Anaemia in chronic obstructive pulmonary disease. Does it really matter?

Chronic Obstructive Pulmonary Disease and Its Effect on Red Blood Cell Indices

Chronic obstructive pulmonary disease (COPD) constitutes a set of heterogeneous symptoms affecting millions of people worldwide. The associated comorbidities developing in COPD involve dysregulation in physiological pathways resulting from systemic inflammation in respiratory airways. In addition to mentioning the pathophysiology, stages, and consequences of COPD, this paper also defines red blood cell (RBC) indices such as hemoglobin, hematocrit, mean corpuscular volume, mean corpuscular hemoglobin concentration, red blood cell distribution width, and RBC count. It explains the role of RBC indices and RBC structural abnormalities with disease severity and exacerbations in COPD patients. Although many factors have been studied as a marker of morbidity and mortality for COPD patients, RBC indices have emerged as revolutionary evidence. Therefore, the effectiveness of evaluating RBC indices in COPD patients and their importance as a negative predictor of survival, mortality, and clinical outcomes have been debated through rigorous literature reviews. Furthermore, the prevalence, mechanisms of development, and prognosis of underlying anemia and polycythemia in COPD have also been evaluated, with anemia most significantly associated with COPD. Therefore, more studies should be conducted to address underlying anemia in COPD patients to lessen the severity and disease burden. Correcting the RBC indices in COPD patients remarkably impacts the quality of life and reduces in-patient admissions, healthcare resource utilization, and costs. Hence, it is noteworthy to understand the significance of considering RBC indices while dealing with COPD patients.

Causal association between iron deficiency anemia and chronic obstructive pulmonary disease: A bidirectional two-sample Mendelian randomization study

BACKGROUND

Observational studies have found an association between iron deficiency anemia (IDA) and chronic obstructive pulmonary disease (COPD) risk. However, whether IDA plays a role in COPD development remains unclear.

OBJECTIVES

This study was performed to explore the causal association between IDA and COPD.

METHODS

We obtained summary statistics for IDA from 6087 cases and 211,115 controls of European ancestry in an open genome-wide association study (GWAS) to select strongly associated single nucleotide polymorphisms that could serve as instrumental variables for IDA (P < 5 × 10-8). Additional summary statistics for COPD were obtained from 6915 COPD cases and 186,723 controls of European ancestry from a publicly available GWAS. A bidirectional Mendelian randomization analysis was performed using inverse variance weighting as the primary method of analysis. The reliability of the results was verified by heterogeneity and sensitivity analysis.

RESULTS

IDA increased the risk of COPD, with an odds ratio (OR) of 1.15 (95% confidence interval (CI: 1.04-1.25, p = 0.002). There was no evidence of a causal effect of COPD on IDA risk, with an OR of 0.99 (95% CI: 0.87-1.13, p = 0.91). The sensitivity analysis showed no evidence of heterogeneity or horizontal pleiotropy.

CONCLUSIONS

We found that IDA increases the risk of COPD. Additionally, there was no evidence that COPD increases the risk of IDA. Therefore, IDA should be considered in future COPD risk studies and reintroduced as a potential therapeutic target. The relationship between COPD and IDA risk requires further study using indirect mechanisms.

The Oxygen Cascade from Atmosphere to Mitochondria as a Tool to Understand the (Mal)adaptation to Hypoxia

Hypoxia is a life-threatening challenge for about 1% of the world population, as well as a contributor to high morbidity and mortality scores in patients affected by various cardiopulmonary, hematological, and circulatory diseases. However, the adaptation to hypoxia represents a failure for a relevant portion of the cases as the pathways of potential adaptation often conflict with well-being and generate diseases that in certain areas of the world still afflict up to one-third of the populations living at altitude. To help understand the mechanisms of adaptation and maladaptation, this review examines the various steps of the oxygen cascade from the atmosphere to the mitochondria distinguishing the patterns related to physiological (i.e., due to altitude) and pathological (i.e., due to a pre-existing disease) hypoxia. The aim is to assess the ability of humans to adapt to hypoxia in a multidisciplinary approach that correlates the function of genes, molecules, and cells with the physiologic and pathological outcomes. We conclude that, in most cases, it is not hypoxia by itself that generates diseases, but rather the attempts to adapt to the hypoxia condition. This underlies the paradigm shift that when adaptation to hypoxia becomes excessive, it translates into maladaptation.

Janus, or the Inevitable Battle Between Too Much and Too Little Oxygen

Significance: Oxygen levels are key regulators of virtually every living mammalian cell, under both physiological and pathological conditions. Starting from embryonic and fetal development, through the growth, onset, and progression of diseases, oxygen is a subtle, although pivotal, mediator of key processes such as differentiation, proliferation, autophagy, necrosis, and apoptosis. Hypoxia-driven modifications of cellular physiology are investigated in depth or for their clinical and translational relevance, especially in the ischemic scenario. Recent Advances: The mild or severe lack of oxygen is, undoubtedly, related to cell death, although abundant evidence points at oscillating oxygen levels, instead of permanent low pO₂, as the most detrimental factor. Different cell types can consume oxygen at different rates and, most interestingly, some cells can shift from low to high consumption according to the metabolic demand. Hence, we can assume that, in the intracellular compartment, oxygen tension varies from low to high levels depending on both supply and consumption. Critical Issues: The positive balance between supply and consumption leads to a pro-oxidative environment, with some cell types facing hypoxia/hyperoxia cycles, whereas some others are under fairly constant oxygen tension. Future Directions: Within this frame, the alterations of oxygen levels (dysoxia) are critical in two paradigmatic organs, the heart and brain, under physiological and pathological conditions and the interactions of oxygen with other physiologically relevant gases, such as nitric oxide, can alternatively contribute to the worsening or protection of ischemic organs. Further, the effects of dysoxia are of pivotal importance for iron metabolism. Antioxid. Redox Signal. 37, 972-989.

Assessment of Inter-relationship between Anemia and COPD In Accordance with Altitude

Background:

Anemia, a common blood disorder has been analysed for the risk for chronic obstructive pulmonary disease (COPD), a predominant respiratory condition. The COPD patients have been found to have anemia due to inflammation, accounting for about 7.5-33%.

Objectives:

To predict the influence of anemia in the COPD occurrence as well as to depict the role of change in altitudes in the occurrence of anemic as well as COPD.

Methodology:

A total of 17 hematological parameters has been analysed in the anemic and COPD patients along with the control samples of low and high altitude regions and the significance of the results has been calculated.

Results:

The hematological parameter comparison between anemia and COPD samples of two different altitudes showed highly significant variations (p<0.001) as well as slighter significant variations (p<0.01, p<0.05 and p<0.1) in most of the parameters as well as the prevalence of anemic condition among the COPD patients was significant.

Conclusion:

The considered hematological parameters shown to have a considerable influence in the occurrence of anemia and COPD as well as in the occurrence of anemia in COPD patients along with the change in altitudes.

Impact of Correcting Nutritional Deficiency Anemias in the Elderly on Hospitalizations, Falls, and Mortalities

Background

The incidence and prevalence of anemia increase with age, particularly in adults older than 65 years, and it is associated with a number of adverse health outcomes (AHO), particularly hospitalizations, falls and mortalities. Given that approximately one-third of these anemias are due to reversible causes, we studied whether the treatment of nutritional deficiency anemia (NDA), namely iron deficiency anemia (IDA), cobalamin deficiency anemia (CDA), and folate deficiency anemia (FDA), improves AHO; and explored whether each NDA had different AHO.

Methods

We reviewed electronic medical records of our internal medicine office patients aged 65 years or older, who had a diagnosis of anemia in a non-acute setting.

Results

Total 600 patients were included. Mean age was 75.2 years. Thirty-one point three percent had NDA (CDA 15.3%, IDA 12.3%, FDA 3.7%); and 68.7% had other anemias whom we categorized as non-nutritional deficiency anemias (NNDA), which included anemia of chronic disease (11.2%), myelodysplastic syndrome (6.2%), renal insufficiency anemia (5.7%) and unexplained anemia (45.6%). Even after adequate treatment, IDA group had significantly more hospitalizations (median, 25th - 75th: 2 (0 - 4) vs. 0 (0 - 1), P < 0.001), falls (median, 25th - 75th: 1 (0 - 3) vs. 0 (0 - 1), P < 0.001) and mortalities (10.8% vs. 3.4%, P = 0.011); CDA group had significantly more hospitalizations (median, 25th - 75th: 1 (0 - 2) vs. 0 (0 - 1), P = 0.007), but no difference in falls (median, 25th - 75th: 0 (0 - 1) vs. 0 (0 - 1), P = 0.171) and mortalities (7.6% vs. 3.4%, P = 0.083); and FDA group had significantly more hospitalizations (median, 25th - 75th: 1 (0 - 2) vs. 0 (0 - 1), P = 0.001), but no difference in falls (median, 25th - 75th: 0 (0 - 1) vs. 0 (0 - 1), P = 0.615) and mortalities (4.5% vs. 3.4%, P = 0.550), compared to the NNDA group. Age, Black race, higher number of comorbidities, presence of malignancy and use of direct oral anticoagulants were associated with increased odds of AHO in patients with NDA.

Conclusions

Compared to the patients with NNDA, patients with IDA had more hospitalizations, falls and mortalities even after adequate treatment; while patients with CDA and FDA had only more hospitalizations. Adequate treatment mitigated falls and mortalities in elderly patients with CDA and FDA.

Iron Replacement and Redox Balance in Non-Anemic and Mildly Anemic Iron Deficiency COPD Patients: Insights from a Clinical Trial

In COPD patients, non-anemic iron deficiency (NAID) is a common systemic manifestation. We hypothesized that in COPD patients with NAID, iron therapy may improve systemic oxidative stress. The FACE (Ferinject assessment in patients with COPD and iron deficiency to improve exercise tolerance) study was a single-blind, unicentric, parallel-group, placebo-controlled clinical trial (trial registry: 2016-001238-89). Sixty-six patients were enrolled (randomization 2:1): iron arm, n = 44 and placebo arm, n = 22, with similar clinical characteristics. Serum levels of 3-nitrotyrosine, MDA-protein adducts, and reactive carbonyls, catalase, superoxide dismutase (SOD), glutathione, Trolox equivalent antioxidant capacity (TEAC), and iron metabolism biomarkers were quantified in both groups. In the iron-treated patients compared to placebo, MDA-protein adducts and 3-nitrotyrosine serum levels significantly declined, while those of GSH increased and iron metabolism parameters significantly improved. Hepcidin was associated with iron status parameters. This randomized clinical trial evidenced that iron replacement elicited a decline in serum oxidative stress markers along with an improvement in GSH levels in patients with stable severe COPD. Hepcidin may be a surrogate biomarker of iron status and metabolism in patients with chronic respiratory diseases. These findings have potential clinical implications in the management of patients with severe COPD.

Comorbidities and mortality risk factors for patients with bronchiectasis

Introduction: Comorbidities in patients with bronchiectasis are common and have a significant impact on clinical outcomes, contributing to lower quality of life, lung function, and exacerbation frequency. At least 13 comorbidities have been associated with a higher risk of mortality in bronchiectasis patients. Nonetheless, the kind of relationship between bronchiectasis and comorbidities is heterogeneous and poorly understood.Areas covered: different biological mechanisms leading to bronchiectasis could have a role in the development of the associated comorbidities. Some comorbidities could have a causal relationship with bronchiectasis, possibly through a variable degree of systemic inflammation, such as in rheumatic disorders and bowel inflammatory diseases. Other comorbidities, such as COPD or asthma, could be associated through airway inflammation and there is an uncertain cause-effect relationship. Finally, shared risk factors could link different comorbidities to bronchiectasis such as in the case of cardiovascular diseases, where the known link between chronic systemic inflammation and pulmonary infection could play a significant role.Expert opinion: Although different tools have been developed to assess the role of comorbidities in bronchiectasis , we believe that the implementation of current strategies to manage them is absolutely necessary and could significantly improve long-term prognosis in patients with bronchiectasis.

Effect of PM10 on pulmonary immune response and fetus development

Despite numerous reports that ambient particulate matter is a key determinant for human health, toxicity data produced based on physicochemical properties of particulate matters is very lack, suggesting lack of scientific evidence for regulation. In this study, we sampled inhalable particulate matters (PM10) in northern Seoul, Korea. PM10 showed atypical- and fiber-type particles with the average size and the surface charge of 1,598.1 ± 128.7 nm and -27.5 ± 2.8, respectively, and various toxic elements were detected in the water extract. On day 90 after the first pulmonary exposure, total cell number dose-dependently increased in the lungs of both sexes of mice. PM10 induced Th1-dominant immune response with pathological changes in both sexes of mice. Meanwhile, composition of total cells and expression of proteins which functions in cell-to-cell communication showed different trends between sexes. Following, male and female mice were mated to identify effects of PM10 to the next generation. PM10 remained in the lung of dams until day 21 after birth, and the levels of IgA and IgE increased in the blood of dams exposed to the maximum dose compared to control. In addition, the interval between births of fetuses, the number of offspring, the neonatal survival rate (day 4 after birth) and the sex ratio seemed to be affected at the maximum dose, and particularly, all offspring from one dam were stillborn. In addition, expression of HIF-1α protein increased in the lung tissue of dams exposed to PM10, and level of hypoxia-related proteins was notably enhanced in PM10-exposed bronchial epithelial cells compared to control. Taken together, we suggest that inhaled PM10 may induce Th1-shifting immune response in the lung, and that it may affect reproduction (fetus development) by causing lung hypoxia. Additionally, we propose that further study is needed to identify particle-size-dependent effects on development of the next generation.

Hepcidin Is Essential for Alveolar Macrophage Function and Is Disrupted by Smoke in a Murine Chronic Obstructive Pulmonary Disease Model

Chronic obstructive pulmonary disease (COPD) is a debilitating lung disease associated with cigarette smoking. Alterations in local lung and systemic iron regulation are associated with disease progression and pathogenesis. Hepcidin, an iron regulatory peptide hormone, is altered in subjects with COPD; however, the molecular role of hepcidin in COPD pathogenesis remains to be determined. In this study, using a murine model of smoke-induced COPD, we demonstrate that lung and circulating hepcidin levels are inhibited by cigarette smoke. We show that cigarette smoke exposure increases erythropoietin and bone marrow-derived erythroferrone and leads to expanded but inefficient erythropoiesis in murine bone marrow and an increase in ferroportin on alveolar macrophages (AMs). AMs from smokers and subjects with COPD display increased expression of ferroportin as well as hepcidin. Notably, murine AMs exposed to smoke fail to increase hepcidin in response to Gram-negative or Gram-positive infection. Loss of hepcidin in vivo results in blunted functional responses of AMs and exaggerated responses to Streptococcus pneumoniae infection.

Pathobiology of frailty in lung disease

Frailty is a clinical state of vulnerability to stressors resulting from cumulative alterations in multiple physiological and molecular systems. Frailty assessment in patients with chronic disease is useful for identifying those who are at increased risk for poor clinical and patient reported outcomes. Due to biobehavioral changes purported to cause both frailty and certain chronic lung diseases, patients with lung disease appear susceptible to frailty and prone to developing it decades earlier than community dwelling healthy populations. Herein, we review the literature and potential pathobiological mechanisms underpinning associations between frailty in lung disease and age, sex, comorbidity and symptom burden, severity of lung disease, inflammatory biomarkers, various clinical parameters, body composition measures, and physical activity levels. We also propose a multipronged program of future research focused on improving the accuracy and precision of frailty measurement in lung disease, identifying blood-based biomarkers and measures of body composition for frailty, determining whether subphenotypes of frailty with distinct pathobiology exist, and developing personalized interventions that target the specific underlying mechanisms causing frailty.

Comorbidities, repeated hospitalizations, and age ≥ 80 years as indicators of anemia development in the older population

Anemia represents a common condition among the elderly; however, its prevalence and causes are not well known. This retrospective analysis was performed on 981 patients aged ≥ 60 in Poland over 2013-2014. The prevalence of anemia was 17.2% and increased with age. The predominant causes of anemia were the following: anemia of chronic disease (33.1%), unexplained anemia (28.4%), deficiency anemia (22.5%, including iron deficiency 13%), and chemo-/radiotherapy-induced anemia (8.9%). In the multivariate logistic regression model, factors increasing the risk of anemia were the following: age ≥ 80 years (OR 2.29; 95%CI 1.19-4.42; P = 0.013), the number of comorbidities (two diseases OR 2.85; 95%CI 1.12-7.30; P = 0.029, three diseases OR 6.28; 95%CI 2.22-17.76; P = 0.001, four diseases OR 4.64; 95%CI 1.27-17.01; P = 0.021), and hospitalizations (OR 1.34; 95%CI 1.13-1.58; P = 0.001). After a 2-year follow-up, the cumulative survival among patients without anemia in relation to the group with anemia was 90.76 vs. 78.08% (P < 0.001). In the multivariate model, anemia (HR 3.33, 95%CI 1.43-7.74, P = 0.005), heart failure (HR 2.94, 95%CI 1.33-6.50, P = 0.008), and cancer (HR 3.31, 95%CI 1.47-7.49, P < 0.004) were all significantly correlated with mortality. In patients ≥ 60 years, the incidence of anemia increases with age, number of comorbidities, and frequency of hospitalizations and has an adverse impact on survival.

The pharmacological treatment of chronic comorbidities in COPD: mind the gap!

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is commonly associated with other chronic diseases, which poses several diagnostic and therapeutic problems. Indeed, important comorbidities frequently remain unrecognized and, then, untreated, whereas respiratory drugs may have non respiratory side effects, and selected non respiratory drugs may variably affect the respiratory function.

OBJECTIVE

to describe: how COPD affects the presentation and contributes to the diagnostic challenges of its most common comorbidities; how coexisting COPD impacts the therapeutic approach to selected comorbidities and viceversa.

METHODS

we distinguish comorbidities of COPD depending upon whether they are complications of COPD or share risk factors, mainly smoke, with it or, finally, aggravate COPD. We describe atypical presentations of and diagnostic clues to comorbidities and suggest screening procedures. Finally, the main therapeutic problems, as resulting from the risk of untoward effects of therapies of COPD and its comorbidity, with special attention to drug-drug interactions and possible overdosages, are described.

RESULTS

selected complications of COPD, such as osteoporosis, sarcopenia and dysphagia, are rarely recognized and treated, likely due to the poor awareness of them. Important comorbidities, such as coronary artery disease, chronic heart failure, obstructive sleep apnoea syndrome and chronic renal failure, also should be systematically searched for because of their commonly variant presentation. Disease-related symptoms should be distinguished from drug effects or drug-drug interaction effects.

CONCLUSIONS

a truly comprehensive view of the complex COPD patient, hopefully capitalizing on multidimensional geriatric assessment, is needed to dissect the many components of health status impairment and to provide the optimal care. Selected screening procedures are highly desirable to identify frequently missed comorbidities. Pharmacosurveillance is an essential part of the approach to COPD and its comorbidities.

Impact of anemia on short-term survival in severe COPD exacerbations: a cohort study

PURPOSE

Anemia is reported to be an independent predictor of hospitalizations and survival in COPD. However, little is known of its impact on short-term survival during severe COPD exacerbations. The primary objective of this study was to determine whether the presence of anemia increases the risk of death in acute respiratory failure due to severe COPD exacerbations.

PATIENTS AND METHODS

Consecutive patients with COPD exacerbation who were admitted to the intensive care unit with the diagnosis of acute respiratory failure and required either invasive or noninvasive ventilation (NIV) were analyzed.

RESULTS

A total of 106 patients (78.3% male; median age 71 years) were included in the study; of them 22 (20.8%) needed invasive ventilation immediately and 84 (79.2%) were treated with NIV. NIV failure was observed in 38 patients. Anemia was present in 50% of patients, and 39 patients (36.8%) died during hospital stay. When compared to nonanemic patients, hospital mortality was significantly higher in the anemic group (20.8% vs 52.8%, respectively; P=0.001). Stepwise multivariate logistic regression analysis showed that presence of anemia and NIV failure were independent predictors of hospital mortality with odds ratios (95% confidence interval) of 3.99 ([1.39-11.40]; P=0.010) and 2.56 ([1.60-4.09]; P<0.001), respectively. Anemia was not associated with long-term survival in this cohort.

CONCLUSION

Anemia may be a risk factor for hospital death in severe COPD exacerbations requiring mechanical ventilatory support.

A cross-sectional study of the prevalence and associations of iron deficiency in a cohort of patients with chronic obstructive pulmonary disease

OBJECTIVES

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality. Iron deficiency, with or without anaemia, is associated with other chronic conditions, such as congestive heart failure, where it predicts a worse outcome. However, the prevalence of iron deficiency in COPD is unknown. This observational study aimed to determine the prevalence of iron deficiency in COPD and associations with differences in clinical phenotype.

SETTING

University hospital outpatient clinic.

PARTICIPANTS

113 adult patients (65% male) with COPD diagnosed according to GOLD criteria (forced expiratory volume in 1 s (FEV1): forced vital capacity (FVC) ratio <0·70 and FEV1 <80% predicted); with age-matched and sex-matched control group consisting of 57 healthy individuals.

MAIN OUTCOME MEASURES

Prevalence of iron deficiency, defined as: any one or more of (1) soluble transferrin receptor >28.1 nmol/L; (2) transferrin saturation <16% and (3) ferritin <12 µg/L. Severity of hypoxaemia, including resting peripheral arterial oxygen saturation (SpO2) and nocturnal oximetry; C reactive protein (CRP); FEV1; self-reported exacerbation rate and Shuttle Walk Test performance.

RESULTS

Iron deficiency was more common in patients with COPD (18%) compared with controls (5%). In the COPD cohort, CRP was higher in patients with iron deficiency (median 10.5 vs 4.0 mg/L, p<0.001), who were also more hypoxaemic than their iron-replete counterparts (median resting SpO2 92% vs 95%, p<0.001), but haemoglobin concentration did not differ. Patients with iron deficiency had more self-reported exacerbations and a trend towards worse exercise tolerance.

CONCLUSIONS

Non-anaemic iron deficiency is common in COPD and appears to be driven by inflammation. Iron deficiency associates with hypoxaemia, an excess of exacerbations and, possibly, worse exercise tolerance, all markers of poor prognosis. Given that it has been shown to be beneficial in other chronic diseases, intravenous iron therapy should be explored as a novel therapeutic option in COPD.

Anemia in Chronic obstructive pulmonary disease: Prevalence, pathogenesis, and potential impact

Chronic obstructive pulmonary disease (COPD) is a common preventable and treatable lifestyle-related disease with high global prevalence. COPD is associated with significant morbidity and mortality worldwide. Comorbidities are important events in the natural history of the disease and have a negative effect on the morbidity and mortality of COPD patients. Cardiac diseases, lung cancer, osteoporosis, and depression are common comorbidities reported for COPD. Recently, anemia has been recognized as a frequent comorbidity in COPD patients. The prevalence of anemia in patients with COPD varies from 7.5% to 33%. Anemia of chronic disease (ACD) is probably the most common type of anemia associated with COPD. ACD is driven by COPD-mediated systemic inflammation. Anemia in COPD is associated with greater healthcare resource utilization, impaired quality of life, decreased survival, and a greater likelihood of hospitalization. We need large prospective studies to discern the association between anemia and COPD.

Pulmonary and hemostatic toxicity of multi-walled carbon nanotubes and zinc oxide nanoparticles after pulmonary exposure in Bmal1 knockout mice

BACKGROUND

Pulmonary exposure to nanoparticles (NPs) may affect, in addition to pulmonary toxicity, the cardiovascular system such as procoagulant effects, vascular dysfunction and progression of atherosclerosis. However, only few studies have investigated hemostatic effects after pulmonary exposure.

METHODS

We used Bmal1 (brain and muscle ARNT-like protein-1) knockout (Bmal1(-/-)) mice which have a disturbed circadian rhythm and procoagulant phenotype, to study the pulmonary and hemostatic toxicity of multi-walled carbon nanotubes (MWCNTs) and zinc oxide (ZnO) NPs after subacute pulmonary exposure. Bmal1(-/-) and wild-type (Bmal1(+/+)) mice were exposed via oropharyngeal aspiration, once a week, during 5 consecutive weeks, to a cumulative dose of 32 or 128 μg MWCNTs or 32 or 64 μg ZnO NPs.

RESULTS

MWCNTs caused a pronounced inflammatory response in the lung with increased cell counts in the broncho-alveolar lavage and increased secretion of interleukin-1β and cytokine-induced neutrophil chemo-attractant (KC), oxidative stress (increased ratio of oxidized versus reduced glutathione and decreased total glutathione) as well as anemic and procoagulant effects as evidenced by a decreased prothrombin time with increased fibrinogen concentrations and coagulation factor (F)VII. In contrast, the ZnO NPs seemed to suppress the inflammatory (decreased neutrophils in Bmal1(-/-) mice) and oxidative response (increased total glutathione in Bmal1(-/-) mice), but were also procoagulant with a significant increase of FVIII. The procoagulant effects, as well as the significant correlations between the pulmonary endpoints (inflammation and oxidative stress) and hemostasis parameters were more pronounced in Bmal1(-/-) mice than in Bmal1(+/+) mice.

CONCLUSIONS

The Bmal1(-/-) mouse is a sensitive animal model to study the procoagulant effects of engineered NPs. The MWCNTs and ZnO NPs showed different pulmonary toxicity but both NPs induced procoagulant effects, suggesting different mechanisms of affecting hemostasis. However, the correlation analysis suggests a causal association between the observed pulmonary and procoagulant effects.

Anaemia in chronic obstructive pulmonary disease: an insight into its prevalence and pathophysiology

Chronic obstructive pulmonary disease (COPD) is a major health problem, with increasing morbidity and mortality. There is a growing literature regarding the extra-pulmonary manifestations of COPD, which can have a significant impact on symptom burden and disease progression. Anaemia is one of the more recently identified co-morbidities, with a prevalence that varies between 4.9% and 38% depending on patient characteristics and the diagnostic criteria used. Systemic inflammation seems to be an important factor for its establishment and repeated bursts of inflammatory mediators during COPD exacerbations could further inhibit erythropoiesis. However, renal impairment, malnutrition, low testosterone levels, growth hormone level abnormalities, oxygen supplementation, theophylline treatment, inhibition of angiotensin-converting enzyme and aging itself are additional factors that could be associated with the development of anaemia. The present review evaluates the published literature on the prevalence and significance of anaemia in COPD. Moreover, it attempts to elucidate the reasons for the high variability reported and investigates the complex pathophysiology underlying the development of anaemia in these patients.

Long acting release-octreotide as "rescue" therapy to control angiodysplasia bleeding: A retrospective study of 98 cases

BACKGROUND

Gastrointestinal angiodysplasias are an important cause of difficult to manage bleeding, especially in older patients.

AIM

To retrospectively evaluate the long-term efficacy of long acting release-octreotide in controlling angiodysplasia bleeding.

METHODS

98 patients with a history of bleeding due to gastrointestinal angiodysplasias lasting over 2 years were retrospectively selected among those treated from January 2000 to December 2008. All patients had received octreotide 0.1mg tid for 28 days and, then from day 14, long acting release-octreotide 20mg monthly, for 6 months.

RESULTS

The mean follow-up was 78 months. In all patients mean haemoglobin levels significantly increased and the number of bleeding episodes, hospitalizations, patients requiring blood transfusions and units of transfused red cells significantly decreased, compared to the two-year observation period before starting therapy. According to outcome patients were classified as: 40 full responders (40.8%), 32 relapsers (32.6%) and 26 poor responders (26.5%). At multivariate analysis age >65 years, male sex, chronic antiplatelet therapy, chronic obstructive pulmonary disease and chronic renal failure were the only covariates independently associated with poor response to therapy.

CONCLUSION

Our study suggests that long acting release-octreotide could be used as rescue therapy to control bleeding due to gastrointestinal angiodysplasias in patients not suitable for endoscopic or surgical treatments.

Meta-analysis of routine blood tests as predictors of mortality in COPD

Objective

The purpose of this study was to examine whether routine blood tests can be useful in predicting mortality in COPD patients.

Methods

Eligible studies were found through a search conducted in the PubMed and Embase databases, the Cochrane Library, and the Web of Knowledge. Twelve studies were included for the meta-analysis of five biochemical markers. Pooled odds ratios (ORs), matching 95% confidence intervals (CIs), and p-values for each of the biochemical markers were calculated using the random effect model.

Results

The following four examined biochemical markers were shown to be associated with mortality in patients suffering from COPD: anemia (OR=2.62, 95% CI: 1.60; 4.29, p=0.01), hypoalbuminemia (OR=2.90, 95% CI: 1.56; 5.40, p=0.0008), elevated NT-proBNP (OR=7.54, 95% CI: 4.04; 14.10, p<0.00001), and elevated cardiac troponin T (OR=3.10, 95% CI: 1.11; 8.25, p=0.03). hs-CRP was not found to be associated with increased mortality.

Conclusion

In this study, we found that anemia, hypoalbuminemia, elevated NT-proBNP, and elevated cardiac troponin T were associated with increased mortality in patients suffering from COPD.

Anemia and iron deficiency in COPD patients: prevalence and the effects of correction of the anemia with erythropoiesis stimulating agents and intravenous iron

BACKGROUND

Little is known about iron deficiency (ID) and anemia in Chronic Obstructive Pulmonary Disease (COPD). The purposes of this study were: (i) To study the prevalence and treatment of anemia and ID in patients hospitalized with an exacerbation of COPD. (ii) to study the hematological responses and degree of dyspnea before and after correction of anemia with subcutaneous Erythropoiesis Stimulating Agents (ESAs) and intravenous (IV) iron therapy, in ambulatory anemic patients with both COPD and chronic kidney disease.

METHODS

(i) We examined the hospital records of all patients with an acute exacerbation of COPD (AECOPD) to assess the investigation, prevalence, and treatment of anemia and ID. (ii) We treated 12 anemic COPD outpatients with the combination of ESAs and IV-iron, given once weekly for 5 weeks. One week later we measured the hematological response and the severity of dyspnea by Visual Analogue Scale (VAS).

RESULTS

(i) Anemia and iron deficiency in hospitalized COPD patients: Of 107 consecutive patients hospitalized with an AECOPD, 47 (43.9%) were found to be anemic on admission. Two (3.3%) of the 60 non-anemic patients and 18 (38.3%) of the 47 anemic patients had serum iron, percent transferrin saturation (%Tsat) and serum ferritin measured. All 18 (100%) anemic patients had ID, yet none had oral or IV iron subscribed before or during hospitalization, or at discharge. (ii) Intervention outpatient study: ID was found in 11 (91.7%) of the 12 anemic ambulatory patients. Hemoglobin (Hb), Hematocrit (Hct) and the VAS scale scores increased significantly with the ESAs and IV-iron treatment. There was a highly significant correlation between the ∆Hb and ∆VAS; rs = 0.71 p = 0.009 and between the ∆Hct and ∆VAS; rs = 0.8 p = 0.0014.

CONCLUSIONS

ID is common in COPD patients but is rarely looked for or treated. Yet correction of the ID in COPD patients with ESAs and IV iron can improve the anemia, the ID, and may improve the dyspnea.

Chronic bronchitis in COPD patients is associated with increased risk of exacerbations: a cross-sectional multicentre study

BACKGROUND AND AIMS

Chronic bronchitis (CB) in chronic obstructive pulmonary disease (COPD) patients is associated with increased mortality, frequent exacerbations and faster disease progression. This study investigates the prevalence of CB in a large population of COPD patients to identify features associated with CB.

METHODS

Cross-sectional multicentre study in patients with Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages 2-4 from Belgium and Luxembourg.

RESULTS

The 974 patients included were on average 67.8 ± 9.6 years old; 72% were male, FEV1 was 52.5 ± 15.8% of predicted. The prevalence of CB was 64% (622/974). In patients with CB, the number of pack-years smoked and the prevalence of chronic respiratory failure, cachexia and skeletal muscle wasting were significantly higher, whereas FEV1 and FEV1 /VC were lower. The prevalence of CB increased with GOLD stage and was higher in patients with emphysema and those exposed to occupational risk factors. The CB group had more exacerbations, a higher percentage of patients with frequent exacerbations (37.3% vs. 14.2% of patients; p < 0.0001), increased COPD-related, non-intensive care unit hospitalisations and all-cause hospitalisation rates. In multiple logistic regression analysis, frequent exacerbation was the most important independent variable associated with CB, followed by current smoking, chronic respiratory failure, COPD duration and age.

CONCLUSIONS

CB prevalence in GOLD stage 2-4 COPD patients is high. CB is related to current tobacco smoking, and prevalence increases with COPD severity and duration, emphysema and age. CB could be the hallmark of a subtype of COPD easy to identify in clinical practice, associated with increased disease severity and increased risk of exacerbation.