Comorbidities and burden of COPD: a population based case-control study

Examining the Impact of Social Support on Psychological Well-Being Among Canadian Individuals With COPD: Implications for Government Policies

Chronic obstructive pulmonary disease (COPD) is a significant respiratory disease and is globally ranked as the third leading cause of death. In Canada, the direct healthcare costs associated with COPD are estimated to be $1.5 billion annually. This study utilized quantitative analyses to examine the impact of specific dimensions of social support, namely, guidance, reliable alliance, reassurance of worth, attachment, and social integration within a clinically identified population of individuals with COPD who exhibit symptoms of depression and anxiety. The study was based on the Social Provisions Theory and stress-buffering hypothesis, utilizing large-scale population data from Statistics Canada's 2012 Canadian Community Health Survey (CCHS) Mental Health component. On a national scale, individuals were more likely to report a decreased sense of belonging to a group of friends (social integration) and struggle to depend on others in stressful times (reliable alliance) while experiencing symptoms of anxiety and depression. These findings underscore the potential benefits of integrating peer support, socialization initiatives, and caregiver training into clinical programs designed for individuals with COPD.

Auditory function assessment in patients with chronic obstructive pulmonary disease

Background

Chronic obstructive pulmonary disease is a multisystem disease with multiple comorbidities. Hearing is dependent on the cochlear functions that may be affected by oxygenation. Affection of hearing is problematic and represents a major concern that should be seriously investigated as an important comorbidity in chronic obstructive pulmonary disease patients.

Objective

To assess auditory status among chronic obstructive pulmonary disease patients.

Methodology

The current study was carried out at Al-Azhar University Hospitals, Cairo, from 1 August 2021 to 2022, including 120 participants. In addition to the control group (60 healthy participants), there were two study groups: chronic obstructive pulmonary disease patients with respiratory failure group (30 patients) and non-respiratory failure group (30 patients). Hearing functions were studied using pure tone audiometry, and auditory brain stem response.

Results

There was statistically significant hearing impairment in chronic obstructive pulmonary disease patients in comparison to control group. The hearing impairment was more significant in chronic obstructive pulmonary disease with respiratory failure group in comparison to chronic obstructive pulmonary disease without respiratory failure group. The auditory impairment shows a negative interrelationship with oxygen tension (PaO2) and a positive interrelationship with the smoking index.

Conclusion

Hearing affection was meaningfully higher among chronic obstructive pulmonary disease patients and more prominent in patients with respiratory failure. Hypoxia results in deterioration of pure tone audiometry and increased absolute and interpeak latencies in auditory brain stem response. At every frequency, the mean pure tone audiometry thresholds were higher for chronic obstructive pulmonary disease groups than control group albeit remaining in the mild to moderate area of hearing loss. Retro-cochlear affection was suggested among patients with chronic obstructive pulmonary disease as evidenced with the prolongation of auditory brain stem response waves latencies.

Comorbidities and mortality among patients with chronic obstructive pulmonary disease

INTRODUCTION

Comorbidities are common in patients with chronic obstructive pulmonary disease (COPD). Estimates of prevalence, incidence and prognostic impact of comorbidities provide foundational knowledge of COPD epidemiology. We examined the prevalence, incidence and prognostic impact of 21 comorbidities among patients with COPD compared with the Danish general population.

METHODS

We conducted a nationwide, population-based cohort study based on longitudinal Danish registry data, covering all Danish hospitals (2010-2021). The cohorts comprised 142 973 patients with a first-time hospital-based diagnosis of COPD and 428 917 age-matched and sex-matched comparators from the general population. During follow-up, we estimated the 5-year risk and risk difference, using competing risk methods when applicable.

RESULTS

At time of diagnosis, the comorbidities with the highest prevalence were mood, stress-related or anxiety disorders (25.2% for patients with COPD vs 13.1% for comparators), osteoporosis/hip fractures (17.4% vs 9.9%), diabetes (15.6% vs 10.5%), peripheral arterial disease (13.5% vs 4.9%) and heart failure (13.3% vs 4.0%). During follow-up, the risk of most incident comorbidities was markedly elevated among patients with COPD. The five comorbidities associated with the highest 5-year absolute risk difference with respect to the risk in the general population were mood, stress-related or anxiety disorders (5.7%), osteoporosis/hip fractures (5.6%), heart failure (4.2%), smoking-related cancers (2.8%) and peripheral arterial disease (2.7%). The 5-year mortality risk was 43% vs 17.7%. Among patients with COPD, the 5-year mortality risk markedly increased with the number of comorbidities present.

CONCLUSIONS

Our population-based findings underscore the importance of considering comorbidities in the management of COPD.

Subtyping Social Determinants of Health in All of Us: Network Analysis and Visualization Approach

Background

Social determinants of health (SDoH), such as financial resources and housing stability, account for between 30-55% of people's health outcomes. While many studies have identified strong associations among specific SDoH and health outcomes, most people experience multiple SDoH that impact their daily lives. Analysis of this complexity requires the integration of personal, clinical, social, and environmental information from a large cohort of individuals that have been traditionally underrepresented in research, which is only recently being made available through the All of Us research program. However, little is known about the range and response of SDoH in All of Us, and how they co-occur to form subtypes, which are critical for designing targeted interventions.

Objective

To address two research questions: (1) What is the range and response to survey questions related to SDoH in the All of Us dataset? (2) How do SDoH co-occur to form subtypes, and what are their risk for adverse health outcomes?

Methods

For Question-1, an expert panel analyzed the range of SDoH questions across the surveys with respect to the 5 domains in Healthy People 2030 (HP-30), and analyzed their responses across the full All of Us data (n=372,397, V6). For Question-2, we used the following steps: (1) due to the missingness across the surveys, selected all participants with valid and complete SDoH data, and used inverse probability weighting to adjust their imbalance in demographics compared to the full data; (2) an expert panel grouped the SDoH questions into SDoH factors for enabling a more consistent granularity; (3) used bipartite modularity maximization to identify SDoH biclusters, their significance, and their replicability; (4) measured the association of each bicluster to three outcomes (depression, delayed medical care, emergency room visits in the last year) using multiple data types (surveys, electronic health records, and zip codes mapped to Medicaid expansion states); and (5) the expert panel inferred the subtype labels, potential mechanisms that precipitate adverse health outcomes, and interventions to prevent them.

Results

For Question-1, we identified 110 SDoH questions across 4 surveys, which covered all 5 domains in HP-30. However, the results also revealed a large degree of missingness in survey responses (1.76%-84.56%), with later surveys having significantly fewer responses compared to earlier ones, and significant differences in race, ethnicity, and age of participants of those that completed the surveys with SDoH questions, compared to those in the full All of Us dataset. Furthermore, as the SDoH questions varied in granularity, they were categorized by an expert panel into 18 SDoH factors. For Question-2, the subtype analysis (n=12,913, d=18) identified 4 biclusters with significant biclusteredness (Q=0.13, random-Q=0.11, z=7.5, P<0.001), and significant replication (Real-RI=0.88, Random-RI=0.62, P<.001). Furthermore, there were statistically significant associations between specific subtypes and the outcomes, and with Medicaid expansion, each with meaningful interpretations and potential targeted interventions. For example, the subtype Socioeconomic Barriers included the SDoH factors not employed, food insecurity, housing insecurity, low income, low literacy, and low educational attainment, and had a significantly higher odds ratio (OR=4.2, CI=3.5-5.1, P-corr<.001) for depression, when compared to the subtype Sociocultural Barriers. Individuals that match this subtype profile could be screened early for depression and referred to social services for addressing combinations of SDoH such as housing insecurity and low income. Finally, the identified subtypes spanned one or more HP-30 domains revealing the difference between the current knowledge-based SDoH domains, and the data-driven subtypes.

Conclusions

The results revealed that the SDoH subtypes not only had statistically significant clustering and replicability, but also had significant associations with critical adverse health outcomes, which had translational implications for designing targeted SDoH interventions, decision-support systems to alert clinicians of potential risks, and for public policies. Furthermore, these SDoH subtypes spanned multiple SDoH domains defined by HP-30 revealing the complexity of SDoH in the real-world, and aligning with influential SDoH conceptual models such as by Dahlgren-Whitehead. However, the high-degree of missingness warrants repeating the analysis as the data becomes more complete. Consequently we designed our machine learning code to be generalizable and scalable, and made it available on the All of Us workbench, which can be used to periodically rerun the analysis as the dataset grows for analyzing subtypes related to SDoH, and beyond.

Gender-specific disease trajectories prior to the onset of COPD allow individualized screening and early intervention

BACKGROUND

Nation-wide hospitalization databases include diagnostic information at the level of an entire population over an extended period of time. Comorbidity network and early disease development can be unveiled. Chronic obstructive pulmonary disease (COPD) is an underdiagnosed condition for which it is crucial to identify early disease indicators. The identification of gender-specific conditions preceding the onset of COPD may reveal disease progression patterns allowing for early diagnosis and intervention. The objective of the study was to investigate the antecedent hospitalization history of patients newly diagnosed with COPD and to retrace a gender-specific trajectory of coded entities prior to the onset of COPD.

MATERIAL AND METHODS

A population-wide hospitalization database including information about all hospitalizations in Switzerland between 2002 and 2018 was used. COPD cases were extracted from the database and comorbidities occurring prior to the onset of COPD identified. Comorbidities significantly over-represented in COPD compared with a 1:1, age- and sex-matched control population were identified and their longitudinal evolution was analyzed.

RESULTS

Between 2002 and 2018, 697,714 hospitalizations with coded COPD were recorded in Switzerland. Sixty-two diagnoses were significantly over-represented before onset of COPD. These preceding comorbidities included both well-established conditions and novel links to COPD. Early pre-conditions included nicotine and alcohol abuse, obesity and cardiovascular diseases. Later comorbidities included atrial fibrillation, diseases of the genitourinary system and pneumonia. Atherosclerotic heart diseases were more prevalent in males, whereas hypothyroidism, varicose and intestinal disorders were more frequent in females. Disease trajectories were validated using an independent data set.

CONCLUSIONS

Gender-specific disease trajectories highlight early indicators and pathogenetic links between COPD and antecedent diseases and could allow for early detection and intervention.

Features of Kidney Function in Patients With Comorbidity of Arterial Hypertension and Chronic Obstructive Pulmonary Disease

Background and objective Chronic kidney disease (CKD) and hypertension are closely linked in terms of cause and effect. Decreased renal function is usually associated with increased blood pressure, and a steady increase in blood pressure accelerates the decline in renal function. In this study, we aimed to investigate laboratory parameters of renal function - blood creatinine level, urine creatinine level, urea blood level, urine albumin level, and in particular, serum cystatin C level - as early predictors of kidney damage and assess the filtration function of the kidneys based on the glomerular filtration rate (GFR) in patients with isolated arterial hypertension, those with a comorbid pathology of hypertension and chronic obstructive pulmonary disease (COPD). and those with isolated COPD. Materials and methods The study included a total of 101 patients (the final sample consisted of 88 patients) with hypertension and COPD, who were divided into three groups: Group I consisted of 38 patients with hypertension, Group II comprised 27 patients with hypertension and COPD, and Group III was made up of 23 patients with COPD. The average age of patients in groups - presented as mean [standard deviation (SD)] - was as follows - Group I: 55.7 (11.2) years, Group II: 59.3 (9.2) years, and Group III: 57.8 (9.1) years. For statistical data processing, the program Statistics 10 was used. Results The level of blood creatinine - presented as median (Me) and interquartile range (IQR) - was statistically significantly different between the groups, and the values in the three groups were as follows - Group I (patients with hypertension): 88.3 (84.2; 102.7) μmol/l, Group II (patients with comorbid pathology of arterial hypertension and COPD): 99.0 (80.0; 115.0) μmol/l, and Group III (patients with COPD): 84.6 (75.0; 94.2) μmol/l (p=0.008). The highest level was determined in patients with hypertension and comorbid COPD, while the lowest was in the comparison group, in patients with COPD. Urinary creatinine levels were as follows - Group I: 1081.0 (578.0; 1749.0) mg/l, Group II: 1318.5 (1124.0; 1817.0) mg/l, and Group III: 822.0 (625.0; 1320.5) mg/l (p=0.08). Blood urea values were as follows - Group I: 5.7 (5.2; 6.0) mmol/l, Group II: 5.7 (4.9; 6.6) mmol/l, Group III: 5.9 (4.4; 7.7) mmol/l. The calculation of GFR revealed a statistically significant difference between the three groups - Group I: 70.5 (56.0; 83.0) ml/min, Group II: 66.5 (57.0; 77.0) ml/min, and Group III: 81.5 (70.0; 88.0) ml/min (p=0.02). The cystatin C level was 1.16 (1.03; 1.27) mg/l in Group I, 1.3 (1.22; 1.38) mg/l in Group II, and 1.05 (0.96; 1.05) mg/l in Group III. Conclusions In patients of all three groups, there was a decrease in renal filtration function based on the results of creatinine and cystatin C levels. Even in the group of patients with COPD without kidney disease, a decrease in GFR was observed. We noted a negative aggravating effect of COPD on renal function in patients with hypertension, which can be attributed to increased endothelial dysfunction and increased general inflammation in this group of patients.

Factors affecting length of hospital stay in chronic obstructive pulmonary disease patients in a tertiary hospital of Nepal: A retrospective cross-sectional study

Background

Despite the increasing burden of chronic obstructive pulmonary disease in Nepal, studies analyzing the factors associated with inpatient length of hospital stay are lacking.

Methods

This is a retrospective, cross-sectional hospital-based study conducted between July 2020 and July 2021 on patients admitted to the inpatient ward of Pulmonary and Critical Care Medicine of Tribhuvan University Teaching Hospital with a primary diagnosis of acute exacerbation of chronic obstructive pulmonary disease. The sample size of our study was 90. Clinical and demographic factors, blood investigation parameters, and treatment received were analyzed via univariate and multivariate analysis to find the factors associated with length of stay.

Results

The mean age of chronic obstructive pulmonary disease patients was 68.84 ± 10.22 years, with 42.2% of males and 43.3% of current smokers. The length of hospital stay ranged from 2 to 25 days, with an average stay of 6.69 ± 4.02 days. Factors associated with length of stay are the number of comorbidities (p = 0.007), blood eosinophils at admission (p = 0.022), and use of mechanical ventilatory support (p < 0.001).

Conclusions

Proper management of comorbidities and eosinophilic exacerbations as well as careful use of mechanical ventilatory support are required to further reduce the duration of hospital stay in chronic obstructive pulmonary disease patients.

•

This study is the first of its kind identifying the factors associated with the length of hospital stay in COPD patients in Nepal.

•

COPD is the fifth most common cause of inpatient admission in Nepal and per our study the length of stay was 6.69 days.

•

The culprits identified for the increase length of stay were the number of comorbidities, blood eosinophils at admission and use of mechanical ventilator support.

In-hospital survival paradox in patients with sleep apnea-A nation-wide nested case-control study

BACKGROUND

Sleep apnea (SA) is a prevalent disorder characterized by recurrent events of nocturnal apnea originating from obstructive and/or central mechanisms. SA disrupts normal sleep and can lead to a series of complications when left untreated. SA results in intermittent hypoxia which has an impact on the cardio- and cerebrovascular system. Hospitalized patients with SA typically have a greater burden of comorbidity, a longer length of hospital stay, but may show an improvement of in-hospital mortality compared to patients without diagnosed SA. The reason for this survival benefit is controversial and we aimed to clarify this protective effect in the light of predictive factors including SA-associated comorbidities using a nation-wide hospitalization database.

METHODS AND FINDINGS

Data were extracted from a nation-wide hospitalization database provided by the Swiss Federal Office for Statistics. Hospitalized patients with a SA co-diagnosis were extracted from the database together with a 1:1-matched control population without SA. Overall, 212'581 patients with SA were hospitalized in Switzerland between 2002 and 2018. Compared to the controls, SA cases had a longer median length of hospital stay (7 days; 95% CI: 3 to 15 vs. 4 days; 95% CI: 2 to 10) (p < 0.001) and a higher median number of comorbidities (8 comorbidities; IQR: 5 to 11 vs. 3 comorbidities; IQR: 1 to 6) (p < 0.001). The risk of in-hospital mortality was lower in the SA cases compared to the controls (OR: 0.73; 95% CI: 0.7 to 0.76; p < 0.001). SA was associated with a survival benefit in hospitalizations related to 28 of 47 conditions with the highest rate of in-hospital death. Sixty-three comorbidities were significantly over-represented in SA cases among which obesity, hypertension and anatomic nasal deviations were associated with a significant decrease of in-hospital mortality.

CONCLUSIONS

Compared to matched controls, SA was associated with significant and relevant inpatient survival benefit in a number of most deadly conditions. Within SA-patients, associated comorbidities mostly correlated with a poorer prognosis, whereas obesity and hypertension were associated with an improved in-hospital mortality.

PREVALENCE AND IMPACT OF COMORBIDITIES IN INDIVIDUALS WITH COPD: A SYSTEMATIC REVIEW

This study aimed to describe the prevalence of comorbidities associated with chronic obstructive pulmonary disease (COPD) and their relation with relevant outcomes. A systematic review based on the PRISMA methodology was performed from January 2020 until July 2021. The MEDLINE, Lilacs, and Scielo databases were searched to identify studies related to COPD and its comorbidities. Observational studies on the prevalence of comorbidities in COPD patients and costs with health estimates, reduced quality of life, and mortality were included. Studies that were restricted to one or more COPD pain assessments and only specific comorbidities such as osteoporosis, bronchitis, and asthma were excluded. The initial search identified 1,409 studies and after applying the inclusion and exclusion criteria, 20 studies were finally selected for analysis (comprising data from 447,459 COPD subjects). The most frequent COPD comorbidities were: hypertension (range, 17%–64.7%), coronary artery disease (19.9%–47.8%), diabetes (10.2%–45%), osteoarthritis (18%–43.8%), psychiatric conditions (12.1%–33%), and asthma (14.7%–32.5%). Several comorbidities had an impact on the frequency and severity of COPD exacerbations, quality of life, and mortality risk, in particular malignancies, coronary artery disease, chronic heart failure, and cardiac arrhythmias. Comorbidities, especially cardiovascular diseases and diabetes, are frequent in COPD patients, and some of them are associated with higher mortality.

Short-term exposure to ambient air pollution and pneumonia hospital admission among patients with COPD: a time-stratified case-crossover study

Background

Pneumonia is a major contributor to hospital admission for patients with chronic obstructive pulmonary disease (COPD). However, evidence for acute effects of ambient air pollution exposure on pneumonia hospital admission among patients with COPD is scarce. We aimed to examine the association between short-term exposure to ambient air pollution and pneumonia hospital admission among patients with COPD.

Methods

We enrolled COPD cases aged ≥ 60 years old and further filtered those who were admitted into hospitals from pneumonia during 2016–2019 in Guangdong province, China for main analysis. A time-stratified case-crossover design was applied to investigate the association and conditional logistic regression model was used for data analysis. We performed inverse distance weighting method to estimate daily individual-level exposure on particulate matter with an aerodynamic diameter ≤ 2.5 μm (PM_2.5), particulate matter with an aerodynamic diameter ≤ 10 μm (PM₁₀), sulfur dioxide (SO₂), nitrogen dioxide (NO₂), carbon monoxide (CO), and ozone (O₃) based on personal residential addresses.

Results

We included 6473 pneumonia hospital admissions during the study period. Each interquartile range (IQR) increase in PM_2.5 (lag 2; IQR, 22.1 μg/m³), SO₂ (lag 03; IQR, 4.2 μg/m³), NO₂ (lag 03; IQR, 21.4 μg/m³), and O₃ (lag 04; IQR, 57.9 μg/m³) was associated with an odds ratio in pneumonia hospital admission of 1.043 (95% CI: 1.004–1.083), 1.081 (95% CI: 1.026–1.140), 1.045 (95% CI: 1.005–1.088), and 1.080 (95% CI: 1.018–1.147), respectively. Non-linear trends for PM_2.5, PM₁₀, and SO₂ were observed in the study. Sex, age at hospital admission, and season at hospital admission did not modify the associations.

Conclusions

We found significantly positive associations of short-term exposure to PM_2.5, SO₂, NO₂, and O₃ with pneumonia hospital admission among COPD patients. It provides new insight for comprehensive pneumonia prevention and treatment among COPD patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-01989-9.

Interaction Between Chronic Bronchitis and Blood Cadmium Levels on the Prevalence of Myocardial Infarction in US Adults: The National Health and Nutritional Examination Survey, 2005-2016

OBJECTIVE

To explore the interaction between chronic bronchitis and blood cadmium on the prevalence of myocardial infarction.

METHODS

We used weighted US-NHANES data. Multivariate survey logistic regression was used to examine the associations between myocardial infarction, cadmium concentration and chronic bronchitis. Adjusted odds ratios, 95% confidence intervals were computed.

RESULTS

There was a significant interaction (OR=1.33, CI = [1.01, 1.74]) between chronic bronchitis and blood cadmium level on the presence of myocardial infarction. For 1 μg/L increase in cadmium level, people with chronic bronchitis had 1.65 (1.24 × 1.33) times the odds of having myocardial infarction, while those without chronic bronchitis would be only 1.24 times as likely having the outcome (OR = 1.24, CI = [1.05, 1.46]).

CONCLUSION

Findings highlights the role of chronic bronchitis on the relationship between blood cadmium concentration and myocardial infarction. Prospective cohort designs are needed to confirm these findings.

Predicting 30-days Readmission Risk for COPD Patients Care through a Federated Machine Learning Architecture on FAIR Data: Development and Validation Study (Preprint)

Background

Owing to the nature of health data, their sharing and reuse for research are limited by legal, technical, and ethical implications. In this sense, to address that challenge and facilitate and promote the discovery of scientific knowledge, the Findable, Accessible, Interoperable, and Reusable (FAIR) principles help organizations to share research data in a secure, appropriate, and useful way for other researchers.

Objective

The objective of this study was the FAIRification of existing health research data sets and applying a federated machine learning architecture on top of the FAIRified data sets of different health research performing organizations. The entire FAIR4Health solution was validated through the assessment of a federated model for real-time prediction of 30-day readmission risk in patients with chronic obstructive pulmonary disease (COPD).

Methods

The application of the FAIR principles on health research data sets in 3 different health care settings enabled a retrospective multicenter study for the development of specific federated machine learning models for the early prediction of 30-day readmission risk in patients with COPD. This predictive model was generated upon the FAIR4Health platform. Finally, an observational prospective study with 30 days follow-up was conducted in 2 health care centers from different countries. The same inclusion and exclusion criteria were used in both retrospective and prospective studies.

Results

Clinical validation was demonstrated through the implementation of federated machine learning models on top of the FAIRified data sets from different health research performing organizations. The federated model for predicting the 30-day hospital readmission risk was trained using retrospective data from 4.944 patients with COPD. The assessment of the predictive model was performed using the data of 100 recruited (22 from Spain and 78 from Serbia) out of 2070 observed (records viewed) patients during the observational prospective study, which was executed from April 2021 to September 2021. Significant accuracy (0.98) and precision (0.25) of the predictive model generated upon the FAIR4Health platform were observed. Therefore, the generated prediction of 30-day readmission risk was confirmed in 87% (87/100) of cases.

Conclusions

Implementing a FAIR data policy in health research performing organizations to facilitate data sharing and reuse is relevant and needed, following the discovery, access, integration, and analysis of health research data. The FAIR4Health project proposes a technological solution in the health domain to facilitate alignment with the FAIR principles.

The Effect of Multimorbidity Patterns and the Impact of Comorbid Anxiety and Depression on Primary Health Service Use: The Men Androgen Inflammation Lifestyle Environment and Stress (MAILES) Study

This study sought to determine patterns of multimorbidity and quantify their impact on use of primary health services in the presence and absence of anxiety and depression among a cohort of urban community-dwelling men in Australia. The analytic sample consisted of men (n = 2039; age 38–85) from the follow-up wave of a prospective cohort study of all participants of the Florey Adelaide Male Ageing Study (FAMAS; Stage 2 [2007–2010]) and age-matched men from the North-West Adelaide Health Study (NWAHS; Stage 3 [2008–2010]). Self-reported data and linkage with a national universal health coverage scheme (Medicare) provided information on the prevalence of eight chronic conditions and health service utilization information (including annual GP visits). Obesity and cardiovascular disease (CVD) were associated with the highest number of comorbid conditions. Two nonrandom multimorbidity “clusters” emerged: “CVD, Obesity, Diabetes” and “CVD, Obesity, Osteoarthritis.” Participants with conditions comorbid with CVD were more likely to have 10 or more annual GP visits, compared to multimorbidity involving other conditions. In comparison to participants without CVD, the presence of CVD increased the chance of having 10 or more annual GP visits (adjusted risk ratio: 3.7; 95% CI [2.8, 4.8]). When CVD was comorbid with anxiety and depression, having 10 or more annual GP visits was more common (adjusted risk ratio: 1.8; 95% CI [1.2, 2.5]). Multimorbidity patterns involving CVD, especially for multimorbidity that includes CVD with comorbid anxiety and depression, should be considered in developing clinical trials to better inform medical decision-making and care for patients with CVD and comorbid conditions.

Factors Influencing the Length of Hospital Stay Among Patients with Chronic Obstructive Pulmonary Disease (COPD) in Macao Population: A Retrospective Study of Inpatient Health Record

Purpose

This study aims to identify the effects of patient and clinical therapy factors on the length of hospital stay (LOS) for admission due to chronic obstructive pulmonary disease (COPD) in Macao.

Patients and Methods

Health record of patients with COPD admitted to Kiang Wu Hospital from January 2017 to December 2019 was retrospectively analyzed. Demographic information, blood test results, clinical therapies, and LOS were described and analyzed by multivariable regression.

Results

A total of 1116 admissions were included with the average LOS being 12.28 (±9.23) days. Among them, 735 (66.6%) were male with mean age 79.42 (±10.35) years old, 697 were current or previous smokers (62.5%), and 360 (32.2%) had 3 or more comorbidities. During hospitalization, the most common treatments received were oxygen therapy (n=991,88.8%), antibiotics (n=828,74.2%), and systemic steroids (n=596,53.4%); only 120 (10.8%) had pulmonary rehabilitation (PR) and 128 (11.5%) received noninvasive ventilation (NIV). Inhaled medications were used during nearly 95% of hospitalization cases, while 2 and 3 types of inhaled medications were used during 230 (20.6%) and 582 (52.2%) hospitalization cases, respectively. Patient factors including age (B=0.178, 95% CI:0.535–1.072), being female (B=−1.147, 95% CI:-0.138–0.056), being current (B=−0.086, 95% CI:-0.124–0.018) or previous smoker (B=0.072, 95% CI:0.004–0.087), having 1, 2, 3 and over 3 comorbidities (B=0.126, 95% CI:0.034–0.147; B=0.125, 95% CI:0.031–0.144; B=0.116, 95% CI:0.028–0.146, B=0.090, 95% CI:0.021–0.166) and having low hemoglobin level (B=−0.118, 95% CI:-0.629- −0.214) exhibited significant associations with LOS. The use of NIV (B=0.080, 95% CI:0.022–0.138), pulmonary rehabilitation (B=0.269, 95% CI:0.212–0.327), two and three types of inhaled medications (B=0.109, 95% CI:0.003–0.166, B=0.255, 95% CI:0.083–0.237) were significantly associated with longer LOS (P<0.05).

Conclusion

NIV, PR and combined inhaled medications, which are often used for AECOPD, are the main clinical therapies associated with longer LOS in Macao. Smoking cessation, early treatments of comorbidities may be crucial to avoiding AECOPD and reducing LOS and disease burden.

Indacaterol/glycopyrronium affects lung function and cardiovascular events in patients with chronic obstructive pulmonary diseases: A meta-analysis

BACKGROUND

Bronchodilators are the cornerstone for treating patients with chronic obstructive pulmonary diseases (COPD), although some studies have shown that dual bronchodilators may exacerbate incidence of adverse cardiovascular events. Here, we evaluated the cardiopulmonary safety of indacaterol/glycopyrronium (IND/GLY) using a meta-analysis.

METHODS

We searched PubMed, OVID, Cochrane Library and Web of Science databases, using "indacaterol/glycopyrronium", "indacaterol/glycopyrrolate", "IND/GLY", "QVA149", "chronic obstructive pulmonary diseases", "COPD", "chronic obstructive airway disease", "chronic obstructive lung disease" as key words. Acute exacerbation of COPD and FEV₁ as indicators of pulmonary function and occurrence of hypertension, atrial fibrillation, myocardial infarction and heart failure as indicators of cardiovascular safety.

RESULTS

A total of 23 articles, comprising 21,238 participants, were included in the analysis. FEV₁ values were significantly different compared to IND/GLY and single bronchodilator therapy (LABA or LAMA), with the MD 0.11 L (95%CI: 0.10-0.13, P<0.01). Hypertension was more frequent in the IND/GLY, than the single bronchodilator therapy group, although this difference was insignificant (IND/GLY vs LABA, RR=1.88, P = 0.09; IND/GLY vs LAMA, RR=1.42, P = 0.08; IND/GLY vs LABA+ICS, RR=1.85, P = 0.23). In addition, IND/GLY did not significantly increase the risk of myocardial infarction (IND/GLY vs LAMA or double therapy, total RR: 1.49, 95%CI: 0.72-3.08, P = 0.28), atrial fibrillation (IND/GLY vs LAMA, RR: 1.62, 95%CI: 0.64-4.10, P = 0.31) and heart failure (IND/GLY vs LAMA, RR: 0.40, 95%CI: 0.07-2.33, P = 0.31) in COPD patients.

CONCLUSIONS

IND/GLY significantly reduced incidence of acute COPD exacerbations, and slowed down the decline of FEV₁. Adequate safety measures are needed to control incidence of adverse cardiovascular events.

Fate or coincidence: do COPD and major depression share genetic risk factors?

Major depressive disorder (MDD) is a common comorbidity in chronic obstructive pulmonary disease (COPD), affecting up to 57% of patients with COPD. Although the comorbidity of COPD and MDD is well established, the causal relationship between these two diseases is unclear. A large-scale electronic health record clinical biobank and genome-wide association study summary statistics for MDD and lung function traits were used to investigate potential shared underlying genetic susceptibility between COPD and MDD. Linkage disequilibrium score regression was used to estimate genetic correlation between phenotypes. Polygenic risk scores (PRS) for MDD and lung function traits were developed and used to perform a phenome-wide association study (PheWAS). Multi-trait-based conditional and joint analysis identified single-nucleotide polymorphisms (SNPs) influencing both lung function and MDD. We found genetic correlations between MDD and all lung function traits were small and not statistically significant. A PRS-MDD was significantly associated with an increased risk of COPD in a PheWAS [odds ratio (OR) = 1.12, 95% confidence interval (CI): 1.09-1.16] when adjusting for age, sex and genetic ancestry, but this relationship became attenuated when controlling for smoking history (OR = 1.08, 95% CI: 1.04-1.13). No significant associations were found between the lung function PRS and MDD. Multi-trait-based conditional and joint analysis identified three SNPs that may contribute to both traits, two of which were previously associated with mood disorders and COPD. Our findings suggest that the observed relationship between COPD and MDD may not be driven by a strong shared genetic architecture.

Diagnostic and therapeutic challenges of chronic obstructive pulmonary disease in the elderly

PURPOSE OF REVIEW

Chronic obstructive pulmonary disease (COPD) imposes a large burden on the global population and even more so for the elderly who face significant obstacles in the diagnosis, management, and psychosocial effects of the disease. This review describes the current challenges and key points in the management of COPD in the elderly.

RECENT FINDINGS

Lower limit rather than fixed cut off of the FEV1/FVC ratio can improve the diagnosis and better predict COPD mortality. High relative to standard dose influenza vaccination reduces confirmed cases of influenza overall and reduces hospitalizations in older nursing home residents. Simple interventions that include electronic health record tracking can significantly improve vaccination rates. Although many inhaler and nebulized medications are available for the elderly, the final regimen is usually determined by a combination of expense, issues with proper device use (from difficulty with coordination, hand grip, inspiratory flows or cognitive function) and the side effect profile. Fortunately, the switch to cheaper or better covered alternatives can be well tolerated with improvement in adherence and exacerbations of COPD. Finally, caution should be made against ageism, which may be a factor in the recommendation of rehabilitation or palliative care in the elderly COPD patient, as both are underused despite evidence of benefit.

SUMMARY

Although care for the elderly COPD patient can be difficult, we summarize key points that the physician should be cognizant of to provide comprehensive care.

Pattern of comorbidities and 1-year mortality in elderly patients with COPD hospitalized in internal medicine wards: data from the RePoSI Registry

Currently, chronic obstructive pulmonary disease (COPD) represents the fourth cause of death worldwide with significant economic burden. Comorbidities increase in number and severity with age and are identified as important determinants that influence the prognosis. In this observational study, we retrospectively analyzed data collected from the RePoSI register. We aimed to investigate comorbidities and outcomes in a cohort of hospitalized elderly patients with the clinical diagnosis of COPD. Socio-demographic, clinical characteristics and laboratory findings were considered. The association between variables and in-hospital, 3-month and 1-year follow-up were analyzed. Among 4696 in-patients, 932 (19.8%) had a diagnosis of COPD. Patients with COPD had more hospitalization, a significant overt cognitive impairment, a clinically significant disability and more depression in comparison with non-COPD subjects. COPD patients took more drugs, both at admission, in-hospital stay, discharge and 3-month and 1-year follow-up. 14 comorbidities were more frequent in COPD patients. Cerebrovascular disease was an independent predictor of in-hospital mortality. At 3-month follow-up, male sex and hepatic cirrhosis were independently associated with mortality. ICS-LABA therapy was predictor of mortality at in-hospital, 3-month and 1-year follow-up. This analysis showed the severity of impact of COPD and its comorbidities in the real life of internal medicine and geriatric wards.

Telomere length dynamics over 10-years and related outcomes in patients with COPD

Background

Chronic obstructive pulmonary disease (COPD) has been proposed as a disease of accelerated aging. Several cross-sectional studies have related a shorter telomere length (TL), a marker of biological aging, with COPD outcomes. Whether accelerated telomere shortening over time relates to worse outcomes in COPD patients, is not known.

Methods

Relative telomere length (T/S) was determined by qPCR in DNA samples from peripheral blood in 263 patients at baseline and up to 10 years post enrolment. Yearly clinical and lung function data of 134 patients with at least two-time measures of T/S over this time were included in the analysis.

Results

At baseline, T/S inversely correlated with age (r = − 0.236; p < 0.001), but there was no relationship between T/S and clinical and lung function variables (p > 0.05). Over 10 years of observation, there was a median shortening of TL of 183 bp/year for COPD patients. After adjusting for age, gender, active smoking and mean T/S, patients that shortened their telomeres the most over time, had worse gas exchange, more lung hyperinflation and extrapulmonary affection during the follow-up, (PaO₂ p < 0.0001; K_CO p = 0.042; IC/TLC p < 0.0001; 6MWD p = 0.004 and BODE index p = 0.009). Patients in the lowest tertile of T/S through the follow-up period had an increased risk of death [HR = 5.48, (1.23–24.42) p = 0.026].

Conclusions

This prospective study shows an association between accelerated telomere shortening and progressive worsening of pulmonary gas exchange, lung hyperinflation and extrapulmonary affection in COPD patients. Moreover, persistently shorter telomeres over this observation time increase the risk for all-cause mortality.

Serum Albumin Concentrations in Stable Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

Background: Chronic obstructive pulmonary disease (COPD) is a progressive condition characterized by chronic airway inflammation and lung parenchyma damage. Systemic inflammation and oxidative stress also play a role in the pathogenesis of COPD. Serum albumin is a negative acute-phase protein with antioxidant effects and an important marker of malnutrition. The aim of this meta-analysis was to investigate differences in serum albumin concentrations between patients with stable COPD and non-COPD subjects. Methods: A systematic search was conducted, using the terms “albumin” and “chronic obstructive pulmonary disease” or “COPD”, in the electronic databases PubMed and Web of Science, from inception to May 2020. Results: Twenty-six studies were identified on a total of 2554 COPD patients and 2055 non-COPD controls. Pooled results showed that serum albumin concentrations were significantly lower in COPD patients (standard mean difference, SMD = −0.50, 95% CI −0.67 to −0.32; p < 0.001). No significant differences were observed in SMD of serum albumin concentrations between COPD patients with forced expiratory volume in the 1st second (FEV1) < 50% and those with FEV1 > 50%. Conclusions: Our systematic review and meta-analysis showed that serum albumin concentrations are significantly lower in patients with stable COPD compared to non-COPD controls. This supports the presence of a deficit in systemic anti-inflammatory and antioxidant defense mechanisms in COPD.

Advances in understanding of mechanisms related to increased cardiovascular risk in COPD

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) represents a serious global health issue that is commonly associated with cardiovascular (CV) disease (CVD). The close relationship between COPD and CVD could be explained by different factors, first and foremost a chronic low-grade systemic inflammation implicated in the pathogenesis of both diseases and several stimuli enhancing the inflammatory processes and causing a mixed condition with worse outcomes than either disorder alone.

AREAS COVERED

The present narrative review considers the mechanisms underlying the increased CV risk in COPD, and it provides insights on biomarkers and predictive models to predict CVD in COPD patients.

EXPERT OPINION

COPD patients often remain asymptomatic of CVD, with respiratory symptoms generally attributed to the preexisting pulmonary disease. It is fundamental to understand the mechanistic pathways that underpin the intimate relationship between the two disorders. However, it is still not clear what is the origin of the common background of low-grade systemic inflammation, it could be a 'spillover' or a general inflammatory state. Primary prevention, cross-collaboration between specialists and early detection via predictive biomarkers and validated models are fundamental to stratify COPD patients according to CV risk.

How High-Risk Comorbidities Co-Occur in Readmitted Patients With Hip Fracture: Big Data Visual Analytical Approach

BACKGROUND

When older adult patients with hip fracture (HFx) have unplanned hospital readmissions within 30 days of discharge, it doubles their 1-year mortality, resulting in substantial personal and financial burdens. Although such unplanned readmissions are predominantly caused by reasons not related to HFx surgery, few studies have focused on how pre-existing high-risk comorbidities co-occur within and across subgroups of patients with HFx.

OBJECTIVE

This study aims to use a combination of supervised and unsupervised visual analytical methods to (1) obtain an integrated understanding of comorbidity risk, comorbidity co-occurrence, and patient subgroups, and (2) enable a team of clinical and methodological stakeholders to infer the processes that precipitate unplanned hospital readmission, with the goal of designing targeted interventions.

METHODS

We extracted a training data set consisting of 16,886 patients (8443 readmitted patients with HFx and 8443 matched controls) and a replication data set consisting of 16,222 patients (8111 readmitted patients with HFx and 8111 matched controls) from the 2010 and 2009 Medicare database, respectively. The analyses consisted of a supervised combinatorial analysis to identify and replicate combinations of comorbidities that conferred significant risk for readmission, an unsupervised bipartite network analysis to identify and replicate how high-risk comorbidity combinations co-occur across readmitted patients with HFx, and an integrated visualization and analysis of comorbidity risk, comorbidity co-occurrence, and patient subgroups to enable clinician stakeholders to infer the processes that precipitate readmission in patient subgroups and to propose targeted interventions.

RESULTS

The analyses helped to identify (1) 11 comorbidity combinations that conferred significantly higher risk (ranging from P<.001 to P=.01) for a 30-day readmission, (2) 7 biclusters of patients and comorbidities with a significant bicluster modularity (P<.001; Medicare=0.440; random mean 0.383 [0.002]), indicating strong heterogeneity in the comorbidity profiles of readmitted patients, and (3) inter- and intracluster risk associations, which enabled clinician stakeholders to infer the processes involved in the exacerbation of specific combinations of comorbidities leading to readmission in patient subgroups.

CONCLUSIONS

The integrated analysis of risk, co-occurrence, and patient subgroups enabled the inference of processes that precipitate readmission, leading to a comorbidity exacerbation risk model for readmission after HFx. These results have direct implications for (1) the management of comorbidities targeted at high-risk subgroups of patients with the goal of pre-emptively reducing their risk of readmission and (2) the development of more accurate risk prediction models that incorporate information about patient subgroups.

Adherence to inhalers and comorbidities in COPD patients. A cross-sectional primary care study from Greece

Background

Comorbidities and adherence to inhaled therapy appears to have a major impact on treatment goals, health status and disease control in chronic obstructive pulmonary disease (COPD). Aim of the study was to assess levels of adherence to inhalers, comorbidities and associations with COPD outcomes in patients residing in rural and semi-urban areas of Greece.

Methods

Two hundred fifty-seven COPD patients were enrolled from primary health care in 2015–2016. Physicians used structured interviews and questionnaires to assess quality of life and disease status. Patients were classified into groups according to GOLD 2019 guidelines (based on CAT and mMRC). Adherence to inhalers was measured with the Test of Adherence to Inhalers (TAI). Multivariate linear and logistics regression models were used to assess associations between comorbidities and adherence to inhalers with COPD outcomes, including CAT and mMRC scores, exacerbations and GOLD A-D status.

Results

74.1% of COPD patients reported poor adherence, while most of them were characterized as deliberate non-compliers (69.5%). 77.1% had ≥2 comorbidities, with overweight/obese (82.2%), hypertension (72.9%) and diabetes mellitus (58%) being the most prevalent. In multivariate analysis, COPD outcomes having significant associations with poor adherence included worse health status [OR (95% CI) 4.86 (1.61–14.69) and 2.93 (1.51–5.71) based on CAT and mMRC, respectively], having ≥2 exacerbations in the past year [4.68 (1.51–4.44)], and disease status e.g., be in groups C or D [3.13 (1.49–8.53) and 3.35 (1.24–9.09) based on CAT and mMRC, respectively). Subjects with gastroesophageal reflux showed better inhaler adherence [OR (95% CI) 0.17 (0.6–0.45)], but none of the comorbid conditions was associated with COPD outcomes after adjustments.

Conclusions

Poor adherence to inhalers and comorbidities are both prevalent in COPD patients of primary care residing in rural/semi-urban areas of Greece, with adherence influencing COPD outcomes. Raising awareness of patients and physicians on the importance of comorbidities control and inhaler adherence may lead to interventions and improve outcomes.

In Patients with Mild-to-Moderate COPD, Tobacco Smoking, and Not COPD, Is Associated with a Higher Risk of Cardiovascular Comorbidity

Background

Comorbidities including cardiovascular diseases are very common in chronic obstructive pulmonary disease (COPD) secondary to tobacco smoking and contribute to the overall severity of the disease. In non-smoking COPD, which accounts for about 25% of COPD cases worldwide, current knowledge on the frequency and determinants of comorbidities remains scarce. The aims of the current study were to assess the frequency of major comorbidities and to evaluate their determinants in a group of non-selected patients with mild-to-moderate COPD who were exposed to organic dust (dairy farmers), to tobacco smoking, or to both, and in controls without COPD who were exposed to organic dust (dairy farmers), or to tobacco smoking, or to both, or who were without exposure.

Patients and Methods

A total of 4665 subjects (2323 dairy farmers and 2342 non-farmers) including 355 patients with COPD and 4310 controls with normal spirometry were recruited through a large COPD screening program. Self-reported physician-diagnosed diseases with plausible links to COPD were recorded in this cross-sectional study.

Results

Whatever the exposure, cardiovascular comorbidities were not more frequent in patients with COPD than their counterparts without airflow limitation. A higher risk of major cardiovascular comorbidities was associated with tobacco smoking and a lower risk was associated with exposure to organic dusts.

Conclusion

Tobacco smoking (but not COPD) is associated with higher frequency of cardiovascular comorbidities. By contrast, being a dairy farmer exposed to organic dusts is associated with a lower frequency of the same comorbidities. This reinforces the crucial need for controlling established cardiovascular risk factors even in patients with mild-to-moderate COPD.

The Geographical Distribution of Morbidity Caused By Chronic Obstructive Pulmonary Disease in Turkey: COPDTURKEY-2

Background

Chronic obstructive pulmonary disease (COPD) is one of the most prevalent causes for morbidity and mortality, and it creates a cumulative economic and social burden.

Aims

To determine the distribution of the prevalence of patients in Turkey who were diagnosed with COPD and their morbidity rates, according to the regions and cities they belong to. Moreover, the study contributes to the prevention and cure services of COPD that should be planned in the future.

Study Design

A retrospective cohort.

Methods

The database of the Social Security Institution from 2016 has been scanned. All the data with prescription registration, with the code ICD-10, J44.0-J44.9, which were aimed for diagnosing and/or cure, have been evaluated with a retrospective cohort.

Results

In 2016, 955,369 patients who were admitted as outpatients to the hospitals were diagnosed with COPD. The average number of annual COPD cases that were admitted was 2.09. Twenty percent (20%) of the outpatient applications were via emergency room. The rate of hospitalization among the applicants was 17.75%, with a total of 1,994,325. The average annual number of hospitalizations of men was higher than that of women. The average number of hospitalization days was 6.52. The region with the highest prevalence of outpatient admission and hospitalization was the Black Sea Region.

Conclusion

The high rate of hospitalization was considered to be the outcome of the insufficient “outpatient” management.

Impact of Comorbidities and Commonly Used Drugs on Mortality in COPD - Real-World Data from a Primary Care Setting

Background

Life expectancy is significantly shorter for patients with chronic obstructive pulmonary disease (COPD) than the general population. Concurrent diseases are known to infer an increased mortality risk in those with COPD, but the effects of pharmacological treatments on survival are less established. This study aimed to examine any associations between commonly used drugs, comorbidities and mortality in Swedish real-world primary care COPD patients.

Methods

Patients with physician-diagnosed COPD from a large primary care population were observed retrospectively, utilizing primary care records and mandatory Swedish national registers. The time to all-cause death was assessed in a stepwise multiple Cox proportional hazards regression model including demography, socioeconomic factors, exacerbations, comorbidities and medication.

Results

During the observation period (1999-2009) 5776 (32.5%) of 17,745 included COPD patients died. Heart failure (hazard ratio [HR]: 1.88, 95% confidence interval [CI]: 1.74-2.04), stroke (HR: 1.52, 95% CI: 1.40-1.64) and myocardial infarction (HR: 1.40, 95% CI: 1.24-1.58) were associated with an increased risk of death. Use of inhaled corticosteroids (ICS; HR: 0.79, 95% CI: 0.66-0.94), beta-blockers (HR: 0.86, 95% CI: 0.76-0.97) and acetylsalicylic acid (ASA; HR: 0.87, 95% CI: 0.77-0.98) was dose-dependently associated with a decreased risk of death, whereas use of long-acting muscarinic antagonists (LAMA; HR: 1.33, 95% CI: 1.14-1.55) and N-acetylcysteine (NAC; HR: 1.26, 95% CI: 1.08-1.48) were dose-dependently associated with an increased risk of death in COPD patients.

Conclusion

This large, retrospective, observational study of Swedish real-world primary care COPD patients indicates that coexisting heart failure, stroke and myocardial infarction were the strongest predictors of death, underscoring the importance of timely recognition and treatment of comorbidities. A decreased risk of death associated with the use of ICS, beta-blockers and ASA, and an increased risk associated with the use of LAMA and NAC, was also found.

Evaluating the disease and treatment information provided to patients with chronic obstructive pulmonary disease at the time of discharge according to GOLD discharge guidelines

Objective

To evaluate the disease and treatment information provided to patients with chronic obstructive pulmonary disease at hospital discharge.

Methods

This was a cross-sectional study including hospitalized patients with chronic obstructive pulmonary disease at three tertiary hospitals. The study was based on seven items of the Global Initiative for Obstructive Lung Disease (GOLD) discharge guidelines. Two hospitals in this study had a Medical Residency Program in Pulmonology, and one did not have the program.

Results

Fifty-four patients were evaluated. Large amounts of information were provided concerning effective pharmacological maintenance (item 1), blood gas evaluation/measurement of oxygen saturation (item 2), assessment of inhalation technique (item 4), and maintenance therapy (item 5). Less information was provided regarding comorbidity management planning (item 3), the completion of antibiotic/corticosteroid therapy (item 6) and follow-up with the attending physician or specialist (item 7) had less information. We observed significant differences between hospitals for items 1, 4 and 7, and better performance in hospitals with medical residency in pulmonology.

Conclusion

Hospitalized patients with chronic obstructive pulmonary disease received little to no information about the seven items addressed by GOLD discharge guidelines. This finding suggests that these guidelines should be used more often by clinicians in hospital with or without medical residency in pulmonology. The lack of specialized care resulted in insufficient amount of information for patients with chronic obstructive pulmonary disease at discharge.

Chronic Obstructive Pulmonary Disease and the Optimal Timing of Lung Transplantation

Chronic obstructive pulmonary disease (COPD) accounts for the largest proportion of respiratory deaths worldwide and was historically the leading indication for lung transplantation. The success of lung transplantation procedures is measured as survival benefit, calculated as survival with transplantation minus predicted survival without transplantation. In chronic obstructive pulmonary disease, it is difficult to show a clear and consistent survival benefit. Increasing knowledge of the risk factors, phenotypical heterogeneity, systemic manifestations, and their management helps improve our ability to select candidates and list those that will benefit the most from the procedure.

[Chronic obstructive pulmonary disease and cardiovascular comorbidity]

In recent years, a greater understanding of the heterogeneity and complexity of chronic obstructive pulmonary disease (COPD) has come from the point of view of an integrated clinical assessment of severity, pathophysiology, and the relationship with other pathologies. A typical COPD patient suffers on average 4 or more concomitant diseases and every day about a third of patients take from 5 to 10 different drugs. The mechanisms of the interaction of COPD and cardiovascular disease (CVD) include the effects of systemic inflammation, hyperinflation (hyperinflation) of the lungs and bronchial obstruction. The risk of developing CVD in patients with COPD is on average 2-3 times higher than in people of a comparable age in the general population, even taking into account the risk of smoking. The prevalence of coronary heart disease, heart failure, and rhythm disturbances among COPD patients is significantly higher than in the general population. The article discusses in detail the safety of prescribing various groups of drugs for the treatment of CVD in patients with COPD. Achieving success in understanding and managing patients with COPD and CVD is possible using an integrated multidisciplinary approach.

Consequences of chronic kidney disease in chronic obstructive pulmonary disease

Background

The combination of chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD) is associated with a higher prevalence of comorbidities and increased mortality. The impact of kidney function on patient-centered outcomes in COPD has not been evaluated.

Methods

Patients from the German COPD and Systemic Consequences - Comorbidities Network (COSYCONET) cohort COPD were analysed. CKD was diagnosed if the estimated glomerular filtration rate (eGFR) measurements were < 60 mL/min/1.73m² at study inclusion and six month later. The effect of CKD, on comorbidities, symptoms [modified British Medical Research Council dyspnoea scale], physical capacity [six-minute walk test, and timed up and go] and St George’s Respiratory Questionnaire were analysed. Restricted cubic spline models were used to evaluate a nonlinear relationship between eGFR with patient-centered outcomes, cox survival analysis was applied to evaluate mortality.

Results

2274 patients were analysed, with CKD diagnosed in 161 (7.1%). Spline models adjusted for age, gender, BMI, FEV₁ and cardiovascular comorbidities revealed independent associations between eGFR with modified British Medical Research Council dyspnoea scale, St George’s Respiratory Questionnaire, (p < 0.001 and p = 0.011), six-minute walk test (p = 0.015) and timed up and go (p < 0.001). CKD was associated with increased mortality, independently from for other cardiovascular comorbidities (hazard ratio 2.3; p < 0.001).

Conclusion

These data show that CKD is a relevant comorbidity in COPD patients which impacts on patient-centered outcomes and mortality.

Trial registration

NCT01245933

Electronic supplementary material

The online version of this article (10.1186/s12931-019-1107-x) contains supplementary material, which is available to authorized users.

Combined effects of lung function, blood gases and kidney function on the exacerbation risk in stable COPD: Results from the COSYCONET cohort

RATIONALE

Alterations of acid-base metabolism are an important outcome predictor in acute exacerbations of COPD, whereas sufficient metabolic compensation and adequate renal function are associated with decreased mortality. In stable COPD there is, however, only limited information on the combined role of acid-base balance, blood gases, renal and respiratory function on exacerbation risk grading.

METHODS

We used baseline data of the COPD cohort COSYCONET, applying linear and logistic regression analyses, the results of which were implemented into a comprehensive structural equation model. As most informative parameters it comprised the estimated glomerular filtration rate (eGFR), lung function defined via forced expiratory volume in 1 s (FEV₁), intrathoracic gas volume (ITGV) and (diffusing capacity for carbon monoxide (DLCO), moreover arterial oxygen content (CaO₂), partial pressure of oxygen (PaCO₂), base exess (BE) and exacerbation risk according to GOLD criteria. All measures were adjusted for age, gender, body-mass index, the current smoking status and pack years.

RESULTS

1506 patients with stable COPD (GOLD grade 1-4; mean age 64.5 ± 8.1 y; mean FEV₁ 54 ± 18 %predicted, mean eGFR 82.3 ± 16.9 mL/min/1.73 m²) were included. BE was linked to eGFR, lung function and PaCO₂ and played a role as indirect predictor of exacerbation risk via these measures; moreover, eGFR was directly linked to exacerbation risk. These associations remained significant after taking into account medication (diuretics, oral and inhaled corticosteroids), whereby corticosteroids had effects on exacerbation risk and lung function, diuretics on eGFR, BE and lung function.

CONCLUSION

Even in stable COPD acid-base metabolism plays a key integrative role in COPD risk assessment despite rather small deviations from normality. It partially mediates the effects of impairments in kidney function, which are also directly linked to exacerbation risk.

Interaction between blood lead level and chronic obstructive pulmonary disease (COPD) on risk of heart attack or stroke: USA NHANES, 2013-2014

BACKGROUND

Among all risk factors of cardiovascular disease (CVD), lead is associated with cardiovascular mortality. Besides CVD, blood lead level is also related to the chronic obstructive pulmonary disease (COPD). The inter-relationship of CVD, blood lead level and COPD are not yet studied.

OBJECTIVE

The aim of this study is to examine the interaction of COPD and blood lead level on the occurrence of heart attack.

METHODS

This analyzed data is from the 2013-2014 NHANES. The final analysis included 5736 adults. Survey logistic regression models were built to control confounders. We computed adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

A significant interaction (OR = 0.26, CI = 0.12, 0.56) between COPD and blood lead level on the occurrence of heart attack was observed. Those who had COPD were 4.05 times more likely to have heart attack than those who did not have COPD for 1 μg/dL increase in blood lead level. Similarly, a significant interaction between COPD and lead was found for the occurrence of stroke (OR = 0.44, CI = 0.19,1.00), leading to 1.15 times likely to have stroke than those who did not have COPD for 1 μg/dL increase in blood lead level. For the combined outcome, OR = 0.28 with CI=(0.14, 0.57).

CONCLUSIONS

The low lead level today means more effect of COPD on the occurrence of heart attack and stroke. More studies required to understand the pathways of the association of COPD, CVD and lead due to their shared risk factors.

Disease-Specific Comorbidity Clusters in COPD and Accelerated Aging

Background: Patients with chronic obstructive pulmonary disease (COPD) often suffer from multiple morbidities, which occur in clusters and are sometimes related to accelerated aging. This study aimed to assess the disease specificity of comorbidity clusters in COPD and their association with a biomarker of accelerated aging as a potential mechanistic factor. Methods: Body composition, metabolic, cardiovascular, musculoskeletal, and psychological morbidities were objectively evaluated in 208 COPD patients (age 62 ± 7 years, 58% males, FEV₁ 50 ± 16% predicted) and 200 non-COPD controls (age 61 ± 7 years, 45% males). Based on their presence and severity, the morbidities were clustered to generate distinct clusters in COPD and controls. Telomere length in circulating leukocytes was compared across the clusters. Results: (co)morbidities were more prevalent in COPD patients compared to controls (3.9 ± 1.7 vs. 2.4 ± 1.5, p < 0.05). A “Psychologic” and “Cachectic” cluster were only present in the COPD population. “Less (co)morbidity”, “Cardiovascular”, and “Metabolic” clusters were also observed in controls, although with less complexity. Telomere length was reduced in COPD patients, but did not differ between the (co)morbidity clusters in both populations. Conclusions: Two COPD-specific comorbidity clusters, a “Cachectic” and “Psychologic” cluster, were identified and warrant further studies regarding their development. Accelerated aging was present across various multimorbidity clusters in COPD.

Revealing Methodological Challenges in Chronic Obstructive Pulmonary Disease Studies Assessing Comorbidities: A Narrative Review

Beyond respiratory impairment, patients with chronic obstructive pulmonary disease (COPD) often suffer from comorbidities which are associated with worse health status, higher health care costs and worse prognosis. Reported prevalences of comorbidities largely differ between studies which might be explained by different assessment methods (objective assessment, self-reported assessment, or assessment by medical records), heterogeneous study populations, inappropriate control groups, incomparable methodologies, etc. This narrative review demonstrates and further evaluates the variability in prevalence of several comorbidities in patients with COPD and control individuals and discusses several shortcomings and pitfalls which need to be considered when interpreting comorbidity data. Like in other chronic organ diseases, the accurate diagnosis and integrated management of comorbidities is a key for outcome in COPD. This review highlights that there is a need to move from the starting point of an established index disease towards the concept of the development of multimorbidity in the elderly including COPD as an important and highly prevalent pulmonary component.

Airflow Obstruction and Cardio-metabolic Comorbidities

Chronic obstructive pulmonary disease (COPD) is characterized by airflow obstruction and often co-exists with cardiovascular disease (CVD), hypertension and diabetes. This international study assessed the association between airflow obstruction and these comorbidities. 23,623 participants (47.5% males, 19.0% current smokers, age: 55.1 ± 10.8 years) in 33 centers in the Burden of Obstructive Lung Disease (BOLD) initiative were included. 10.4% of subjects had airflow obstruction. Self-reports of physician-diagnosed CVD (heart disease or stroke), hypertension and diabetes were regressed against airflow obstruction (post-bronchodilator FEV1/FVC < 5th percentile of reference values), adjusting for age, sex, smoking (including pack-years), body mass index and education. Analyses were undertaken within center and meta-analyzed across centers checking heterogeneity using the I2-statistic. Crude odds ratios for the association with airflow obstruction were 1.42 (95% CI: 1.20-1.69) for CVD, 1.24 (1.02-1.51) for hypertension, and 0.93 (0.76-1.15) for diabetes. After adjustment these were 1.00 (0.86-1.16) (I2:6%) for CVD, 1.14 (0.99-1.31) (I2:53%) for hypertension, and 0.76 (0.64-0.89) (I2:1%) for diabetes with similar results for men and women, smokers and nonsmokers, in richer and poorer centers. Alternatively defining airflow obstruction by FEV1/FVC < 2.5th percentile or 0.70, did not yield significant other results. In conclusion, the associations of CVD and hypertension with airflow obstruction in the general population are largely explained by age and smoking habits. The adjusted risk for diabetes is lower in subjects with airflow obstruction. These findings emphasize the role of common risk factors in explaining the coexistence of cardio-metabolic comorbidities and COPD.

Association of Cardiovascular Disease With Respiratory Disease

BACKGROUND

The relationship between respiratory diseases and individual cardiovascular diseases, and the impact of cardiovascular diseases on mortality in patients with respiratory disease, are unclear.

OBJECTIVES

This study sought to determine the relationship between chronic obstructive pulmonary disease (COPD), asthma and interstitial lung disease (ILD), and individual cardiovascular diseases, and evaluate the impact of individual cardiovascular diseases on all-cause mortality in respiratory conditions.

METHODS

The authors conducted a cohort study of all patients admitted to 7 National Health Service hospitals across the North West of England, between January 1, 2000, and March 31, 2013, with relevant respiratory diagnoses, with age-matched and sex-matched control groups.

RESULTS

A total of 31,646 COPD, 60,424 asthma, and 1,662 ILD patients were included. Control groups comprised 158,230, 302,120, and 8,310 patients, respectively (total follow-up 2,968,182 patient-years). COPD was independently associated with ischemic heart disease (IHD), heart failure (HF), atrial fibrillation, and peripheral vascular disease, all of which were associated with all-cause mortality (e.g., odds ratio for the association of COPD with HF: 2.18 [95% confidence interval (CI): 2.08 to 2.26]; hazard ratio for the contribution of HF to mortality in COPD: 1.65 [95% CI: 1.61 to 1.68]). Asthma was independently associated with IHD, and multiple cardiovascular diseases contributed to mortality (e.g., HF hazard ratio: 1.81 [95% CI: 1.75 to 1.87]). ILD was independently associated with IHD and HF, both of which were associated with mortality. Patients with lung disease were less likely to receive coronary revascularization.

CONCLUSIONS

Lung disease is independently associated with cardiovascular diseases, particularly IHD and HF, which contribute significantly to all-cause mortality. However, patients with lung disease are less likely to receive coronary revascularization.

Geographic Disparities in Previously Diagnosed Health Conditions in Colorectal Cancer Patients Are Largely Explained by Age and Area Level Disadvantage

Background: Geographical disparity in colorectal cancer (CRC) survival rates may be partly due to aging populations and disadvantage in more remote locations; factors that also impact the incidence and outcomes of other chronic health conditions. The current study investigates whether geographic disparity exists amongst previously diagnosed health conditions in CRC patients above and beyond age and area-level disadvantage and whether this disparity is linked to geographic disparity in CRC survival.

Methods: Data regarding previously diagnosed health conditions were collected via computer-assisted telephone interviews with a cross-sectional sample of n = 1,966 Australian CRC patients between 2003 and 2004. Ten-year survival outcomes were acquired in December 2014 from cancer registry data. Multivariate logistic regressions were applied to test associations between previously diagnosed health conditions and survival rates in rural, regional, and metropolitan areas.

Results: Results suggest that only few geographical disparities exist in previously diagnosed health conditions for CRC patients and these were largely explained by socio-economic status and age. Living in an inner regional area was associated with cardio-vascular conditions, one or more respiratory diseases, and multiple respiratory diagnoses. Higher occurrences of these conditions did not explain lower CRC-specific 10 years survival rates in inner regional Australia.

Conclusion: It is unlikely that health disparities in terms of previously diagnosed conditions account for poorer CRC survival in regional and remote areas. Interventions to improve the health of regional CRC patients may need to target issues unique to socio-economic disadvantage and older age.

Real-world retrospective cohort study ARCTIC shows burden of comorbidities in Swedish COPD versus non-COPD patients

This study aimed to generate real-world evidence to assess the burden of comorbidities in COPD patients, to effectively manage these patients and optimize the associated healthcare resource allocation. ARCTIC is a large, real-world, retrospective cohort study conducted in Swedish COPD patients using electronic medical record data collected between 2000 and 2014. These patients were studied for prevalence of various comorbidities and for association of these comorbidities with exacerbations, mortality, and healthcare costs compared with an age-, sex-, and comorbidities-matched non-COPD reference population. A total of 17,479 patients with COPD were compared with 84,514 non-COPD reference population. A significantly higher prevalence of various comorbidities was observed in COPD patients 2 years post-diagnosis vs. reference population, with the highest percentage increase observed for cardiovascular diseases (81.8% vs. 30.7%). Among the selected comorbidities, lung cancer was relatively more prevalent in COPD patients vs. reference population (relative risk, RR = 5.97, p < 0.0001). Ischemic heart disease, hypertension, depression, anxiety, sleep disorders, osteoporosis, osteoarthritis, and asthma caused increased mortality rates in COPD patients. Comorbidities that were observed to be significantly associated with increased number of severe exacerbations in COPD patients included heart failure, ischemic heart disease, depression/anxiety, sleep disorders, osteoporosis, lung cancer, and stroke. The cumulative healthcare costs associated with comorbidities over 2 years after the index date were observed to be significantly higher in COPD patients (€27,692) vs. reference population (€5141) (p < 0.0001). The data support the need for patient-centered treatment strategies and targeted healthcare resource allocation to reduce the humanistic and economic burden associated with COPD comorbidities.

Impact of Comorbidities on the Treatment of Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) frequently exists alongside other chronic diseases. Comorbidities can have a significant influence on the course of COPD, affecting disease-related symptoms and increasing morbidity and mortality in patients. Studies indicate that management of comorbid COPD can be improved by engaging in a multidisciplinary team-based approach. A collaborative effort from different disease specialists and health care professionals, together with disease self-management and management programs, could improve the outcomes of patients with comorbid COPD.

Long-Term Outcomes in Patients with Incident Chronic Obstructive Pulmonary Disease after Acute Kidney Injury: A Competing-Risk Analysis of a Nationwide Cohort

Both acute kidney injury (AKI) and chronic obstructive pulmonary disease (COPD) are associated with increased morbidity and mortality. However, the incidence of de novo COPD in patients with AKI, and the impact of concurrent COPD on the outcome during post-AKI care is unclear. Patients who recovered from dialysis-requiring AKI (AKI-D) during index hospitalizations between 1998 and 2010 were identified from nationwide administrative registries. A competing risk analysis was conducted to predict the incidence of adverse cardiovascular events and mortality. Among the 14,871 patients who recovered from temporary dialysis, 1535 (10.7%) were identified as having COPD (COPD group) one year after index discharge and matched with 1473 patients without COPD (non-COPD group) using propensity scores. Patients with acute kidney disease superimposed withs COPD were associated with a higher risk of incident ischemic stroke (subdistribution hazard ratio (sHR), 1.52; 95% confidence interval (95% CI), 1.17 to 1.97; p = 0.002) and congestive heart failure (CHF; sHR, 1.61; (95% CI), 1.39 to 1.86; p < 0.001). The risks of incident hemorrhagic stroke, myocardial infarction, end-stage renal disease, and mortality were not statistically different between the COPD and non-COPD groups. This observation adds another dimension to accumulating evidence regarding pulmo-renal consequences after AKI.

Coronary lesions in patients with COPD (Global Initiative for Obstructive Lung Disease stages I-III) and suspected or confirmed coronary arterial disease

Background

Systemic inflammation is the pathophysiological link between coronary artery disease (CAD) and COPD. However, the influence of subclinical COPD on patients with suspected or diagnosed CAD is largely unknown. Thus, this study was designed to evaluate the degree of coronary involvement in patients with COPD and suspected or confirmed CAD.

Methods

In this cross-sectional study, carried out between March 2015 and June 2017, 210 outpatients with suspected or confirmed CAD were examined by both spirometry and coronary angiography or multidetector computed tomography. These patients were divided into two groups: with and without COPD. Size, site, extent, and calcification of the coronary lesions, and the severity of COPD were analyzed.

Results

COPD patients (n = 101) presented with a higher frequency of obstructive coronary lesions ≥50% (n = 72, 71.3%), multivessels (n = 29, 28.7%), more lesions of the left coronary trunk (n = 18, 17.8%), and more calcified atherosclerotic plaques and higher Agatston coronary calcium score than the patients without COPD (P < 0.0001). The more severe the COPD in the Global Initiative for Obstructive Lung Disease stages, the more severe the CAD and the more calcified coronary plaques (P < 0.0001). However, there was no difference between the two groups with respect to the main risk factors for CAD. In the univariate analysis, COPD was an independent predictor of obstructive CAD (odds ratio [OR] 4.78; 95% confidence interval: 2.21–10.34; P < 0.001).

Conclusion

In patients with suspected CAD, comorbid COPD was associated with increased severity and extent of coronary lesions, calcific plaques, and elevated calcium score independent of the established risk factors for CAD. In addition, the more severe the COPD, the greater the severity of coronary lesions and calcification present.

Continuity of care and its effect on readmissions for COPD patients: A comparative study of Norway and Germany

BACKGROUND

This study compares continuity of care between Germany - a social health insurance country, and Norway - a national health service country with gatekeeping and patient lists for COPD patients before and after initial hospitalization. We also investigate how subsequent readmissions are affected.

METHODS

Continuity of Care Index (COCI), Usual Provider Index (UPC) and Sequential Continuity Index (SECON) were calculated using insurance claims and national register data (2009-14). These indices were used in negative binomial and logistic regressions to estimate incident rate ratios (IRR) and odds ratios (OR) for comparing readmissions.

RESULTS

All continuity indices were significantly lower in Norway. One year readmissions were significantly higher in Germany, whereas 30-day rates were not. All indices measured one year after discharge were negatively associated with one-year readmissions for both countries. Significant associations between indices measured before hospitalization and readmissions were only observed in Norway - all indices for one-year readmissions and SECON for 30-day readmissions.

CONCLUSION

Our findings indicate higher continuity is associated with reductions in readmissions following initial COPD admission. This is observed both before and after hospitalization in a system with gatekeeping and patient lists, yet only after for a system lacking such arrangements. These results emphasize the need for policy strategies to further investigate and promote care continuity in order to reduce hospital readmission burden for COPD patients.

Chronic Obstructive Pulmonary Disease (COPD) as a disease of early aging: Evidence from the EpiChron Cohort

BACKGROUND

Aging is an important risk factor for most chronic diseases. Patients with COPD develop more comorbidities than non-COPD subjects. We hypothesized that the development of comorbidities characteristically affecting the elderly occur at an earlier age in subjects with the diagnosis of COPD.

METHODS AND FINDINGS

We included all subjects carrying the diagnosis of COPD (n = 27,617), and a similar number of age and sex matched individuals without the diagnosis, extracted from the 727,241 records of individuals 40 years and older included in the EpiChron Cohort (Aragon, Spain). We compared the cumulative number of comorbidities, their prevalence and the mortality risk between both groups. Using network analysis, we explored the connectivity between comorbidities and the most influential comorbidities in both groups. We divided the groups into 5 incremental age categories and compared their comorbidity networks. We then selected those comorbidities known to affect primarily the elderly and compared their prevalence across the 5 age groups. In addition, we replicated the analysis in the smokers' subgroup to correct for the confounding effect of cigarette smoking. Subjects with COPD had more comorbidities and died at a younger age compared to controls. Comparison of both cohorts across 5 incremental age groups showed that the number of comorbidities, the prevalence of diseases characteristic of aging and network's density for the COPD group aged 56-65 were similar to those of non-COPD 15 to 20 years older. The findings persisted after adjusting for smoking.

CONCLUSION

Multimorbidity increases with age but in patients carrying the diagnosis of COPD, these comorbidities are seen at an earlier age.

Defining the relationship between COPD and CVD: what are the implications for clinical practice?

Cardiovascular diseases (CVDs) are arguably the most important comorbidities in chronic obstructive pulmonary disease (COPD). CVDs are common in people with COPD, and their presence is associated with increased risk for hospitalization, longer length of stay and all-cause and CVD-related mortality. The economic burden associated with CVD in this population is considerable and the cumulative cost of treating comorbidities may even exceed that of treating COPD itself. Our understanding of the biological mechanisms that link COPD and various forms of CVD has improved significantly over the past decade. But despite broad acceptance of the prognostic significance of CVDs in COPD, there remains widespread under-recognition and undertreatment of comorbid CVD in this population. The reasons for this are unclear; however institutional barriers and a lack of evidence-based guidelines for the management of CVD in people with COPD may be contributory factors. In this review, we summarize current knowledge relating to the prevalence and incidence of CVD in people with COPD and the mechanisms that underlie their coexistence. We discuss the implications for clinical practice and highlight opportunities for improved prevention and treatment of CVD in people with COPD. While we advocate more active assessment for signs of cardiovascular conditions across all age groups and all stages of COPD severity, we suggest targeting those aged under 65 years. Evidence indicates that the increased risks for CVD are particularly pronounced in COPD patients in mid-to-late-middle-age and thus it is in this age group that the benefits of early intervention may prove to be the most effective.

Chronic Obstructive Pulmonary Disease and Cardiac Diseases. An Urgent Need for Integrated Care

Chronic obstructive pulmonary disease (COPD) is a global health issue with high social and economic costs. Concomitant chronic cardiac disorders are frequent in patients with COPD, likely owing to shared risk factors (e.g., aging, cigarette smoke, inactivity, persistent low-grade pulmonary and systemic inflammation) and add to the overall morbidity and mortality of patients with COPD. The prevalence and incidence of cardiac comorbidities are higher in patients with COPD than in matched control subjects, although estimates of prevalence vary widely. Furthermore, cardiac diseases contribute to disease severity in patients with COPD, being a common cause of hospitalization and a frequent cause of death. The differential diagnosis may be challenging, especially in older and smoking subjects complaining of unspecific symptoms, such as dyspnea and fatigue. The therapeutic management of patients with cardiac and pulmonary comorbidities may be similarly challenging: bronchodilators may have cardiac side effects, and, vice versa, some cardiac medications should be used with caution in patients with lung disease. The aim of this review is to summarize the evidence of the relationship between COPD and the three most frequent and important cardiac comorbidities in patients with COPD: ischemic heart disease, heart failure, and atrial fibrillation. We have chosen a practical approach, first summarizing relevant epidemiological and clinical data, then discussing the diagnostic and screening procedures, and finally evaluating the impact of lung-heart comorbidities on the therapeutic management of patients with COPD and heart diseases.

Does Cardiovascular Comorbidity Influence the Prescribing of Bronchodilators in Chronic Obstructive Pulmonary Disease?

BACKGROUND

Cardiovascular disease (CVD) is the most prevalent comorbidity for chronic obstructive pulmonary disease (COPD). Potential adverse cardiovascular events of bronchodilators warrant their cautionary use in the comorbid COPD-CVD population, yet little is known about the prescribing of bronchodilators in this high-risk patient group.

OBJECTIVE

To determine whether comorbid CVD is associated with reduced bronchodilator prescribing in patients with COPD. In addition, we explored how the association was modified by gender, concurrent asthma, and concomitant β-blocker (BB) use.

METHODS

A cross-sectional study was conducted using the 2010 National Ambulatory Medical Care Survey. All visits among diagnosed COPD patients 40 years and older were examined. Logistic regression on survey-weighted data was used to predict treatment with bronchodilators and determine the influence of gender, asthma, and BBs on bronchodilator prescribing.

RESULTS

Among 11 627 061 ambulatory COPD visits, we found a significantly lower bronchodilator treatment rate among patients with comorbid CVD (32.3%) than among patients without CVD (57.6%). The observed effect was modified by gender, asthma, and BBs. Deprescribing was more pronounced for females than males, for nonusers of BBs than users of BBs, and for asthma patients than nonasthma patients. CVD did not affect bronchodilator prescribing in either asthmatic or nonasthmatic males taking BBs.

CONCLUSIONS

Most COPD patients with concurrent CVD were less likely to be prescribed bronchodilators, with the exception of males who were also prescribed BBs. Thus, this study highlights a specific patient subgroup for whom the guidelines are less likely to be observed.

Prevalence of chronic kidney disease in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

Background

The incidence and prevalence of chronic kidney disease (CKD) continue to rise worldwide. Increasing age, diabetes, hypertension, and cigarette smoking are well-recognized risk factors for CKD. Chronic obstructive pulmonary disease (COPD) is characterized by chronic airway inflammation leading to airway obstruction and parenchymal lung destruction. Due to some of the common pathogenic mechanisms, COPD has been associated with increased prevalence of CKD.

Methods

Systematic review of medical literature reporting the incidence and prevalence of CKD in patients with COPD using the Cochrane Collaboration Methodology, and conduct meta-analysis to study the cumulative effect of the eligible studies. We searched Medline via Ovid, PubMed, EMBASE and ISI Web of Science databases from 1950 through May, 2016. We included prospective and retrospective observational studies that reported the prevalence of CKD in patients with COPD.

Results

Our search resulted in 19 eligible studies of which 9 have been included in the meta-analysis. The definition of CKD was uniform across all the studies included in analysis. COPD was found to be associated with CKD in the included epidemiological studies conducted in many countries. Our meta-analysis showed that COPD was found to be associated with a significantly increased prevalence of CKD (Odds Ratio [OR] = 2.20; 95% Confidence Interval [CI] 1.83, 2.65). Study limitations: Studies included are observational studies. However, given the nature of our research question there is no possibility to perform a randomized control trial.

Conclusions

Patients with COPD have increased odds of developing CKD. Future research should investigate the pathophysiological mechanism behind this association, which may lead to better outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0315-0) contains supplementary material, which is available to authorized users.

Chronic obstructive pulmonary disease phenotypes using cluster analysis of electronic medical records

Chronic obstructive pulmonary disease is a heterogeneous disease. In this retrospective study, we hypothesize that it is possible to identify clinically relevant phenotypes by applying clustering methods to electronic medical records. We included all the patients >40 years with a diagnosis of chronic obstructive pulmonary disease admitted to the University of New Mexico Hospital between 1 January 2011 and 1 May 2014. We collected admissions, demographics, comorbidities, severity markers and treatments. A total of 3144 patients met the inclusion criteria: 46 percent were >65 years and 52 percent were males. The median Charlson score was 2 (interquartile range: 1-4) and the most frequent comorbidities were depression (36%), congestive heart failure (25%), obesity (19%), cancer (19%) and mild liver disease (18%). Using the sphere exclusion method, nine clusters were obtained: depression-chronic obstructive pulmonary disease, coronary artery disease-chronic obstructive pulmonary disease, cerebrovascular disease-chronic obstructive pulmonary disease, malignancy-chronic obstructive pulmonary disease, advanced malignancy-chronic obstructive pulmonary disease, diabetes mellitus-chronic kidney disease-chronic obstructive pulmonary disease, young age-few comorbidities-high readmission rates-chronic obstructive pulmonary disease, atopy-chronic obstructive pulmonary disease, and advanced disease-chronic obstructive pulmonary disease. These clusters will need to be validated prospectively.