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Davis TME, Drinkwater JJ, Davis WA. Pulmonary Function Trajectories Over 6 Years and Their Determinants in Type 2 Diabetes: The Fremantle Diabetes Study Phase II. Diabetes Care 2024; 47:483-490. [PMID: 38211617 DOI: 10.2337/dc23-1726] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/22/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To assess whether there are clusters of people with type 2 diabetes with distinct temporal profiles of lung function changes and characteristics. RESEARCH DESIGN AND METHODS Group-based trajectory modeling (GBTM) identified groups of participants with type 2 diabetes from the community-based observational Fremantle Diabetes Study Phase II (FDS2) who had at least two biennial measurements of forced expiratory volume in 1 s as a percentage of predicted (FEV1%pred) over 6 years. Independent associates of group membership were assessed using multinomial regression. RESULTS Of 1,482 potential FDS2 participants, 1,074 (72.5%; mean age, 65.2 years; 45.5% female; median diabetes duration, 8.0 years) were included in the modeling. The best fitting GBTM model identified four groups categorized by FEV1%pred trajectory: high (19.5%; baseline FEV1%pred, 106.5 ± 9.5%; slope 0%/year), medium (47.7%; FEV1%pred, 87.3 ± 8.7%; slope, -0.32%/year), low (25.0%; baseline FEV1%pred, 68.9 ± 9.8%; slope, -0.72%/year), and very low (7.9%; baseline FEV1%pred, 48.8 ± 9.6%; slope, -0.68%/year). Compared with the high group, the other groups were characterized by nonmodifiable and modifiable risk factors associated with lung function decline in the general population (including ethnicity, marital status, smoking, obesity, coronary heart disease, and chronic respiratory disease). The main, diabetes-specific, significant predictor of group membership was a higher HbA1c in the very low group. There was a graded increase in mortality from 6.7% in the high group to 22.4% in the very low group. CONCLUSIONS Measurement of lung function in type 2 diabetes could help optimize clinical management and improve prognosis, including addressing glycemic control in those with a very low FEV1%pred.
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Affiliation(s)
- Timothy M E Davis
- University of Western Australia Medical School, Fremantle Hospital, Fremantle, Western Australia, Australia
- Department of Endocrinology and Diabetes, Fiona Stanley and Fremantle Hospitals Group, Murdoch, Western Australia, Australia
| | - Jocelyn J Drinkwater
- University of Western Australia Medical School, Fremantle Hospital, Fremantle, Western Australia, Australia
- Lions Outback Vision, Lions Eye Institute, Nedlands, Australia
| | - Wendy A Davis
- University of Western Australia Medical School, Fremantle Hospital, Fremantle, Western Australia, Australia
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Chan KC, Zhu H, Yu M, Yuen HM, Dai S, Chin HY, Choy J, Chan J, Tsoi D, Siu B, Au CT, Li AM. Applicability of the Global Lung Function Initiative prediction equations in Hong Kong Chinese children. Pediatr Pulmonol 2023; 58:3235-3245. [PMID: 37642271 DOI: 10.1002/ppul.26649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/08/2023] [Accepted: 08/12/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND AND OBJECTIVE This study aimed to assess the applicability of the Global Lung Function Initiative (GLI) prediction equations for spirometry in Hong Kong children and to develop prediction equations based on the Generalized Additive Models for Location, Scale, and Shape (GAMLSS) modeling. METHODS Healthy Chinese children and adolescents aged 6-17 years old were recruited from randomly selected schools to undergo spirometry. The measurements were transformed to z-score according to the GLI-2012 equations for South East (SE) Asians and the GLI-2022 global race-neutral equations. Prediction equations for spirometric indices were developed with GAMLSS modeling to identify predictors. RESULTS A total of 886 children (477 boys) with a mean age of 12.5 years (standard deviation [SD] 3.3 years) were included. By the GLI-2012 SE Asian equations, positive mean z-scores were observed in forced expiratory volume in 1 s (FEV1 ) (boys: 0.138 ± SD 0.828; girls: 0.206 ± 0.823) and forced vital capacity (FVC) (boys: 0.160 ± 0.930; girls: 0.310 ± 0.895) in both sexes. Negative mean z-scores were observed in FEV1 /FVC ratio (boys: -0.018 ± 0.998; girls: -0.223 ± 0.897). In contrast, negative mean z-scores in FEV1 and FVC, and positive mean z-scores in FEV1 /FVC were observed when adopting the GLI-2022 race-neutral equations. The mean z-scores were all within the range of ±0.5. By GAMLSS models, age and height were significant predictors for all four spirometric indices, while weight was an additional predictor for FVC and FEV1 . CONCLUSION Our study provided data supporting the applicability of the GLI prediction equations in Hong Kong Chinese children. The GLI-2012 equations may underestimate FEV1 and FVC, while the GLI-2022 equations may overestimate the parameters, but the differences lie within the physiological limits. By GAMLSS modeling, weight was an additional predictor for FVC and FEV1 .
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Affiliation(s)
- Kate C Chan
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Paediatric Respiratory Research, Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
- Hong Kong Hub of Paediatric Excellence, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Huichen Zhu
- Department of Statistics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Michelle Yu
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Hoi-Man Yuen
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Siyu Dai
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Hui-Yen Chin
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jonathan Choy
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jeffrey Chan
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Dana Tsoi
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Brian Siu
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Chun T Au
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
- Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Albert M Li
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Paediatric Respiratory Research, Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
- Hong Kong Hub of Paediatric Excellence, The Chinese University of Hong Kong, Hong Kong SAR, China
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Kitazawa H, Jiang A, Nohra C, Ota H, Wu JKY, Ryan CM, Chow CW. Changes in interpretation of spirometry by implementing the GLI 2012 reference equations: impact on patients tested in a hospital-based PFT lab in a large metropolitan city. BMJ Open Respir Res 2022; 9:9/1/e001389. [PMID: 36600407 PMCID: PMC9743406 DOI: 10.1136/bmjresp-2022-001389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 11/18/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The Global Lung Function Initiative (GLI-2012) focused on race/ethnicity as an important factor in determining reference values. This study evaluated the effects of changing from Canadian reference equations developed from an all-Caucasian cohort with European ancestry to the GLI-2012 on the interpretation of spirometry in a multiethnic population and aimed to identify the ethnic groups affected by discrepant interpretations. METHODS Clinically indicated spirometry in a multiethnic population (aged 20-80 years) collected from 2018 to 2021 was analysed. The predicted and lower limit of normal (LLN) values were calculated using three sets of reference equations: Canadian, GLI-race/ethnic-based (GLI-Race) and GLI-race/ethnic-neutral (GLI-Other). We compared the prevalence of concordance in the abnormal diagnoses (defined as <LLN) for forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and FEV1/FVC among the three reference values, and evaluated whether race/ethnicity was associated with discordance. RESULTS Data from 406 participants were evaluated (non-Caucasian 43.6%). There was 85%-87% concordance for normal/abnormal FVC and FEV1 interpretations among the Canadian, GLI-Race and GLI-Other reference equations. In all ethnic groups, application of the Canadian references for interpretation led to a higher prevalence of abnormal (<LLN) FVC and FEV1compared with GLI-Race and GLI-Other. This trend was more prominent in Black, South-East Asian and Mixed/other ethnic groups when comparing the Canadian to the GLI-Race equations. In contrast, the discordance rates were similar among ethnic groups when compared with the GLI-Other reference equations. Interpretation of FEV1/FVC had a high rate of agreement among all equations. CONCLUSION Interpretation using Canadian reference equations was associated with a higher prevalence of restrictive physiology compared with the GLI-2012 equations, particularly if the GLI-Race were used. These observations were mostly found in non-white Caucasian groups, highlighting the need to choose reference equations that reflect closely the ethnic mix of the population being evaluated in order to optimise patient management.
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Affiliation(s)
- Haruna Kitazawa
- Department of Medicine, University Health Network, Toronto, Ontario, Canada,Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Annie Jiang
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Cynthia Nohra
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Honami Ota
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Joyce K Y Wu
- Department of Medicine, University Health Network, Toronto, Ontario, Canada,Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Clodagh M Ryan
- Department of Medicine, University Health Network, Toronto, Ontario, Canada,Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada,Sleep Research Laboratory, Toronto Rehabilitation Institute University Health Network, Toronto, Ontario, Canada
| | - Chung-Wai Chow
- Department of Medicine, University Health Network, Toronto, Ontario, Canada,Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Frenzel S, Bis JC, Gudmundsson EF, O’Donnell A, Simino J, Yaqub A, Bartz TM, Brusselle GGO, Bülow R, DeCarli CS, Ewert R, Gharib SA, Ghosh S, Gireud-Goss M, Gottesman RF, Ikram MA, Knopman DS, Launer LJ, London SJ, Longstreth W, Lopez OL, Melo van Lent D, O’Connor G, Satizabal CL, Shrestha S, Sigurdsson S, Stubbe B, Talluri R, Vasan RS, Vernooij MW, Völzke H, Wiggins KL, Yu B, Beiser AS, Gudnason V, Mosley T, Psaty BM, Wolters FJ, Grabe HJ, Seshadri S. Associations of Pulmonary Function with MRI Brain Volumes: A Coordinated Multi-Study Analysis. J Alzheimers Dis 2022; 90:1073-1083. [PMID: 36213999 PMCID: PMC9712227 DOI: 10.3233/jad-220667] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Previous studies suggest poor pulmonary function is associated with increased burden of cerebral white matter hyperintensities and brain atrophy among elderly individuals, but the results are inconsistent. OBJECTIVE To study the cross-sectional associations of pulmonary function with structural brain variables. METHODS Data from six large community-based samples (N = 11,091) were analyzed. Spirometric measurements were standardized with respect to age, sex, height, and ethnicity using reference equations of the Global Lung Function Initiative. Associations of forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and their ratio FEV1/FVC with brain volume, gray matter volume, hippocampal volume, and volume of white matter hyperintensities were investigated using multivariable linear regressions for each study separately and then combined using random-effect meta-analyses. RESULTS FEV1 and FVC were positively associated with brain volume, gray matter volume, and hippocampal volume, and negatively associated with white matter hyperintensities volume after multiple testing correction, with little heterogeneity present between the studies. For instance, an increase of FVC by one unit was associated with 3.5 ml higher brain volume (95% CI: [2.2, 4.9]). In contrast, results for FEV1/FVC were more heterogeneous across studies, with significant positive associations with brain volume, gray matter volume, and hippocampal volume, but not white matter hyperintensities volume. Associations of brain variables with both FEV1 and FVC were consistently stronger than with FEV1/FVC, specifically with brain volume and white matter hyperintensities volume. CONCLUSION In cross-sectional analyses, worse pulmonary function is associated with smaller brain volumes and higher white matter hyperintensities burden.
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Affiliation(s)
- Stefan Frenzel
- Department of Psychiatry and Psychotherapy, University Medicine Greifswald, Greifswald, Germany
| | - Joshua C. Bis
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA
| | | | - Adrienne O’Donnell
- Framingham Heart Study, Framingham, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Jeannette Simino
- Gertrude C. Ford Memory Impairment and Neurodegenerative Dementia (MIND) Center, University of Mississippi Medical Center, Jackson, MS, USA
- Department of Data Science, John D. Bower School of Population Health, University of Mississippi Medical Center, Jackson, MS, USA
| | - Amber Yaqub
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Traci M. Bartz
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Guy G. O. Brusselle
- Department of Respiratory Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Robin Bülow
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Charles S. DeCarli
- Department of Neurology and Center for Neuroscience, University of California at Davis, Sacramento, CA, USA
- Imaging of Dementia and Aging (IDeA) Laboratory, Department of Neurology, University of California-Davis, Davis, CA, USA
| | - Ralf Ewert
- Department of Internal Medicine B, Cardiology, Intensive Care, Pulmonary Medicine and Infectious Diseases, University Medicine Greifswald, Greifswald, Germany
| | - Sina A. Gharib
- Center for Lung Biology, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Saptaparni Ghosh
- Framingham Heart Study, Framingham, MA, USA
- Department of Neurology, Boston University Schoolof Medicine, Boston, MA, USA
| | - Monica Gireud-Goss
- Glenn Biggs Institute for Alzheimer and Neurodegenerative Diseases, The University of Texas Health Science Center at San Antonio, SanAntonio, TX, USA
| | - Rebecca F. Gottesman
- Stroke, Cognition, and Neuroepidemiology (SCAN) section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - M. Arfan Ikram
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Lenore J. Launer
- Laboratory of Epidemiology, Demography, and Biometry, National Institute on Aging, Bethesda, MD, USA
| | - Stephanie J. London
- Epidemiology Branch, National Institute of Environmental Health Sciences (NIEHS), National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Research Triangle Park, NC, USA
| | - W.T. Longstreth
- Department of Neurology, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Oscar L. Lopez
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Debora Melo van Lent
- Framingham Heart Study, Framingham, MA, USA
- Department of Neurology, Boston University Schoolof Medicine, Boston, MA, USA
- Glenn Biggs Institute for Alzheimer and Neurodegenerative Diseases, The University of Texas Health Science Center at San Antonio, SanAntonio, TX, USA
| | - George O’Connor
- Framingham Heart Study, Framingham, MA, USA
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Claudia L. Satizabal
- Glenn Biggs Institute for Alzheimer and Neurodegenerative Diseases, The University of Texas Health Science Center at San Antonio, SanAntonio, TX, USA
- Department of Population Health Sciences, The University of Texas Health Science Center at San Antonio, SanAntonio, TX, USA
| | - Srishti Shrestha
- Gertrude C. Ford Memory Impairment and Neurodegenerative Dementia (MIND) Center, University of Mississippi Medical Center, Jackson, MS, USA
- Department of Neurology, School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Beate Stubbe
- Department of Internal Medicine B, Cardiology, Intensive Care, Pulmonary Medicine and Infectious Diseases, University Medicine Greifswald, Greifswald, Germany
| | - Rajesh Talluri
- Department of Data Science, John D. Bower School of Population Health, University of Mississippi Medical Center, Jackson, MS, USA
| | - Ramachandran S. Vasan
- Framingham Heart Study, Framingham, MA, USA
- Section of Preventive Medicine and Epidemiology, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Meike W. Vernooij
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Henry Völzke
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Kerri L. Wiggins
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Bing Yu
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Alexa S. Beiser
- Framingham Heart Study, Framingham, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
- Department of Neurology, Boston School of Medicine, Boston, MA, USA
| | - Vilmundur Gudnason
- Icelandic Heart Association, Kopavogur, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Thomas Mosley
- Gertrude C. Ford Memory Impairment and Neurodegenerative Dementia (MIND) Center, University of Mississippi Medical Center, Jackson, MS, USA
- Department of Neurology, School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
- Department of Medicine, School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Bruce M. Psaty
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Frank J. Wolters
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Hans J. Grabe
- Department of Psychiatry and Psychotherapy, University Medicine Greifswald, Greifswald, Germany
- German Center for Neurodegenerative Disease (DZNE), partner site Rostock/Greifswald, Germany
| | - Sudha Seshadri
- Framingham Heart Study, Framingham, MA, USA
- Department of Neurology, Boston University Schoolof Medicine, Boston, MA, USA
- Glenn Biggs Institute for Alzheimer and Neurodegenerative Diseases, The University of Texas Health Science Center at San Antonio, SanAntonio, TX, USA
- Department of Neurology, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Vaz Fragoso CA, Leo-Summers LS, Gill TM, McAvay GJ. Re-evaluation of the Uplift Clinical Trial Using Age-Appropriate Spirometric Criteria. Chest 2020; 158:539-549. [PMID: 32278783 DOI: 10.1016/j.chest.2020.02.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 01/13/2020] [Accepted: 02/14/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND The clinical trial of tiotropium in COPD, UPLIFT, enrolled adults with a mean age of 65 years and moderate-to-severe airflow obstruction, based on criteria from the Global Initiative for Chronic Obstructive Lung Disease (GOLD). For the UPLIFT cohort, however, GOLD-based criteria are not age-appropriate. RESEARCH QUESTION Will the use of more age-appropriate criteria for airflow obstruction from the Global Lung Function Initiative (GLI) modify the spirometric classification of the UPLIFT cohort and, in turn, the mortality effect of tiotropium in COPD? STUDY DESIGN AND METHODS Baseline spirometric classifications were first cross-tabulated by GLI- and GOLD-based criteria. Next, in GLI- and GOLD-based airflow obstruction, modified intention-to-treat analyses evaluated differences in time to death over 4 years, comparing tiotropium vs placebo. Because treatment response may differ by COPD severity, the mortality effect also was evaluated within stratum defined by GLI- and GOLD-based moderate and severe airflow obstruction. RESULTS Of 5,898 participants with GOLD-based airflow-obstruction, staged as moderate in 2,739 (46.4%) and severe in 3,156 (53.5%), GLI-based criteria established airflow obstruction in 5,750 (97.5%), staged as moderate in 795 (13.5%) and severe in 4,947 (83.9%). Relative to placebo, tiotropium yielded statistically nonsignificant adjusted hazard ratios (adjHRs) (95% CI) for death of 0.91 (0.80-1.04) and 0.91 (0.79-1.03) in GLI- and GOLD-based airflow obstruction, respectively. However, statistically significant effect modification was observed, but only in GLI-based moderate and severe airflow-obstruction, with tiotropium yielding adjHRs for death of 0.53 (0.34-0.81) and 0.99 (0.86-1.13), respectively. The P value for interaction was .007. INTERPRETATION Mortality reduction by tiotropium was only statistically significant in GLI-based moderate airflow-obstruction, a group that was underrepresented in UPLIFT because of severity misclassification by the original GOLD-based enrollment criteria.
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Affiliation(s)
- Carlos A Vaz Fragoso
- Veterans Affairs (VA) Connecticut Healthcare System, West Haven; Yale University School of Medicine, Department of Internal Medicine, New Haven, CT.
| | - Linda S Leo-Summers
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT
| | - Thomas M Gill
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT
| | - Gail J McAvay
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT
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