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Giraldo-Montoya ÁM, Torres-Duque CA, Giraldo-Cadavid LF, Laucho-Contreras ME, González-Flórez A, Santos AM, Tuta-Quintero EA, Celli BR, González-García M. Sputum Biomarkers in Wood and Tobacco Smoke Etiotypes of Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2023; 19:1-10. [PMID: 38179428 PMCID: PMC10763680 DOI: 10.2147/copd.s439064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/19/2023] [Indexed: 01/06/2024] Open
Abstract
Introduction There is a need to better understand the etiotypes of chronic obstructive pulmonary disease (COPD) beyond the tobacco-smoke (TS-COPD). Wood smoke COPD (WS-COPD) is characterized by greater airway compromise, milder emphysema, and slower rate of lung function decline than TS-COPD. However, it is unclear if these two etiotypes of COPD have differences in sputum biomarker concentrations. Objective was to compare sputum levels of selected sputum biomarkers between WS-COPD and TS-COPD, and healthy controls. Methods Eighty-eight women (69±12 years) were recruited and classified into: WS-COPD (n=31), TS-COPD (n=29) and controls (n=28). Using ELISA, we determined induced sputum levels of metalloproteinase 9 (MMP-9), chemokine ligand 5 (CCL5), interleukin-8 (IL-8), chemokine ligand 16 (CCL16/HCC-4) and vascular endothelial growth factor (VEGF-1). Differences were analyzed by Kruskal-Wallis and Mann-Whitney-U tests and correlation between airflow limitation and biomarkers by Spearman's test. Results At similar degree of airflow obstruction, anthropometrics and medications use, the level of sputum CCL5 was higher in TS-COPD than WS-COPD (p=0.03) without differences in MMP-9, IL-8, CCL16/HCC-4, and VEGF-1. Women with WS-COPD and TS-COPD showed significantly higher sputum levels of MMP-9, IL-8 and CCL5 compared with controls (p<0.001). FEV1% predicted correlated negatively with levels of MMP-9 (rho:-0.26; P=0.016), CCL5 (rho:-0.37; P=0.001), IL-8 (rho:-0.42; P<0.001) and VEGF (rho:-0.22; P=0.04). Conclusion While sputum concentrations of MMP-9, IL-8, and CCL5 were higher in COPD women compared with controls, women with TS-COPD had higher levels of CCL5 compared with those with WS-COPD. Whether this finding relates to differences in pathobiological pathways remains to be determined.
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Affiliation(s)
- Ángela María Giraldo-Montoya
- CINEUMO, Research Center, Fundación Neumológica Colombiana, Bogotá, Colombia
- School of Medicine, Universidad Tecnológica de Pereira, Pereira, Colombia
| | - Carlos A Torres-Duque
- CINEUMO, Research Center, Fundación Neumológica Colombiana, Bogotá, Colombia
- Biosciences Doctoral, Universidad de La Sabana, Chía, Colombia
| | - Luis F Giraldo-Cadavid
- Medical Department, Fundación Neumológica Colombiana, Bogotá, Colombia
- Epidemiology and Biostatistics Department, Universidad de La Sabana, Chía, Colombia
| | | | | | | | - Eduardo A Tuta-Quintero
- CINEUMO, Research Center, Fundación Neumológica Colombiana, Bogotá, Colombia
- Epidemiology and Biostatistics Department, Universidad de La Sabana, Chía, Colombia
| | | | - Mauricio González-García
- CINEUMO, Research Center, Fundación Neumológica Colombiana, Bogotá, Colombia
- School of Medicine, Universidad de La Sabana, Chía, Colombia
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Lee JH, Kim S, Kim YJ, Lee SW, Lee JS, Oh YM. COPD Risk Factor Profiles in General Population and Referred Patients: Potential Etiotypes. Int J Chron Obstruct Pulmon Dis 2023; 18:2509-2520. [PMID: 37965078 PMCID: PMC10642581 DOI: 10.2147/copd.s427774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/01/2023] [Indexed: 11/16/2023] Open
Abstract
Purpose To identify the risk factors for chronic obstructive pulmonary disease (COPD) in view of potential etiotypes in a general population and referred COPD patients. Patients and Methods We performed a cross-sectional observational study utilizing two distinct datasets: a dataset of a general population including 2430 subjects with COPD from the Korea National Health and Nutrition Examination Survey (KNHANES) and another dataset of referral clinics including 579 patients with COPD from the Korean Obstructive Lung Disease (KOLD). Results The mean age of both groups was 67 years, and 71.2% and 93.8% were male in the COPD subjects from the KNHANES and the KOLD, respectively. The mean forced expiratory volume in 1 second of predicted value was 79.1% (KNHANES) and 55.4% (KOLD). The frequency of risk factors of cigarette smoking (C), infection (I), pollution (P), and asthma (A) was 54.6%, 9.4%, 10.7%, and 7.9%, respectively, in the KNHANES COPD subjects, and 88.4%, 26.6%, 41.6%, and 35.2%, respectively, in the KOLD COPD subjects. Risk factors were unidentified in 32.6% (KNHANES) and 3.1% (KOLD) of COPD subjects. Additionally, 14.1% and 66.2% of subjects with COPD had two or more risk factors in the KNHANES and KOLD, respectively. Conclusion The profiles of risk factors C, I, P, and A were identified and appeared to be different among the two COPD groups from a general population or referral clinics. In some of the COPD subjects, risk factors were not identified, so we should endeavour to find out unidentified COPD risk factors, especially in the general population.
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Affiliation(s)
- Jang Ho Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sehee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ye-Jee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sei Won Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Seung Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yeon-Mok Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
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3
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Wu D, Xiang Y. Role of mucociliary clearance system in respiratory diseases. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2023; 48:275-284. [PMID: 36999475 PMCID: PMC10930340 DOI: 10.11817/j.issn.1672-7347.2023.220372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Indexed: 04/01/2023]
Abstract
Mucociliary clearance system is the primary innate defense mechanism of the lung. It plays a vital role in protecting airways from microbes and irritants infection. Mucociliary clearance system, which is mediated by the actions of airway and submucosal gland epithelial cells, plays a critical role in a multilayered defense system via secreting fluids, electrolytes, antimicrobial and anti-inflammatory proteins, and mucus onto airway surfaces. Changes in environment, drugs or diseases can lead to mucus overproduction and cilia dysfunction, which in turn decrease the rate of mucociliary clearance and enhance mucus gathering. The dysfunction of mucociliary clearance system often occurs in several respiratory diseases, such as primary ciliary dysfunction, cystic fibrosis, asthma and chronic obstructive pulmonary disease, which are characterized by goblet cell metaplasia, submucosal gland cell hypertrophy, mucus hypersecretion, cilia adhesion, lodging and loss, and airway obstruction.
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Affiliation(s)
- Di Wu
- Department of Physiology, School of Basic Medical Science, Central South University, Changsha 410013, China.
| | - Yang Xiang
- Department of Physiology, School of Basic Medical Science, Central South University, Changsha 410013, China.
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4
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Liu M, Yin D, Wang Y, Wang W, Fu T, Duan Y, Hu M, Huang K. Comparing the Performance of Two Screening Questionnaires for Chronic Obstructive Pulmonary Disease in the Chinese General Population. Int J Chron Obstruct Pulmon Dis 2023; 18:541-552. [PMID: 37065634 PMCID: PMC10103780 DOI: 10.2147/copd.s403603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/27/2023] [Indexed: 04/18/2023] Open
Abstract
Purpose Screening questionnaires can help identify individuals at a high risk of COPD. This study aimed to compare the performance of the COPD population screener (COPD-PS) and COPD screening questionnaire (COPD-SQ) on the general population as a full cohort and stratified by urbanization. Methods We recruited subjects who underwent a health checkup at urban and rural community health centers in Beijing. All eligible subjects completed the COPD-PS and COPD-SQ, then spirometry. Spirometry-defined COPD was defined as a post-bronchodilator FEV1/FVC<70%. Symptomatic COPD was defined as a post-bronchodilator FEV1/FVC<70% and respiratory symptoms. Receiver operating characteristic (ROC) curve analysis compared the discriminatory power of the two questionnaires, and stratified by urbanization. Results We identified 129 spirometry-defined and 92 symptomatic COPD cases out of 1350 enrolled subjects. The optimal cut-off score for the COPD-PS was 4 for spirometry-defined and 5 for symptomatic COPD. The optimum cut-off score for the COPD-SQ was 15 for both spirometry-defined and symptomatic COPD. The COPD-PS and COPD-SQ had similar AUC values for spirometry-defined (0.672 vs 0.702) and symptomatic COPD (0.734 vs 0.779). The AUC of the COPD-SQ tended to be higher in rural areas than that of the COPD-PS for spirometry-defined COPD (0.700 vs 0.653, P = 0.093). Conclusion The COPD-PS and COPD-SQ had comparable discriminatory power for detecting COPD in the general population while the COPD-SQ performed better in rural areas. A pilot study for validating and comparing the diagnostic accuracy of different questionnaires is required when screening for COPD in a new environment.
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Affiliation(s)
- Meishan Liu
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Danfeng Yin
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Ying Wang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Wenjun Wang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Tingting Fu
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yuting Duan
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Mengjia Hu
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Kewu Huang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People’s Republic of China
- Correspondence: Kewu Huang, Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, No. 8, Gongti South Road, Chaoyang District, Beijing, 100020, People’s Republic of China, Tel +86-010-85231167, Email
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5
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Mortimer K, Montes de Oca M, Salvi S, Balakrishnan K, Hadfield RM, Ramirez-Venegas A, Halpin DMG, Ozoh Obianuju B, Han MeiLan K, Perez Padilla R, Kirenga B, Balmes JR. Household air pollution and COPD: cause and effect or confounding by other aspects of poverty? Int J Tuberc Lung Dis 2022; 26:206-216. [PMID: 35197160 PMCID: PMC8886958 DOI: 10.5588/ijtld.21.0570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
SETTING : Household air pollution (HAP) and chronic obstructive pulmonary disease (COPD) are both major public health problems, reported to cause around 4 million and 3 million deaths every year, respectively. The great majority of these deaths, as well as the burden of disease during life is felt by people in low- and middle-income countries (LMICs). OBJECTIVE AND DESIGN : The extent to which HAP causes COPD is controversial; we therefore undertook this review to offer a viewpoint on this from the Global Initiative for COPD (GOLD). RESULTS : We find that while COPD is well-defined in many studies on COPD and HAP, there are major limitations to the definition and measurement of HAP. It is thus difficult to disentangle HAP from other features of poverty that are themselves associated with COPD. We identify other limitations to primary research studies, including the use of cross-sectional designs that limit causal inference. CONCLUSION : There is substantial preventable morbidity and mortality associated with HAP, COPD and poverty, separately and together. Although it may not be possible to define clear causal links between HAP and COPD, there is a clear urgency to reduce the avoidable burden of disease these inflict on the world’s poor.
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Affiliation(s)
- K Mortimer
- University of Cambridge, Cambridge, UK, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - M Montes de Oca
- Hospital Universitario de Caracas Universidad Central de Venezuela and Centro Médico de Caracas, Caracas, Venezuela
| | - S Salvi
- Pulmocare Research and Education (PURE) Foundation, Pune, India
| | | | - R M Hadfield
- Australian Institute for Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - A Ramirez-Venegas
- Departamento de Investigación en Tabaquismo y EPOC, Instituto Nacional de Enfermedades Respiratorias, Mexico
| | - D M G Halpin
- College of Medicine and Health, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - B Ozoh Obianuju
- Department of Medicine, College of Medicine, University of Lagos, Lagos, Nigeria
| | | | - R Perez Padilla
- Departamento de Investigación en Tabaquismo y EPOC, Instituto Nacional de Enfermedades Respiratorias, Mexico
| | - B Kirenga
- Makerere University Lung Institute, Kampala, Uganda
| | - J R Balmes
- Department of Medicine, University of California, San Francisco and Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
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Ramírez-Venegas A, Montiel-Lopez F, Falfan-Valencia R, Pérez-Rubio G, Sansores RH. The "Slow Horse Racing Effect" on Lung Function in Adult Life in Chronic Obstructive Pulmonary Disease Associated to Biomass Exposure. Front Med (Lausanne) 2021; 8:700836. [PMID: 34307427 PMCID: PMC8295605 DOI: 10.3389/fmed.2021.700836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/15/2021] [Indexed: 01/31/2023] Open
Abstract
Although different trajectories in lung function decline have been identified in patients with COPD associated to tobacco exposure (TE-COPD), genetic, environmental, and infectious factors affecting lung function throughout life have not been fully elucidated in patients with COPD associated to biomass (BE-COPD). In this review, we present current epidemiological findings and notable advances in the natural history of lung decline in BE-COPD, as well as conditions modeling the FEV1 trajectory, such as health insults, during the first years of childhood. Evidence shows that women exposed to biomass smoke reach adult life with a lower FEV1 than expected. However, in contrast to the “horse racing effect” predicting an excessive lung-function decline in forthcoming years, as observed in smokers, this decline is slower in non-smokers, and no rapid decliners are observed. Accordingly, BE-COPD might be considered another phenotype of COPD based on assessments of lung function decline. Likewise, other functional and clinical aspects described in this review suggest that this condition might be similar to TE-COPD. More research is needed to fully characterize this subgroup of variants of COPD.
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Affiliation(s)
- Alejandra Ramírez-Venegas
- Department of Tobacco Smoking and COPD Research, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Francisco Montiel-Lopez
- Department of Tobacco Smoking and COPD Research, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Ramces Falfan-Valencia
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Gloria Pérez-Rubio
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Raúl H Sansores
- Department of Respiratory Medicine, Medica Sur Clinic and Foundation, Mexico City, Mexico
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7
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Rao SR, Chitra GA, Elavarasu G, Kamaraj P, Kaliaperumal K, Kaur P. Exposure to mosquito coil and biomass fuel smoke and respiratory health in rural Tamil Nadu, India. J Public Health (Oxf) 2021; 44:625-633. [PMID: 33912972 DOI: 10.1093/pubmed/fdab119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 03/11/2021] [Accepted: 03/23/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Mosquito coil smoke, along with biomass fuel smoke, are sources of indoor air pollution. Biomass fuel smoke has been studied as a risk factor for poor respiratory outcomes. However, in an Indian context, few studies examine the effect of mosquito coil exposure on poor respiratory outcomes at the community level. OBJECTIVES To estimate the prevalence of the biomass fuel and mosquito coil use and to determine the association between the use of bio-mass fuel and mosquito coil and poor respiratory health. METHODS A cross-sectional survey of 4662 individuals (above the age of 30 years) was conducted using a pre-tested questionnaire. Trained interviewers collected data on current and past use of biomass fuels and mosquito coils, usage practices and respiratory health. We computed proportions for exposure variables namely biomass fuel, mosquito coil use and other covariates. We conducted univariate analysis, followed by multivariate logistic regression. RESULTS The prevalence of ever use of biomass fuels was high (wood: 97.9%; cow dung cake: 76.0% and crop residue: 54.4%). Current use of wood, cow dung cake and crop residue was prevalent among 75.7, 24.3 and 30.9% respondents, respectively. Almost 70% of respondents had ever used mosquito coils, whereas 54% were current users. Overall, 5.5% respondents had poor respiratory health either due to chronic bronchitis or asthma. In multivariate analysis, use of combination of all three biomass fuel types (adjusted odds ratio [AOR] 1.69, 95% confidence interval [CI]: 1.13-2.54) and use of mosquito coil more than or equal to 5 days per week (AOR 1.43, 95% CI: 1.04-1.99) were associated with poor respiratory health after adjusting for covariates age, gender, smoking, kitchen type and for each other. CONCLUSIONS Use of biomass fuels and mosquito coils was high in the study population and was associated with poor respiratory health. Therefore, mosquito coil smoke should also be considered an important source of indoor air pollution, similar to biomass fuel exposure. Community education about these sources of indoor air pollution and increased coverage of cleaner fuels and alternative mosquito control methods should be the way forward in the rural areas.
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Affiliation(s)
- Sudha Ramachandra Rao
- National Institute of Epidemiology, Division of Non Communicable Diseases, Chennai, Tamil Nadu 600 077, India
| | - Grace A Chitra
- Department of Epidemiology, Global Institute of Public Health, Ananthapuri Hospitals and Research Institute, Chacka, Thiruvananthapuram, Kerala 695024, India
| | - G Elavarasu
- National Institute of Epidemiology, Division of Non Communicable Diseases, Chennai, Tamil Nadu 600 077, India
| | - P Kamaraj
- National Institute of Epidemiology, Division of Non Communicable Diseases, Chennai, Tamil Nadu 600 077, India
| | - Kanagasabai Kaliaperumal
- National Institute of Epidemiology, Division of Non Communicable Diseases, Chennai, Tamil Nadu 600 077, India
| | - Prabhdeep Kaur
- National Institute of Epidemiology, Division of Non Communicable Diseases, Chennai, Tamil Nadu 600 077, India
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8
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Siddharthan T, Pollard SL, Jackson P, Robertson NM, Wosu AC, Rahman N, Padalkar R, Sekitoleko I, Namazzi E, Alupo P, Hurst JR, Kalyesubula R, Dowdy D, Wise R, Barnes PJ, Checkley W, Kirenga B. Effectiveness of low-dose theophylline for the management of biomass-associated COPD (LODOT-BCOPD): study protocol for a randomized controlled trial. Trials 2021; 22:213. [PMID: 33726828 PMCID: PMC7962083 DOI: 10.1186/s13063-021-05163-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 02/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND COPD is a leading cause of death globally, with the majority of morbidity and mortality occurring in low- and middle-income country (LMIC) settings. While tobacco-smoke exposure is the most important risk factor for COPD in high-income settings, household air pollution from biomass smoke combustion is a leading risk factor for COPD in LMICs. Despite the high burden of biomass smoke-related COPD, few studies have evaluated the efficacy of pharmacotherapy in this context. Currently recommended inhaler-based therapy for COPD is neither available nor affordable in most resource-limited settings. Low-dose theophylline is an oral, once-a-day therapy, long used in high-income countries (HICs), which has been proposed for the management of COPD in LMICs in the absence of inhaled steroids and/or bronchodilators. The Low-dose Theophylline for the Management of Biomass-Associated COPD (LODOT-BCOPD) trial investigates the clinical efficacy and cost-effectiveness of low-dose theophylline for the management of biomass-related COPD in a low-income setting. METHODS LODOT-BCOPD is a randomized, double-blind, placebo-controlled trial to test the efficacy of low-dose theophylline in improving respiratory symptoms in 110 participants with moderate to severe COPD in Central Uganda. The inclusion criteria are as follows: (1) age 40 to 80 years, (2) full-time resident of the study area, (3) daily biomass exposure, (4) post-bronchodilator FEV1/FVC below the 5th percentile of the Global Lung Initiative mixed ethnic reference population, and (5) GOLD Grade B-D COPD. Participants will be randomly assigned to receive once daily low-dose theophylline (200 mg ER, Unicontin-E) or placebo for 52 weeks. All participants will receive education about self-management of COPD and rescue salbutamol inhalers. We will measure health status using the St. George's Respiratory Questionnaire (SGRQ) and quality of life using the EuroQol-5D (EQ-5D) at baseline and every 6 months. In addition, we will assess household air pollution levels, serum inflammatory biomarkers (fibrinogen, hs-CRP), and theophylline levels at baseline, 1 month, and 6 months. The primary outcome is change in SGRQ score at 12 months. Lastly, we will assess the cost-effectiveness of the intervention by calculating quality-adjusted life years (QALYs) from the EQ-5D. TRIAL REGISTRATION ClinicalTrials.gov NCT03984188 . Registered on June 12, 2019 TRIAL ACRONYM: Low-dose Theophylline for the Management of Biomass-Associated COPD (LODOT-BCOPD).
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Affiliation(s)
- Trishul Siddharthan
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA. .,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA.
| | - Suzanne L Pollard
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA.,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA
| | - Peter Jackson
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, USA
| | - Nicole M Robertson
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA.,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA
| | - Adaeze C Wosu
- Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA.,Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Nihaal Rahman
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA.,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA
| | - Roma Padalkar
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA.,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA
| | - Isaac Sekitoleko
- Makerere University Lung Institute, Makerere College of Health Sciences, Kampala, Uganda
| | - Esther Namazzi
- Makerere University Lung Institute, Makerere College of Health Sciences, Kampala, Uganda
| | - Patricia Alupo
- Makerere University Lung Institute, Makerere College of Health Sciences, Kampala, Uganda
| | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Robert Kalyesubula
- Department of Physiology, Makerere College of Health Sciences, Kampala, Uganda.,African Community Center for Social Sustainability, Nakaseke, Uganda
| | - David Dowdy
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Robert Wise
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA.,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA
| | - Peter J Barnes
- National Health and Lung Institute, Imperial College, London, UK
| | - William Checkley
- Division of Pulmonary and Critical Care, University of Miami, School of Medicine, Johns Hopkins University, 1951 NW 7th Ave, Suite 2308, Miami, FL, 33136, USA.,Center for Global Non-Communicable Diseases, Johns Hopkins University, Baltimore, USA
| | - Bruce Kirenga
- Makerere University Lung Institute, Makerere College of Health Sciences, Kampala, Uganda
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Abstract
Worldwide, more than 4 million deaths annually are attributed to indoor air pollution. This largely preventable exposure represents a key target for reducing morbidity and mortality worldwide. Significant respiratory health effects are observed, ranging from attenuated lung growth and development in childhood to accelerated lung function decline and is determined by chronic obstructive pulmonary disease later in life. Personal exposure to household air pollutants include household characteristics, combustion of solid fuels, cooking practices, and household pest allergens. This review outlines important sources of indoor air pollution, their respiratory health effects, and strategies to reduce household pollution and improve lung health across the globe.
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Affiliation(s)
- Sarath Raju
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Johns Hopkins School of Medicine, 1830 East Monument Street Fifth Floor, Baltimore, MD, 21287, USA.
| | - Trishul Siddharthan
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Johns Hopkins School of Medicine, 1830 East Monument Street Fifth Floor, Baltimore, MD, 21287, USA
| | - Meredith C McCormack
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Johns Hopkins School of Medicine, 1830 East Monument Street Fifth Floor, Baltimore, MD, 21287, USA
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10
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Ortega-Martínez A, Pérez-Rubio G, Ramírez-Venegas A, Ramírez-Díaz ME, Cruz-Vicente F, Martínez-Gómez MDL, Ramos-Martínez E, Abarca-Rojano E, Falfán-Valencia R. Participation of HHIP Gene Variants in COPD Susceptibility, Lung Function, and Serum and Sputum Protein Levels in Women Exposed to Biomass-Burning Smoke. Diagnostics (Basel) 2020; 10:E734. [PMID: 32977420 PMCID: PMC7598157 DOI: 10.3390/diagnostics10100734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND A variety of organic materials (biomass) are burned for cooking and heating purposes in poorly ventilated houses; smoke from biomass combustion is considered an environmental risk factor for chronic obstructive pulmonary disease COPD. In this study, we attempted to determine the participation of single-nucleotide variants in the HHIP (hedgehog-interacting protein) gene in lung function, HHIP serum levels, and HHIP sputum supernatant levels in Mexican women with and without COPD who were exposed to biomass-burning smoke. METHODS In a case-control study (COPD-BS, n = 186, BBES, n = 557) in Mexican women, three SNPs (rs13147758, rs1828591, and rs13118928) in the HHIP gene were analyzed by qPCR; serum and supernatant sputum protein levels were determined through ELISA. RESULTS The rs13118928 GG genotype is associated with decreased risk (p = 0.021, OR = 0.51, CI95% = 0.27-0.97) and the recessive genetic model (p = 0.0023); the rs1828591-rs13118928 GG haplotype is also associated with decreased risk (p = 0.04, OR = 0.65, CI95% 0.43-0.98). By the dominant model (rs13118928), the subjects with one or two copies of the minor allele (G) exhibited higher protein levels. Additionally, two correlations with the AG genotype were identified: BBES with FEV1 (p = 0.03, r2 = 0.53) and COPD-BS with FEV1/FVC (p = 0.012, r2 = 0.54). CONCLUSIONS Single-nucleotide variants in the HHIP gene are associated with decreased COPD risk, higher HHIP serum levels, and better lung function in Mexican women exposed to biomass burning.
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Affiliation(s)
- Alejandro Ortega-Martínez
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City 14080, Mexico; (A.O.-M.); (G.P.-R.)
- Sección de Estudios de Posgrado e Investigación. Escuela Superior de Medicina, Instituto Politécnico Nacional, Plan de San Luis y Díaz Mirón s/n, Casco de Santo Tomas, Mexico City 11340, Mexico
| | - Gloria Pérez-Rubio
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City 14080, Mexico; (A.O.-M.); (G.P.-R.)
| | - Alejandra Ramírez-Venegas
- Tobacco Smoking and COPD Research Department, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City 14080, Mexico;
| | - María Elena Ramírez-Díaz
- Coordinación de Vigilancia Epidemiológica, Jurisdicción 06 Sierra, Tlacolula de Matamoros Oaxaca, Servicios de Salud de Oaxaca, Oaxaca 70400, Mexico;
| | - Filiberto Cruz-Vicente
- Internal Medicine Department. Hospital Civil Aurelio Valdivieso, Servicios de Salud de Oaxaca, Oaxaca 68050, Mexico;
| | | | - Espiridión Ramos-Martínez
- Experimental Medicine Research Unit, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City 06720, Mexico;
| | - Edgar Abarca-Rojano
- Sección de Estudios de Posgrado e Investigación. Escuela Superior de Medicina, Instituto Politécnico Nacional, Plan de San Luis y Díaz Mirón s/n, Casco de Santo Tomas, Mexico City 11340, Mexico
| | - Ramcés Falfán-Valencia
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City 14080, Mexico; (A.O.-M.); (G.P.-R.)
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Siddharthan T, Gupte A, Barnes PJ. Chronic Obstructive Pulmonary Disease Endotypes in Low- and Middle-Income Country Settings: Precision Medicine for All. Am J Respir Crit Care Med 2020; 202:171-172. [PMID: 32396738 PMCID: PMC7365372 DOI: 10.1164/rccm.202001-0165ed] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Trishul Siddharthan
- Division of Pulmonary and Critical Care MedicineJohns Hopkins UniversityBaltimore, Maryland
| | - Akshay Gupte
- Division of Infectious DiseasesJohns Hopkins UniversityBaltimore, Marylandand
| | - Peter J Barnes
- National Health and Lung InstituteImperial CollegeLondon, United Kingdom
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12
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Velasco-Torres Y, Ruiz V, Montaño M, Pérez-Padilla R, Falfán-Valencia R, Pérez-Ramos J, Pérez-Bautista O, Ramos C. Participation of the miR-22-HDAC4-DLCO Axis in Patients with COPD by Tobacco and Biomass. Biomolecules 2019; 9:E837. [PMID: 31817742 PMCID: PMC6995507 DOI: 10.3390/biom9120837] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/28/2019] [Accepted: 12/04/2019] [Indexed: 12/31/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation and systemic inflammation. The main causes of COPD include interaction between genetic and environmental factors associated with tobacco smoking (COPD-TS) and/or exposure to biomass smoke (COPD-BS). Several microRNAs (miRNAs) control posttranscriptional regulation of COPD-TS associated gene expression. The miR-22-HDAC4-IL-17 axis was recently characterized. It is still unknown, however, whether this axis, participates in COPD-BS. To investigate, 50 patients diagnosed with severe-to-very severe COPD GOLD (Global Initiative for Chronic Obstructive Lung Disease) stages III/IV, were recruited, 25 women had COPD-BS (never smokers, exposed heavily to BS) and 25 had COPD-TS. Serum levels of miRNA-22-3p were measured by RT (Reverse Transcription)-qPCR, while the concentration of HDAC4 (Histone deacetylase 4) was detected by ELISA. Additionally, we looked for association between serum HDAC4 and DLCOsb (Single-breath diffusing capacity of the lung for carbon monoxide), as % of predicted by age, height, and gender, one of the main differences described between COPD-BS and COPD-TS. Women with COPD-BS were older and shorter and had a higher DLCOsb %P (percent predicted) compared to COPD-TS. Serum miR-22-3p was downregulated in COPD-BS relative to COPD-TS. In contrast, the concentration of HDAC4 was higher in COPD-BS compared to COPD-TS. Furthermore, a positive correlation between serum HDAC4 levels and DLCOsb %P was observed. We concluded that the miR-22-HDAC4-DLCO axis behaves differently in patients with COPD-BS and COPD-TS.
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Affiliation(s)
- Yadira Velasco-Torres
- Biological and Health Sciences, Universidad Autónoma Metropolitana-Xochimilco (UAM-X), Mexico City 04960, Mexico;
| | - Víctor Ruiz
- Molecular Biology Laboratory, Department of Research in Pulmonary Fibrosis, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas (INER), Mexico City 14080, Mexico;
| | - Martha Montaño
- Cellular Biology Laboratory, Department of Research in Pulmonary Fibrosis, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas (INER), Mexico City 14080, Mexico;
| | - Rogelio Pérez-Padilla
- Department of Research in Smoking and COPD, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas (INER), Mexico City 14080, Mexico;
| | - Ramcés Falfán-Valencia
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas (INER), Mexico City 14080, Mexico;
| | - Julia Pérez-Ramos
- Division of Biological and Health Sciences, Universidad Autónoma Metropolitana-Xochimilco (UAM-X), Mexico City 04960, Mexico;
| | - Oliver Pérez-Bautista
- Department of Research in Smoking and COPD, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas (INER), Mexico City 14080, Mexico;
| | - Carlos Ramos
- Cellular Biology Laboratory, Department of Research in Pulmonary Fibrosis, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas (INER), Mexico City 14080, Mexico;
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13
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Bellou V, Belbasis L, Konstantinidis AK, Tzoulaki I, Evangelou E. Prognostic models for outcome prediction in patients with chronic obstructive pulmonary disease: systematic review and critical appraisal. BMJ 2019; 367:l5358. [PMID: 31585960 PMCID: PMC6776831 DOI: 10.1136/bmj.l5358] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To map and assess prognostic models for outcome prediction in patients with chronic obstructive pulmonary disease (COPD). DESIGN Systematic review. DATA SOURCES PubMed until November 2018 and hand searched references from eligible articles. ELIGIBILITY CRITERIA FOR STUDY SELECTION Studies developing, validating, or updating a prediction model in COPD patients and focusing on any potential clinical outcome. RESULTS The systematic search yielded 228 eligible articles, describing the development of 408 prognostic models, the external validation of 38 models, and the validation of 20 prognostic models derived for diseases other than COPD. The 408 prognostic models were developed in three clinical settings: outpatients (n=239; 59%), patients admitted to hospital (n=155; 38%), and patients attending the emergency department (n=14; 3%). Among the 408 prognostic models, the most prevalent endpoints were mortality (n=209; 51%), risk for acute exacerbation of COPD (n=42; 10%), and risk for readmission after the index hospital admission (n=36; 9%). Overall, the most commonly used predictors were age (n=166; 41%), forced expiratory volume in one second (n=85; 21%), sex (n=74; 18%), body mass index (n=66; 16%), and smoking (n=65; 16%). Of the 408 prognostic models, 100 (25%) were internally validated and 91 (23%) examined the calibration of the developed model. For 286 (70%) models a model presentation was not available, and only 56 (14%) models were presented through the full equation. Model discrimination using the C statistic was available for 311 (76%) models. 38 models were externally validated, but in only 12 of these was the validation performed by a fully independent team. Only seven prognostic models with an overall low risk of bias according to PROBAST were identified. These models were ADO, B-AE-D, B-AE-D-C, extended ADO, updated ADO, updated BODE, and a model developed by Bertens et al. A meta-analysis of C statistics was performed for 12 prognostic models, and the summary estimates ranged from 0.611 to 0.769. CONCLUSIONS This study constitutes a detailed mapping and assessment of the prognostic models for outcome prediction in COPD patients. The findings indicate several methodological pitfalls in their development and a low rate of external validation. Future research should focus on the improvement of existing models through update and external validation, as well as the assessment of the safety, clinical effectiveness, and cost effectiveness of the application of these prognostic models in clinical practice through impact studies. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017069247.
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Affiliation(s)
- Vanesa Bellou
- Department of Hygiene and Epidemiology, University of Ioannina Medical School, Ioannina, Greece
- Department of Respiratory Medicine, University Hospital of Ioannina, University of Ioannina Medical School, Ioannina, Greece
| | - Lazaros Belbasis
- Department of Hygiene and Epidemiology, University of Ioannina Medical School, Ioannina, Greece
| | - Athanasios K Konstantinidis
- Department of Respiratory Medicine, University Hospital of Ioannina, University of Ioannina Medical School, Ioannina, Greece
| | - Ioanna Tzoulaki
- Department of Hygiene and Epidemiology, University of Ioannina Medical School, Ioannina, Greece
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
- MRC-PHE Center for Environment, School of Public Health, Imperial College London, London, UK
| | - Evangelos Evangelou
- Department of Hygiene and Epidemiology, University of Ioannina Medical School, Ioannina, Greece
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
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Abstract
Across China and Southeast Asia, over 17,000 bears are currently farmed for bile, predominantly for traditional Chinese medicines. Bears on farms in China are cage confined and undergo repeated daily bile extraction facilitated by surgically implanted catheters or gallbladder fistulas. Numerous health problems have been reported in bile-farmed bears including peritonitis, abdominal hernias, and extraction site abscessation. Between 2009 and 2014, five Asiatic black bears ( Ursus thibetanus) and one Asiatic black/Eurasian brown bear ( Ursus arctos arctos) hybrid, rescued from the bear bile industry in China, died from ruptured and/or dissecting aortic aneurysm. Medical records were reviewed and two bears exhibited no clinical signs prior to death. In four bears, clinical findings varied and included increased stereotypic behavior prior to death, epistaxis, retinal lesions, dysphagia, weight loss, and acute onset of hyporexia. On postmortem examination, hemopericardium with dissection and/or rupture of the ascending aorta and left ventricular wall hypertrophy were present in all cases. No evidence of infectious disease, connective tissue disorders, or congenital cardiac disease was identified. Based on these observations screening thoracic radiography was performed on all bears at the rescue center and aortic dilation was identified in 73 of 134 (54.5%) bile-extracted bears. To the authors' knowledge, aortic aneurysm, rupture, and/or dissection have not been previously reported in any bear species and the high prevalence in this population of bears suggests an association with bile-farming practices. Future studies are needed to investigate the etiopathogenesis of this condition to aid in early diagnosis and improved management of bears being rescued from bile farms across Asia.
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Ramírez-Venegas A, Velázquez-Uncal M, Aranda-Chávez A, Guzmán-Bouilloud NE, Mayar-Maya ME, Pérez Lara-Albisua JL, Hernández-Zenteno RDJ, Flores-Trujillo F, Sansores RH. Bronchodilators for hyperinflation in COPD associated with biomass smoke: clinical trial. Int J Chron Obstruct Pulmon Dis 2019; 14:1753-1762. [PMID: 31496674 PMCID: PMC6689558 DOI: 10.2147/copd.s201314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 04/12/2019] [Indexed: 01/25/2023] Open
Abstract
Introduction The efficacy of long-acting bronchodilators for COPD associated with biomass (BE-COPD) has not been properly evaluated. Objective To determine the acute effect of indacaterol (IND) 150 μg q.d and tiotropium (TIO) 18 μg q.d. on lung hyperinflation, walking distance (WD) and dyspnea during the six-minute walking test (6MWT) in moderate BE-COPD at 30, 60 and 240 mins post-drug administration. Design Randomized, controlled, open-level, crossover noninferiority clinical trial. Forty-two women with BE-COPD were randomly assigned to a bronchodilator sequence: IND–TIO or vice versa. Results There were statistically significant changes over time in inspiratory capacity (IC) (p<0.0001), FEV1 (p<0.0001) and FVC (p<0.0001) when IND was used. When TIO was administered, an increase over all time periods was observed only for FEV1 (p<0.0001) and FVC (p<0.0001), whereas for IC an increase was observed only at 30 mins and 24 hrs after TIO administration. We did not find clinically significant increases in WD and dyspnea after the administration of both bronchodilators. Conclusion Both IND and TIO showed significant and fast onset improvement in hyperinflation. Therefore, either of them may be recommended as a first line of treatment for COPD associated with BE-COPD.
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Affiliation(s)
- Alejandra Ramírez-Venegas
- Department of Tobacco Smoking and COPD Research, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosió Villegas", Mexico City, Mexico
| | - Mónica Velázquez-Uncal
- Department of Tobacco Smoking and COPD Research, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosió Villegas", Mexico City, Mexico
| | - Adrián Aranda-Chávez
- Department of Tobacco Smoking and COPD Research, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosió Villegas", Mexico City, Mexico
| | - Nicolás Eduardo Guzmán-Bouilloud
- Department of Tobacco Smoking and COPD Research, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosió Villegas", Mexico City, Mexico
| | - María Eugenia Mayar-Maya
- Department of Medical Attention, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosió Villegas", Mexico City, Mexico
| | - José Luis Pérez Lara-Albisua
- Department of Tobacco Smoking and COPD Research, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosió Villegas", Mexico City, Mexico
| | - Rafael de Jesus Hernández-Zenteno
- Obstructive Disease Ward, Pulmonary Obstructive Diseases Clinical Service, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Mexico City, Mexico
| | - Fernando Flores-Trujillo
- Obstructive Disease Ward, Pulmonary Obstructive Diseases Clinical Service, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Mexico City, Mexico
| | - Raúl H Sansores
- Department of Respiratory Medicine, Medica Sur Clinic & Foundation , Mexico City, Mexico
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16
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Abstract
The PLATINO and PREPOCOL population-based studies documented the prevalence of chronic obstructive pulmonary disease (COPD) in several Latin American (Mexico City, Sao Paulo, Montevideo, Santiago and Caracas) and Colombian (Medellin, Bogota, Barranquilla, Bucaramanga and Cali) cities. COPD ranged between 6.2 and 19.6% in individuals ≥40 years of age, with substantial rates of underdiagnosis (up to 89%) but also overdiagnosis, mostly due to the lack of spirometric confirmation. The main risk factor was tobacco smoking, but male gender and age were also associated with COPD. COPD in never smokers represented about one third of the cases and was associated with previous history of tuberculosis or a diagnosis of asthma. COPD associated with biomass smoke exposure was a common clinical phenotype in Latin America, found as a risk factor in PREPOCOL and other observational studies in the region. Smoking has been decreasing in Latin America and efforts have been made to implement cleaner biomass stoves. Unfortunately, treatment of COPD in Latin America remains highly variable with low rates of smoking cessation counselling, low use of inhaled bronchodilators and influenza vaccination. A primary-care approach to COPD, particularly in the form of integrated programs is lacking but would be critical to improving rates of diagnosis and treatment of COPD.
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17
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Pérez-Bautista O, Montaño M, Pérez-Padilla R, Zúñiga-Ramos J, Camacho-Priego M, Barrientos-Gutiérrez T, Buendía-Roldan I, Velasco-Torres Y, Ramos C. Women with COPD by biomass show different serum profile of adipokines, incretins, and peptide hormones than smokers. Respir Res 2018; 19:239. [PMID: 30514305 PMCID: PMC6280373 DOI: 10.1186/s12931-018-0943-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 11/19/2018] [Indexed: 01/27/2023] Open
Abstract
Background The main causes of COPD are tobacco smoking (COPD-TS) and biomass smoke exposure (COPD-BS). COPD-TS is known to induce changes in adipokines, incretins, and peptide hormones, frequent biomarkers of inflammation; however, it is unknown if similar changes occur in COPD-BS. Methods Clinical and physiological characteristics, and serum concentration of C-peptide, ghrelin, GIP, GLP-1, glucagon, insulin, leptin, PAI-1, resistin, and visfatin were measured in women with COPD-BS, COPD-TS, and healthy controls. Data were compared with one-way ANOVA and Tukey’s post hoc test; nonparametric were expressed as median (interquartile ranges), with Kruskal-Wallis and Dunn’s post-hoc test. Multivariate analysis, age, BMI, MS, and FEV1% pred with levels of inflammatory mediators in COPD women. Results FEV1% pred, FVC% pred, and FEV1/FVC ratio were decremented in COPD. In COPD-TS increased C-peptide, ghrelin, GIP, GLP-1, and leptin, and reduced glucagon, PAI-1, resistin, and visfatin. In COPD-BS enlarged ghrelin, insulin, leptin, and PAI-1 comparatively with COPD-TS and control, while C-peptide and GLP-1 relatively with controls; conversely, glucagon, and resistin were reduced. Multivariate analysis showed association of ghrelin, insulin, PAI-1, and visfatin with BS exposure. Conclusions women with COPD-BS have a distinct profile of adipokines, incretins, and peptide hormones, and specifically with ghrelin, insulin, PAI-1, and visfatin related to BS exposure.
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Affiliation(s)
- Oliver Pérez-Bautista
- Departamento de Investigación en Tabaquismo y EPOC, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas (INERICV), Ciudad de México, Mexico
| | - Martha Montaño
- Departamento de Investigación en Fibrosis Pulmonar, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas (INERICV), Talpan 4502, C.P. 14080, Ciudad de México, Mexico
| | - Rogelio Pérez-Padilla
- Departamento de Investigación en Tabaquismo y EPOC, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas (INERICV), Ciudad de México, Mexico
| | - Joaquín Zúñiga-Ramos
- Laboratorio de Inmunobiología y Genética, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas (INERICV), Ciudad de México, Mexico
| | - Mariana Camacho-Priego
- Departamento de Investigación en Tabaquismo y EPOC, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas (INERICV), Ciudad de México, Mexico
| | - Tonatiuh Barrientos-Gutiérrez
- Centro de Investigación en Salud Poblacional, Instituto Nacional de Salud Pública (INSP), Cuernavaca, Morelos, Mexico
| | - Ivette Buendía-Roldan
- Departamento de Investigación en Fibrosis Pulmonar, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas (INERICV), Talpan 4502, C.P. 14080, Ciudad de México, Mexico
| | - Yadira Velasco-Torres
- Doctorado en Ciencias Biológicas y de la Salud, Universidad Autónoma Metropolitana-Xochimilco (UAMX), Ciudad de México, Mexico
| | - Carlos Ramos
- Departamento de Investigación en Fibrosis Pulmonar, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas (INERICV), Talpan 4502, C.P. 14080, Ciudad de México, Mexico.
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Schraufnagel DE, Balmes JR, Cowl CT, De Matteis S, Jung SH, Mortimer K, Perez-Padilla R, Rice MB, Riojas-Rodriguez H, Sood A, Thurston GD, To T, Vanker A, Wuebbles DJ. Air Pollution and Noncommunicable Diseases: A Review by the Forum of International Respiratory Societies' Environmental Committee, Part 1: The Damaging Effects of Air Pollution. Chest 2018; 155:409-416. [PMID: 30419235 DOI: 10.1016/j.chest.2018.10.042] [Citation(s) in RCA: 255] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/28/2018] [Accepted: 10/31/2018] [Indexed: 11/24/2022] Open
Abstract
Air pollution poses a great environmental risk to health. Outdoor fine particulate matter (particulate matter with an aerodynamic diameter < 2.5 μm) exposure is the fifth leading risk factor for death in the world, accounting for 4.2 million deaths and > 103 million disability-adjusted life years lost according to the Global Burden of Disease Report. The World Health Organization attributes 3.8 million additional deaths to indoor air pollution. Air pollution can harm acutely, usually manifested by respiratory or cardiac symptoms, as well as chronically, potentially affecting every organ in the body. It can cause, complicate, or exacerbate many adverse health conditions. Tissue damage may result directly from pollutant toxicity because fine and ultrafine particles can gain access to organs, or indirectly through systemic inflammatory processes. Susceptibility is partly under genetic and epigenetic regulation. Although air pollution affects people of all regions, ages, and social groups, it is likely to cause greater illness in those with heavy exposure and greater susceptibility. Persons are more vulnerable to air pollution if they have other illnesses or less social support. Harmful effects occur on a continuum of dosage and even at levels below air quality standards previously considered to be safe.
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Affiliation(s)
- Dean E Schraufnagel
- Pulmonary, Critical Care, Sleep and Allergy, University of Illinois at Chicago, Chicago, IL.
| | - John R Balmes
- Department of Medicine, University of California, San Francisco, Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA
| | - Clayton T Cowl
- Divisions of Preventive, Occupational, and Aerospace Medicine, and Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Sara De Matteis
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Soon-Hee Jung
- Department of Pathology, Wonju Colleage of Medicine Yonsei University, Seoul, South Korea
| | - Kevin Mortimer
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Mary B Rice
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Akshay Sood
- Pulmonary, Critical Care, and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - George D Thurston
- Departments of Environmental Medicine and Population Health, New York University School of Medicine, New York, NY
| | - Teresa To
- The Hospital for Sick Children, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Anessa Vanker
- Department of Paediatrics and Child Health & MRC Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Donald J Wuebbles
- School of Earth, Society, and Environment, Department of Atmospheric Sciences, University of Illinois, Urbana, IL
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Shaikh M, Sood RG, Sarkar M, Thakur V. Quantitative Computed Tomography (CT) Assessment of Emphysema in Patients with Severe Chronic Obstructive Pulmonary Disease (COPD) and its Correlation with Age, Sex, Pulmonary Function Tests, BMI, Smoking, and Biomass Exposure. Pol J Radiol 2017; 82:760-766. [PMID: 29657642 PMCID: PMC5894027 DOI: 10.12659/pjr.903278] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 03/19/2017] [Indexed: 12/13/2022] Open
Abstract
Background To evaluate the role of HRCT in quantifying emphysema in severe COPD patients and to study the variations in the pattern of emphysema in relation to age, sex, FEV1, smoking index, biomass exposure, and BMI. Material/Methods Automatic lung segmentation of HRCT scans in 41 severe COPD patients (GOLD stage III or more) was done using an emphysema protocol. The extent of emphysema was assessed using the density mask method with a threshold of –950 HU (%LAA-950). The percentage of emphysema in each lung lobe and both lungs was correlated with 6 parameters – age, sex, BMI, smoking index, biomass exposure, and FEV1. Results Smoking resulted in homogenously distributed emphysema regardless of the severity of smoking. BMI was inversely correlated with the extent of emphysema. A significant association was found between the percentage of emphysema in the right lower lobe and BMI (P=0.015), between biomass exposure and the percentage of emphysema in RUL, RLL, and both lungs (P values of 0.024, 0.016, and 0.036, respectively). The extent of emphysema was disproportionately low compared to the amount of obstruction on PFTs, indicating an airway predominant variety of COPD with significant biomass exposure. Conclusions Smoking is associated with a relatively homogenous distribution of emphysema with no regional predilection. Biomass exposure produces predominantly right-sided emphysema. BMI decreases with increasing levels of emphysema in the right lower lobe. These risk factors of emphysema patterns are helpful in deciding on the management, including surgical options.
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Affiliation(s)
- Minhaj Shaikh
- Department of Radiology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - Ram Gopal Sood
- Department of Radiology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - Malay Sarkar
- Department of Pulmonary Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - Vijay Thakur
- Department of Radiology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
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Pleasants RA, Riley IL, Mannino DM. Defining and targeting health disparities in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2016; 11:2475-2496. [PMID: 27785005 PMCID: PMC5065167 DOI: 10.2147/copd.s79077] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The global burden of chronic obstructive pulmonary disease (COPD) continues to grow in part due to better outcomes in other major diseases and in part because a substantial portion of the worldwide population continues to be exposed to inhalant toxins. However, a disproportionate burden of COPD occurs in people of low socioeconomic status (SES) due to differences in health behaviors, sociopolitical factors, and social and structural environmental exposures. Tobacco use, occupations with exposure to inhalant toxins, and indoor biomass fuel (BF) exposure are more common in low SES populations. Not only does SES affect the risk of developing COPD and etiologies, it is also associated with worsened COPD health outcomes. Effective interventions in these people are needed to decrease these disparities. Efforts that may help lessen these health inequities in low SES include 1) better surveillance targeting diagnosed and undiagnosed COPD in disadvantaged people, 2) educating the public and those involved in health care provision about the disease, 3) improving access to cost-effective and affordable health care, and 4) markedly increasing the efforts to prevent disease through smoking cessation, minimizing use and exposure to BF, and decreasing occupational exposures. COPD is considered to be one the most preventable major causes of death from a chronic disease in the world; therefore, effective interventions could have a major impact on reducing the global burden of the disease, especially in socioeconomically disadvantaged populations.
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Affiliation(s)
- Roy A Pleasants
- Duke Asthma, Allergy, and Airways Center
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine
- Durham VA Medical Center, Durham, NC
| | - Isaretta L Riley
- Duke Asthma, Allergy, and Airways Center
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine
- Durham VA Medical Center, Durham, NC
| | - David M Mannino
- Division of Pulmonary, Critical Care, and Sleep Medicine, Pulmonary Epidemiology Research Laboratory, University of Kentucky, Lexington, KY, USA
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van Gemert F, Chavannes N, Kirenga B, Jones R, Williams S, Tsiligianni I, Vonk J, Kocks J, de Jong C, van der Molen T. Socio-economic factors, gender and smoking as determinants of COPD in a low-income country of sub-Saharan Africa: FRESH AIR Uganda. NPJ Prim Care Respir Med 2016; 26:16050. [PMID: 27597659 PMCID: PMC5011937 DOI: 10.1038/npjpcrm.2016.50] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 06/06/2016] [Accepted: 06/17/2016] [Indexed: 01/29/2023] Open
Abstract
In Uganda, biomass smoke seems to be the largest risk factor for the development of COPD, but socio-economic factors and gender may have a role. Therefore, more in-depth research is needed to understand the risk factors. The aim of this study was to investigate the impact of socio-economic factors and gender differences on the COPD prevalence in Uganda. The population comprised 588 randomly selected participants (>30 years) who previously completed the FRESH AIR Uganda study. In this post hoc analysis, the impact of several socio-economic characteristics, gender and smoking on the prevalence of COPD was assessed using a logistic regression model. The main risk factors associated with COPD were non-Bantu ethnicity (odds ratio (OR) 1.73, 95% confidence interval (CI) 1.06–2.82, P=0.030), biomass fuel use for heating (OR 1.76, 95% CI 1.03–3.00, P=0.038), former smoker (OR 1.87, 95% CI 0.97–3.60, P=0.063) and being unmarried (OR 0.087, 95% CI 0.93–2.95, P=0.087). A substantial difference in the prevalence of COPD was seen between the two ethnic groups: non-Bantu 20% and Bantu 12.9%. Additional analysis between these two groups showed significant differences in socio-economic circumstances: non-Bantu people smoked more (57.7% vs 10.7%), lived in tobacco-growing areas (72% vs 14.8%) and were less educated (28.5% vs 12.9% had no education). With regard to gender, men with COPD were unmarried (OR 3.09, 95% CI 1.25–7.61, P=0.015) and used more biomass fuel for heating (OR 2.15, 95% CI 1.02–4.54, P=0.045), and women with COPD were former smokers (OR 3.35, 95% CI 1.22–9.22, P=0.019). Only a few socio-economic factors (i.e., smoking, biomass fuel use for heating, marital status and non-Bantu ethnicity) have been found to be associated with COPD. This applied for gender differences as well (i.e., for men, marital status and biomass fuel for heating, and for women being a former smoker). More research is needed to clarify the complexity of the different risk factors.
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Affiliation(s)
- Frederik van Gemert
- Department of General Practice, Groningen Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Niels Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Bruce Kirenga
- Division of Pulmonary Medicine, Makerere University Lung Institute, Mulago Hospital, Makerere University, Kampala, Uganda
| | - Rupert Jones
- Centre for Clinical Trials and Population Studies, Plymouth University Peninsula School of Medicine and Dentistry, Plymouth, UK
| | - Sian Williams
- Executive Office, International Primary Care Respiratory Group, London, UK
| | - Ioanna Tsiligianni
- Department of General Practice, Groningen Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Judith Vonk
- Department of Epidemiology, Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Janwillem Kocks
- Department of General Practice, Groningen Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Corina de Jong
- Department of General Practice, Groningen Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thys van der Molen
- Department of General Practice, Groningen Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Is Chronic Obstructive Pulmonary Disease Caused by Wood Smoke a Different Phenotype or a Different Entity? ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.arbr.2016.06.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Torres-Duque CA, García-Rodriguez MC, González-García M. Is Chronic Obstructive Pulmonary Disease Caused by Wood Smoke a Different Phenotype or a Different Entity? Arch Bronconeumol 2016; 52:425-31. [PMID: 27207325 DOI: 10.1016/j.arbres.2016.04.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 04/03/2016] [Accepted: 04/04/2016] [Indexed: 01/29/2023]
Abstract
Around 40% of the world's population continue using solid fuel, including wood, for cooking or heating their homes. Chronic exposure to wood smoke is a risk factor for developing chronic obstructive pulmonary disease (COPD). In some regions of the world, this can be a more important cause of COPD than exposure to tobacco smoke from cigarettes. Significant differences between COPD associated with wood smoke (W-COPD) and that caused by smoking (S-COPD) have led some authors to suggest that W-COPD should be considered a new COPD phenotype. We present a review of the differences between W-COPD and S-COPD. On the premise that wood smoke and tobacco smoke are not the same and the physiopathological mechanisms they induce may differ, we have analyzed whether W-COPD can be considered as another COPD phenotype or a distinct nosological entity.
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Abstract
Chronic Obstructive Pulmonary Disease (COPD) affects 12-16 million people in the United States and is the third-leading cause of death. In developed countries, smoking is the greatest risk factor for the development of COPD, but other exposures also contribute to the development and progression of the disease. Several studies suggest, though are not definitive, that outdoor air pollution exposure is linked to the prevalence and incidence of COPD. Among individuals with COPD, outdoor air pollutants are associated with loss of lung function and increased respiratory symptoms. In addition, outdoor air pollutants are also associated with COPD exacerbations and mortality. There is much less evidence for the impact of indoor air on COPD, especially in developed countries in residences without biomass exposure. The limited existing data suggests that indoor particulate matter and nitrogen dioxide concentrations are linked to increased respiratory symptoms among patients with COPD. In addition, with the projected increases in temperature and extreme weather events in the context of climate change there has been increased attention to the effects of heat exposure. Extremes of temperature-both heat and cold-have been associated with increased respiratory morbidity in COPD. Some studies also suggest that temperature may modify the effect of pollution exposure and though results are not conclusive, understanding factors that may modify susceptibility to air pollution in patients with COPD is of utmost importance.
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Affiliation(s)
- Nadia N. Hansel
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Environmental Health Sciences, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Meredith C. McCormack
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Environmental Health Sciences, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Victor Kim
- Temple University, Philadelphia, Pennsylvania, USA
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[COPD: Gender equality now!]. Rev Mal Respir 2016; 33:203-5. [PMID: 26782993 DOI: 10.1016/j.rmr.2015.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 11/17/2015] [Indexed: 10/22/2022]
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The chronic bronchitis phenotype in chronic obstructive pulmonary disease: features and implications. Curr Opin Pulm Med 2016; 21:133-41. [PMID: 25575367 DOI: 10.1097/mcp.0000000000000145] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW Chronic obstructive pulmonary disease (COPD) is a major public health problem that is projected to rank fifth worldwide in terms of disease burden and third in terms of mortality. Chronic bronchitis is associated with multiple clinical consequences, including hastening lung function decline, increasing risk of exacerbations, reducing health-related quality of life, and possibly raising all-cause mortality. Recent data suggest greater elucidation on the risk factors, radiologic characteristics, and treatment regimens. Our goal was to review the literature on chronic bronchitis that has been published in the past few years. RECENT FINDINGS A growing body of literature that more carefully describes environmental risk factors, epidemiology, and genetics associated with chronic bronchitis. In addition, as computed tomography technology continues to improve, the radiologic phenotype associated with chronic bronchitis is better understood. SUMMARY With these new data, the clinician can recognize the newly described risk factors and the associated phenotype for chronic bronchitis and entertain new treatment options for this high-risk population.
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Solleiro-Villavicencio H, Quintana-Carrillo R, Falfán-Valencia R, Vargas-Rojas MI. Chronic obstructive pulmonary disease induced by exposure to biomass smoke is associated with a Th2 cytokine production profile. Clin Immunol 2015; 161:150-5. [PMID: 26220216 DOI: 10.1016/j.clim.2015.07.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 07/18/2015] [Accepted: 07/21/2015] [Indexed: 01/25/2023]
Abstract
Smoking and exposure to biomass smoke induce the release of pro-inflammatory mediators and the activation of T helper cells. The resulting inflammatory response contributes to the development of COPD. Clinical heterogeneity exists among COPD patients, particularly between patients with disease associated with tobacco smoking (TS-COPD) and those exposed to biomass smoke (BE-COPD). The aim of this study was to identify whether exposure to tobacco and biomass smokes promotes different Th responses that contribute to clinical variability. The study only included women. The frequency of Th17 cells in patients with TS-COPD was significantly higher than in patients with BE-COPD and healthy controls (HC). In contrast, patients with BE-COPD had higher levels of Th2 cells than TS-COPD and HC. In accordance, IL-4 serum concentration was higher in BE-COPD than in TS-COPD. Our data indicates that the different responses induced by these two irritants may underlie the clinical heterogeneity between TS- and BE-COPD patients.
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Affiliation(s)
- Helena Solleiro-Villavicencio
- Programa de Doctorado en Ciencias Biomédicas, Facultad de Medicina, Universidad Nacional Autónoma de México,Mexico City, Mexico.
| | - Roger Quintana-Carrillo
- Departamento de Investigación sobre Tabaco, Instituto Nacional de Salud Pública, Cuernavaca, Mexico.
| | - Ramcés Falfán-Valencia
- Laboratorio de HLA, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico.
| | - María Inés Vargas-Rojas
- Programa de Doctorado en Ciencias Biomédicas, Facultad de Medicina, Universidad Nacional Autónoma de México,Mexico City, Mexico; Departamento de Investigación en Microbiología, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico.
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