)
- Hilal Altinoz
- Pulmonary Division, Acibadem University School of Medicine
| | - Nalan Adiguzel
- Sureyyapasa Thoracic Diseases and Thoracic Surgery Training Hospital, Istanbul, Turkey
| | - Cuneyt Salturk
- Sureyyapasa Thoracic Diseases and Thoracic Surgery Training Hospital, Istanbul, Turkey
| | - Gokay Gungor
- Sureyyapasa Thoracic Diseases and Thoracic Surgery Training Hospital, Istanbul, Turkey
| | - Ozlem Mocin
- Sureyyapasa Thoracic Diseases and Thoracic Surgery Training Hospital, Istanbul, Turkey
| | - Huriye Berk Takir
- Sureyyapasa Thoracic Diseases and Thoracic Surgery Training Hospital, Istanbul, Turkey
| | - Feyza Kargin
- Sureyyapasa Thoracic Diseases and Thoracic Surgery Training Hospital, Istanbul, Turkey
| | - Merih Balci
- Sureyyapasa Thoracic Diseases and Thoracic Surgery Training Hospital, Istanbul, Turkey
| | - Oner Dikensoy
- Pulmonary Division, Acibadem University School of Medicine
| | - Zuhal Karakurt
- Sureyyapasa Thoracic Diseases and Thoracic Surgery Training Hospital, Istanbul, Turkey
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11
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Martín-Lesende I, Recalde E, Viviane-Wunderling P, Pinar T, Borghesi F, Aguirre T, Recio M, Martínez ME, Asua J. Mortality in a cohort of complex patients with chronic illnesses and multimorbidity: a descriptive longitudinal study. BMC Palliat Care 2016; 15:42. [PMID: 27068572 PMCID: PMC4828889 DOI: 10.1186/s12904-016-0111-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 03/22/2016] [Indexed: 11/10/2022] Open
Abstract
Background Certain advanced chronic conditions (heart failure, chronic lung disease) are associated with high mortality. Nevertheless, most of the time, patients with these conditions are not given the same level of attention or palliative care as those with cancer. The objective of this study was to assess mortality and its association with other variables in a cohort of complex multimorbid patients with heart failure and/or lung disease from two consecutive telemonitoring studies. Methods This multicentre longitudinal study was conducted between 2010 and 2015. We included 83 patients (27 without telemonitoring) with heart failure and/or lung disease with > 1 hospital admission in the previous year and great difficulties leaving home or were housebound. The following variables were indicators of their complex clinical condition: old age (mean: 81 years), comorbidity (Charlson Comorbidity Index score ≥ 2: 86.2 %), both conditions concurrently (54.2 %) and home oxygen therapy (52 %). We assessed mortality (rate, cause and place of death) and its association with: age, sex, telemonitoring, functional status (Barthel score), quality of life (EQ-5D visual analogue scale), number of medications, and all-cause and condition-specific (due to conditions prompting inclusion) admissions during the previous year. Uni- and bivariate analysis and logistic regression were performed, considering p < 0.05 significant. Results A total of 61 patients died within 5 years, representing 31.2 %/year (95 % CI: 23–40.1 %), considering the overall follow-up (sum of individual follow-up days). Of these, 81 % of deaths (95 % CI: 69.1–89–1 %) were due to the condition prompting inclusion, and 83.3 % (95 % CI: 72–90.7 %) died in hospital (median: 8.5 days). Mortality was lower among those under telemonitoring (p = 0.027), and with fewer condition-specific admissions the previous year (p = 0.006); the latter also showed the strongest association in the multivariate analysis (Exp(B) = 6.115). Conclusions Complex patients with multimorbidity had a high mortality rate, generally dying due to the condition for which they had been included, and in hospital (83.3 %). New approaches for managing such patients should be considered, introducing palliative care as required, and using more comprehensive predictors of mortality (functional status and quality of life), together with those related to the illness itself (previous admissions, progression and symptoms).
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Affiliation(s)
- I Martín-Lesende
- Bilbao-Basurto Integrated Health Organisation, Centro de Salud de San Ignacio Health Centre, C/Larrako Torre, 9, 48015, Bilbao, Spain.
| | - E Recalde
- Begoña Health Centre. Basque Health Service (Osakidetza), Bilbao, Spain
| | - P Viviane-Wunderling
- Bilbao-Basurto Integrated Health Organisation, Centro de Salud de San Ignacio Health Centre, C/Larrako Torre, 9, 48015, Bilbao, Spain
| | - T Pinar
- Bilbao-Basurto Integrated Health Organisation, Centro de Salud de San Ignacio Health Centre, C/Larrako Torre, 9, 48015, Bilbao, Spain
| | - F Borghesi
- Bilbao-Basurto Integrated Health Organisation, Centro de Salud de San Ignacio Health Centre, C/Larrako Torre, 9, 48015, Bilbao, Spain
| | - T Aguirre
- Bilbao-Basurto Integrated Health Organisation, Centro de Salud de San Ignacio Health Centre, C/Larrako Torre, 9, 48015, Bilbao, Spain
| | - M Recio
- Bilbao-Basurto Integrated Health Organisation, Centro de Salud de San Ignacio Health Centre, C/Larrako Torre, 9, 48015, Bilbao, Spain
| | - M E Martínez
- Bilbao-Basurto Integrated Health Organisation, Centro de Salud de San Ignacio Health Centre, C/Larrako Torre, 9, 48015, Bilbao, Spain
| | - J Asua
- Basque Office for Health Technology Assessment (OSTEBA), Department of Health, Government of the Basque Country, Vitoria, Spain
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12
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Ou CY, Chen CZ, Lee CH, Lin CC, Chang HY, Hsiue TR. Pulmonary function change in patients with Sauropus androgynus-related obstructive lung disease 15 years later. J Formos Med Assoc 2012; 112:630-4. [PMID: 24120153 DOI: 10.1016/j.jfma.2012.07.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Revised: 07/29/2012] [Accepted: 07/30/2012] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND/PURPOSE Little is understood about the clinical course and prognosis of patients with Sauropus androgynus-related obstructive lung disease. The aim of this study was to investigate their clinical manifestations and pulmonary function change 15 years after the acute episode. METHODS A descriptive, observational study of patients with S androgynus-related obstructive lung disease, diagnosed 15 years ago, was conducted. We evaluated their pulmonary function and the Modified Medical Research Council (MMRC) dyspnea scale. Saint George's Respiratory Questionnaire (SGRQ) was also performed. Age- and forced expiratory volume in one second (FEV1)-matched chronic obstructive pulmonary disease (COPD) patients were used as a reference group for comparison of clinical manifestations. RESULTS Twenty-nine of 49 patients, diagnosed at our hospital 15 years ago, could be contacted. Four patients died and one patient was ventilator-dependent. Sixteen patients were willing to come to our hospital to have pulmonary function and questionnaire evaluation. The FEV1 of these patients declined only 1.6 ± 21.6 mL/year over a 15-year period. Meanwhile, the severity of their dyspnea and their health-related quality of life were better than age- and FEV1-matched COPD patients as shown by the MMRC dyspnea scale (1.4 ± 0.8 vs. 2.0 ± 1.0; p = 0.037) and symptom domain of the SGRQ (32.6 ± 18.4 vs. 43.5 ± 20.3; p = 0.006). CONCLUSION After an acute deterioration, patients with S androgynus-related obstructive lung disease had a stationary pulmonary function over a period of 15 years, and their clinical manifestations were less severe than age- and FEV1-matched COPD patients. A further study with a larger sample size may be needed to confirm these findings.
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Affiliation(s)
- Chih-Ying Ou
- Division of Chest Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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13
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Abstract
PURPOSE OF REVIEW Anorexia is a severe debilitating symptom characterizing the clinical course of several chronic diseases. It negatively impacts on patient outcome by contributing to weight loss, lean body mass catabolism and adipose tissue wasting. Although disease-associated anorexia may stand alone as a clinically relevant symptom, it is now considered as a component of the cachexia syndrome. The present review discusses experimental and clinical data indicating that the pathogenic mechanisms of anorexia may also suggest a neural control of tissue wasting in cachexia. RECENT FINDINGS Consistent data show that selective melanocortin receptor antagonism modulates food intake and reduces wasting in experimental models of chronic disease. Consequently, ghrelin administration, whose prophagic effects are related to melanocortin antagonism, has been tested both in animal studies and human trials, with promising effects, although restoration of lean body mass has been not achieved. More interest is driven by the use of small molecules selectively antagonising hypothalamic melanocortin receptors. SUMMARY The 'brain-muscle axis' coordinated by the hypothalamus seems to mediate the onset of not only anorexia but also tissue wasting in cachexia, by centrally influencing energy homeostasis and the balance between anabolism and catabolism.
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14
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Vaz Fragoso CA, Concato J, McAvay G, Van Ness PH, Rochester CL, Yaggi HK, Gill TM. Chronic obstructive pulmonary disease in older persons: A comparison of two spirometric definitions. Respir Med 2010; 104:1189-96. [PMID: 20199857 DOI: 10.1016/j.rmed.2009.10.030] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Revised: 10/10/2009] [Accepted: 10/20/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Among older persons, we previously endorsed a two-step spirometric definition of chronic obstructive pulmonary disease (COPD) that requires a ratio of forced expiratory volume in 1sec to forced vital capacity (FEV(1)/FVC) below .70, and an FEV(1) below the 5th or 10th standardized residual percentile ("SR-tile strategy"). OBJECTIVE To evaluate the clinical validity of an SR-tile strategy, compared to a current definition of COPD, as published by the Global Initiative for Obstructive Lung Disease (GOLD-COPD), in older persons. METHODS We assessed national data from 2480 persons aged 65-80 years. In separate analyses, we evaluated the association of an SR-tile strategy with mortality and respiratory symptoms, relative to GOLD-COPD. As per convention, GOLD-COPD was defined solely by an FEV(1)/FVC<.70, with severity staged according to FEV(1) cut-points at 80 and 50 percent predicted (%Pred). RESULTS Among 831 participants with GOLD-COPD, the risk of death was elevated only in 179 (21.5%) of those who also had an FEV(1)<5th SR-tile; and the odds of having respiratory symptoms were elevated only in 310 (37.4%) of those who also had an FEV(1)<10th SR-tile. In contrast, GOLD-COPD staged at an FEV(1) 50-79%Pred led to misclassification (overestimation) in terms of 209 (66.4%) and 77 (24.6%) participants, respectively, not having an increased risk of death or likelihood of respiratory symptoms. CONCLUSION Relative to an SR-tile strategy, the majority of older persons with GOLD-COPD had neither an increased risk of death nor an increased likelihood of respiratory symptoms. These results raise concerns about the clinical validity of GOLD guidelines in older persons.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT 06516, USA.
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15
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Vaz Fragoso CA, Concato J, McAvay G, Van Ness PH, Rochester CL, Yaggi HK, Gill TM. The ratio of FEV1 to FVC as a basis for establishing chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2009; 181:446-51. [PMID: 20019341 DOI: 10.1164/rccm.200909-1366oc] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The lambda-mu-sigma (LMS) method is a novel approach that defines the lower limit of normal (LLN) for the ratio of FEV1/FVC as the fifth percentile of the distribution of Z scores. The clinical validity of this threshold as a basis for establishing chronic obstructive pulmonary disease is unknown. OBJECTIVE To evaluate the association between the LMS method of determining the LLN for the FEV1/FVC, set at successively higher thresholds, and clinically meaningful outcomes. METHODS Using data from a nationally representative sample of 3,502 white Americans aged 40-80 years, we stratified the FEV1/FVC according to the LMS-LLN, with thresholds set at the 5th, 10th, 15th, 20th, and 25th percentiles (i.e., LMS-LLN5, LMS-LLN10, etc.). We then evaluated whether these thresholds were associated with an increased risk of death or prevalence of respiratory symptoms. Spirometry was not specifically completed after a bronchodilator. MEASUREMENTS AND MAIN RESULTS Relative to an FEV1/FVC greater than or equal to LMS-LLN25 (reference group), the risk of death and the odds of having respiratory symptoms were elevated only in participants who had an FEV1/FVC less than LMS-LLN(5), with an adjusted hazard ratio of 1.68 (95% confidence interval, 1.34-2.12) and an adjusted odds ratio of 2.46 (95% confidence interval, 2.01-3.02), respectively, representing 13.8% of the cohort. Results were similar for persons aged 40-64 years and those aged 65-80 years. CONCLUSIONS In white persons aged 40-80 years, an FEV1/FVC less than LMS-LLN5 identifies persons with an increased risk of death and prevalence of respiratory symptoms. These results support the use of the LMS-LLN5 threshold for establishing chronic obstructive pulmonary disease.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Yale Claude D. Pepper Older Americans Independence Center, New Haven, Connecticut, USA.
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16
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Vaz Fragoso CA, Concato J, McAvay G, Van Ness PH, Rochester CL, Yaggi HK, Gill TM. Defining chronic obstructive pulmonary disease in older persons. Respir Med 2009; 103:1468-76. [PMID: 19464159 DOI: 10.1016/j.rmed.2009.04.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2008] [Revised: 04/17/2009] [Accepted: 04/23/2009] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To develop a more age-appropriate spirometric definition of chronic obstructive pulmonary disease (COPD) among older persons. METHODS Using data from the Third National Health and Nutrition Examination Survey (NHANES III), we developed a two-part spirometric definition of COPD in older persons, aged 65-80 years, that 1) determines a cut-point for the ratio of forced expiratory volume in 1 s to forced vital capacity (FEV1/FVC) based on mortality risk; and 2) among persons below this critical FEV1/FVC threshold, determines cut-points for the FEV1, expressed as a standardized residual percentile (SR-tile) and based on the prevalence of respiratory symptoms and mortality risk. Measurements included spirometry, health questionnaires, and mortality (National Death Index). RESULTS There were 2480 older participants with a mean age of 71.7 years; 1372 (55.4%) had a smoking history, 1097 (44.2%) had respiratory symptoms and, over the course of 12-years, 868 (35.0%) had died. Among participants with an FEV1/FVC<.70 and FEV1<5th SR-tile, representing 7.7% of the cohort, the risk of death was doubled (adjusted hazard ratio, 2.01; 95% confidence interval [CI], 1.60-2.54). Among participants with an FEV1/FVC<.70 and FEV1<10th SR-tile, representing 13.4% of the cohort, the prevalence of respiratory symptoms was elevated (adjusted odds ratio, 2.44; CI, 1.79-3.33). CONCLUSION In a large, nationally representative sample of community-living older persons, defining COPD based on an FEV1/FVC<.70, with FEV1 cut-points at the 10th and 5th SR-tiles, identifies individuals with an increased prevalence of respiratory symptoms and an increased risk of death, respectively.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Claude D. Pepper Older Americans Independence Center, Yale University, New Haven, CT, USA.
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17
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Conte C, Cascino A, Giuliano S, Fidanza R, Fiandra F, Fanelli FR, Laviano A. The driving brain: the CNS in the pathogenesis and treatment of anorexia-cachexia syndrome. Expert Rev Endocrinol Metab 2009; 4:153-160. [PMID: 30780858 DOI: 10.1586/17446651.4.2.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over the past few years, medical care has dramatically improved knowledge of the pathogenic mechanisms of diseases, leading to more effective therapies as well as improved technologies, yielded to enhance survival for diseases that, just a few decades ago, would have been considered lethal. Unfortunately, not all diseases can be completely defeated. In many circumstances, therapies may delay the progression of the disease, leading to improved survival but bringing new issues to light. Of particular interest are nutritional and metabolic alterations due to both prolonged clinical course of disease and long-term therapies. Anorexia-cachexia syndrome often complicates the course of chronic illnesses. Anorexia (i.e., loss of appetite) and cachexia (i.e., loss of weight due to lean body mass and fat-mass wasting) are both associated with a number of diseases. The aim of this article is to highlight the clinical impact of the anorexia-cachexia syndrome and to review current and future etiologic therapeutic approaches.
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Affiliation(s)
- Caterina Conte
- a Department of Clinical Medicine, Sapienza University of Rome, viale dell'Università 37, 00185 Rome, Italy.
| | - Antonia Cascino
- b Department of Clinical Medicine, Sapienza University of Rome, viale dell'Università 37, 00185 Rome, Italy.
| | - Simone Giuliano
- c Department of Clinical Medicine, Sapienza University of Rome, viale dell'Università 37, 00185 Rome, Italy.
| | - Rina Fidanza
- d Department of Clinical Medicine, Sapienza University of Rome, viale dell'Università 37, 00185 Rome, Italy
| | - Federica Fiandra
- e Department of Clinical Medicine, Sapienza University of Rome, viale dell'Università 37, 00185 Rome, Italy.
| | - Filippo Rossi Fanelli
- f Department of Clinical Medicine, Sapienza University of Rome, viale dell'Università 37, 00185 Rome, Italy.
| | - Alessandro Laviano
- g Department of Clinical Medicine, Sapienza University of Rome, viale dell'Università 37, 00185 Rome, Italy.
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18
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Abstract
Mortality due to chronic obstructive pulmonary disease continues to rise, whereas mortality rates related to cardiovascular disease appear to be slowing, or even declining. This is due at least in part to more widespread use of preventative therapies that have been shown to reduce cardiovascular mortality, raising the question of whether appropriate use of therapies for chronic obstructive pulmonary disease which potentially reduce mortality could have a similar impact. This article discusses approaches used successfully in managing heart disease and considers whether these can be applied to chronic obstructive pulmonary disease and whether a better understanding of the strongest predictors of mortality in chronic obstructive pulmonary disease is needed. It reviews the role of inhaled corticosteroids, both alone and in combination with long-acting beta(2)-agonists, in individuals with chronic obstructive pulmonary disease, including the role of combination therapy with inhaled corticosteroids/long-acting beta(2)-agonists (budesonide/formoterol or salmeterol/fluticasone propionate) in decreasing exacerbations and improving health status, potentially providing survival benefits in chronic obstructive pulmonary disease. This review also discusses the potential impact of treatments indicated for cardiovascular disease on chronic obstructive pulmonary disease and possible links between the two diseases.
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Affiliation(s)
- David Halpin
- Royal Devon & Exeter Hospital Barrack Road Exeter EX2 5DW, UK.
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19
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Theofilogiannakos EK, Anogeianaki A, Tsekoura P, Glouftsios P, Ilonidis G, Hatzitolios A, Anogianakis G. Arrhythmogenesis in patients with stable chronic obstructive pulmonary disease. J Cardiovasc Med (Hagerstown) 2008; 9:89-93. [DOI: 10.2459/jcm.0b013e328028fe73] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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20
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Seamark DA, Seamark CJ, Halpin DMG. Palliative care in chronic obstructive pulmonary disease: a review for clinicians. J R Soc Med 2007; 100:225-33. [PMID: 17470930 PMCID: PMC1861418 DOI: 10.1177/014107680710000512] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a progressive condition characterized by airflow obstruction which ultimately kills many patients. It is common in both men and women and there is a 24-30% 5-year survival rate in the UK for those with severe disease. The annual death rate in the UK from COPD approaches that from lung cancer. Patients' symptoms can be improved by drug therapy, but stopping smoking is also an effective way of improving the outcome in patients at all stages of COPD. Predicting prognosis has been difficult in COPD due to the variable illness trajectory. However, assessment of severity of lung function impairment, frequency of exacerbations and requirement for long term oxygen therapy can help identify patients entering the final 12 months of life. Symptom burden and impact on activities of daily living for patients with COPD are comparable with that of cancer patients, and palliative care approaches are equally necessary, yet few publications exist to guide clinicians in this area. An evidence base exists for the management of dyspnoea with oxygen therapy and opioid drugs. There is less evidence for the effective treatment of depression and anxiety, fatigue and pain, and treatment is based on experience and considered best practice. This review discusses the problems that patients experience and offers practical guidance. The management of patients should be shared between primary and secondary care, with multidisciplinary teams being involved at an early stage. Patients and their families require honest and clear communication about the condition and what to expect in the future. The strict application of advance care planning and directives may not be feasible or appropriate, but there is evidence that attitudes towards resuscitation and artificial ventilation can be explored without distress. The requirement by patients and carers for surveillance and timely support is acknowledged, but how to provide such input is as yet unclear, with little evidence to support the widespread implementation of nurse-led management interventions. The hospice movement has become increasingly involved in the management of life-threatening, non-malignant disease and should be involved in the multidisciplinary care of patients dying from COPD.
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21
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Seamark DA, Seamark CJ, Halpin DMG. Palliative care in chronic obstructive pulmonary disease: a review for clinicians. J R Soc Med 2007. [PMID: 17470930 DOI: 10.1258/jrsm.100.5.225] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a progressive condition characterized by airflow obstruction which ultimately kills many patients. It is common in both men and women and there is a 24-30% 5-year survival rate in the UK for those with severe disease. The annual death rate in the UK from COPD approaches that from lung cancer. Patients' symptoms can be improved by drug therapy, but stopping smoking is also an effective way of improving the outcome in patients at all stages of COPD. Predicting prognosis has been difficult in COPD due to the variable illness trajectory. However, assessment of severity of lung function impairment, frequency of exacerbations and requirement for long term oxygen therapy can help identify patients entering the final 12 months of life. Symptom burden and impact on activities of daily living for patients with COPD are comparable with that of cancer patients, and palliative care approaches are equally necessary, yet few publications exist to guide clinicians in this area. An evidence base exists for the management of dyspnoea with oxygen therapy and opioid drugs. There is less evidence for the effective treatment of depression and anxiety, fatigue and pain, and treatment is based on experience and considered best practice. This review discusses the problems that patients experience and offers practical guidance. The management of patients should be shared between primary and secondary care, with multidisciplinary teams being involved at an early stage. Patients and their families require honest and clear communication about the condition and what to expect in the future. The strict application of advance care planning and directives may not be feasible or appropriate, but there is evidence that attitudes towards resuscitation and artificial ventilation can be explored without distress. The requirement by patients and carers for surveillance and timely support is acknowledged, but how to provide such input is as yet unclear, with little evidence to support the widespread implementation of nurse-led management interventions. The hospice movement has become increasingly involved in the management of life-threatening, non-malignant disease and should be involved in the multidisciplinary care of patients dying from COPD.
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22
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Decramer M, Selroos O. Asthma and COPD: differences and similarities. With special reference to the usefulness of budesonide/formoterol in a single inhaler (Symbicort) in both diseases. Int J Clin Pract 2005; 59:385-98. [PMID: 15853852 DOI: 10.1111/j.1368-5031.2005.00509.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Asthma and chronic obstructive pulmonary disease (COPD) both have a high prevalence worldwide and yet each condition remains underdiagnosed. Despite a number of common features, these inflammatory respiratory syndromes have distinct clinical outcomes. COPD represents a greater economic burden than asthma because it has a less favourable prognosis and is associated with greater morbidity and mortality. Therefore, it is important to distinguish between these two diseases at an early stage, so that appropriate therapy can be prescribed to prevent deterioration. However, effective treatments that may be used in both conditions can minimise the effects of misdiagnosis and maximise the impact of treatment without the associated complexity when both conditions occur together. The current review summarises the differences and similarities of asthma and COPD, in terms of risk factors, pathophysiology, symptoms and diagnosis, to provide greater understanding of the role of budesonide/formoterol in a single inhaler in both diseases.
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Affiliation(s)
- M Decramer
- Respiratory Division, U.Z. Gasthuisberg, Katholieke University, Leuven, Belgium.
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23
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Pang SMC, Tse CY, Chan KS, Chung BPM, Leung AKA, Leung EMF, Ko SKK. An empirical analysis of the decision-making of limiting life-sustaining treatment for patients with advanced chronic obstructive pulmonary disease in Hong Kong, China. J Crit Care 2004; 19:135-44. [PMID: 15484173 DOI: 10.1016/j.jcrc.2004.08.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To understand the prognostic and quality-of-life considerations surrounding life-sustaining treatment decisions for patients with advanced chronic obstructive pulmonary disease (COPD) in Hong Kong China. METHODS A documentary review of 49 COPD patients and 19 patient case studies from the medical departments of 2 hospitals were undertaken to examine the practices of DNI decision-making (do not perform mechanical ventilation and cardiopulmonary resuscitation). Statistical, event, and thematic analyses were conducted to delineate the prognostic and quality-of-life factors that shaped the not for intubation and mechanical ventilation (DNI) decisions. RESULTS Three major treatment-limiting decision-making patterns existed in practice: 1) Patient-initiated and shared decision-making with physician (n = 14); 2) Physician-initiated and shared decision-making with the patient/family members (n = 24); and 3) Physician-initiated DNI decision-making with patient family, but without patient participation due to mental incapacity (n = 11). Prognostic considerations include physiological parameters, performance status, concomitant diseases, therapeutic regimens, and the utilization of medical services. Three major themes were delineated regarding the way in which the patients evaluated their life quality in the context of DNI status. They are prognostic awareness, illness burdens, and existential concerns. DISCUSSION A decision-making framework used by patients/families/physicians to limit life-sustaining treatments in patients with advanced COPD is delineated. Observations regarding how treatment limiting decision-making for patients with advanced chronic illnesses can be improved in Hong Kong are discussed.
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Affiliation(s)
- Samantha M C Pang
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR.
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Borg S, Ericsson A, Wedzicha J, Gulsvik A, Lundbäck B, Donaldson GC, Sullivan SD. A computer simulation model of the natural history and economic impact of chronic obstructive pulmonary disease. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2004; 7:153-67. [PMID: 15164805 DOI: 10.1111/j.1524-4733.2004.72318.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
OBJECTIVE Chronic obstructive pulmonary disease (COPD) is a major health problem with high societal costs. The Global Initiative for Chronic Lung Disease (GOLD) has identified a need for health economics data for COPD. For chronic diseases, such as COPD, where the natural history of disease is lifetime, a modeling approach for economic evaluation may be more realistic than prospective, piggy-backed clinical trials or specific COPD cohort studies. Simulation models can be used to extrapolate clinical data beyond the limited time frame of clinical trials, to analyze subgroups of patients or to explore uncertainty regarding the results by using sensitivity analysis techniques. Our purpose has been to develop a flexible computer simulation model for COPD that will represent disease progression and GOLD recommendations, useful for economic evaluations of new medicines to meet the needs of various payer requirements for reimbursement and resource allocation. METHODS This article describes a two-dimensional Markov model, which uses data from multiple sources about disease progression, exacerbation frequency and duration, mortality, costs, burden of illness, and the relationships between those variables. The model is evaluated using stochastic uncertainty analysis, it allows comparison of treatments affecting different disease mechanisms, and it uses primary data validated against published sources. RESULTS We have evaluated two hypothetical interventions treating different features of the disease (lung function decline and acute exacerbations). These analyses show that reducing lung function decline must be a long-term strategy compared to reducing the number of exacerbations. It was necessary to have a long term like 30 years, with 10,000 patients and 20% increase in price, or 20 years with equal prices to show cost-effectiveness with statistical significance for a treatment that reduces lung function decline. CONCLUSIONS Our study shows the value of modeling as a tool for evaluating different scenarios and for combining several sources of data, to provide estimates that would otherwise be unavailable. Clinical trials of this size and duration would be unrealistic.
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Nishimura K, Izumi T, Tsukino M, Oga T. Dyspnea is a better predictor of 5-year survival than airway obstruction in patients with COPD. Chest 2002; 121:1434-40. [PMID: 12006425 DOI: 10.1378/chest.121.5.1434] [Citation(s) in RCA: 647] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND FEV(1) is regarded as the most significant correlate of survival in COPD and is used as a measure of disease severity in the staging of COPD. Recently, however, the categorization of patients with COPD on the basis of the level of dyspnea has similarly been reported to be useful in the prediction of health-related quality of life and improvement in exercise performance after pulmonary rehabilitation. STUDY OBJECTIVES We compared the effects of the level of dyspnea and disease severity, as evaluated by airway obstruction, on the 5-year survival rate of patients with COPD. DESIGN AND METHODS A total of 227 patients with COPD were enrolled in a 5-year, prospective, multicenter study in the Kansai area of Japan, involving 20 divisions of respiratory medicine from various university and city hospitals. RESULTS After 5 years, 183 patients were available for the follow-up examination (follow-up rate, 81%). The 5-year cumulative survival rate among patients with COPD was 73%. The effect of disease staging, based on the American Thoracic Society (ATS) guideline as evaluated by the percentage of predicted FEV(1), on the 5-year survival rate was not significant (p = 0.08). However, the level of dyspnea was significantly correlated to the 5-year survival rate (p < 0.001). The Cox proportional hazards model revealed that the level of dyspnea had a more significant effect on survival than disease severity based on FEV(1). CONCLUSIONS The categorization of patients with COPD on the basis of the level of dyspnea was more discriminating than staging of disease severity using the ATS guideline with respect to 5-year survival. Dyspnea should be included as one of the variables, in addition to airway obstruction, for evaluating patients with COPD in terms of mortality.
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Kelly MG, Elborn JS. Admissions with chronic obstructive pulmonary disease after publication of national guidelines. Ir J Med Sci 2002; 171:16-9. [PMID: 11993587 DOI: 10.1007/bf03168933] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The British Thoracic Society (BTS) published guidelines on managing acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in 1997. AIM To audit admissions with AECOPD and to see how well these guidelines were adhered to. Methods All patients admitted were identified and 50 selected for audit. RESULTS The mean age was 72 years and 52% were female. Admission C reactive protein (CRP) and white cell count (WCC) were 49 (12.7) mg/l and 10.97 (0.64) x 10(9)/l respectively. Six were acidotic and 16 hypercapnoeic. Median length of stay (LOS) was six days. Twenty-one fulfilled admission criteria. Thirty-seven had > or = 2 Anthonisen criteria. Nine had spirometry performed. Correlations were seen between appropriateness of admission score and pH (r=-0.41, p=0.01) and LOS (r=-0.43, p=0.002) and between Anthonisen criteria score and age (r=0.33, p=0.018). Symptom score correlated with PaO2 (r=-0.38, p=0.02), LOS (r=0.27, p=0.06) and age (r=0.38, p=0.007). LOS correlated with PaCO2 (r=0.33, p=0.04). CONCLUSION Admissions are chiefly comprised of an ill, elderly population. Careful adherence to guidelines could result in fewer admissions.
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Affiliation(s)
- M G Kelly
- Department of Respiratory Medicine, Belfast City Hospital, Belfast, Northern Ireland.
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