Underdiagnosis and Overdiagnosis of Chronic Obstructive Pulmonary Disease

The Effect of a Post-Bronchodilator FEV 1 /FVC < 0.7 on COPD Diagnosis and Treatment: A Regression Discontinuity Design

Background

Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend the diagnosis of chronic obstructive pulmonary disease (COPD) only in patients with a post-bronchodilator forced expiratory volume in 1 second to forced vital capacity ratio (FEV 1 /FVC) less than 0.7. However the impact of this recommendation on clinical practice is unknown.

Research Question

What is the effect of a documented post-bronchodilator FEV 1 /FVC < 0.7 on the diagnosis and treatment of COPD?

Study Design and Methods

We used a national electronic health record database to identify clinical encounters between 2007 to 2022 with patients 18 years of age and older in which a post-bronchodilator FEV 1 /FVC value was documented. An encounter was associated with a COPD diagnosis if a diagnostic code for COPD was assigned, and was associated with COPD treatment if a prescription for a medication commonly used to treat COPD was filled within 90 days. We used a regression discontinuity design to measure the effect of a post-bronchodilator FEV 1 /FVC < 0.7 on COPD diagnosis and treatment.

Results

Among 27 817 clinical encounters, involving 18 991 patients, a post-bronchodilator FEV 1 /FVC < 0.7 was present in 14 876 (53.4%). The presence of a documented post-bronchodilator FEV 1 /FVC < 0.7 had a small effect on the probability of a COPD diagnosis, increasing by 6.0% (95% confidence interval [CI] 1.1% to 10.9%) from 38.0% just above the 0.7 cutoff to 44.0% just below this cutoff. The presence of a documented post-bronchodilator FEV 1 /FVC had no effect on the probability of COPD treatment ( - 2.1%, 95% CI - 7.2% to 3.0%).

Interpretation

The presence of a documented post-bronchodilator FEV 1 /FVC < 0.7 has only a small effect on the probability that a clinician will make a guideline-concordant diagnosis of COPD and has no effect on corresponding treatment decisions.

Gender Differences in the Diagnosis of Chronic Obstructive Pulmonary Disease after Spirometry

Background

Women are more likely than men to report delays in the diagnosis of chronic obstructive pulmonary disease (COPD), though the etiology of these delays is unknown. We sought to test whether delays in COPD diagnosis persist after the performance of spirometry.

Methods

We used the Optum Labs Data Warehouse to identify patients 18 years of age and older without a prior diagnosis of COPD, with a post-bronchodilator forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) ratio of less than 0.7 on spirometry. We used a Cox proportional hazards model to compare the time to diagnosis after spirometry in men and women, adjusting for age, race, ethnicity, tobacco use, and post-bronchodilator FEV1/FVC.

Results

The probability of receiving a COPD diagnosis after the performance of spirometry was lower among women than men (adjusted hazard ratio [aHR] 0.66, 95% confidence interval [CI] 0.50 to 0.88).

Conclusion

In this retrospective cohort study of patients with spirometric evidence of obstruction, the time to diagnosis of COPD was greater among women than men. While previous vignette-based studies have found that gender differences in the diagnosis of COPD resolve with the performance of spirometry, we found that gender differences persist after spirometry has been performed. Clinicians were less likely to diagnose COPD in women even when spirometry supported this diagnosis.

Lung cancer among outpatients with COPD: a 7-year cohort study

Introduction

Lung cancer (LC) is the most common cause of cancer-related deaths worldwide, and its prognosis upon metastasis remains poor. Patients with COPD face a significantly elevated LC risk, up to six times greater than those with normal lung function. We aimed to investigate LC prevalence and stage distribution among COPD outpatients. Furthermore, we aimed to outline the COPD-related variables associated with referral for LC examination.

Methods

We conducted a retrospective analysis encompassing the period from 1 January 2012 to 31 December 2018 on all outpatients with COPD and LC and individuals referred for LC examinations.

Results

Among all COPD outpatients, 2231 patients (18%) were referred for LC examinations and 565 (4.6%) were diagnosed with LC. LC patients with COPD were more likely to be stage I-II, in contrast to the non-COPD LC population (46% versus 26%, p<0.001 for all). Patients referred for LC examinations exhibited higher use of COPD-related medications, reported more severe dyspnoea (69% versus 66% with Medical Research Council dyspnoea score >2) and experienced a greater frequency of exacerbations (30% versus 24% with two or more exacerbations).

Conclusion

Our study revealed a notably high LC incidence among COPD outpatients. LC patients with COPD were diagnosed at earlier stages, and outpatients with more pronounced COPD symptoms were more inclined to undergo LC diagnostics. The overrepresentation of LC cases among COPD outpatients emphasises the importance of tailoring specific screening initiatives for this demographic.

The Accuracy of PUMA Questionnaire in Combination With Peak Expiratory Flow Rate to Identify At-risk, Undiagnosed COPD Patients

INTRODUCTION

The English PUMA questionnaire emerges as an effective COPD case-finding tool. We aimed to use the PUMA questionnaire in combination with peak expiratory flow rate (PEFR) to improve case-finding efficacy in Chinese population.

METHODS

This cross-sectional, observational study included two stages: translating English to Chinese PUMA (C-PUMA) questionnaire with linguistic validation and psychometric evaluation, followed by clinical validation. Eligible participants (with age ≥40 years, respiratory symptoms, smoking history ≥10 pack-years) were enrolled and subjected to three questionnaires (C-PUMA, COPD assessment test [CAT], and generic health survey [SF-12V2]), PEFR measurement, and confirmatory spirometry. The C-PUMA score and PEFR were incorporated into a PUMA-PEFR prediction model applying binary logistic regression coefficients to estimate the probability of COPD (PCOPD).

RESULTS

C-PUMA was finalized through standard forward-backward translation processes and confirmation of good readability, comprehensibility, and reliability. In clinical validation, 240 participants completed the study. 78/240 (32.5%) were diagnosed with COPD. C-PUMA exhibited significant validity (correlated with CAT or physical component scores of SF-12V2, both P<0.05, respectively). PUMA-PEFR model had higher diagnostic accuracy than C-PUMA alone (area under ROC curve, 0.893 vs. 0.749, P<0.05). The best cutoff values of C-PUMA and PUMA-PEFR model (PCOPD) were ≥6 and ≥0.39, accounting for a sensitivity/specificity/numbers needed to screen of 77%/64%/3 and 79%/88%/2, respectively. C-PUMA ≥5 detected more underdiagnosed patients, up to 11.5% (vs. C-PUMA ≥6).

CONCLUSION

C-PUMA is well-validated. The PUMA-PEFR model provides more accurate and cost-effective case-finding efficacy than C-PUMA alone in at-risk, undiagnosed COPD patients. These tools can be useful to detect COPD early.

Early Diagnosis and Treatment of COPD and Asthma - A Randomized, Controlled Trial

BACKGROUND

Many persons with chronic obstructive pulmonary disease (COPD) or asthma have not received a diagnosis, so their respiratory symptoms remain largely untreated.

METHODS

We used a case-finding method to identify adults in the community with respiratory symptoms without diagnosed lung disease. Participants who were found to have undiagnosed COPD or asthma on spirometry were enrolled in a multicenter, randomized, controlled trial to determine whether early diagnosis and treatment reduces health care utilization for respiratory illness and improves health outcomes. Participants were assigned to receive the intervention (evaluation by a pulmonologist and an asthma-COPD educator who were instructed to initiate guideline-based care) or usual care by their primary care practitioner. The primary outcome was the annualized rate of participant-initiated health care utilization for respiratory illness. Secondary outcomes included changes from baseline to 1 year in disease-specific quality of life, as assessed with the St. George Respiratory Questionnaire (SGRQ; scores range from 0 to 100, with lower scores indicating better health status); symptom burden, as assessed with the COPD Assessment Test (CAT; scores range from 0 to 40, with lower scores indicating better health status); and forced expiratory volume in 1 second (FEV1).

RESULTS

Of 38,353 persons interviewed, 595 were found to have undiagnosed COPD or asthma and 508 underwent randomization: 253 were assigned to the intervention group and 255 to the usual-care group. The annualized rate of a primary-outcome event was lower in the intervention group than in the usual-care group (0.53 vs. 1.12 events per person-year; incidence rate ratio, 0.48; 95% confidence interval [CI], 0.36 to 0.63; P<0.001). At 12 months, the SGRQ score was lower than the baseline score by 10.2 points in the intervention group and by 6.8 points in the usual-care group (difference, -3.5 points; 95% CI, -6.0 to -0.9), and the CAT score was lower than the baseline score by 3.8 points and 2.6 points, respectively (difference, -1.3 points; 95% CI, -2.4 to -0.1). The FEV1 increased by 119 ml in the intervention group and by 22 ml in the usual-care group (difference, 94 ml; 95% CI, 50 to 138). The incidence of adverse events was similar in the trial groups.

CONCLUSIONS

In this trial in which a strategy was used to identify adults in the community with undiagnosed asthma or COPD, those who received pulmonologist-directed treatment had less subsequent health care utilization for respiratory illness than those who received usual care. (Funded by Canadian Institutes of Health Research; UCAP ClinicalTrials.gov number, NCT03148210.).

Burden of cardiovascular disease attributed to air pollution: a systematic review

BACKGROUND

Cardiovascular diseases (CVDs) are estimated to be the leading cause of global death. Air pollution is the biggest environmental threat to public health worldwide. It is considered a potentially modifiable environmental risk factor for CVDs because it can be prevented by adopting the right national and international policies. The present study was conducted to synthesize the results of existing studies on the burden of CVDs attributed to air pollution, namely prevalence, hospitalization, disability, mortality, and cost characteristics.

METHODS

A systematic search was performed in the Scopus, PubMed, and Web of Science databases to identify studies, without time limitations, up to June 13, 2023. Exclusion criteria included prenatal exposure, exposure to indoor air pollution, review studies, conferences, books, letters to editors, and animal and laboratory studies. The quality of the articles was evaluated based on the Agency for Healthcare Research and Quality Assessment Form, the Newcastle-Ottawa Scale, and Drummond Criteria using a self-established scale. The articles that achieved categories A and B were included in the study.

RESULTS

Of the 566 studies obtained, based on the inclusion/exclusion criteria, 92 studies were defined as eligible in the present systematic review. The results of these investigations supported that chronic exposure to various concentrations of air pollutants, increased the prevalence, hospitalization, disability, mortality, and costs of CVDs attributed to air pollution, even at relatively low levels. According to the results, the main pollutant investigated closely associated with hypertension was PM2.5. Furthermore, the global DALY related to stroke during 2016-2019 has increased by 1.8 times and hospitalization related to CVDs in 2023 has increased by 8.5 times compared to 2014.

CONCLUSION

Ambient air pollution is an underestimated but significant and modifiable contributor to CVDs burden and public health costs. This should not only be considered an environmental problem but also as an important risk factor for a significant increase in CVD cases and mortality. The findings of the systematic review highlighted the opportunity to apply more preventive measures in the public health sector to reduce the footprint of CVDs in human society.

Home spirometry appears accurate and feasible for monitoring chronic respiratory disease

Spirometry is underutilised and can be difficult to access. This study assessed the accuracy and feasibility of home spirometry compared to gold standard. Findings suggest home spirometry is accurate and feasible across many respiratory disease groups. https://bit.ly/42TLoYd.

Prevalence and disparities in influenza vaccination among patients with COPD: A French nationwide population study

INTRODUCTION

Despite concordant international recommendations, many surveys found disappointing rates of influenza vaccination in at-risk populations, ranging from 23% in overall COPD population to more than 70% in more severe COPD subjects. Therefore, we assessed the proportion of French COPD patients non-vaccinated for influenza and their clinical and socio-demographic factors.

MATERIEL AND METHODS

This was a national retrospective study based on the French health insurance database. We identified "diagnosed COPD", defined as subjects hospitalized at least once in 2017 with a principal or associated diagnosis of COPD, and "suspected COPD" as those who were prescribed at least thrice long-acting bronchodilators (LAB), after exclusion of patients with a principal diagnosis or secondary associated diagnosis of asthma or cystic fibrosis, patients deceased before the influenza season and patients hospitalized in long-term or in palliative care unit. Multivariate logistic regression was used to assess the association between patients' characteristics and the lack of influenza vaccination.

RESULTS

From the national database, 1 474 396 subjects were identified as "suspected COPD" of whom 528 114 were excluded because of previous diagnosis of asthma or cystic fibrosis, and 350 566 as "diagnosed COPD". Among the 1 296 848 patients included, 646 687 patients (53.3%) were vaccinated against influenza. Non-vaccinated subjects were significantly younger (62.1 vs 71.6 years old), more often women (47.9% vs 43.1%) and had fewer comorbidities assessed by Charlson's index (3.0 ± 2.2 vs 4.3 ± 2.1). Lack of vaccination was also associated with a lower LAB usage. Also, non-vaccinated subjects neither had severe exacerbation during the study period. Besides there was a significant heterogeneity in vaccination rate by geographic region, from 47% to 57%. In multivariate analysis, variables independently associated with the lack of influenza vaccination were female gender, younger age, fewer comorbidities and lower socio-economic level.

CONCLUSIONS

This study using the French exhaustive health insurance database shows that influenza vaccination among COPD patients remains dramatically low and must become a high-priority public-health strategy.

[New clinical guidelines for COPD - a paradigm shift: A review]

Chronic obstructive pulmonary disease is now one of the most common noncommunicable diseases and the main causes of morbidity, disability and mortality in the world. In recent years, new approaches to epidemiology, diagnosis, classification (categorization), evaluation of phenotypes, as well as characterization and assessment of the severity of сhronic obstructive pulmonary disease exacerbations have emerged. Modern approaches to starting and subsequent drug therapy have changed significantly. This is largely due to the results of recently conducted major clinical trials, demonstrated high efficacy of triple fixed combinations, including inhaled glucocorticosteroids, long-acting beta-agonists and long-acting anticholinergic drugs. The use of non-medication methods (smoking cessation, physical activity and respiratory rehabilitation) and modern approaches to the treatment of respiratory failure and antibiotic therapy remain important. In terms of their significance, all these updates have a significant impact on real clinical practice and can be considered as a novel paradigm of the approaches to the diagnosis and management of this disease.

Proposing the potential of utilizing the CAT score for early detection of COPD in asymptomatic patients, shifting towards a patient-centered approach: A review

Chronic obstructive pulmonary disease (COPD) constitutes a significant public health challenge, with delayed diagnosis and underdiagnosis being pervasive issues. The United States Preventive Service Task Force recommends restricting COPD screening to symptomatic smokers, a focus that has exhibited limitations, leading to delayed diagnoses, and imposing a substantial burden on patients, their families, and the healthcare system. This paper explores an alternative approach, highlighting the potential utility of the COPD assessment test (CAT) score as a prescreening tool. A CAT score of 10 or higher could serve as an appropriate threshold for further diagnostic procedures, given its robust correlation with pulmonary function test parameters and is valuable capacity to quantify patients' symptoms. The utilization of CAT as a prescreening tool in primary care signifies a transition towards a more patient-centered and comprehensive approach to COPD diagnosis and care.

Using Machine Learning with Impulse Oscillometry Data to Develop a Predictive Model for Chronic Obstructive Pulmonary Disease and Asthma

We aimed to develop and validate a machine learning model using impulse oscillometry system (IOS) profiles for accurately classifying patients into three assessment-based categories: no airflow obstruction, asthma, and chronic obstructive pulmonary disease (COPD). Our research questions were as follows: (1) Can machine learning methods accurately classify obstructive disease states based solely on multidimensional IOS data? (2) Which IOS parameters and modeling algorithms provide the best discrimination? We used data for 480 patients (240 with COPD and 240 with asthma) and 84 healthy individuals for training. Physiological and IOS parameters were combined into six feature combinations. The classification algorithms tested were logistic regression, random forest, neural network, k-nearest neighbor, and support vector machine. The optimal feature combination for identifying individuals without pulmonary obstruction, with asthma, or with COPD included 15 IOS and physiological features. The neural network classifier achieved the highest accuracy (0.786). For discriminating between healthy and unhealthy individuals, two combinations of twenty-three features performed best in the neural network algorithm (accuracy of 0.929). When distinguishing COPD from asthma, the best combination included 15 features and the neural network algorithm achieved an accuracy of 0.854. This study provides compelling technical evidence and clinical justifications for advancing IOS data-driven models to aid in COPD and asthma management.

Olfactory decline develops in parallel with frailty in older US adults with obstructive lung diseases

BACKGROUND

Frailty is prevalent among older adults with asthma or chronic obstructive pulmonary disease (obstructive lung diseases [OLDs]). Frailty and OLD's co-occurrence is associated with increased hospitalization/mortality. Chemosensory dysfunction is closely connected to both OLD and frailty. We evaluated the utility of olfactory decline as a biomarker of frailty in the setting of OLD.

METHODS

We performed a prospective, longitudinal, nationally representative study of community-dwelling older US adults in the National Social Life, Health and Aging Project, an omnibus in-home survey. Respondents reported a physician's diagnosis of OLD. Decline in odor identification and sensitivity over 5 years and frailty (adapted fried frailty phenotype criteria) were measured using standard tools. Multivariate logistic regressions evaluated the association between OLD status, olfactory decline, and frailty.

RESULTS

We compared individuals with OLD (n = 98; mean age 71.2 years, 59.2% women) and those without OLD (n = 1036; mean age 69.5 years, 58.9% women). Olfactory identification decline was associated with developing frailty over the 5-year follow-up period in individuals with OLD (odds ratio [OR] = 9.1, 95% confidence interval [CI] = 2.1-38.6, p = 0.003). Olfactory decline predicted incidence of frailty in individuals with OLD (identification: OR = 4.8, 95% CI = 1.3-17.5, P = 0.018; sensitivity: OR = 6.1, 95%CI = 1.2-31.0, p = 0.030) but not in those without OLD adjusting for demographics, heavy alcohol use, current smoking, and comorbidity. Results were robust to different thresholds for olfactory decline and frailty development.

CONCLUSIONS

Older adults with OLD who experience olfactory decline face higher odds of developing frailty. Use of olfactory decline as a biomarker to identify frailty could allow earlier intervention and decrease adverse outcomes for high-risk older adults with OLD.

Screening and staging of chronic obstructive pulmonary disease with deep learning based on chest X-ray images and clinical parameters

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is underdiagnosed with the current gold standard measure pulmonary function test (PFT). A more sensitive and simple option for early detection and severity evaluation of COPD could benefit practitioners and patients.

METHODS

In this multicenter retrospective study, frontal chest X-ray (CXR) images and related clinical information of 1055 participants were collected and processed. Different deep learning algorithms and transfer learning models were trained to classify COPD based on clinical data and CXR images from 666 subjects, and validated in internal test set based on 284 participants. External test including 105 participants was also performed to verify the generalization ability of the learning algorithms in diagnosing COPD. Meanwhile, the model was further used to evaluate disease severity of COPD by predicting different grads.

RESULTS

The Ensemble model showed an AUC of 0.969 in distinguishing COPD by simultaneously extracting fusion features of clinical parameters and CXR images in internal test, better than models that used clinical parameters (AUC = 0.963) or images (AUC = 0.946) only. For the external test set, the AUC slightly declined to 0.934 in predicting COPD based on clinical parameters and CXR images. When applying the Ensemble model to determine disease severity of COPD, the AUC reached 0.894 for three-classification and 0.852 for five-classification respectively.

CONCLUSION

The present study used DL algorithms to screen COPD and predict disease severity based on CXR imaging and clinical parameters. The models showed good performance and the approach might be an effective case-finding tool with low radiation dose for COPD diagnosis and staging.

Capturing COPD heterogeneity: anomaly detection and parametric response mapping comparison for phenotyping on chest computed tomography

Background

Chronic obstructive pulmonary disease (COPD) poses a substantial global health burden, demanding advanced diagnostic tools for early detection and accurate phenotyping. In this line, this study seeks to enhance COPD characterization on chest computed tomography (CT) by comparing the spatial and quantitative relationships between traditional parametric response mapping (PRM) and a novel self-supervised anomaly detection approach, and to unveil potential additional insights into the dynamic transitional stages of COPD.

Methods

Non-contrast inspiratory and expiratory CT of 1,310 never-smoker and GOLD 0 individuals and COPD patients (GOLD 1-4) from the COPDGene dataset were retrospectively evaluated. A novel self-supervised anomaly detection approach was applied to quantify lung abnormalities associated with COPD, as regional deviations. These regional anomaly scores were qualitatively and quantitatively compared, per GOLD class, to PRM volumes (emphysema: PRMEmph, functional small-airway disease: PRMfSAD) and to a Principal Component Analysis (PCA) and Clustering, applied on the self-supervised latent space. Its relationships to pulmonary function tests (PFTs) were also evaluated.

Results

Initial t-Distributed Stochastic Neighbor Embedding (t-SNE) visualization of the self-supervised latent space highlighted distinct spatial patterns, revealing clear separations between regions with and without emphysema and air trapping. Four stable clusters were identified among this latent space by the PCA and Cluster Analysis. As the GOLD stage increased, PRMEmph, PRMfSAD, anomaly score, and Cluster 3 volumes exhibited escalating trends, contrasting with a decline in Cluster 2. The patient-wise anomaly scores significantly differed across GOLD stages (p < 0.01), except for never-smokers and GOLD 0 patients. In contrast, PRMEmph, PRMfSAD, and cluster classes showed fewer significant differences. Pearson correlation coefficients revealed moderate anomaly score correlations to PFTs (0.41-0.68), except for the functional residual capacity and smoking duration. The anomaly score was correlated with PRMEmph (r = 0.66, p < 0.01) and PRMfSAD (r = 0.61, p < 0.01). Anomaly scores significantly improved fitting of PRM-adjusted multivariate models for predicting clinical parameters (p < 0.001). Bland-Altman plots revealed that volume agreement between PRM-derived volumes and clusters was not constant across the range of measurements.

Conclusion

Our study highlights the synergistic utility of the anomaly detection approach and traditional PRM in capturing the nuanced heterogeneity of COPD. The observed disparities in spatial patterns, cluster dynamics, and correlations with PFTs underscore the distinct - yet complementary - strengths of these methods. Integrating anomaly detection and PRM offers a promising avenue for understanding of COPD pathophysiology, potentially informing more tailored diagnostic and intervention approaches to improve patient outcomes.

The Benefits and Harms of Lung Cancer Screening in Individuals With Comorbidities

Introduction

Individuals with a history of smoking and a high risk of lung cancer often have a high prevalence of smoking-related comorbidities. The presence of these comorbidities might alter the benefit-to-harm ratio of lung cancer screening by influencing the risk of complications, quality of life, and competing risks of death. Nevertheless, individuals with chronic diseases are underrepresented in screening clinical trials. In this study, we use microsimulation modeling to determine the impact of chronic diseases on lung cancer benefits and harms.

Methods

We extended a validated lung cancer screening microsimulation model that comprehensively recapitulates an individual's lung cancer development, progression, detection, follow-up, treatment, and survival. We parameterized the model to reflect the impact of chronic diseases on complications from invasive testing, quality of life, and mortality in individuals in five-year age categories between the ages of 50 and 80 years. Outcomes included life-years (LY) gained per 100,000 in patients with chronic obstructive pulmonary disease, diabetes mellitus, heart disease, and history of stroke compared with screening-eligible individuals without comorbidities.

Results

Among individuals between the ages of 50 and 54 years, we found that the presence of a comorbidity altered the LY gained from screening per 100,000 individuals depending on the comorbidity: 4296 LY with no comorbidities; 3462 LY, 3260 LY, 3031 LY, and 3257 LY with chronic obstructive pulmonary disease, heart disease, diabetes mellitus, and stroke, respectively. We observed greater reductions in LY gained in individuals with two comorbidities; we observed similar patterns for individuals between the ages of 55 and 59 years, 60 and 64 years, 65 and 69 years, 70 and 74 years, and 75 and 80 years.

Conclusions

Comorbidities reduce LY gained from screening per 100,000 compared with no comorbidities, and our results can be used by clinicians when discussing the benefits and harms of screening in their patients with comorbidities.

Real-world treatment trajectories of adults with newly diagnosed asthma or COPD

BACKGROUND

There is a lack of knowledge on how patients with asthma or chronic obstructive pulmonary disease (COPD) are globally treated in the real world, especially with regard to the initial pharmacological treatment of newly diagnosed patients and the different treatment trajectories. This knowledge is important to monitor and improve clinical practice.

METHODS

This retrospective cohort study aims to characterise treatments using data from four claims (drug dispensing) and four electronic health record (EHR; drug prescriptions) databases across six countries and three continents, encompassing 1.3 million patients with asthma or COPD. We analysed treatment trajectories at drug class level from first diagnosis and visualised these in sunburst plots.

RESULTS

In four countries (USA, UK, Spain and the Netherlands), most adults with asthma initiate treatment with short-acting ß2 agonists monotherapy (20.8%-47.4% of first-line treatments). For COPD, the most frequent first-line treatment varies by country. The largest percentages of untreated patients (for asthma and COPD) were found in claims databases (14.5%-33.2% for asthma and 27.0%-52.2% for COPD) from the USA as compared with EHR databases (6.9%-15.2% for asthma and 4.4%-17.5% for COPD) from European countries. The treatment trajectories showed step-up as well as step-down in treatments.

CONCLUSION

Real-world data from claims and EHRs indicate that first-line treatments of asthma and COPD vary widely across countries. We found evidence of a stepwise approach in the pharmacological treatment of asthma and COPD, suggesting that treatments may be tailored to patients' needs.

Exploring the novel duo of Reticulocalbin, and Sideroflexin as future biomarker candidates for Exacerbated Chronic Obstructive Pulmonary Disease

BACKGROUND

COPD is a complex respiratory disorder with high morbidity and mortality rates. Even with the current conventional diagnostic methods, including circulating inflammatory biomarkers, underdiagnosis rates in COPD remain as high as 70%. Our study was a comparative cross-sectional study that aimed to address the diagnostic challenges by identifying future biomarker candidates in COPD variants.

METHODS

This study used a label-free plasma proteomics approach that combined mass spectrometric data with bioinformatics to shed light on the functional roles of differentially expressed proteins in the COPD lung microenvironment. The predictive capacity of the screened proteins was assessed using Receiver Operating Characteristic (ROC) curves, with Western blot analysis validating protein expression patterns in an independent cohort.

RESULTS

Our study identified three DEPs-reticulocalbin-1, sideroflexin-4, and liprinα-3 that consistently exhibited altered expression in COPD exacerbation. ROC analysis indicated strong predictive potential, with AUC values of 0.908, 0.715, and 0.856 for RCN1, SFXN4, and LIPα-3, respectively. Validation through Western blot analysis confirmed their expression patterns in an independent validation cohort.

CONCLUSIONS

Our study discovered a novel duo of proteins reticulocalbin-1, and sideroflexin-4 that showed potential as valuable future biomarkers for the diagnosis and clinical management of COPD exacerbations.

COPD in Never-Smokers: BOLD Australia Study

Purpose

Tobacco smoking is the major risk factor for COPD, and it is common for other risk factors in never-smokers to be overlooked. We examined the prevalence of COPD among never-smokers in Australia and identified associated risk factors.

Methods

We used data from the Australia Burden of Obstructive Lung Disease (BOLD) study, a cross-section of people aged ≥40 years from six sites. Participants completed interviews and post-bronchodilator spirometry. COPD was primarily defined as an FEV1/FVC ratio <0.70 and secondarily as the ratio less than the lower limit of normal (LLN).

Results

The prevalence of COPD in the 1656 never-smokers who completed the study was 10.5% (95% CI: 9.1-12.1%) [ratio

Conclusion

COPD was prevalent in this population of never-smokers aged 40 years and over. This finding highlights the significance of risk factors other than smoking in the development of COPD.

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Key Words

• BOLD
• LLN
• burden of obstructive lung disease
• lower limit of normal
• non-smokers
• prevalence
• spirometry

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MESH Headings

• Female
• Male
• Humans
• Adult
• Middle Aged
• Child
• Smokers
• Pulmonary Disease, Chronic Obstructive/diagnosis
• Pulmonary Disease, Chronic Obstructive/epidemiology
• Asthma
• Odds Ratio
• Australia/epidemiology

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Grants

• National Health and Medical Research Council (NHMRC) of Australia
• Thoracic Society of Australia and New Zealand
• Robert Pierce Grant-in-Aid for Indigenous Lung Health
• Air Liquide, AstraZeneca; GlaxoSmithKline; and Boehringer Ingelheim

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Affiliation(s)

Marsha A Ivey School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia School of Medicine, Faculty of Medical Sciences, The University of the West Indies, St Augustine, Trinidad and Tobago
Sheree M Smith School of Nursing and Midwifery, Campbelltown Campus, Western Sydney University, Penrith, NSW, 2751, Australia Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
Geza Benke School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia
Brett G Toelle Respiratory and Environmental Epidemiology Group, Woolcock Institute of Medical Research, Sydney, NSW, 2037, Australia Sydney Local Health District, Sydney, NSW, 2050, Australia
Michael L Hunter School of Population and Global Health, University of Western Australia, Perth, WA, 6009, Australia
Alan L James Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital and Medical School, University of Western Australia, Perth, WA, 6009, Australia
Graeme P Maguire Curtin Medical School, Curtin University, Perth, WA, 6102, Australia
Richard Wood-Baker School of Medicine, University of Tasmania, Hobart, TAS, 7000, Australia
David P Johns Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
Guy B Marks Respiratory and Environmental Epidemiology Group, Woolcock Institute of Medical Research, Sydney, NSW, 2037, Australia School of Clinical Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
Michael J Abramson School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia

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Cardiovascular diseases burden attributable to ambient PM2.5 pollution from 1990 to 2019: A systematic analysis for the global burden of disease study 2019

BACKGROUND

Ambient PM2.5 pollution (APMP2.5) was the leading environmental risk factor for cardiovascular diseases (CVDs) worldwide. An up-to-date comprehensive study is needed to provide global epidemiological patterns.

METHODS

Detailed data on CVDs burden attributable to APMP2.5 were obtained from the Global Burden of Disease Study (GBD) 2019. We calculated the estimated annual percentage change (EAPC) to assess temporal trends in age-standardized rates of deaths and disability-adjusted life years (DALYs) over 30 years.

RESULTS

Globally, CVDs attributable to APMP2.5 resulted in 2.48 million deaths and 60.91 million DALYs, with an increase of 122%, respectively from 1990 to 2019. In general, men suffered markedly higher burden than women, but the gap will likely turn narrow. As for age distribution, CVDs deaths and DALYs attributable to APMP2.5 mainly occurred in the elder group (>70 years). Low- and middle-income regions endured the higher CVDs burden due to the higher exposure to APMP2.5, and the gap may potentially expand further compared with high-income regions. For regions, the highest age-standardized rates of APMP2.5-related CVDs deaths and DALYs were observed mainly in Central Asia, while the lowest was observed in Australasia. At the national level, countries with the largest ASDR decline were clustered in western Europe, while Equatorial Guinea, Timor-Leste and Bhutan exhibited relatively rapid increases over this period.

CONCLUSIONS

The global CVDs burden attributable to APMP2.5 has contributed to the heterogeneity of spatial and temporal distribution. APMP2.5-related CVDs deaths have largely shifted from higher SDI regions to those with a lower SDI. Globally, APMP2.5-attributable CVDs pose a significant threat to public health and diseases burden has increased over time, particularly in male, old-aged populations. The governments and health systems should take measures to reduce air pollution to impede this rising trend.

Impact of chronic obstructive pulmonary disease in patients with atrial fibrillation: an analysis from the GLORIA-AF registry

AIMS

Chronic obstructive pulmonary disease (COPD) may influence management and prognosis of atrial fibrillation (AF), but this relationship has been scarcely explored in contemporary global cohorts. We aimed to investigate the association between AF and COPD, in relation to treatment patterns and major outcomes.

METHODS AND RESULTS

From the prospective, global GLORIA-AF registry, we analysed factors associated with COPD diagnosis, as well as treatment patterns and risk of major outcomes in relation to COPD. The primary outcome was the composite of all-cause death and major adverse cardiovascular events (MACEs). A total of 36 263 patients (mean age 70.1 ± 10.5 years, 45.2% females) were included; 2,261 (6.2%) had COPD. The prevalence of COPD was lower in Asia and higher in North America. Age, female sex, smoking, body mass index, and cardiovascular comorbidities were associated with the presence of COPD. Chronic obstructive pulmonary disease was associated with higher use of oral anticoagulant (OAC) [adjusted odds ratio (aOR) and 95% confidence interval (CI): 1.29 (1.13-1.47)] and higher OAC discontinuation [adjusted hazard ratio (aHR) and 95% CI: 1.12 (1.01-1.25)]. Chronic obstructive pulmonary disease was associated with less use of beta-blocker [aOR (95% CI): 0.79 (0.72-0.87)], amiodarone and propafenone, and higher use of digoxin and verapamil/diltiazem. Patients with COPD had a higher hazard of primary composite outcome [aHR (95% CI): 1.78 (1.58-2.00)]; no interaction was observed regarding beta-blocker use. Chronic obstructive pulmonary disease was also associated with all-cause death [aHR (95% CI): 2.01 (1.77-2.28)], MACEs [aHR (95% CI): 1.41 (1.18-1.68)], and major bleeding [aHR (95% CI): 1.48 (1.16-1.88)].

CONCLUSION

In AF patients, COPD was associated with differences in OAC treatment and use of other drugs; Patients with AF and COPD had worse outcomes, including higher mortality, MACE, and major bleeding.

Validity of the Espiro Mobile Application in the Interpretation of Spirometric Patterns: An App Accuracy Study

Spirometry is a pulmonary function test where correct interpretation of the results is crucial for accurate diagnosis of disease. There are online tools to assist in the interpretation of spirometry results; however, as yet none are validated. We evaluated the interpretation accuracy of the Espiro app using pulmonologist interpretations as the gold standard. This is an observational descriptive study in which 118 spirometry results were interpreted by the Espiro app, two pulmonologists, two primary care physicians, and two residents of a primary care training program. We determined the interpretation accuracy of the Espiro app and the concordance of the pattern and severity interpretation between the Espiro app and each of the observers using Cohen's kappa coefficient (k). We obtained a sensitivity and specificity for the Espiro app of 97.5% (95% confidence interval (CI): 86.8-99.9%) and 94.9% (95%CI: 87.4-98.6%) with pulmonologist 1 and 100% (95%CI: 91.6-100%) and 98.7% (95%CI: 92.9-99.9%) with pulmonologist 2. The concordance for the pattern interpretation was greater than k 0.907, representing almost perfect agreement. The concordance of the severity interpretation was greater than k 0.807, representing substantial to almost perfect agreement. We concluded that the Espiro app is a valid tool for spirometry interpretation.

Impact of Undiagnosed Chronic Obstructive Pulmonary Disease and Asthma on Symptoms, Quality of Life, Healthcare Use, and Work Productivity

Rationale: A significant proportion of individuals with chronic obstructive pulmonary disease (COPD) and asthma remain undiagnosed. Objectives: The objective of this study was to evaluate symptoms, quality of life, healthcare use, and work productivity in subjects with undiagnosed COPD or asthma compared with those previously diagnosed, as well as healthy control subjects. Methods: This multicenter population-based case-finding study randomly recruited adults with respiratory symptoms who had no previous history of diagnosed lung disease from 17 Canadian centers using random digit dialing. Participants who exceeded symptom thresholds on the Asthma Screening Questionnaire or the COPD Diagnostic Questionnaire underwent pre- and post-bronchodilator spirometry to determine if they met diagnostic criteria for COPD or asthma. Two control groups, a healthy group without respiratory symptoms and a symptomatic group with previously diagnosed COPD or asthma, were similarly recruited. Measurements and Main Results: A total of 26,905 symptomatic individuals were interviewed, and 4,272 subjects were eligible. Of these, 2,857 completed pre- and post-bronchodilator spirometry, and 595 (21%) met diagnostic criteria for COPD or asthma. Individuals with undiagnosed COPD or asthma reported greater impact of symptoms on health status and daily activities, worse disease-specific and general quality of life, greater healthcare use, and poorer work productivity than healthy control subjects. Individuals with undiagnosed asthma had symptoms, quality of life, and healthcare use burden similar to those of individuals with previously diagnosed asthma, whereas subjects with undiagnosed COPD were less disabled than those with previously diagnosed COPD. Conclusions: Undiagnosed COPD or asthma imposes important, unmeasured burdens on the healthcare system and is associated with poor health status and negative effects on work productivity.

The future landscape of immunology in COPD: A bibliometric analysis

BACKGROUND

This study was conducted to provide a comparative and comprehensive analysis of the last 50 years of research in the immunology of chronic obstructive pulmonary disease (COPD) and to identify future research priorities and directions.

METHODS

We obtained publication information from the Web of Science Core Collection (WoSCC) database. Scimago Graphica, CiteSpace, VOSviewer, GraphPad Prism, Microsoft Excel 365, and the R package "bibliometrix" were used for bibliometric analysis. The methodologies used were burst citation, clustering and co-citation, keyword co-occurrence, and cooperative network graph clustering algorithms.

RESULTS

A total of 2239 articles and reviews were included in the analysis. The number of annual publications showed an upward trend amidst fluctuations. The countries, institutions, journals, and authors with the highest number of publications were the USA, Imperial College London (ICL), Journal of Allergy and Clinical Immunology, and Murphy TF. There are 58 references and 13 keywords with a burst citation nature in the last 3 years, related to the study of inflammatory mechanisms.

CONCLUSION

We used bibliometric analysis to understand the research progress regarding immune function in COPD. Meanwhile, we found that the hotspots of COPD immunology in basic research focus on the analysis of etiology and risk factors, and the exploration of the immune system; and the hotspots of COPD in clinical research focus on epidemiology, and the prevention and management of different subtypes of COPD.

Polygenic risk scores identify heterogeneity in asthma and chronic obstructive pulmonary disease

BACKGROUND

Asthma and chronic obstructive pulmonary disease (COPD) have distinct and overlapping genetic and clinical features.

OBJECTIVE

We sought to test the hypothesis that polygenic risk scores (PRSs) for asthma (PRSAsthma) and spirometry (FEV1 and FEV1/forced vital capacity; PRSspiro) would demonstrate differential associations with asthma, COPD, and asthma-COPD overlap (ACO).

METHODS

We developed and tested 2 asthma PRSs and applied the higher performing PRSAsthma and a previously published PRSspiro to research (Genetic Epidemiology of COPD study and Childhood Asthma Management Program, with spirometry) and electronic health record-based (Mass General Brigham Biobank and Genetic Epidemiology Research on Adult Health and Aging [GERA]) studies. We assessed the association of PRSs with COPD and asthma using modified random-effects and binary-effects meta-analyses, and ACO and asthma exacerbations in specific cohorts. Models were adjusted for confounders and genetic ancestry.

RESULTS

In meta-analyses of 102,477 participants, the PRSAsthma (odds ratio [OR] per SD, 1.16 [95% CI, 1.14-1.19]) and PRSspiro (OR per SD, 1.19 [95% CI, 1.17-1.22]) both predicted asthma, whereas the PRSspiro predicted COPD (OR per SD, 1.25 [95% CI, 1.21-1.30]). However, results differed by cohort. The PRSspiro was not associated with COPD in GERA and Mass General Brigham Biobank. In the Genetic Epidemiology of COPD study, the PRSAsthma (OR per SD: Whites, 1.3; African Americans, 1.2) and PRSspiro (OR per SD: Whites, 2.2; African Americans, 1.6) were both associated with ACO. In GERA, the PRSAsthma was associated with asthma exacerbations (OR, 1.18) in Whites; the PRSspiro was associated with asthma exacerbations in White, LatinX, and East Asian participants.

CONCLUSIONS

PRSs for asthma and spirometry are both associated with ACO and asthma exacerbations. Genetic prediction performance differs in research versus electronic health record-based cohorts.

Patient message preferences to promote clinical conversations about chronic obstructive pulmonary disease (COPD): A discrete choice experiment

The purpose of this study was to identify message features that motivate patients to initiate clinical conversations about Chronic Obstructive Pulmonary Disease (COPD). A secondary aim was to determine whether preferred message features vary by socio-demographic and behavioral characteristics. A discrete choice experiment was conducted in August 2020. Participants were asked to select which messages would motivate them to speak with a clinician about COPD. This included selecting messages across 8 choice sets, or a systematic combination of messages reflecting 6 attributes (e.g., susceptibility, call-to-action, emotion-frame, efficacy, message source, organizational support). The final sample was 928, which included adults (M = 62.07; SD = 10.14 years old) who identified as non-Hispanic, white, and with at least some college experience. Message attributes ranked from most to least important were COPD susceptibility (25.53% [95% CI = 24.39, 26.66]), message source (19.32% [95% CI = 18.41-20.24]), COPD organization logo (19.13%; [95% CI = 18.26, 20.01]), call-to-action (14.12%; [95% CI = 13.40, 14.85], emotion-frame (13.24% [95% CI = 12.55-13.94]), and efficacy (8.65%; [95% CI = 8.20-9.09]). Participants preferred susceptibility messages about COPD signs/symptoms rather than risk behaviors related to smoking tobacco and environmental exposures. They also preferred messages from medical authorities (i.e., clinicians, COPD organization), a call-to-action that supports their autonomy in screening decision-making, and a message that conveys hope for living a healthy life with COPD and builds their self-efficacy to get screened. Differences in message preferences were detected according to age, gender, race, ethnicity, education level, and current vs. former smoking status. This study identified message features that motivate clinical conversations about COPD, especially those from subgroups who are disproportionately at-risk for its late-stage diagnosis.

Respiratory Symptoms, Disease Burden, and Quality of Life in Australian Adults According to GOLD Spirometry Grades: Data from the BOLD Australia Study

Purpose

Population data on the burden of chronic obstructive pulmonary disease (COPD) are often based on patient-reported diagnoses of COPD, emphysema or chronic bronchitis, without spirometry. We aimed to investigate the relationship between health burden, quality of life and severity of airway obstruction in Australian adults aged ≥40 years.

Methods

We used data from the BOLD Australia study, which included randomly selected adults aged ≥40 years from six study sites to reflect the sociodemographic and geographic diversity of the Australian population (n = 3522). Participants with post-bronchodilator airflow limitation (ratio of forced expiratory volume in 1 second FEV1 to forced vital capacity <0.7) were grouped by GOLD spirometry grades 1-4. Quality of life was assessed with Short Form 12 (SF-12) Health Survey Questionnaire. Health burden was assessed as lost time off work or social activities, and healthcare utilization.

Results

Of the study sample, 2969 participants did not have airflow limitation, 294 (8.4%) were classified as GOLD Grade 1, 212 (6.0%) as GOLD 2 and 43 (1.2%) as GOLD 3-4. Participants with higher GOLD grades had more respiratory symptoms, more comorbidities and greater burden than those with lower GOLD grades. The scores of mental and physical subscales of SF-12 were lower, indicating worse quality of life, from the no airflow limitation group to the GOLD 3-4 group (P = 0.03 and P < 0.001, respectively).

Conclusion

Greater airflow limitation is associated with greater burden and poor quality of life. Interventions to prevent, or reduce the level of, airflow limitation will reduce the symptom burden and improve quality of life for patients.

Comparison of the Diagnostic Performance of Five Clinical Questionnaires for Chronic Obstructive Pulmonary Disease

Background

Chronic obstructive pulmonary disease (COPD) remains one of the most prevalent pathologies in the world and is among the leading causes of mortality and morbidity, partially due to underdiagnosis. The use of clinical questionnaires to identify high-risk individuals to take them to further diagnostic procedures has emerged as a strategy to address this problem.

Objective

To compare the performance of the COULD IT BE COPD, CDQ, COPD-PS, LFQ, and PUMA questionnaires for COPD diagnosis.

Methods

A cross-sectional study was carried out on subjects who underwent spirometry in the third-level center. Data were collected between January 2015 and March 2020. Bivariate analysis was performed between the study variables and the presence of COPD. The area under the receiver operating characteristics curve (AUC-ROC), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) for each questionnaire were calculated. The AUC-ROCs were compared with the DeLong test, considering a p value <0.05 statistically significant.

Results

681 subjects met the inclusion criteria and were taken to the final analysis. The prevalence of COPD was 27.5% (187/681). The mean age of the subjects was 65.9 years (SD ± 11.79); 46.3% (315/681) were female, and 83.6% (569/681) reported respiratory symptoms. Statistically significant relationship was found for COPD diagnosis with male sex, older age, respiratory symptoms, and exposure to wood smoke (p value <0.05). The AUC-ROCs of the questionnaires were between 0.581 and 0.681. The COULD IT BE COPD questionnaire had a lower discriminatory capacity AUC-ROC of 0.581, concerning the other scores (DeLong test, p = 0.0002).

Conclusion

The CDQ, COPD-PS, LFQ, PUMA, and COULD IT BE COPD questionnaires have acceptable performance for the diagnosis of COPD together with low sensitivity and specificity. Therefore, its use must be complemented with other diagnostic tests or techniques such as pulmonary function tests.

Chronic Obstructive Pulmonary Disease Overdiagnosis and Overtreatment: A Meta-Analysis

This meta-analysis of observational studies aimed at estimating the overall prevalence of overdiagnosis and overtreatment in subjects with a clinical diagnosis of Chronic Obstructive Pulmonary Disease (COPD). MedLine, Scopus, Embase and Cochrane databases were searched, and random-effect meta-analyses of proportions were stratified by spirometry criteria (Global Initiative for COPD (GOLD) or Lower Limit of Normal (LLN)), and setting (hospital or primary care). Forty-two studies were included. Combining the data from 39 datasets, including a total of 23,765 subjects, the pooled prevalence of COPD overdiagnosis, according to the GOLD definition, was 42.0% (95% Confidence Interval (CI): 37.3-46.8%). The pooled prevalence according to the LLN definition was 48.2% (40.6-55.9%). The overdiagnosis rate was higher in primary care than in hospital settings. Fourteen studies, including a total of 8183 individuals, were included in the meta-analysis estimating the prevalence of COPD overtreatment. The pooled rates of overtreatment according to GOLD and LLN definitions were 57.1% (40.9-72.6%) and 36.3% (17.8-57.2%), respectively. When spirometry is not used, a large proportion of patients are erroneously diagnosed with COPD. Approximately half of them are also incorrectly treated, with potential adverse effects and a massive inefficiency of resources allocation. Strategies to increase the compliance to current guidelines on COPD diagnosis are urgently needed.

Serum α-Klotho level, lung function, airflow obstruction and inflammatory markers in US adults

Background

α-Klotho is a pleiotropic protein that may have anti-oxidative and anti-inflammatory properties in the lung, but its role in airflow obstruction or lung function is largely unknown.

Methods

This was a cross-sectional study of 6046 adults aged 40-79 years in the US National Health and Nutrition Examination Survey (NHANES) 2007-2012. We used multivariable logistic or linear regression to examine the relation between serum α-Klotho level and airflow obstruction, defined as forced expiratory volume in 1 s (FEV1) <80% of predicted and FEV1/forced vital capacity (FVC) ratio <0.70; FEV1, FVC and FEV1/FVC as percentage of predicted; and inflammatory markers in blood (white blood cell count, eosinophils, neutrophils and C-reactive protein (CRP)).

Results

α-Klotho levels in the second to fourth quartiles (Q2-Q4) were associated with significantly decreased odds of airflow obstruction (adjusted OR for Q2-Q4 versus lowest quartile (Q1) 0.54 (95% CI 0.35-0.81)) in never-smokers and ex-smokers with <10 pack-years of smoking, but not in current smokers or ex-smokers with ≥10 pack-years of smoking. In all participants, each unit increment in log10-transformed α-Klotho level was significantly associated with 5.0% higher FEV1 % pred and 3.7% higher FVC % pred. Higher α-Klotho was also associated with lower eosinophils, neutrophils and CRP in participants both with and without airflow obstruction.

Conclusions

Higher serum α-Klotho is associated with lower inflammatory markers and higher lung function in adults with and without airflow obstruction, and with decreased odds of airflow obstruction in never-smokers and ex-smokers with <10 pack-years of smoking. Further studies are warranted to replicate our findings and evaluate underlying mechanisms.

Pneumonia Risk Increased by Dementia-Related Daily Living Difficulties: Poor Oral Hygiene and Dysphagia as Contributing Factors

OBJECTIVE

Although pneumonia is the leading cause of death among patients with dementia, the specific underlying causes remain unclear. In particular, the potential connection between pneumonia risk and dementia-related daily living difficulties, such as oral hygiene practice and mobility impairment, and the use of physical restraint as a management practice, has not been extensively studied.

METHODS

In our retrospective study, we included 454 admissions corresponding to 336 individual patients with dementia who were admitted to a neuropsychiatric unit due to behavioral and psychological symptoms. The admissions were divided into two groups: those who developed pneumonia while hospitalized (n=62) and those who did not (n=392). We investigated differences between the two groups in terms of dementia etiology, dementia severity, physical conditions, medical complications, medication, dementia-related difficulties in daily living, and physical restraint. To control potential confounding variables, we used mixed effects logistic regression analysis to identify risk factors for pneumonia in this cohort.

RESULTS

Our study found that the development of pneumonia in patients with dementia was associated with poor oral hygiene, dysphagia, and loss of consciousness. Physical restraint and mobility impairment showed a weaker, nonsignificant association with the development of pneumonia.

CONCLUSIONS

Our findings suggest that pneumonia in this population may be caused by two primary factors: increased pathogenic microorganisms in the oral cavity due to poor hygiene, and an inability to clear aspirated contents due to dysphagia and loss of consciousness. Further investigation is needed to clarify the relationship between physical restraint, mobility impairment, and pneumonia in this population.

Health trajectories before initiation of non-invasive ventilation for chronic obstructive pulmonary disease: a French nationwide database analysis

Background

Chronic obstructive pulmonary disease (COPD) is the most common indication for long-term domiciliary non-invasive ventilation (NIV) but there is uncertainty in data supporting current guidelines. This study described health trajectories before initiation of at-home NIV in people with COPD, and compared mortality outcomes between groups with different pre-NIV health trajectories.

Methods

Data were from the French national health insurance reimbursement system database for individuals with COPD aged ≥40 years and ≥1 reimbursement for NIV between 1 January 2015 and 31 December 2019. Common health trajectories were determined using time sequence analysis through K-clustering (TAK analysis).

Findings

Data from 54,545 individuals were analysed; the population was elderly (median age 70 years) with multiple comorbidities. Four clusters were generated. Cluster 1 (n = 35,975/54,545; 66%) had NIV initiated in ambulatory settings or after the first acute event/exacerbation. Cluster 2 (6653/54,545; 12%) started NIV after ≥2 severe exacerbations in the previous 6 months. Cluster 3 (11,375/54,545; 21%) started NIV after frequent severe COPD-related exacerbations in the previous year. Cluster 4 (652/54,545; 1%) started NIV after many long-lasting severe exacerbations. The four clusters differed in age, sex, comorbidities, pre-NIV investigations, and prescriber/location of NIV initiation. Mortality differed significantly between clusters: highest in Cluster 4 and lowest in Cluster 1.

Interpretation

The significant heterogeneity in clinical initiation of NIV probably reflects the current lack of strong evidence and guideline recommendations. Knowledge about the characteristics and outcomes in different clusters should be used to address inequities and facilitate more consistent and personalised use domiciliary NIV in COPD.

Funding

JLP and SB are supported by the French National Research Agency in the framework of the "Investissements d'avenir" program (ANR-15-IDEX-02) and the "e-health and integrated care and trajectories medicine and MIAI artificial intelligence (ANR-19-P3IA-0003)" Chairs of excellence from the Grenoble Alpes University Foundation. This work was supported by ResMed.

Development of a daily predictive model for the exacerbation of chronic obstructive pulmonary disease

Acute exacerbation (AE) of chronic obstructive pulmonary disease (COPD) compromises health status; it increases disease progression and the risk of future exacerbations. We aimed to develop a model to predict COPD exacerbation. We merged the Korean COPD subgroup study (KOCOSS) dataset with nationwide medical claims data, information regarding weather, air pollution, and epidemic respiratory virus data. The Korean National Health and Nutrition Examination Survey (KNHANES) dataset was used for validation. Several machine learning methods were employed to increase the predictive power. The development dataset consisted of 590 COPD patients enrolled in the KOCOSS cohort; these were randomly divided into training and internal validation subsets on the basis of the individual claims data. We selected demographic and spirometry data, medications for COPD and hospital visit for AE, air pollution data and meteorological data, and influenza virus data as contributing factors for the final model. Six machine learning and logistic regression tools were used to evaluate the performance of the model. A light gradient boosted machine (LGBM) afforded the best predictive power with an area under the curve (AUC) of 0.935 and an F1 score of 0.653. Similar favorable predictive performance was observed for the 2151 individuals in the external validation dataset. Daily prediction of the COPD exacerbation risk may help patients to rapidly assess their risk of exacerbation and will guide them to take appropriate intervention in advance. This might lead to reduction of the personal and socioeconomic burdens associated with exacerbation.

Case-Finding tool for COPD in LMIC (COLA) - translation and cross-cultural adaptation into Brazilian Portuguese language

OBJECTIVE

To translate and cross-culturally adapt the COPD in Low- and middle-income countries (LMICs) Assessment (COLA) questionnaire into Brazilian Portuguese, a case-finding instrument for chronic obstructive pulmonary disease (COPD).

METHODS

Translation and cross-cultural adaptation were completed in six steps: the original version was translated into Brazilian Portuguese by two native speakers of the target language; the translated versions were synthesized; back-translation was performed by two native speakers of the original language; the back-translation and the Brazilian Portuguese version of the COLA were reviewed and harmonized by an expert committee of specialists; and, then, the pre-final version was tested by 30 health professionals who were asked if the items were clear to understand. The acceptability, clarity, and understandability of the translated version were evaluated. A final review of the questionnaire was produced by the authors and approved by the author of the original questionnaire.

RESULTS

Some idiomatic, semantic, and experiential inconsistencies were identified and properly adjusted. Item 3 was considered the most unclear item (23,3%). Items 7, 8, and 9 presented clarity above 80% (93%, 90%, and 90%, respectively). Suggestions were discussed and incorporated into the tool and COLA was found to be clear and easy to understand.

CONCLUSIONS

The Brazilian version of the COLA was easily understood by healthcare professionals and adapted to Brazilian culture. Translation and cultural adaptation of the COLA instrument into Brazilian Portuguese can be an important case-finding instrument for chronic obstructive pulmonary disease in Brazil.

Underdiagnosis and misclassification of COPD in Sweden - A Nordic Epilung study

INTRODUCTION

The prevalence of COPD tends to level off in populations with decreasing prevalence of smoking but the extent of underdiagnosis in such populations needs further investigation.

AIM

To investigate underdiagnosis and misclassification of COPD with a focus on socio-economy, lifestyle determinants and healthcare utilization.

METHOD

The 1839 participants were selected from two ongoing large-scale epidemiological research programs: The Obstructive Lung Disease in Northern Sweden Studies and the West Sweden Asthma Study. COPDGOLD was defined according to the fixed post-bronchodilator spirometric criteria FEV1/FVC<0.70 in combination with respiratory symptoms.

RESULTS

Among the 128 participants who fulfilled the criteria for COPDGOLD, the underdiagnosis was 83.6% (n = 107) of which 57.9% were men. The undiagnosed participants were younger, had higher FEV1% of predicted and less frequently a family history of bronchitis. One in four of the undiagnosed had utilized healthcare and had more frequently utilized healthcare due to a burden of respiratory symptoms than the general population without COPD. Underdiagnosis was not related to educational level. Misclassification of COPD was characterized by being a woman with low education, ever smoker, having respiratory symptoms and having a previous asthma diagnosis.

CONCLUSION

In the high income country Sweden, the underdiagnosis of COPD was highly prevalent. Reduced underdiagnosis can contribute to risk factor modification, medical treatment and self-management strategies in early stages of the disease, which may prevent disease progression and improve the quality of life among those affected. Therefore, there is a need to increase the use of spirometry in primary care to improve the diagnostic accuracy.

Reductions in inhaler greenhouse gas emissions by addressing care gaps in asthma and chronic obstructive pulmonary disease: an analysis

INTRODUCTION

Climate change from greenhouse gas (GHG) emissions represents one of the greatest public health threats of our time. Inhalers (and particularly metred-dose inhalers (MDIs)) used for asthma and chronic obstructive pulmonary disease (COPD), constitute an important source of GHGs. In this analysis, we aimed to estimate the carbon footprint impact of improving three distinct aspects of respiratory care that drive avoidable inhaler use in Canada.

METHODS

We used published data to estimate the prevalence of misdiagnosed disease, existing inhaler use patterns, medication class distributions, inhaler type distributions and GHGs associated with inhaler actuations, to quantify annual GHG emissions in Canada: (1) attributable to asthma and COPD misdiagnosis; (2) attributable to overuse of rescue inhalers due to suboptimally controlled symptoms; and (3) avoidable by switching 25% of patients with existing asthma and COPD to an otherwise comparable therapeutic option with a lower GHG footprint.

RESULTS

We identified the following avoidable annual GHG emissions: (1) ~49 100 GHG metric tons (MTs) due to misdiagnosed disease; (2) ~143 000 GHG MTs due to suboptimal symptom control; and (3) ~262 100 GHG MTs due to preferential prescription of strategies featuring MDIs over lower-GHG-emitting options (when 25% of patients are switched to lower GHG alternatives). Combined, the GHG emission reductions from bridging these gaps would be the equivalent to taking ~101 100 vehicles off the roads each year.

CONCLUSIONS

Our analysis shows that the carbon savings from addressing misdiagnosis and suboptimal disease control are comparable to those achievable by switching one in four patients to lower GHG-emitting therapeutic strategies. Behaviour change strategies required to achieve and sustain delivery of evidence-based real-world care are complex, but the added identified incentive of carbon footprint reduction may in itself prove to be a powerful motivator for change among providers and patients. This additional benefit can be leveraged in future behaviour change interventions.

Patterns of care in the management of high-risk COPD in the US (2011-2019): an observational study for the CONQUEST quality improvement program

Background

In this study, we compare management of patients with high-risk chronic obstructive pulmonary disease (COPD) in the United States to national and international guidelines and quality standards, including the COllaboratioN on QUality improvement initiative for achieving Excellence in STandards of COPD care (CONQUEST).

Methods

Patients were identified from the DARTNet Practice Performance Registry and categorized into three high-risk cohorts in each year from 2011 to 2019: newly diagnosed (≤12 months after diagnosis), already diagnosed, and patients with potential undiagnosed COPD. Patients were considered high-risk if they had a history of exacerbations or likely exacerbations (respiratory consult with prescribed medication). Descriptive statistics for 2019 are reported, along with annual trends.

Findings

In 2019, 10% (n = 16,610/167,197) of patients met high-risk criteria. Evidence of spirometry for diagnosis was low; in 2019, 81% (n = 1228/1523) of patients newly diagnosed at high-risk had no record of spirometry/peak expiratory flow in the 12 months pre- or post-diagnosis and 43% (n = 651/1523) had no record of COPD symptom review. Among those newly and already diagnosed at high-risk, 52% (n = 4830/9350) had no evidence of COPD medication.

Interpretation

Findings suggest inconsistent adherence to evidence-based guidelines, and opportunities to improve identification, documentation of services, assessment, therapeutic intervention, and follow-up of patients with COPD.

Funding

This study was conducted by the Observational and Pragmatic Research Institute (OPRI) Pte Ltd and was partially funded by Optimum Patient Care Global and AstraZeneca Ltd. No funding was received by the Observational & Pragmatic Research Institute Pte Ltd (OPRI) for its contribution.

Incidence of chronic disease following smoking cessation treatment: A matched cohort study using linked administrative healthcare data in Ontario, Canada

Scarce evidence is available on the impact of real-world smoking cessation treatment on subsequent health outcomes, such as incidence of chronic disease. This study compared two cohorts of people that smoke-those that enrolled in a smoking cessation program, and a matched control that had not accessed the program-to assess the incidence of cancer, chronic obstructive pulmonary disease, diabetes, hypertension, and major cardiovascular events over a 5-year follow-up period. We selected five sub-cohorts with matched treatment-control pairs in which both individuals were at risk of the five chronic diseases. Incident chronic disease from index date until December 31, 2017, was determined through linkage with routinely collected healthcare data. The cumulative incidence of each chronic disease was estimated using the cumulative incidence function with death as a competing risk. Gray's test was used to test for a difference between matched treatment and control groups in the chronic disease-specific cumulative incidence function over follow-up. Analyses were stratified by sex. Among females, cumulative incidence of diabetes was higher over follow-up for the treatment group (5-year cumulative incidence 5.8% vs 4.2%, p = 0.004), but did not differ for the four other chronic diseases. Among males, cumulative incidence of chronic obstructive pulmonary disease (12.2% vs 9.1%, p < 0.001) and diabetes (6.7% vs 4.8%, p < 0.001) both had higher 5-year cumulative incidence for the treated versus control groups but did not differ for the other three chronic diseases. We conclude that accessing primary-care based smoking cessation treatment is associated with increased incidence of diabetes for both sexes, and chronic obstructive pulmonary disease for males (possibly due to under diagnosis prior to treatment), within 5 years of treatment. The associations detected require further research to understand causal relationships.

Different Case Finding Approaches to Optimise COPD Diagnosis: Evidence from the RADICALS Trial

Aim

Diagnosis of COPD in primary care is hindered by underuse of spirometry. Case finding using validated symptom and health status questionnaires, and simple handheld devices in high-risk populations may improve diagnosis. This study aimed to determine the best combination of measures to optimise COPD diagnosis in the primary care setting.

Methods

We recruited 335 current or ex-smokers, including those with an established diagnosis of COPD from general practices. Participants' FEV1 and FEV6 were measured using a handheld spirometry device (COPD-6®). Each completed the COPD assessment test (CAT), a modified Medical Research Council (mMRC) dyspnoea scale, St George's Respiratory Questionnaire (SGRQ) and smoking history questionnaire. From these data we calculated the predictive validity for spirometry-confirmed diagnosis of COPD. Area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, positive and negative predictive values (PPV, NPV) were calculated for each. Kappa coefficient was used to measure the agreement between the Fixed-Ratio (FR) and Lower Limit of Normal (LLN) spirometric criteria in diagnosing COPD.

Results

FEV1/FEV6 <0.70 alone showed significant association (p<0.0001) with COPD diagnosis and good predictive accuracy (AUROC=0.725). However, no further improvement was found after combining SGRQ, CAT and mMRC with FEV1/FEV6. FEV1/FEV6 <0.70 using the COPD-6® handheld device had moderate sensitivity (65.7%) and high PPV (90.1%), high specificity (79.3%) and NPV (44.8%). There was good agreement between FR and LLN definitions (κ=0.70).

Conclusion

Handheld micro-spirometers can facilitate case finding of COPD in smokers and ex-smokers attending general practice. The fixed ratio criterion currently recommended by COPD-X guidelines offers the simplest method for diagnosing COPD in Australian primary care.

Current Progress of COPD Early Detection: Key Points and Novel Strategies

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide, with approximately 70% to 80% of adults with COPD being undiagnosed. Patients with undiagnosed COPD are at increased risk of poor outcomes and a worsened quality of life, making early detection a crucial strategy to mitigate the impact of COPD and reduce the burden on healthcare systems. In the past decade, increased interest has been focused on the development of effective strategies and instrument for COPD early detection. However, identifying undiagnosed cases of COPD is still challenging. Both screening and case-finding approaches have been adopted to identify undiagnosed COPD, with case-finding being recommended by the 2023 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline and the updated United States Preventive Services Task Force (USPTF) recommendation. Nonetheless, the approaches, criteria, and instruments used for early detection of COPD are varied. However, advances in the taxonomy and risk factors of COPD are continuously being investigated. It is important to continuously assess the current state of knowledge on COPD early detection, given the challenges associated with identifying undiagnosed COPD. This review aims to highlight recent advances in early detection of COPD. To discuss the current challenge and opportunity in COPD early detection, providing an overview of existing literature on COPD case-finding strategies, including the approaches, criteria for subjects, and instruments. The review also summarizes the current progress in COPD case-findings and proposes a COPD case-finding flowchart as an efficient method for identifying at risk COPD patients.

Assessment of Five Questionnaires for Chronic Obstructive Pulmonary Disease in a Southern Italian Population: A Proof-of-Concept Study

Background and Objectives: Chronic obstructive pulmonary disease (COPD) is a growing burden to society, and remains underdiagnosed in Italy. This study aimed at evaluating five validated screening questionnaires to consider which one was the most accurate, and the optimal cut-off score for each to be considered for the Southern Italian population. Materials and Methods: A total of 144 patients were recruited in the study. The age range was 46-85 years. All subjects underwent spirometry, and completed the five questionnaires: CDQ, LFQ, COPD-PS, COPD-SQ, and CAPTURE. Receiver-operator curves (ROC) were drawn for each questionnaire. The area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), values for the optimal cut-off score and previously recommended score were calculated and compared. Results: Of the questionnaires, the CDQ, LFQ, and COPD-SQ had significant differences between COPD (n = 86) and non-COPD (n = 52) groups. The AUCs for each questionnaire with (95%CI) were: CAPTURE, 0.602 (0.431-0.773); CDQ, 0.714 (0.555-0.872); LFQ, 0.331 (0.183-0.479; COPD-PS, 0.652 (0.497-0.807); and COPD-SQ, 0.679 (0.520-0.837). Only the CDQ and COPD-SQ had significant AUC screening characteristics. The optimal cut-off values for the CDQ, LFQ, and COPD-PS were modified to 22, 10, and 4, respectively. The COPD-SQ remained at 17. Conclusion: The CDQ and COPD-SQ can discriminate between individuals with and without COPD in the Italian population. The CDQ has a moderate screening accuracy, and the COPD-PS and COPD-SQ have low accuracy, when the optimal cut-off scores are used. Of the five questionnaires assessed, the CDQ and COPD-SQ questionnaires could be used for screening for COPD in the Southern Italian population.

Clinical characteristics of adults with self-reported diagnosed asthma and/or COPD: data from the BOLD Australia Study

Background

Diagnosis of asthma and chronic obstructive pulmonary disease (COPD) in the community is variable, often without spirometry. Some studies report that adults with both diagnostic labels (asthma+COPD) have worse health outcomes than those with asthma or COPD only, but data for Australian adults are limited. We investigated the relationship between clinical characteristics and self-reported diagnoses of asthma, COPD and both.

Method

We used data from the BOLD Australia study, which included randomly selected adults aged ≥40 years from six study sites. The BOLD questionnaires and spirometry test were used in all sites. Participants were grouped by self-reported diagnosis. Demographic and clinical characteristics and lung function were compared between groups.

Results

Of the study sample (n=3522), 336 reported asthma only, 172 reported COPD only, 77 reported asthma+COPD and 2937 reported neither. Fewer than half of participants with a COPD diagnosis (with or without asthma) had airflow limitation. Participants with asthma+COPD had more respiratory symptoms and greater airflow limitation than those with either diagnosis alone. Having asthma+COPD was independently associated with a higher probability of having clinically important breathlessness (modified Medical Research Council score ≥2) than asthma only (adjusted OR 3.44, 95% CI 1.86-6.33) or COPD only (adjusted OR 3.28, 95% CI 1.69-6.39). Airflow limitation (Global Initiative for Chronic Obstructive Lung Disease 2 or higher, using post-bronchodilator forced expiratory volume in 1 s/forced vital capacity ratio <0.7) was similar between asthma only and COPD only, but twice as prevalent in asthma+COPD (adjusted OR 2.18 and 2.58, respectively).

Conclusions

Adults with diagnoses of asthma+COPD have a higher symptom and disease burden than those with diagnoses of asthma only or COPD only. These patients should receive regular comprehensive reviews because of the substantially increased burden of having both diagnoses.

Diagnostic spirometry in COPD is increasing, a comparison of two Swedish cohorts

Spirometry should be used to confirm a diagnosis of chronic obstructive pulmonary disease (COPD). This test is not always performed, leading to possible misdiagnosis. We investigated whether the proportion of patients with diagnostic spirometry has increased over time as well as factors associated with omitted or incorrectly interpreted spirometry. Data from medical reviews and a questionnaire from primary and secondary care patients with a doctors' diagnosis of COPD between 2004 and 2010 were collected. Data were compared with a COPD cohort diagnosed between 2000 and 2003. Among 703 patients with a first diagnosis of COPD between 2004 and 2010, 88% had a diagnostic spirometry, compared with 59% (p < 0.001) in the previous cohort. Factors associated with not having diagnostic spirometry were current smoking (OR 2.21; 95% CI 1.36-3.60), low educational level (OR 1.81; 1.09-3.02) and management in primary care (OR 2.28; 1.02-5.14). The correct interpretation of spirometry results increased (75% vs 82%; p = 0.010). Among patients with a repeated spirometry, 94% had a persistent FEV₁/FVC or FEV₁/VC ratio <0.70.

Prevalence and clinical characteristics of non-malignant CT detected incidental findings in the SUMMIT lung cancer screening cohort

BACKGROUND

Pulmonary and extrapulmonary incidental findings are frequently identified on CT scans performed for lung cancer screening. Uncertainty regarding their clinical significance and how and when such findings should be reported back to clinicians and participants persists. We examined the prevalence of non-malignant incidental findings within a lung cancer screening cohort and investigated the morbidity and relevant risk factors associated with incidental findings. We quantified the primary and secondary care referrals generated by our protocol.

METHODS

The SUMMIT study (NCT03934866) is a prospective observational cohort study to examine the performance of delivering a low-dose CT (LDCT) screening service to a high-risk population. Spirometry, blood pressure, height/weight and respiratory history were assessed as part of a Lung Health Check. Individuals at high risk of lung cancer were offered an LDCT and returned for two further annual visits. This analysis is a prospective evaluation of the standardised reporting and management protocol for incidental findings developed for the study on the baseline LDCT.

RESULTS

In 11 115 participants included in this analysis, the most common incidental findings were coronary artery calcification (64.2%) and emphysema (33.4%). From our protocolised management approach, the number of participants requiring review for clinically relevant findings in primary care was 1 in 20, and the number potentially requiring review in secondary care was 1 in 25.

CONCLUSIONS

Incidental findings are common in lung cancer screening and can be associated with reported symptoms and comorbidities. A standardised reporting protocol allows systematic assessment and standardises onward management.

Digital health in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) can be prevented and treated through effective care, reducing exacerbations and hospitalizations. Early identification of individuals at high risk of COPD exacerbation is an opportunity for preventive measures. However, many patients struggle to follow their treatment plans because of a lack of knowledge about the disease, limited access to resources, and insufficient clinical support. The growth of digital health-which encompasses advancements in health information technology, artificial intelligence, telehealth, the Internet of Things, mobile health, wearable technology, and digital therapeutics-offers opportunities for improving the early diagnosis and management of COPD. This study reviewed the field of digital health in terms of COPD. The findings showed that despite significant advances in digital health, there are still obstacles impeding its effectiveness. Finally, we highlighted some of the major challenges and possibilities for developing and integrating digital health in COPD management.

Radiomics for Improved Detection of Chronic Obstructive Pulmonary Disease in Low-Dose and Standard-Dose Chest CT Scans

Background Approximately half of adults with chronic obstructive pulmonary disease (COPD) remain undiagnosed. Chest CT scans are frequently acquired in clinical practice and present an opportunity to detect COPD. Purpose To assess the performance of radiomics features in COPD diagnosis using standard-dose and low-dose CT models. Materials and Methods This secondary analysis included participants enrolled in the Genetic Epidemiology of COPD, or COPDGene, study at baseline (visit 1) and 10 years after baseline (visit 3). COPD was defined by a forced expiratory volume in the 1st second of expiration to forced vital capacity ratio less than 0.70 at spirometry. The performance of demographics, CT emphysema percentage, radiomics features, and a combined feature set derived from inspiratory CT alone was evaluated. CatBoost (Yandex), a gradient boosting algorithm, was used to perform two classification experiments to detect COPD; the two models were trained and tested on standard-dose CT data from visit 1 (model I) and low-dose CT data from visit 3 (model II). Classification performance of the models was evaluated using area under the receiver operating characteristic curve (AUC) and precision-recall curve analysis. Results A total of 8878 participants (mean age, 57 years ± 9 [SD]; 4180 female, 4698 male) were evaluated. Radiomics features in model I achieved an AUC of 0.90 (95% CI: 0.88, 0.91) in the standard-dose CT test cohort versus demographics (AUC, 0.73; 95% CI: 0.71, 0.76; P < .001), emphysema percentage (AUC, 0.82; 95% CI 0.80, 0.84; P < .001), and combined features (AUC, 0.90; 95% CI: 0.89, 0.92; P = .16). Model II, trained on low-dose CT scans, achieved an AUC of 0.87 (95% CI: 0.83, 0.91) on the 20% held-out test set for radiomics features compared with demographics (AUC, 0.70; 95% CI: 0.64, 0.75; P = .001), emphysema percentage (AUC, 0.74; 95% CI: 0.69, 0.79; P = .002), and combined features (AUC, 0.88; 95% CI: 0.85, 0.92; P = .32). Density and texture features were the majority of the top 10 features in the standard-dose model, whereas shape features of lungs and airways were significant contributors in the low-dose CT model. Conclusion A combination of features representing parenchymal texture and lung and airway shape on inspiratory CT scans can be used to accurately detect COPD. ClinicalTrials.gov registration no. NCT00608764 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Vliegenthart in this issue.

Deep learning to estimate lung disease mortality from chest radiographs

Prevention and management of chronic lung diseases (asthma, lung cancer, etc.) are of great importance. While tests are available for reliable diagnosis, accurate identification of those who will develop severe morbidity/mortality is currently limited. Here, we developed a deep learning model, CXR Lung-Risk, to predict the risk of lung disease mortality from a chest x-ray. The model was trained using 147,497 x-ray images of 40,643 individuals and tested in three independent cohorts comprising 15,976 individuals. We found that CXR Lung-Risk showed a graded association with lung disease mortality after adjustment for risk factors, including age, smoking, and radiologic findings (Hazard ratios up to 11.86 [8.64-16.27]; p < 0.001). Adding CXR Lung-Risk to a multivariable model improved estimates of lung disease mortality in all cohorts. Our results demonstrate that deep learning can identify individuals at risk of lung disease mortality on easily obtainable x-rays, which may improve personalized prevention and treatment strategies.

The Role of IL-33/ST2 in COPD and Its Future as an Antibody Therapy

COPD is a leading cause of mortality and morbidity worldwide and is associated with a high socioeconomic burden. Current treatment includes the use of inhaled corticosteroids and bronchodilators, which can help to improve symptoms and reduce exacerbations; however, there is no solution for restoring lung function and the emphysema caused by loss of the alveolar tissue. Moreover, exacerbations accelerate progression and challenge even more the management of COPD. Mechanisms of inflammation in COPD have been investigated over the past years, thus opening new avenues to develop novel targeted-directed therapies. Special attention has been paid to IL-33 and its receptor ST2, as they have been found to mediate immune responses and alveolar damage, and their expression is upregulated in COPD patients, which correlates with disease progression. Here we summarize the current knowledge on the IL-33/ST2 pathway and its involvement in COPD, with a special focus on developed antibodies and the ongoing clinical trials using anti-IL-33 and anti-ST2 strategies in COPD patients.