Prognostic nutritional index as a predictor of mortality in nontuberculous mycobacterial lung disease

The Influencing Factors of Extensive Lung Lesions and Cavities in Patients With Non-Tuberculous Mycobacterial Lung Disease

Aims/Background The resolution of non-tuberculous mycobacterial (NTM) lung disease is associated with the extent of pulmonary lesions and the presence of lung cavities. This study aims to identify factors influencing the development of extensive lung lesions and cavities in patients with NTM lung disease, thereby generating valuable insights for the management and treatment of NTM lung disease. Methods Retrospective analysis was conducted on clinical data from 198 hospitalized patients with NTM lung disease at the Department of Tuberculosis, The Second Hospital of Nanjing, between 2022 and 2023. Patient data like age, gender, past medical history, nutritional risk screening 2002 (NRS-2002) score, lymphocyte count, peripheral blood neutrophil-to-lymphocyte ratio (NLR), pulmonary computed tomography (CT) imaging findings (including extent of lung lesions and presence of cavities), and T cell subsets count were gathered through electronic medical records and hospital information system (HIS) system. Univariate and multivariate logistic regression analyses were carried out with extensive lung lesions and cavities as dependent variables and other factors as independent variables. Results Among the 198 patients, 138 (69.7%) exhibited extensive lung lesions, while cavities were observed in 76 individuals (38.4%). Based on the results of logistic regression analysis, a high NLR (OR = 4.685 [1.176-18.663], p = 0.029) and an NRS-2002 score ≥3 (OR = 12.082 [3.726-39.183], p < 0.001) were identified as risk factors for the development of extensive lung lesions in patients with NTM lung disease. Furthermore, elevated NLR (OR = 3.454 [1.483-8.047], p = 0.004) was associated with an increased risk of cavities in patients with NTM lung disease. Conclusion In patients with NTM lung disease, high NLR is the risk factor for extensive lung lesions and formation of pulmonary cavities, whereas malnutrition elevates the risk for prevalent lung lesions. Early intervention and active monitoring of these related indicators are necessary to prevent disease progression and enhance overall cure rates.

Usefulness of the mini nutritional assessment short-form for evaluating nutritional status in patients with nontuberculous mycobacterial pulmonary disease: a prospective cross-sectional study

BACKGROUND

Although the Mini Nutritional Assessment (MNA) is recognized as a useful tool for evaluating nutritional status in patients with various diseases, its applicability in patients with nontuberculous mycobacterial pulmonary disease (NTM-PD) remains undetermined.

METHODS

We designed a prospective cross-sectional study to investigate whether the MNA Short-Form (MNA-SF) score can serve as a screening tool to assess the nutritional status of patients with NTM-PD. The MNA-SF was conducted upon patient enrollment, and correlation analyses were performed to compare MNA-SF scores with other nutritional measurements and disease severity. Multivariable logistic regression analyses were conducted to evaluate the association between MNA-SF scores and NTM-PD severity.

RESULTS

The 194 patients with NTM-PD included in the analysis had a median age of 65.0 (59.0-69.0) years; 59.3% (n = 115) had low MNA-SF scores (< 12). The low MNA-SF group exhibited a lower body mass index (19.7 vs. 22.4 kg/m2, p < 0.001) and fat-free mass index (14.7 vs. 15.6 kg/m2, p < 0.001) than the normal MNA-SF group, as well as higher incidences of sarcopenia (20.0% vs. 6.3%, p = 0.008) and adipopenia (35.7% vs. 5.1%, p < 0.001). However, no significant differences in calorie and protein intakes were observed between the two groups. Low MNA-SF scores were associated with radiographic severity (adjusted odds ratio 2.72, 95% confidence interval 1.38-5.36) but not with forced vital capacity.

CONCLUSIONS

The MNA-SF can effectively assess the nutritional status of patients with NTM-PD and can serve as an important clinical indicator in NTM-PD where treatment timing is determined by clinical judgment.

Glasgow prognostic score and body mass index predict short-term discontinuation of the antifibrotic agents pirfenidone and nintedanib

BACKGROUND

The antifibrotic agents pirfenidone and nintedanib have been shown to be effective in patients with idiopathic pulmonary fibrosis (IPF). However, discontinuation of antifibrotic drugs is a major clinical concern because of the lack of alternative treatment options. Therefore, we identified factors that may be useful for predicting the termination of antifibrotic agents.

METHODS

We retrospectively recruited 280 IPF patients treated with antifibrotic drugs between 2009 and 2018 from seven regional core hospitals in Gunma prefecture, Japan.

RESULTS

At four months, the short-term discontinuation group exhibited a significantly worse prognosis in the pirfenidone group and a poorer prognosis in the nintedanib group compared to that in the continuation group. The discontinuation group of pirfenidone at 4 months exhibited lower albumin and higher C-reactive protein (CRP) levels in the sera compared to the group that continued treatment for more than 4 months. In multivariate analysis, the Glasgow prognostic score (GPS), well known as a predictor of cancer prognosis, which comprises serum CRP and albumin levels, predicted early discontinuation and prognosis in the pirfenidone group, whereas the body mass index (BMI) predicted early discontinuation of nintedanib. A high GPS, with both albumin <3.5 g/dL and CRP >1.0 mg/dL, was associated with a poorer prognosis in the pirfenidone group.

CONCLUSION

GPS and BMI were significant factors for short-term pirfenidone and nintedanib discontinuation, respectively. Initial evaluation of GPS and BMI prior to antifibrotic therapy may contribute to less interrupted IPF management, thus leading to better prognostic outcomes in patients with IPF.

Eliciting Patient Insights on the Burden of Nontuberculous Mycobacterial Lung Disease (NTM-LD) and Healthcare Gaps in Germany Through Qualitative Semi-structured Interviews

INTRODUCTION

Nontuberculous mycobacterial lung disease (NTM-LD) is a rare but growing health concern, particularly affecting vulnerable patients with chronic lung conditions. Understanding the patients' perspective on their disease and treatment expectations can help to identify healthcare gaps and improve overall patient care. Therefore, the main objective of the survey study was the evaluation of patient insights on the burden of the disease and healthcare gaps.

METHODS

The study used an online survey as a pre-screener to facilitate recruitment followed by semi-structured qualitative interviews. The interviews were conducted by phone from April 2019 to February 2020 in German language. Only patients with a self-reported confirmed NTM-LD diagnosis, managed and insured in Germany were included in this study.

RESULTS

In total, 20 semi-structured qualitative interviews were conducted. Most (85%) patients had at least one coexisting pulmonary condition with cystic fibrosis (CF, n = 9) being most common. Chronic cough, fatigue, and dyspnea were the most reported symptoms. Of all the symptoms reported, fatigue was perceived as the most burdensome and 85% of patients felt limited in their daily life. It took a median of 5 months for patients to receive an accurate diagnosis of NTM-LD and that time was doubled when excluding patients with CF (range 0-480 months). Ninety percent of interviewed patients (n = 18) received drug treatment for NTM-LD and most of them (n = 17) reported having experienced side effects from their treatment. Patients' expressed a particular need for more comprehensive and reliable patient-friendly information on NTM-LD and a better awareness of physicians as well.

CONCLUSIONS

NTM-LD can considerably impair the lives of patients and their families and/or caregivers. A multidisciplinary approach and establishment of more widespread regional expert centers for NTM-LD management in Germany with well-structured referral and communication pathways accompanied by peer-to-peer support of patient advocacy groups are urgently needed.

The factors associated with mortality and progressive disease of nontuberculous mycobacterial lung disease: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to comprehensively evaluate the factors associated with mortality and progressive disease in NTM-LD patients. We conducted a literature search to identify the eligible studies, dated between January 1, 2007, and April 12, 2021. Forty-one studies with total 10,452 patients were included. The overall all-cause mortality rate was 20% (95% CI 17-24%). The overall rates of clinical and radiographic progressive disease were 46% (95% CI 39-53%) and 43% (95% CI 31-55%), respectively. Older age, male sex, history of TB, diabetes, chronic heart disease, malignancy, systemic immunosuppression, chronic liver disease, presence of cavity, consolidative radiologic features, acid-fast bacillus (AFB) smear positivity, hypoalbuminemia, anemia, increasing platelet count, high CRP, and high ESR were significantly associated with increased all-cause mortality, whereas increasing body mass index (BMI), hemoptysis, and treatment with rifamycin regimen (in M. xenopi) were significantly associated with decreased all-cause mortality in multivariable analysis. History of TB, Aspergillus co-infection, cough, increased sputum, weight loss, presence of cavity, and AFB smear positivity were significantly associated with increased clinical progression with treatment, while older age and low BMI were significantly associated with decreased clinical progression in multivariable analysis. Older age, interstitial lung disease, presence of cavity, consolidative radiologic feature, anemia, high CRP, and leukocytosis were significantly associated with increased radiographic progression after adjusting for covariates. Older age, history of tuberculosis, presence of cavity, consolidative radiologic features, AFB smear positivity, anemia, and high C-reactive protein were common significant factors associated with the all-cause mortality and clinical or radiographic progressive disease of NTM-LD. These factors are thought to directly affect NTM-LD related mortality. The future prediction models for the prognosis of NTM-LD should be established considering these factors.

Incidence of Nontuberculous Mycobacterial Pulmonary Infection, by Ethnic Group, Hawaii, USA, 2005-2019

To further clarify differences in the risk for nontuberculous mycobacterial pulmonary infection (NTM-PI) among ethnic populations in Hawaii, USA, we conducted a retrospective cohort study among beneficiaries of Kaiser Permanente Hawaii (KPH). We abstracted demographic, socioeconomic, clinical, and microbiological data from KPH electronic health records for 2005-2019. An NTM-PI case-patient was defined as a person from whom >1 NTM pulmonary isolate was obtained. We performed Cox proportional hazards regression to estimate incidence of NTM-PI while controlling for confounders. Across ethnic groups, risk for NTM-PI was higher among persons who were underweight (body mass index [BMI] <18.5 kg/m²). Among beneficiaries who self-identified as any Asian ethnicity, risk for incident NTM-PI was increased by 30%. Low BMI may increase susceptibility to NTM-PI, and risk may be higher for persons who self-identify as Asian, independent of BMI.

Clinical significance and safety of combined treatment with chemotherapy and pulmonary rehabilitation regarding health-related quality of life and physical function in nontuberculous mycobacterial pulmonary disease

BACKGROUND

In the treatment of patients with nontuberculous mycobacterial pulmonary disease (NTM-PD), pulmonary rehabilitation (PR) has been recommended as a non-pharmacological therapy. However, no study has validated the combination of chemotherapy and PR in this context. This study investigated the effect of chemotherapy and supervised PR on health-related quality of life (HRQoL) and physical function in NTM-PD patients.

METHODS

This prospective cohort study included patients diagnosed with NTM-PD who had a planned hospitalization of at least 3 weeks for chemotherapy and PR. HRQoL (Leicester Cough Questionnaire [LCQ] and chronic obstructive pulmonary disease assessment test [CAT]), physical function (incremental shuttle walk distance [ISWD], quadriceps force), and C-reactive protein levels were assessed before and after treatment, and the corresponding data were analyzed in conjunction with clinical data. The adverse events of PR were also investigated.

RESULTS

Forty-two patients who met the study criteria were included in the analysis. After treatment, all LCQ item scores, total CAT score and sub-item scores related to respiratory symptoms, ISWD, quadriceps force, and C-reactive protein levels were found to have improved significantly. In the chronic cough with excessive sputum production (CCS) group, the proportions of responders who showed improvements in LCQ and CAT scores and ISWD greater than the corresponding minimal clinically important difference were significantly greater than those in the non-CCS group. No PR-related adverse events were reported.

CONCLUSIONS

Combined treatment with chemotherapy and PR may improve HRQoL and physical function, and supervised PR can be provided safely.

Prognostic nutritional index and mortality in children and adolescents underwent cardiac surgery

Abstract Objectives: to analyze the prognostic nutritional index and factors associated with mortality in children and adolescents with heart disease who underwent cardiac surgery. Methods: this is a longitudinal, retrospective study that included 98 children and adolescents with heart disease from 0 to 14 years old, and assessed the prognostic nutritional index and nutritional status, through the body mass index for age, weight for height, weight for age and height for age. Multiple logistic regression analysis was performed. Results: malnutrition was present in 27 patients, 68 were categorized as having a low prognostic nutritional index and 16 died. In the adjusted analysis, malnutrition (OR=4.11; CI95%=1.26-13.40; p=0.019), the low body mass index for age (OR=4.14; CI95%=1.26-13.61; p=0.019), low weight for height (OR=4.15; CI95%=1.29-13.35; p=0.017) and low weight for age (OR=5.20; CI95%=1.39-19.43; p=0.014) were associated with mortality. Conclusions: malnutrition, low body mass index for age, weight for height and weight for age had shown a significant association with mortality. Despite being an easily applicable indicator of nutritional status, the findings suggest no association between the prognostic nutritional index and mortality in patients with congenital heart disease after cardiac surgery.

The 6-minute walk test predicts mortality in a pulmonary nontuberculous mycobacteria-predominant bronchiectasis cohort

Background

Bronchiectasis is a chronic lung condition frequently associated with nontuberculous mycobacteria pulmonary (NTM) disease. Persons with these conditions are at increased risk of mortality. Patient reported outcome (PRO) instruments and the 6-minute walk test (6MWT) have been shown to predict mortality for several lung conditions, but these measures have not been fully evaluated for bronchiectasis and NTM.

Methods

We conducted a retrospective cohort study among adult patients enrolled in a natural history study of bronchiectasis at the National Heart, Lung, and Blood Institute. Electronic medical records were queried for demographic, clinical, microbiologic, radiographic, and PRO instrument data: St. George’s Respiratory Questionnaire (SGRQ), Medical Research Council Dyspnea Scale, and the Pulmonary Symptom Severity Score (PSSS). The study baseline date was defined as the patient’s first visit after January 1st, 2015 with a SGRQ or 6MWT completed. Follow-up was defined as the interval between the study baseline visit and date of death or December 31st, 2019. Sex-stratified Cox proportional-hazards regression was conducted to identify predictors of mortality. Separate models were run for each PRO and 6MWT measure, controlling for age, body mass index (BMI), fibrocavitary disease status, and M. abscessus infection.

Results

In multivariable Cox proportional-hazards regression models, the PSSS-severity (aHR 1.29, 95% CI 1.04–1.59), the 6MWT total distance walked (aHR 0.938, 95% CI 0.896–0.981) and distance saturation product (aHR 0.930, 95% CI 0.887–0.974) independently predicted mortality. In addition, BMI was significantly predictive of mortality in all models.

Conclusions

The 6MWT and a PRO instrument capturing symptom severity are independently predictive of mortality in our cohort of bronchiectasis patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07054-6.

Differential Discontinuation Profiles between Pirfenidone and Nintedanib in Patients with Idiopathic Pulmonary Fibrosis

Antifibrotic agents have been widely used in patients with idiopathic pulmonary fibrosis (IPF). Long-term continuation of antifibrotic therapy is required for IPF treatment to prevent disease progression. However, antifibrotic treatment has considerable adverse events, and the continuation of treatment is uncertain in many cases. Therefore, we examined and compared the continuity of treatment between pirfenidone and nintedanib in patients with IPF. We retrospectively enrolled 261 consecutive IPF patients who received antifibrotic treatment from six core facilities in Gunma Prefecture from 2009 to 2018. Among them, 77 patients were excluded if the antifibrotic agent was switched or if the observation period was less than a year. In this study, 134 patients treated with pirfenidone and 50 treated with nintedanib were analyzed. There was no significant difference in patient background, discontinuation rate of antifibrotic treatment over time, and survival rate between the two groups. However, the discontinuation rate due to adverse events within one year of antifibrotic treatment was significantly higher in the nintedanib group than in the pirfenidone group (76% vs. 37%, p < 0.001). Furthermore, the discontinuation rate due to adverse events in nintedanib was higher than that of pirfenidone treatment throughout the observation period (70.6% vs. 31.2%, p = 0.016). The pirfenidone group tended to be discontinued due to acute exacerbation or transfer to another facility. The results of this study suggest that better management of adverse events with nintedanib leads to more continuous treatment that prevents disease progression and acute exacerbations, thus improving prognosis in patients with IPF.

A multidisciplinary approach to the management of nontuberculous mycobacterial lung disease: a clinical perspective

INTRODUCTION

Management of nontuberculous mycobacterial lung disease (NTM-LD) can be encumbered by difficult diagnostic criteria and complex treatment decisions. As prevalence of this debilitating, often refractory, progressive lung disease increases globally, management must evolve beyond antimicrobials to encompass holistic and customized treatments coordinated by practitioners across various specialties.

AREAS COVERED

This review aims to complement the recently updated NTM-LD treatment guidelines and expand current approaches to diagnosis, treatment, and disease management in a multidisciplinary dimension. The foundation of effective long-term management of NTM-LD is awareness of diagnostic criteria, individual patient risk factors, and the importance of managing underlying pulmonary and nonpulmonary comorbidities. The value of adopting all available pharmacological and nonpharmacological treatment modalities with a patient-centered approach to address the needs of long-term patient care cannot be minimized.

EXPERT OPINION

This section, while acknowledging the limited advances in understanding of NTM-LD and the availability of newer diagnostic and therapeutic tools over the last decade, underscores the need for a programmatic approach to this chronic, debilitating pulmonary infection. This will not only lead to more comprehensive patient care with better outcomes, but will also inspire and activate robust networks of research and public health initiatives in this field.