COPD assessment test (CAT): simple tool for evaluating quality of life of chemical warfare patients with chronic obstructive pulmonary disease

Systematic review on chronic non-communicable disease in disaster settings

BACKGROUND

Non-communicable diseases (NCDs) constitute the leading cause of mortality globally. Low and middle-income countries (LMICs) not only experience the largest burden of humanitarian emergencies but are also disproportionately affected by NCDs, yet primary focus on the topic is lagging. We conducted a systematic review on the effect of humanitarian disasters on NCDs in LMICs assessing epidemiology, interventions, and treatment.

METHODS

A systematic search in MEDLINE, MEDLINE (PubMed, for in-process and non-indexed citations), Social Science Citation Index, and Global Health (EBSCO) for indexed articles published before December 11, 2017 was conducted, and publications reporting on NCDs and humanitarian emergencies in LMICs were included. We extracted and synthesized results using a thematic analysis approach and present the results by disease type. The study is registered at PROSPERO (CRD42018088769).

RESULTS

Of the 85 included publications, most reported on observational research studies and almost half (48.9%) reported on studies in the Eastern Mediterranean Region (EMRO), with scant studies reporting on the African and Americas regions. NCDs represented a significant burden for populations affected by humanitarian crises in our findings, despite a dearth of data from particular regions and disease categories. The majority of studies included in our review presented epidemiologic evidence for the burden of disease, while few studies addressed clinical management or intervention delivery. Commonly cited barriers to healthcare access in all phases of disaster and major disease diagnoses studied included: low levels of education, financial difficulties, displacement, illiteracy, lack of access to medications, affordability of treatment and monitoring devices, and centralized healthcare infrastructure for NCDs. Screening and prevention for NCDs in disaster-prone settings was supported. Refugee status was independently identified both as a risk factor for diagnosis with an NCD and conferring worse morbidity.

CONCLUSIONS

An increased focus on the effects of, and mitigating factors for, NCDs occurring in disaster-afflicted LMICs is needed. While the majority of studies included in our review presented epidemiologic evidence for the burden of disease, research is needed to address contributing factors, interventions, and means of managing disease during humanitarian emergencies in LMICs.

A Nomogram for Predicting Severe Exacerbations in Stable COPD Patients

Objective

To develop a practicable nomogram aimed at predicting the risk of severe exacerbations in COPD patients at three and five years.

Methods

COPD patients with prospective follow-up data were extracted from Subpopulations and Intermediate Outcome Measures in COPD Study (SPIROMICS) obtained from National Heart, Lung and Blood Institute (NHLBI) Biologic Specimen and Data Repository Information Coordinating Center. We comprehensively considered the demographic characteristics, clinical data and inflammation marker of disease severity. Cox proportional hazard regression was performed to identify the best combination of predictors on the basis of the smallest Akaike Information Criterion. A nomogram was developed and evaluated on discrimination, calibration, and clinical efficacy by the concordance index (C-index), calibration plot and decision curve analysis, respectively. Internal validation of the nomogram was assessed by the calibration plot with 1000 bootstrapped resamples.

Results

Among 1711 COPD patients, 523 (30.6%) suffered from at least one severe exacerbation during follow-up. After stepwise regression analysis, six variables were determined including BMI, severe exacerbations in the prior year, comorbidity index, post-bronchodilator FEV₁% predicted, and white blood cells. Nomogram to estimate patients' likelihood of severe exacerbations at three and five years was established. The C-index of the nomogram was 0.74 (95%CI: 0.71-0.76), outperforming ADO, BODE and DOSE risk score. Besides, the calibration plot of three and five years showed great agreement between nomogram predicted possibility and actual risk. Decision curve analysis indicated that implementation of the nomogram in clinical practice would be beneficial and better than aforementioned risk scores.

Conclusion

Our new nomogram was a useful tool to assess the probability of severe exacerbations at three and five years for COPD patients and could facilitate clinicians in stratifying patients and providing optimal therapies.

Increased levels of inflammatory biomarker CX3CL1 in patients with chronic obstructive pulmonary disease

OBJECTIVE

To investigate the concentration of CX3CL1 in serum of patients with chronic obstructive pulmonary disease (COPD), and to evaluate the associations between the CX3CL1 level and systemic inflammation, small airway obstruction, and COPD assessment test (CAT) scores in COPD patients.

METHODS

Enzyme-linked immunosorbent assay were utilized to detect the CX3CL1 protein in serum separately from 64 patients with COPD and 53 healthy controls.

RESULTS

Compared with healthy non-smokers, healthy smokers and COPD non-smokers, serum CX3CL1 protein levels were significantly elevated in COPD smokers (258.33 ± 56.27 pg/mL versus 177.32 ± 43.21 pg/mL, 185.64 ± 47.03 pg/mL, and 226.55 ± 51.79 pg/mL, P < 0.05). Correlation analysis indicated that serum CX3CL1 in COPD smokers was negatively correlated with FEV₁/FVC (justified r = -0.319, P < 0.001), FEV₁/Pre (justified r = -0.476, P < 0.001), FEV₃/FVC (justified r = -0.354, P < 0.001), MMEF25-75/Pre (justified r = -0.428, P < 0.001), but positively correlated with CRP (justified r = 0.331, P < 0.001) and MMP-12 (justified r = 0.352, P < 0.001). However, our results showed no significant correlation between serum CX3CL1 of COPD smokers and the diffusing capacity of the lung for carbon monoxide (DLCO) (justified r = 0.0397, P = 0.6025), but a positive correlation with COPD assessment test (CAT) scores (justified r = 0.367, P < 0.001). Finally, through multivariate linear analysis, statistical results demonstrated age (β = -0.2694, P = 0.005), FEV₁/Pred (β = -0.2653, P = 0.003), CRP (β = 0.1427, P = 0.0478) and MMP-12 (β = 0.430, P < 0.001) are independent parameters associated with CX3CL1.

CONCLUSION

The results demonstrated that elevated circulating CX3CL1 level is associated with the systemic inflammation, small airway obstruction, and CAT scores in COPD patients, suggesting that CX3CL1 may play crucial roles in the pathogenesis of COPD. Blocking CX3CL1 might prevent the progression of chronic obstructive pulmonary disease.

Severity of chronic obstructive pulmonary disease with 'exacerbator with emphysema phenotype' is associated with potential biomarkers

OBJECTIVE

The present study was designed to investigate the biomarkers levels of fractalkine (FKN), neutrophil elastase (NE) and matrix metalloproteinase-12 (MMP-12) in chronic obstructive pulmonary disease (COPD) with 'exacerbator with emphysema phenotype' and to evaluate the associations between the biomarkers levels and the severity of disease by spirometric measurements.

METHODS

A total of 84 COPD patients and 49 healthy controls were enrolled in our study. ELISA were utilised to detect the FKN, MMP-12 and NE in serum from all subjects.

RESULTS

FKN (p<0.001), NE (p=0.039) and MMP-12 (p<0.001) in serum of COPD patients showed higher levels than that of healthy control subjects. Serum FKN (p<0.001), MMP-12 (p<0.001) and NE (p=0.043) levels were significantly higher in severe and very severe COPD patients than that in mild and moderate COPD patients. Circulating FKN, MMP-12 and NE expression levels were significantly elevated (p<0.001) in COPD smokers compared with COPD non-smokers. The smoke pack years were negatively correlated with FEV₁%pred (r=-0.5036), FEV₁/FVC ratio (r=-0.2847) (FEV, forced expiratory volume; FVC, forced vital capacity). Similarly, we observed a strong positive correlation between the smoke pack years and serum levels of FKN (r=0.4971), MMP-12 (r=0.4315) and NE (r=0.2754). FEV₁%pred was strongly negatively correlated with cytokine levels of FKN (r=-0.4367), MMP-12 (r=-0.3295) and NE (r=-0.2684). Likewise, FEV₁/FVC ratio was negatively correlated with mediators of inflammation levels of FKN (r=-0.3867), MMP-12 (r=-0.2941) and NE (r=-0.2153).

CONCLUSION

Serum FKN, MMP-12 and NE concentrations in COPD patients are directly associated with the severity of COPD with 'exacerbator with emphysema phenotype'. This finding suggests that FKN, MMP-12 and NE might play an important role in the pathophysiology of COPD.

The pulmonary artery-aorta ratio: Is it related to quality of life in chronic obstructive pulmonary disease?

INTRODUCTION

Little is known about the relationship between health status and pulmonary artery diameter in chronic obstructive pulmonary disease (COPD) patients. The aim of this study was to evaluate correlation between pulmonary artery-aorta ratio (P-A ratio) and health status of the individuals, using COPD assessment test (CAT).

MATERIALS AND METHODS

In a cross-sectional study, 112 COPD patients were recruited. The severity of COPD was determined by global initiative for obstructive lung disease (GOLD). After digital chest CT scan, the P-A ratio was measured at the level of bifurcation and compared with CAT score, GOLD stage, exacerbation rate and Modified Medical Research Council (MMRC) score.

RESULTS

The average P-A ratio was 0.89 ± 0.16 and 62.5% of patients had ratio less than one. The P-A ratio correlates significantly with different GOLD stages, CAT score and MMRC score (P < .001, P < .001, P < .001, respectively). Compared patients with low P-A ratio (<1), those with high P-A ratio (≥ 1) showed higher CAT score [11.94 ± 5.94 vs 25.17 ± 5.84] (P < .001). The P-A ratio was significantly higher in frequent (≥2) comparing low (<2) exacerbations [1.07 ± 0.07 vs 0.77 ± 0.06] (P < .001).

CONCLUSION

Significant correlations were found between P-A ratio and GOLD, exacerbation rate and health status, using CAT of patients with COPD. These findings also may suggest the potential role of P-A ratio, in the management of COPD patients.

The Correlation of Serum Brain Natriuretic Peptide and Interleukin-6 with Quality of Life Using the Chronic Obstructive Pulmonary Disease Assessment Test

OBJECTIVE

The aim of this study was to determine the levels of serum pro-brain natriuretic peptide (pro-BNP) and interleukin (IL)-6 in patients with stable chronic obstructive pulmonary disease (COPD) and to correlate these markers with health-related quality of life using the COPD assessment test (CAT).

MATERIALS AND METHODS

Serum pro-BNP and IL-6 levels were measured in 82 patients with stable COPD. Serum pro-BNP and serum IL-6 levels, pulmonary function, and oxygen saturation (SpO2) were measured according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage and CAT score. Also, the associations of both pro-BNP and IL-6 with the clinical parameters of patients were tested.

RESULTS

The serum levels of IL-6 (7.57 [5-11.16] pg/mL) and pro-BNP (120.55 [92.89-144.20] pg/mL) were higher with enhancing disease severity based on the GOLD classification (p = 0.034 and 0.068, respectively). Also, serum levels of pro-BNP (120.55 [89.50-147.90] pg/mL) and IL-6 (6.68 [4.40-11.97] pg/mL) were increased in patients with high CAT scores (p = 0.004 and 0.017, respectively). There was a significant positive correlation between plasma pro-BNP and IL-6 levels (r = 0.332, p = 0.002).

CONCLUSION

The results demonstrated that with increased severity of obstruction based on the GOLD criteria both IL-6 and pro-BNP were elevated. This increase in inflammatory markers was associated with a reduced quality of life and the severity of hypoxia. These findings indicated that lowering IL-6 and pro-BNP could be useful in the management of COPD patients.

COPD Assessment Test for measurement of health status in patients with idiopathic pulmonary fibrosis: A cross-sectional study

BACKGROUND AND OBJECTIVE

The COPD Assessment Test (CAT) has been reported to have potential utility for measuring health status of idiopathic pulmonary fibrosis (IPF). Although the CAT has been developed for the assessment of COPD patients, it has not been fully evaluated exclusively in IPF. This study was designed to evaluate the validity of the CAT in IPF.

METHODS

The clinical data for 106 consecutive subjects with newly diagnosed IPF who completed pulmonary function tests, partial pressure of oxygen in arterial blood (PaO₂ ) at rest, 6-min walk test (6MWT), CAT, St George's Respiratory Questionnaire (SGRQ), modified Medical Research Council (mMRC) dyspnoea grade and Hospital Anxiety and Depression Scale (HADS), were analysed. We assessed the validity of the CAT in comparison with the SGRQ.

RESULTS

The present subjects showed mild to moderate restrictive impairment on spirometry. Mean CAT score and total SGRQ were 12.8 ± 8.0 and 30.8 ± 17.7, respectively. The concurrent validity of the CAT score in comparison with the SGRQ total score was significant (r = 0.72, P < 0.001). Internal consistency (Cronbach's α = 0.869) and repeatability over 3 months (intraclass correlation coefficient = 0.742) of the CAT were also significant. Single regression analysis showed that the CAT had significant construct validity. In multiple regression analysis, mMRC, PaO₂ at rest, minimum SpO₂ during 6MWT and anxiety of HADS were independent predictors for the CAT.

CONCLUSIONS

The CAT is a valid health status measurement in IPF patients. Multiple regression analysis showed that the CAT was significantly correlated with dyspnoea severity, oxygenation impairment and anxiety.

The transient but not resident (TBNR) microbiome: a Yin Yang model for lung immune system

The concept of microbial content of the lung is still controversial. What make this more complicated are controversial results obtaining from different methodologies about lung microbiome and the definition of "lung sterility". Lungs may have very low bacteria but are not completely germ-free. Bacteria are constantly entering from the upper respiratory tract, but are then quickly being cleared. We can find bacterial DNA in the lungs, but it is much harder to ask about living bacteria. Here, we propose that if there is any trafficking of the microorganisms in the lung, it should be a "Transient But Not Resident (TBNR)" model. So, we speculate a "Yin Yang model" for the lung immune system and TBNR. Despite beneficial roles of microbiome on the development of lung immune system, any disruption and alteration in the microbiota composition of upper and lower airways may trigger or lead to several diseases such as asthma, chronic obstructive pulmonary disease and mustard lung disease.

Improving communication between the physician and the COPD patient: an evaluation of the utility of the COPD Assessment Test in primary care

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. It is now considered a systemic inflammatory syndrome and is associated with important comorbidities. In addition to spirometry for evaluating the severity of airflow obstruction, an instrument is required for comprehensive assessment of the disease. The COPD Assessment Test (CAT) is a simple and valid tool for evaluating patient symptoms. The CAT can improve patient–physician communication during routine clinical visits and is useful for assessing functional status and response to treatment. The CAT has a strong correlation with other health status questionnaires, such as the St George’s Respiratory Questionnaire. The main advantages of the CAT are its thorough coverage of the important clinical aspects of disease burden and the shorter time involved in completing it. The aim of this paper is to review the role of the CAT, to compare it with other health-related quality of life questionnaires in the assessment and management of COPD patients, and to emphasize the importance of patient–physician communication in the management of patients with the disease.

Adherence to the Global Initiative for Chronic Obstructive Lung Disease guidelines for management of COPD: a hospital-base study

BACKGROUND AND AIMS

To determine the level of adherence to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, we compared our inpatient management of exacerbations of chronic obstructive pulmonary disease (COPD) to these guidelines.

METHOD

This cross-sectional descriptive study was conducted from January 2011 to April 2012 in a 360-bed teaching hospital in Shiraz, Iran. We recorded the management data for 96 consecutive patients with COPD exacerbation. SPSS 11.5 software (SPSS Inc., Chicago, IL, USA) was used for all statistical analyses.

RESULTS

The mean (standard deviation) age of our patients was 67.3 (14) years, and more than 75% of them were men. Adherence for starting antibiotics was 84.4%. Most of our patients (82.3%) received oxygen therapy, for a level of adherence to GOLD recommendations of 74%. Nearly 95% received a short-acting bronchodilator, and 12.5% received a long-acting bronchodilator. Adherence to the guidelines was 19.8% for oral and 61.4% for inhaled steroids. Adherence to the guidelines was 49% for starting N-acetylcysteine, 77.1% for antitussives and 13.5% for xanthine derivatives (aminophylline and theophylline). The overall adherence to GOLD guidelines was 67.2% at our hospital.

CONCLUSION

The level of adherence to GOLD guidelines for the management of COPD exacerbation was suboptimal at our teaching hospital. Further improvements in adherence to these guidelines are needed.

Avoiding emergency department visits for COPD, pneumonia, and heart failure: when should patients go to the emergency department?

Patients with pneumonia, chronic obstructive pulmonary disease (COPD), and heart failure make frequent visits to the emergency department. Heart failure alone is the reason for more than 1 million emergency department visits annually in the United States. This article describes strategies home care clinicians can use to prevent unnecessary emergency department visits for patients with pneumonia, COPD and heart failure.