COPD and osteoporosis: links, risks, and treatment challenges

Musculoskeletal crosstalk in chronic obstructive pulmonary disease and comorbidities: Emerging roles and therapeutic potentials

Chronic Obstructive Pulmonary Disease (COPD) is a multifaceted respiratory disorder characterized by progressive airflow limitation and systemic implications. It has become increasingly apparent that COPD exerts its influence far beyond the respiratory system, extending its impact to various organ systems. Among these, the musculoskeletal system emerges as a central player in both the pathogenesis and management of COPD and its associated comorbidities. Muscle dysfunction and osteoporosis are prevalent musculoskeletal disorders in COPD patients, leading to a substantial decline in exercise capacity and overall health. These manifestations are influenced by systemic inflammation, oxidative stress, and hormonal imbalances, all hallmarks of COPD. Recent research has uncovered an intricate interplay between COPD and musculoskeletal comorbidities, suggesting that muscle and bone tissues may cross-communicate through the release of signalling molecules, known as "myokines" and "osteokines". We explored this dynamic relationship, with a particular focus on the role of the immune system in mediating the cross-communication between muscle and bone in COPD. Moreover, we delved into existing and emerging therapeutic strategies for managing musculoskeletal disorders in COPD. It underscores the development of personalized treatment approaches that target both the respiratory and musculoskeletal aspects of COPD, offering the promise of improved well-being and quality of life for individuals grappling with this complex condition. This comprehensive review underscores the significance of recognizing the profound impact of COPD on the musculoskeletal system and its comorbidities. By unravelling the intricate connections between these systems and exploring innovative treatment avenues, we can aspire to enhance the overall care and outcomes for COPD patients, ultimately offering hope for improved health and well-being.

Gait differences between COPD and healthy controls: systematic review and meta-analysis

BACKGROUND

Despite the importance of gait as a determinant of falls, disability and mortality in older people, understanding of gait impairment in COPD is limited. This study aimed to identify differences in gait characteristics during supervised walking tests between people with COPD and healthy controls.

METHODS

We searched 11 electronic databases, supplemented by Google Scholar searches and manual collation of references, in November 2019 and updated the search in July 2021. Record screening and information extraction were performed independently by one reviewer and checked for accuracy by a second. Meta-analyses were performed in studies not considered at a high risk of bias.

RESULTS

Searches yielded 21 085 unique records, of which 25 were included in the systematic review (including 1015 people with COPD and 2229 healthy controls). Gait speed was assessed in 17 studies (usual speed: 12; fast speed: three; both speeds: two), step length in nine, step duration in seven, cadence in six, and step width in five. Five studies were considered at a high risk of bias. Low-quality evidence indicated that people with COPD walk more slowly than healthy controls at their usual speed (mean difference (MD) -19 cm·s-1, 95% CI -28 to -11 cm·s-1) and at a fast speed (MD -30 cm·s-1, 95% CI -47 to -13 cm·s-1). Alterations in other gait characteristics were not statistically significant.

CONCLUSION

Low-quality evidence shows that people with COPD walk more slowly than healthy controls, which could contribute to an increased falls risk. The evidence for alterations in spatial and temporal components of gait was inconclusive. Gait impairment appears to be an important but understudied area in COPD.

Self-identified culturally related stressors that influence self-care in older adults with multiple chronic conditions: A qualitative study

AIM

To identify culturally related stressors that influence self-care in Chinese older adults with multiple chronic conditions.

BACKGROUND

Effective self-care can improve health outcomes for chronic conditions, but implementing self-care is challenging. Individuals with multiple chronic conditions face even more self-care complexity than those with single chronic conditions, generating additional stressors. Although stressors have been found to negatively influence self-care in multiple chronic conditions, the role of culture in generating stressors has been neglected.

DESIGN

This paper reports on the qualitative component of a larger mixed-methods study. Two free-response items in a survey were used to identify culturally related stressors that influence self-care. This report adhered to the SRQR guideline checklist.

METHODS

Data were collected between January and April 2022. One hundred and thirty-eight free text responses asking participants to identify stressors that influenced their self-care effectiveness were analysed sequentially using deductive content analysis and thematic analysis.

RESULTS

Findings from deductive content analysis largely confirmed published work in Western literature on stressors complicating self-care, including symptom burdens, financial strains, social disconnection, caregiving responsibilities and major life events. Findings from reflexive thematic analysis extended current literature by identifying three culturally relevant stressors: intergenerational obligations and commitments, ambivalence about receiving care and worries about potential problems.

CONCLUSION

Chinese older adults with multiple chronic conditions identified a wide range of stressors that impacted their day-to-day self-care. This study provided valuable insights into culturally related stressors in older adults with multiple chronic conditions. Findings deepened our knowledge of cultural influences on the success of self-care in older adults with multiple chronic conditions, suggesting the potential for reaching populations across different cultures and regions.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Stressors that might influence self-care ability are important for nurses to assess in people with multiple chronic conditions. The design of self-care interventions should take a culturally tailored intergenerational family-centred approach to help mitigate the impact of stressors and ultimately improve patient outcomes.

IMPACT

What problem did the study address? Stressors documented in older adults with MCCs have all been generated from research with Western populations. China is now home to the largest population of older people in the world. Understanding the influence of culturally relevant stressors on self-care in Chinese older adults with MCCs is lacking. What were the main findings? Findings from deductive content analysis largely confirmed published work in Western literature on stressors that complicated self-care, including symptom burdens, financial strains, social disconnection, caregiving responsibilities and major life events. Findings from reflexive thematic analysis extended current literature by identifying three culturally relevant stressors in older adults with MCCs in China: intergenerational obligations and commitments, ambivalence about receiving care and worries about potential problems. Where and on whom will the research have an impact? The research will have an impact on guiding nurses' assessment of culturally relevant stressors' impact on self-care for older adults with MCCs. In addition, findings could inform research and policy development to aim at mitigating the impact of culturally based stressors on self-care.

REPORTING METHOD

This study adhered to the Standards for Reporting Qualitative Research (SRQR) guideline checklist.

PATIENT OR PUBLIC CONTRIBUTION

During the member-checking process, the validation of findings for accuracy was carried out by 10 participants, who also found resonance between these findings and their own experiences.

The PDE4 Inhibitors Roflumilast and Rolipram Rescue ADO2 Osteoclast Resorption Dysfunction

Autosomal Dominant Osteopetrosis type II (ADO2) is a rare bone disease of impaired osteoclastic bone resorption caused by heterozygous missense mutations in the chloride channel 7 (CLCN7). Adenylate cyclase, which catalyzes the formation of cAMP, is critical for lysosomal acidification in osteoclasts. We found reduced cAMP levels in ADO2 osteoclasts compared to wild-type (WT) osteoclasts, leading us to examine whether regulating cAMP would improve ADO2 osteoclast activity. Although forskolin, a known activator of adenylate cyclase and cAMP levels, negatively affected osteoclast number, it led to an overall increase in ADO2 and WT osteoclast resorption activity in vitro. Next, we examined cAMP hydrolysis by the phosphodiesterase 4 (PDE4) proteins in ADO2 versus WT osteoclasts. QPCR analysis revealed higher expression of the three major PDE4 subtypes (4a, 4b, 4d) in ADO2 osteoclasts compared in WT, consistent with reduced cAMP levels in ADO2 osteoclasts. In addition, we found that the PDE4 antagonists, rolipram and roflumilast, stimulated ADO2 and WT osteoclast formation in a dose-dependent manner. Importantly, roflumilast and rolipram displayed a concentration-dependent increase in osteoclast resorption activity which was greater in ADO2 than WT osteoclasts. Moreover, treatment with roflumilast rescued cAMP levels in ADO2 OCLs. The key findings from our studies demonstrate that osteoclasts from ADO2 mice exhibit reduced cAMP levels and PDE4 inhibition rescues cAMP levels and ADO2 osteoclast activity dysfunction in vitro. The mechanism of action of PDE4 inhibitors and their ability to reduce the high bone mass of ADO2 mice in vivo are currently under investigation. Importantly, these studies advance the understanding of the mechanisms underlying the ADO2 osteoclast dysfunction which is critical for the development of therapeutic approaches to treat clinically affected ADO2 patients.

Epidemiology of Osteoporosis in Patients with Chronic Obstructive Pulmonary Disease in Taiwan

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable chronic condition characterized by progressive, partially reversible airflow obstruction. Osteoporosis represents a significant comorbidity in individuals with COPD. However, the incidence and prevalence of osteoporosis among the COPD population remain unclear in Taiwan. Therefore, our objective is to investigate the incidence and prevalence of osteoporosis in patients with COPD.

METHODS

In this cross-sectional study, we enrolled a COPD population retrieved from the Taiwan National Health Insurance Research Database (NHIRD) spanning the years 2003 to 2016. Osteoporosis patients were identified using diagnosis codes. The study included newly diagnosed COPD patients from 2003 to 2016. The case group comprised patients who developed osteoporosis or osteoporotic fractures after their COPD diagnosis. We calculated the prevalence and incidence of osteoporosis in individuals with COPD and conducted trend tests.

RESULTS

A total of 1,297,579 COPD patients were identified during the period from 2003 to 2016, with 275,233 of them in the osteoporosis group. The average prevalence of osteoporosis among individuals with COPD was 21.21% from 2003 to 2016 in Taiwan. The number of osteoporosis cases increased from 6,727 in 2003 to 24,184 in 2016. The prevalence of osteoporosis among COPD patients increased from 3.62% in 2003 to 18.72% in 2016. The number of osteoporosis cases among individuals with COPD continued to rise over the years, reaching its highest point in 2016 with 24,184 new cases. The incidence of osteoporosis fluctuated during the study period but generally remained around 3,000 cases per 100,000 person-years. Notably, there was a significant upward trend in incidence from 2003 to 2006, after which the trend stabilized and remained relatively constant.

CONCLUSIONS

Our study highlights an increase in both the prevalence and incidence of osteoporosis in individuals with COPD. Given the significant medical, economic, and social implications associated with osteoporosis, a comprehensive and robust assessment of its healthcare burden can offer valuable insights for healthcare system planning and policymaking.

The impact of chronic obstructive pulmonary disease on bone strength

Chronic obstructive pulmonary disease (COPD) is a lifestyle-related disease that develops in middle-aged and older adults, often due to smoking habits, and has been noted to cause bone fragility. COPD is a risk factor for osteoporosis and fragility fracture, and a high prevalence of osteoporosis and incidence of vertebral fractures have been shown in patients with COPD. Findings of lung tissue analysis in patients with COPD are primarily emphysema with a loss of alveolar septal walls, and the severity of pulmonary emphysema is negatively correlated with thoracic spine bone mineral density (BMD). On the other hand, epidemiological studies on COPD and fracture risk have reported a BMD-independent increase in fracture risk; however, verification in animal models and human bone biopsy samples has been slow, and the essential pathogenesis has not been elucidated. The detailed pathological/molecular mechanisms of musculoskeletal complications in patients with COPD are unknown, and basic research is needed to elucidate the mechanisms. This paper discusses the impacts of COPD on bone strength, focusing on findings in animal models in terms of bone microstructure, bone metabolic dynamics, and material properties.

Managing Osteoporosis in COPD

Chronic obstructive pulmonary disease (COPD) is a serious respiratory disease with high morbidity, disability and mortality worldwide. Every year, many people die from the disease or its comorbidities. Osteoporosis is a common complication of COPD, which can lead to increased fractures in COPD patients, aggravate the disease, and then bring great pain and burden to patients. The possible factors leading to osteoporosis in COPD patients include systemic inflammation, corticosteroid use, vitamin D deficiency, physical inactivity, tobacco exposure, lower bone mineral density, hypogonadism, hypoxia, and anemia. In clinical practice, the rate of diagnosis and treatment of osteoporosis in patients with COPD is low. Several studies demonstrated that treating osteoporosis with bisphosphonates could improve bone density, make breathing easier, and improve the quality of life of COPD patients. However, no studies have examined the effect of anti-osteoporosis therapy on fracture prevention in COPD patients. More research is needed to clarify how to implement holistic medical interventions in COPD patients with osteoporosis. We recommend that every COPD patient be screened for osteoporosis and treated with standard medications for primary osteoporosis.

Potential systemic effects of acquired CFTR dysfunction in COPD

Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation, respiratory symptoms, inflammation of the airways, and systemic manifestations of the disease. Genetic susceptibility and environmental factors are important in the development of the disease, particularly exposure to cigarette smoke which is the most notable risk factor. Mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene are the cause of cystic fibrosis (CF), which shares several pathophysiological pulmonary features with COPD, including airway obstruction, chronic airway inflammation and bacterial colonization; in addition, both diseases also present systemic defects leading to comorbidities such as pancreatic, gastrointestinal, and bone-related diseases. In patients with COPD, systemic CFTR dysfunction can be acquired by cigarette smoking, inflammation, and infection. This dysfunction is, on average, about half of that found in CF. Herein we review the literature focusing on acquired CFTR dysfunction and the potential role in the pathogenesis of comorbidities associated with COPD and chronic bronchitis.

Evaluation of Bone Mineral Density in Lung Transplant Recipients by Chest Computed Tomography

INTRODUCTION

Lung transplantation (LT) recipients are at risk of bone mineral density (BMD) loss. Pre- and post-LT BMD loss has been reported in some cross-sectional studies; however, there are limited studies regarding the serial BMD change in LT recipients. The aim of this study was to investigate the serial BMD changes and the clinical characteristics associated with BMD decline.

METHODS

This was a single-center, retrospective observational study. BMD was serially measured in thoracic vertebral bodies (Th4, 7, 10) using computed tomography (CT) before and 3 and 12 months after LT. The frequency of osteoporosis and factors associated with pre-LT osteoporosis and post-LT BMD loss were evaluated. The frequency of post-LT compression fracture and its associated factors were also analyzed.

RESULTS

This study included 128 adult LT recipients. LT recipients had decreased BMD (151.8 ± 42.2 mg/mL) before LT compared with age-, sex-, and smoking index-matched controls (176.2 ± 35.7 mg/mL). The diagnosis of COPD was associated with pre-LT osteoporosis. LT recipients experience further BMD decline after transplantation, and the percentage of recipients classified as exhibiting osteoporosis increased from 20% at baseline to 43% at 12 months. Recipients who had been taking no or small doses of glucocorticoids before LT had rapid BMD loss after LT. Early bisphosphonate use (within 3 months) after LT attenuated BMD loss and decreased new-onset compression fracture.

CONCLUSION

LT recipients are at high risk for BMD loss and compression fracture after LT. Early bisphosphonate use may decrease BMD loss and compression fracture.

Comparison between calcaneus quantitative ultrasound and the gold standard DXA in the ability to detect osteoporosis in chronic obstructive pulmonary disease patients

BACKGROUND

Osteoporosis is a prevalent comorbidity in patients with COPD that is usually underrecognized and hence, undertreated. Compared to the gold standard dual-energy X-ray absorptiometry (DXA), calcaneus quantitative ultrasound (QUS) is less expensive, more portable, and more accessible, especially in less developed countries. The aim of this study was to investigate the ability of calcaneus QUS to screen and prescreen for osteoporosis in patients with COPD.

METHODS

This cross-sectional study enrolled 67 males older than 50 years with clinically stable COPD. DXA scans of the lumbar spine (L2-4) and femoral neck were performed. QUS of the right calcaneus (AOS-100) was used to assess the broadband ultrasound attenuation (BUA), speed of sound (SOS), osteo sono-assessment index (OSI), and T-score. When the T-score was ≤  - 2.5, osteoporosis was diagnosed by both DXA and QUS.

RESULTS

Forty-eight patients (71.6%) had DXA T-scores ≤  - 2.5 at either the lumbar spine or femoral neck. All QUS parameters (BUA, SOS, OSI, and T-score) could discriminate DXA-determined osteoporosis (the area under the curve varied from 0.64 to 0.83). The QUS T-score was significantly moderately correlated with the DXA T-score at both the femoral neck (r = 0.55) and lumbar spine (r = 0.52). The sensitivity and specificity of QUS in identifying osteoporosis were 10.4% and 94.7%, respectively. The positive and negative predictive values were 83.3% and 29.5%, respectively. When a QUS T-score of 0.09 was used as the cutoff, the sensitivity exceeded 90%, and 15% of the DXA scans were not warranted.

CONCLUSIONS

The sensitivity and specificity of calcaneus QUS were not sufficient for QUS to be used as an alternative to DXA for osteoporosis screening. However, QUS may be useful for prescreening before DXA to identify COPD patients who have either a high or low likelihood of osteoporosis. Consequently, QUS reduces the need for DXA referral.

Smoking index and COPD duration as potential risk factors for development of osteoporosis in patients with non-small cell lung cancer - A retrospective case control study evaluated by CT Hounsfield unit

Objective

To investigate the effect of smoking index (calculated as number of cigarettes per day × smoking years) and chronic obstructive pulmonary disease (COPD) duration on osteoporosis (OP)evaluated by opportunistic chest CT in patients with non-small cell lung cancer (NSCLC).

Methods

A total of 101 patients diagnosed with NSCLC were included in our cohort study. Among them, 50 patients with a history of smoking and COPD were assigned to the experimental group, while 51 patients without a history of smoking and COPD were assigned to the control group. Hounsfield unit (HU) value was measured by conventional chest CT to investigate the bone mineral density; and the mean values of axial HU value in the upper, middle and lower parts of T4, T7, T10 and L1 vertebral bodies were measured as the study variables.

Results

There were no significant differences in gender, age, body mass index, type of lung cancer, clinical stage of lung cancer and comorbidities between the two groups (P = 0.938，P = 0.158，P = 0.722,P = 0.596,P = 0.813,P = 0.655). The overall mean HU values of T4, T7, T10, L1 in the experimental group were 116.60 ± 30.67, 110.56 ± 30.03, 109.18 (96.85-122.95), 94.63 (85.20-104.12) and 106.86 ± 22.26, respectively, which were significantly lower than those in the control group (189.55 ± 34.57, 174.54 ± 35.30, 172.73 (156.33-199.50), 158.20 (141.60-179.40) and 177.50 ± 33.49) (P ＜0.05). And in the experimental group, smoking index and COPD duration were significantly and negatively correlated with HU values (r = -0.627, -0.542, P ＜0.05, respectively).

Conclusion

Patients with NSCLC who have a history of smoking and COPD exhibit a notably lower HU value compared to the control groups. Additionally, it has been observed that the smoking index and duration of COPD may be influential factors affecting bone mineral density in NSCLC patients.

CT-Derived Deep Learning-Based Quantification of Body Composition Associated with Disease Severity in Chronic Obstructive Pulmonary Disease

Purpose

Our study aimed to evaluate the association between automated quantified body composition on CT and pulmonary function or quantitative lung features in patients with chronic obstructive pulmonary disease (COPD).

Materials and Methods

A total of 290 patients with COPD were enrolled in this study. The volume of muscle and subcutaneous fat, area of muscle and subcutaneous fat at T12, and bone attenuation at T12 were obtained from chest CT using a deep learning-based body segmentation algorithm. Parametric response mapping-derived emphysema (PRMemph), PRM-derived functional small airway disease (PRMfSAD), and airway wall thickness (AWT)-Pi10 were quantitatively assessed. The association between body composition and outcomes was evaluated using Pearson's correlation analysis.

Results

The volume and area of muscle and subcutaneous fat were negatively associated with PRMemph and PRMfSAD (p < 0.05). Bone density at T12 was negatively associated with PRMemph (r = -0.1828, p = 0.002). The volume and area of subcutaneous fat and bone density at T12 were positively correlated with AWT-Pi10 (r = 0.1287, p = 0.030; r = 0.1668, p = 0.005; r = 0.1279, p = 0.031). However, muscle volume was negatively correlated with the AWT-Pi10 (r = -0.1966, p = 0.001). Muscle volume was significantly associated with pulmonary function (p < 0.001).

Conclusion

Body composition, automatically assessed using chest CT, is associated with the phenotype and severity of COPD.

Prevalence, predictors, dynamic bone change, and treatment efficacy of osteoporosis among chronic obstructive pulmonary disease patients: a prospective cohort study

Background

Osteoporosis is a silent chronic obstructive pulmonary disease (COPD) comorbidity that is often under-detected. We aimed to study the prevalence and potential predictors of osteoporosis in COPD. Dynamic changes in bone mass density (BMD) and treatment efficacy of bisphosphonate were also assessed.

Methods

This prospective cohort study included COPD patients between January 2017 and January 2019. Demographics data, spirometric parameters, and C-reactive protein (CRP) were collected. Bone mineral density (BMD) at the lumbar spine (L2-4) and both femoral necks were measured after enrollment and the 12-month follow-up. Participants were categorized into three groups per the baseline BMD T-score: normal (≥ - 1.0), osteopenia (between -1.0 and - 2.5), and osteoporosis (≤ - 2.5). In the osteoporosis group, alendronate 70 mg/week with vitamin D and calcium was prescribed.

Results

In total, 108 COPD patients were enrolled. The prevalence of osteoporosis and osteopenia were 31.5 and 32.4%, respectively. Advanced age, lower body mass index (BMI), history of exacerbation in the previous year, and high CRP levels were significant predictors of osteoporosis. After 12 months, 35.3% in the osteoporosis group reported new vertebral and femoral fractures, compared to none in the non-osteoporosis group (p < 0.001). In the normal BMD and osteopenia groups showed a further decline in BMD after 12-month. Conversely, the osteoporosis group showed a statistically significant improvement in BMD after anti-resorptive treatment (p < 0.001).

Conclusion

The prevalence of osteoporosis was high in Thai COPD patients. Advanced age, lower BMI, history of exacerbation, and high CRP levels were potential predictors. A rapid decline in BMD was observed in COPD patients without treatment.

Effects of elastase-induced emphysema on muscle and bone in mice

Chronic obstructive pulmonary disease (COPD) causes sarcopenia and osteoporosis. However, the mechanisms underlying muscle and bone loss as well as the interactions between muscle and bone in the COPD state remain unclear. Therefore, we herein investigated the effects of the COPD state on muscle and bone in mice intratracheally administered porcine pancreatic elastase (PPE). The intratracheal administration of PPE to mice significantly reduced trabecular bone mineral density (BMD), trabecular bone volume, trabecular number, cortical BMD and cortical area. It also significantly decreased grip strength, but did not affect muscle mass or the expression of myogenic differentiation-, protein degradation- or autophagy-related genes in the soleus and gastrocnemius muscles. Among the myokines examined, myostatin mRNA levels in the soleus muscles were significantly elevated in mice treated with PPE, and negatively related to grip strength, but not bone parameters, in mice treated with or without 2 U PPE in simple regression analyses. Grip strength positively related to bone parameters in mice treated with or without PPE. In conclusion, we showed that a PPE model of COPD in mice exerts dominant effects on bone rather than skeletal muscles. Increased myostatin expression in the soleus muscles of mice in the COPD state may negatively relate to a reduction in grip strength, but not bone loss.

Alterations in the microenvironment and the effects produced of TRPV5 in osteoporosis

The pathogenesis of osteoporosis involves multiple factors, among which alterations in the bone microenvironment play a crucial role in disrupting normal bone metabolic balance. Transient receptor potential vanilloid 5 (TRPV5), a member of the TRPV family, is an essential determinant of the bone microenvironment, acting at multiple levels to influence its properties. TRPV5 exerts a pivotal influence on bone through the regulation of calcium reabsorption and transportation while also responding to steroid hormones and agonists. Although the metabolic consequences of osteoporosis, such as loss of bone calcium, reduced mineralization capacity, and active osteoclasts, have received significant attention, this review focuses on the changes in the osteoporotic microenvironment and the specific effects of TRPV5 at various levels.

Risk factors and prognostic value of osteoporosis in hospitalized patients with bronchiectasis

BACKGROUND

The risk factors for osteoporosis and its prognostic value in patients with bronchiectasis is not well characterized. We explored the risk factors for osteoporosis and its prognostic impact in hospitalized non-cystic fibrosis bronchiectasis (NCFB) patients in Southeast China.

METHODS

This observational cohort study consecutively enrolled 179 hospitalized patients with NCFB bronchiectasis between 2017 and 2021. The risk factors and the impact of osteoporosis on all-cause mortality were assessed.

RESULTS

21.2% (38/179) of hospitalized NCFB patients were diagnosed with osteoporosis. Patients with osteoporosis had more severe symptoms (assessed by chronic airway assessment test, CAT, median 22 vs. 17, P = 0.017), poorer quality of life (assessed by St. George Respiratory Questionnaires, SQRC, median 42 vs. 27, P = 0.007), more severe disease stage (assessed by bronchiectasis severity index, BSI, median 14 vs. 11, P = 0.02), more comorbidities (assessed by Bronchiectasis Aetiology Comorbidity Index, BACI, median 5 vs. 4, P = 0.021) than patients without. Age, female sex, anemia, post-infection, and history of regular inhaled corticosteroid treatment were independent risk factors for osteoporosis in those patients. 21 patients (11.7%) died over a median follow-up period of 32 months. The all-cause mortality in NCFB patients with osteoporosis [28.94% (11/38)] was significantly higher than those without osteoporosis [7.09% (10/141)] [hazard ratio (HR) 5.34, 95% confidence interval (CI) 2.26-12.67, P < 0.001]. After adjusting for BSI and other confounding factors, osteoporosis was still independently associated with all-cause mortality in hospitalized NCFB patients (HR 4.29, 95% CI 1.75-10.49, P < 0.001).

CONCLUSIONS

Osteoporosis had an independent effect on all-cause mortality in hospitalized NCFB patients. Management of comorbidities, including bone health, is a critical aspect of treating NCFB patients.

Effects of photobiomodulation as an adjunctive treatment in chronic obstructive pulmonary disease: a narrative review

Chronic obstructive pulmonary disease (COPD) is a disease characterized by chronic airway inflammation and remodeling and lung parenchymal inflammation and destruction, which result in many pulmonary and extrapulmonary manifestations. The anti-inflammatory effect of photobiomodulation (PBM) has been reported in previous studies. This review was conducted to evaluate the direct effect of PBM on lung inflammation in COPD. The other effects of PBM on modulation of peripheral and respiratory muscle metabolism and angiogenesis in lung tissues were also discussed. The databases of PubMed, Cochrane Library, and Google Scholar were searched to find the relevant studies. Keywords included PBM and related terms, COPD-related signs, and lung inflammation. A total of 12 articles were selected and reviewed in this study. Based on the present review, PBM is helpful in reducing lung inflammation through decreasing the inflammatory cytokines and chemokines at multiple levels and increasing anti-inflammatory cytokines. In addition, PBM also improves both peripheral and respiratory muscle metabolism and promote angiogenesis. This review demonstrated that PBM is a promising adjunctive treatment modality for COPD management which merits further validation.

Sex-specific characteristics for the coexistence of asthma and COPD in the Canadian population: a cross-sectional analysis of CLSA data

Objective: The coexistence of asthma and COPD (asthma + COPD) is a condition found among patients who present with clinical features of both asthma and COPD. Epidemiological evidence points to an increasingly disproportionate burden of asthma + COPD and COPD in females. The objective of this cross-sectional study is to identify female and male-specific epidemiological and clinical characteristics associated with asthma + COPD.Methods: Baseline data from the comprehensive cohort of Canadian Longitudinal Study on Aging (CLSA) were used in this cross-sectional study which included 30,097 subjects between the ages of 45- and 85-years Participants were categorized into four mutually exclusive groups: asthma + COPD, COPD-only, asthma-only and neither asthma nor COPD.Results: The prevalence was significantly greater in females than males for asthma + COPD (2.71% vs. 1.41%; p < 0.001), COPD-only (3.22% vs. 2.87%; p < 0.001) and asthma-only (13.31% vs. 10.11%; p < 0.001). The association between smoking and asthma + COPD was modified by age in females. Osteoporosis and underactive thyroid disease were significantly more prevalent in females than in males in asthma + COPD, COPD-only and asthma-only groups. In asthma + COPD group, a greater proportion of respiratory symptoms associated with asthma was observed in females whereas a greater proportion of respiratory symptoms associated with COPD was observed in males. Severity of airway obstruction determined by spirometry measurements was greater in males than females.Conclusions: In the Canadian adult population, several epidemiological and clinical characteristics in asthma + COPD varied between females and males. The findings in this study will help healthcare professional in the recognition and management of coexisting asthma and COPD in females and males.

Increased chest CT derived bone and muscle measures capture markers of improved morbidity and mortality in COPD

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a disease of accelerated aging and is associated with comorbid conditions including osteoporosis and sarcopenia. These extrapulmonary conditions are highly prevalent yet frequently underdiagnosed and overlooked by pulmonologists in COPD treatment and management. There is evidence supporting a role for bone-muscle crosstalk which may compound osteoporosis and sarcopenia risk in COPD. Chest CT is commonly utilized in COPD management, and we evaluated its utility to identify low bone mineral density (BMD) and reduced pectoralis muscle area (PMA) as surrogates for osteoporosis and sarcopenia. We then tested whether BMD and PMA were associated with morbidity and mortality in COPD.

METHODS

BMD and PMA were analyzed from chest CT scans of 8468 COPDGene participants with COPD and controls (smoking and non-smoking). Multivariable regression models tested the relationship of BMD and PMA with measures of function (6-min walk distance (6MWD), handgrip strength) and disease severity (percent emphysema and lung function). Multivariable Cox proportional hazards models were used to evaluate the relationship between sex-specific quartiles of BMD and/or PMA derived from non-smoking controls with all-cause mortality.

RESULTS

COPD subjects had significantly lower BMD and PMA compared with controls. Higher BMD and PMA were associated with increased physical function and less disease severity. Participants with the highest BMD and PMA quartiles had a significantly reduced mortality risk (36% and 46%) compared to the lowest quartiles.

CONCLUSIONS

These findings highlight the potential for CT-derived BMD and PMA to characterize osteoporosis and sarcopenia using equipment available in the pulmonary setting.

Osteosarcopenia in Patients with Chronic Obstructive Pulmonary Diseases: Which Pathophysiologic Implications for Rehabilitation?

Chronic obstructive pulmonary disease (COPD) is a burdensome condition affecting a growing number of people worldwide, frequently related to major comorbidities and functional impairment. In these patients, several factors might have a role in promoting both bone and muscle loss, including systemic inflammation, corticosteroid therapies, sedentary behaviours, deconditioning, malnutrition, smoking habits, and alcohol consumption. On the other hand, bone and muscle tissues share several linkages from functional, embryological, and biochemical points of view. Osteosarcopenia has been recently defined by the coexistence of osteoporosis and sarcopenia, but the precise mechanisms underpinning osteosarcopenia in patients with COPD are still unknown. In this scenario, a deeper understanding of the molecular basis of osteosarcopenia might guide clinicians in a personalized approach integrating skeletal muscle health with the pulmonary rehabilitation framework in COPD. Taken together, our results summarized the currently available evidence about the multilevel interactions between osteosarcopenia and COPD to pave the way for a comprehensive approach targeting the most common risk factors of these pathological conditions. Further studies are needed to clarify the role of modern clinical strategies and telemedicine solutions to optimize healthcare delivery in patients with COPD, including osteopenia, osteoporosis, and sarcopenia screening in these subjects.

Use of Supplemental Home Oxygen is Associated With Early Postoperative Complications Following Total Knee Arthroplasty

BACKGROUND

The objective of this study is to evaluate preoperative supplemental home oxygen use as a potential risk factor for both medical and surgical complications following primary elective total knee arthroplasty (TKA) in patients who have respiratory disease (RD).

METHODS

Patients with a diagnosis of RD who underwent elective TKA from 2010 to 2020 were identified using a national database. The rates of postoperative medical and surgical complications, hospital readmissions, and emergency room visits were calculated for RD patients who used supplemental home oxygen and those who did not. Additionally, reimbursements and lengths of stay were determined. Both cohorts were then compared to matched cohorts who did not have RD using logistic regression analyses.

RESULTS

A total of 41,418 patients who underwent TKA with RD on home oxygen and 138,635 patients who had RD without home oxygen use were compared with matched cohorts. The RD cohort with home oxygen use had a significantly higher incidence of periprosthetic joint infection (5.78% versus 2.69%, odds ratio [OR] 1.42, P < .0001), pneumonia (3.95% versus 0.69%, OR 4.44, P < .0001), venous thromboembolism (3.17% versus 2.10%, OR 1.12, P = .007), and periprosthetic fracture (0.82% versus 0.34%, OR 1.72, P < .0001) compared to the matched control cohort. Additionally, the RD with home oxygen cohort had a significantly higher incidence of periprosthetic joint infection (5.78% versus 3.77%, OR 1.15, P < .0001), pneumonia (3.95% versus 1.63%, OR 1.99, P < .0001), and several other medical complications compared to RD patients without home oxygen use.

CONCLUSION

Preoperative supplemental home oxygen use is associated with significantly increased risk of postoperative surgical and medical complications following elective TKA. This finding can help guide risk assessment and the informed consent process prior to surgery.

Pharmacological, Nutritional, and Rehabilitative Interventions to Improve the Complex Management of Osteoporosis in Patients with Chronic Obstructive Pulmonary Disease: A Narrative Review

Osteoporosis is a highly prevalent condition affecting a growing number of patients affected by chronic obstructive pulmonary disease (COPD), with crucial implications for risk of fragility fractures, hospitalization, and mortality. Several risk factors have been identified to have a role in osteoporosis development in COPD patients, including corticosteroid therapy, systemic inflammation, smoke, physical activity levels, malnutrition, and sarcopenia. In this scenario, a personalized multitarget intervention focusing on the pathological mechanisms underpinning osteoporosis is mandatory to improve bone health in these frail patients. Specifically, physical exercise, nutritional approach, dietary supplements, and smoke cessation are the cornerstone of the lifestyle approach to osteoporosis in COPD patients, improving not only bone health but also physical performance and balance. On the other hand, pharmacological treatment should be considered for both the prevention and treatment of osteoporosis in patients at higher risk of fragility fractures. Despite these considerations, several barriers still affect the integration of a personalized approach to managing osteoporosis in COPD patients. However, digital innovation solutions and telemedicine might have a role in optimizing sustainable networking between hospital assistance and community settings to improve bone health and reduce sanitary costs of the long-term management of COPD patients with osteoporosis.

Physical activity and chronic obstructive pulmonary disease: a scoping review

Background

Reduced physical activity (PA) was the strongest predictor of all-cause mortality in patients with chronic obstructive pulmonary disease (COPD). This scoping review aimed to map the evidence on the current landscape of physical activity, barriers and facilitators, and assessment tools across COPD patients.

Methods

Arksey and O’Malley’s scoping review methodology framework guided the conduct of this review. An electronic search was conducted on five English databases (PubMed, Cochrane Library, PsycINFO, CINAHL and Web of Science) and three Chinese databases (CNKI, CQVIP and WAN-FANG) in January 2022. Two authors independently screened the literature, extracted the studies characteristics.

Results

The initial search yielded 4389 results, of which 1954 were duplicates. Of the remaining 135 articles, 42 studies met the inclusion criteria. Among the reviewed articles, there were 14 (33.3%) cross-sectional study, 9 (21.4%) cohort study, 4 (9.5%) longitudinal study, 3 qualitative study, 12 (28.7%) randomized control trials. The main barriers identified were older age, women, lung function, comorbidities, COPD symptoms (fear of breathlessness and injury, severe fatigue, anxiety and depression), GOLD stage, frequency of exacerbation, oxygen use, lack of motivation and environment-related (e.g., season and weather). Twelve studies have evaluated the effects of physical exercise (e.g., walking training, pulmonary rehabilitation (PR), pedometer, self-efficacy enhancing intervention and behavioral modification intervention) on PA and showed significant positive effects on the prognosis of patients. However, in real life it is difficult to maintain PA in people with COPD.

Conclusions

Changing PA behavior in patients with COPD requires multidisciplinary collaboration. Future studies need to identify the best instruments to measure physical activity in clinical practice. Future studies should focus on the effects of different types, time and intensity of PA in people with COPD and conduct randomized, adequately-powered, controlled trials to evaluate the long-term effectiveness of behavioral change interventions in PA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02099-4.

Dynamic Quantitative Magnetic Resonance Imaging Assessment of Areas of the Lung During Free-Breathing of Patients with Chronic Obstructive Pulmonary Disease

RATIONALE AND OBJECTIVES

Changes in the geometry of the chest wall due to lung hyperinflation occur in COPD. However, the quantitative assessment of impaired lung motions and its association with the clinical characteristics of COPD patients are unclear. This study aimed to investigate the respiratory kinetics of COPD patients by dynamic MRI.

MATERIALS AND METHODS

This study enrolled 22 COPD patients and 10 normal participants who underwent dynamic MRI and pulmonary function testing (PFT). Changes in the areas of the lung and mediastinum during respiration were compared between the COPD patients and the normal controls. Relationships between MRI, CT parameters, and clinical measures that included PFT results also were evaluated.

RESULTS

Asynchronous movements and decreased diaphragmatic motion were found in COPD patients. COPD patients had a larger ratio of MRI-measured lung areas at expiration to inspiration, a smaller magnitude of the peak area change ratio, and a smaller mediastinal-thoracic area ratio than the normal participants. The lung area ratio was associated with FEV₁/FVC, predicted RV%, and CT lung volume/predicted total lung capacity (pTLC). The lung area ratio of the right lower and left lower lungs was significantly correlated with emphysema of each lower lobe. The expiratory mediastinal-thoracic area ratio was associated with FEV₁% predicted and RV/TLC.

CONCLUSION

Changes in the lung areas of COPD patients as shown on MRI reflected the severity of airflow limitation, hyperinflation, and the extent of emphysema. Dynamic MRI provides essential information about respiratory kinetics in COPD.

Lower Prevalence of Osteoporosis in Patients with COPD Taking Anti-Inflammatory Compounds for the Treatment of Diabetes: Results from COSYCONET

Background

Patients with chronic obstructive pulmonary disease (COPD) often have osteoporosis and diabetes as comorbid conditions. Anti-diabetic medication, including metformin, has protective effects on osteoporosis in experimental studies. We therefore studied whether patients with COPD receiving anti-diabetic medication had a lower osteoporosis prevalence in a large COPD cohort, COSYCONET.

Methods

Assessment of osteoporosis was based on patients’ reports of physician-based diagnoses and the presence of disease-specific medication. The predictive value of physical characteristics, lung function, comorbidities, cardiovascular medication, and the use of anti-inflammatory diabetes medication, including metformin, sulfonylureas, glinides or DPP4I, was evaluated using logistic regression analysis. ClinicalTrials.gov: NCT01245933.

Results

In total, 2222 patients were eligible for analysis (863 [39%] female, mean age 65 y), 515 of whom had higher symptoms and exacerbations (Global Initiative for Chronic Obstructive Lung Disease group D). Osteoporosis was present in 15.8% of the overall cohort, and in 24.1% of GOLD D patients. Regression analyses identified the following as associated with osteoporosis (p < 0.05): female sex, higher age, lower body-mass index, asthma, higher air trapping, oral steroids, and cardiovascular medication. Although oral anti-diabetic medication was overall not associated with a lower prevalence of osteoporosis (p = 0.131), anti-inflammatory anti-diabetic medication (p = 0.009) and metformin-containing therapy (p = 0.039) were. This was driven by GOLD D patients.

Conclusion

In a large COPD cohort, anti-inflammatory diabetes therapy, including metformin, was associated with a lower prevalence of osteoporosis, especially in patients with higher symptoms and exacerbations. These findings suggest a protective effect of common anti-diabetic medication on osteoporosis, possibly as a result of attenuated systemic inflammation.

Frailty and chronic respiratory disease: the need for a multidisciplinary care model

Background.

Frailty is a state of increased vulnerability to various health stressors but little information is summarized about frailty in patients with specific chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), and asthma.

Objective.

We aimed to describe the burden of frailty on patients with chronic respiratory disorders and to discuss the need for multidisciplinary care services.

Methods.

PubMed and Cochrane Central databases were systematically reviewed for studies reporting outcomes associated with frailty in COPD, IPF, and asthma. Electronic databases were searched for relevant articles published in English from 2010 up to July 2020. Appraisal was carried out based on the Hierarchy of Evidence Rating System and the GRADE guidelines.

Results.

A total of 31 articles met all inclusion criteria with 24 of them at level IV, 1 at level V, and 6 at level VI. Frailty is likely to negatively affect quality of life and to increase the risk of mortality, especially in elderly with COPD, IPF and asthma. Each disease has a particular effect on the balance between health status, respiratory impairment and frailty. A greater understanding of frailty phenotype across different ages, as well as in a range of long-term conditions, is of great necessity in both clinical and research settings. Limited conformity was observed between different methodologies and nature of chronic diseases studied, leading to a further difficulty to extract homogeneous information.

Conclusion.

Literature shows that frailty is prevalent in COPD, IPF, and asthma, after adjusting for shared risk factors. Our findings suggest that frailty should be approached as an entity per se’, in order to assess real mortality risk, alongside respiratory disease severity and the presence of comorbidities. Health care professionals need knowledge, skills and multidisciplinary collaboration to buffer the impact of frailty on everyday practice.

Musculoskeletal ambulation disability symptom complex as a risk factor of incident bone fragility fracture

Objectives

Influence of presenting musculoskeletal ambulation disability symptom complex (MADS) on occurrence of bone fragility fracture (BFF) is investigated with retrospective cohort study.

Methods

A total of 931 subjects joined in the study. Subjects were selected as bone fragility risk positive in the fracture assessment tool questionnaire. Their assumed risk factors were harvested from the medical records and X-ray pictures. They were followed up at least 8 years consecutively, and occurrence of incident BFF was set as primary endpoint. Each assumed risk factor including MADS was evaluated using Cox regression analysis. Subjects were divided into 2 groups according to presence of MADS (G-MADS and G-noMADS). Adjusted hazard ratios between the 2 groups was evaluated using Cox regression analysis. The statistical procedures were performed before and after propensity score matching (PSM) procedures in order to make parallel with assumed risk factors.

Results

Statistically significant risk factors within 5% were prevalent vertebral body fracture, disuse, MADS, cognitive disorder, hypertension, contracture, Parkinsonism, being female sex, hyperlipidemia, insomnia, T-score in the femoral neck ≤ −2.3, chronic kidney disease ≥ stage 2, chronic obstructive pulmonary diseases, glucocorticoid steroid administrated, and osteoarthritis in order of the adjusted hazard ratios (from highest to lowest). Adjusted hazard ratios between G-MADS and G-noMADS were 2.70 and 1.83 for before and after PSM, respectively.

Conclusions

MADS demonstrated as a significant risk factor of BFF occurrence. In treating osteoporosis, fall risk should be aware of as well as bone fragility risk.

Musculoskeletal Disorders in Chronic Obstructive Airway Diseases: A Neglected Clinical Entity

Chronic obstructive pulmonary disease (COPD) is a lung disease that can affect various extra-pulmonary organs; one being the musculoskeletal system. Skeletal muscle dysfunction and osteoporosis are two important musculoskeletal disorders that have an impact on the quality of life in COPD patients in terms of morbidity and mortality. Treatment related adverse effects of COPD such as steroid-induced myopathy and osteoporosis are well recognised. Other comorbidities like sarcopenia, cardiovascular disease, metabolic diseases (diabetes mellitus, obesity, and thyroid diseases), chronic kidney disease, sleep apnoea, anaemia, and depression are also noted, which can contribute to impaired health status, increased healthcare utilisation, and even mortality. As well, it has been shown that autoimmunity and autoimmune rheumatic diseases (AIRDs) are linked to COPD. In this mini-review, we intend to give an overview of different types of musculoskeletal disorders associated with COPD.

Aging and direct medical costs of osteoporotic fractures

INTRODUCTION

This study estimated the direct medical costs of osteoporotic fractures from a large claims database in Korea.

MATERIALS AND METHODS

We compared the medical costs of hip, vertebral, and wrist fractures between two age groups (50-64 years vs 65 years and older). We used a generalized linear model to investigate the drivers of osteoporotic fracture medical costs.

RESULTS

Hip fractures had the highest costs, regardless of age, followed by vertebral and wrist. The cost of hip fracture was USD 7285 for those aged 65 years and over and USD 6589 for those aged 50-64 years. The length of hospital days was higher in hip fracture patients, regardless of age, followed by vertebral and wrist. As the number of hospitalizations increased, the medical cost increased by 33.0% (p < 0.0001). Patients older than 65 years who were hospitalized for a fracture had a longer total length of hospital stay, compared to patients aged 50-64, regardlessness of the site of the fracture. The cost of treating fractures among those 65 years and older increased by 31.8% compared to those 50-64 years old (p < 0.0001). The direct medical costs increased by 8.6% as the number of fractures increased (p = 0.041).

CONCLUSIONS

We identified that osteoporotic fracture-related medical costs and hospitalization days increased with age. Interventions are effective in reducing fracture risk the potential to yield substantial cost savings.

Increased Medical and Implant-Related Complications in Total Hip Arthroplasty Patients With Underlying Chronic Obstructive Pulmonary Disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) has been associated with impaired bone metabolism. The purpose of this study is to investigate rates of readmission, respiratory complications, implant-related complications, and revision after total hip arthroplasty (THA) in patients with and without underlying COPD.

METHODS

The PearlDiver Mariners database was used to divide patients undergoing primary THA (CPT-27130) into two cohorts: 1) THA with COPD (including asthma) or 2) THA without COPD. The incidence of 30-day readmission, COPD exacerbation, pneumonia, other respiratory complications as well as dislocations, mechanical loosening, and joint prosthetic infection was calculated through logistic regression. The risk of THA revision was also assessed through Cox-proportional hazards regression. All regression controlled for age, gender, and medical comorbidities found to be associated with COPD.

RESULTS

Between 2010 and 2018, 97,784 THA patients with COPD and 338,243 THA patient without COPD were studied. THA patients with COPD had higher risk of 30-day readmission (aOR = 1.17, 95% CI 1.11-1.23, P < .0001). There was higher risk of 30-day pneumonia (aOR = 2.07, 95% CI 1.76-2.44, P < .0001). THA patients with COPD also faced higher risk of 30-day dislocations (aOR = 1.31, 95% CI 1.19-1.45, P < .0001), joint prosthetic infections (aOR = 1.25, 95% CI 1.14-1.37, P < .0001), and periprosthetic fracture (aOR = 1.19, 95% CI 1.07-1.32, P = .0015). Regarding revisions, 3.3% of THA patients with COPD underwent THA revision at 1 year, a higher risk than THA patients without COPD (aOR = 1.11, 95% CI 1.06-1.16, P < .0001).

CONCLUSION

Patients undergoing THA with underlying COPD face a higher rate of comorbidities, respiratory complications, implant complications, and revision surgeries, than patients without COPD.

LEVEL OF EVIDENCE

III.

Situational risk factors for fall-related vertebral fractures in older men and women

Situational factors might help explain why most vertebral fractures occur in older people without a previous osteoporosis diagnosis. After adjusting for predisposing risk factors, the activity before the fall, type of fall, and falling direction remained as strong determinants of fall-related vertebral fractures in older men and women.

INTRODUCTION

A matched case-control study was conducted to investigate the effects of situational factors, in addition to predisposing factors, on clinical vertebral fractures in older men and women in Taiwan.

METHODS

Cases were community-dwelling individuals aged ≥ 65 years who visited emergency departments (EDs) of two university-affiliated hospitals due to a fall and had a primary diagnosis of a vertebral fracture during a 1-year period in 2017. Five control patients per case, matched by the time of falling, gender, and age, who sought care in the same ED due to a fall resulting in a soft tissue injury were selected. A total of 64 men (age range: 65 ~ 99 years) and 194 women (age range: 65 ~ 100 years), diagnosed with a vertebral fracture, participated in the study.

RESULTS

Multivariable logistic models were conducted separately for men and women. Results suggested that the following factors were significantly associated with an increased risk of vertebral fractures in men: a low educational level (adjusted odds ratio [OR] = 1.95; 95% confidence interval (CI), 1.02 ~ 3.71), asthma (OR = 2.96; 95% CI, 1.35 ~ 6.92), depression (OR = 4.31; 95% CI, 1.03 ~ 17.5), toileting (OR = 2.30; 95% CI, 1.04 ~ 4.94), slipping (OR = 5.27; 95% CI, 1.80 ~ 15.4), stepping down (OR = 3.99; 95% CI, 1.40 ~ 11.4), sudden leg weakness (OR = 3.73; 95% CI, 1.13 ~ 12.4), and falling backwards (OR = 3.78; 95% CI, 1.83 ~ 7.80); and in women: a fracture history (OR = 2.00; 95% CI, 1.07 ~ 3.76), osteoporosis (OR = 1.94; 95% CI, 1.15 ~ 3.49), getting in/out of the bed/chair (OR = 1.90; 95% CI, 1.07 ~ 3.39), stepping down (OR = 2.10; 95% CI, 1.17 ~ 3.77), and falling backwards (OR = 4.00; 95% CI, 2.39 ~ 6.68) and sideways (OR = 2.61; 95% CI, 1.38 ~ 4.96).

CONCLUSIONS

The combination of predisposing and situational risk factors may display a more comprehensive risk profile for the occurrence of VFs, and thus, interventions that add both types of risk factors may result in greater risk reduction of VFs, although those specifically targeted at situational risk factors during falls are limited and their effectiveness and efficiency remained to be explored.

Prescription Patterns in Patients with Chronic Obstructive Pulmonary Disease and Osteoporosis

Objective

Patients with chronic obstructive pulmonary disease (COPD) have a higher risk of osteoporosis. Few studies have addressed the prescription patterns in osteoporosis patients with COPD. The purpose of this study was to conduct a retrospective study of the prescription patterns in patients with COPD and osteoporosis in Taiwan.

Methods

The study was conducted with data from the Taiwan National Health Insurance Research Database from January 1, 2003, to December 31, 2016. We selected the COPD population in Taiwan older than 40 years with at least one prescription for a bronchodilator. We excluded patients who had osteoporosis, fracture, asthma, or cancer before the diagnosis of COPD. After the diagnosis of COPD, patients who did not have osteoporosis were also excluded. We followed this COPD and osteoporosis cohort until they had been prescribed medication for osteoporosis.

Results

There were 13,407 patients with COPD and osteoporosis who received osteoporosis treatment. Among the patients who received treatment, the majority were female (n = 9136), accounting for 68.14% of all treated patients. A total of 53.4% of the patients had been prescribed steroids least once within the last year before receiving a diagnosis of osteoporosis. A total of 34.61% of the patients received systemic corticosteroids with a daily dose equivalent to 5 mg of prednisolone within the 3 months prior to the diagnosis of osteoporosis. The older the patient was, the higher the probability of the prescription of medication for osteoporosis. Patients with depression had a high probability of receiving medication for osteoporosis with adjusted hazard ratio of 1.141 (95% confidence interval, 1.072-1.214).

Conclusion

The rate of prescriptions for the treatment of osteoporosis in patients with COPD was low. Physicians need to be aware of this issue and treat osteoporosis more aggressively in patients with COPD.

Post-surgery cholecystectomy, hepatectomy, and pancreatectomy patients increase the risk of osteoporotic vertebral fracture

INTRODUCTION

Data is currently lacking regarding association between the cholecystectomy/hepatectomy/pancreatectomy and the development of osteoporotic fracture. A retrospective cohort study was conducted to investigate the relationship between cholecystectomy/hepatectomy/pancreatectomy and the subsequent risk of developing osteoporotic fracture.

MATERIALS AND METHODS

Patients having undergone cholecystectomy, hepatectomy, or pancreatectomy between 2000 and 2012 were selected from the All Population Based Hospitalization File as the surgery cohort (n = 304,081), which was frequency matched with the control cohort (n = 304,081). The Cox proportional hazard model and Kaplan-Meier analysis were applied to measure the hazard ratios and the cumulative incidence of osteoporotic fracture.

RESULTS

A total of 1136 patients in the surgery cohort and 1179 patients in the control cohort were newly diagnosed with osteoporotic fracture. The overall osteoporotic fracture risk in the surgery cohort was 1.12-fold higher [95% confidence interval (CI), 1.03-1.21]. Specifically, surgery cohort had higher vertebral fracture risk than non-surgery cohort [adjusted hazard ratio (aHR) 1.12, Cl, 1.03-1.22]. In addition, patients underwent cholecystectomy (includes open and laparoscopic approaches), hepatectomy (only open approach), and pancreatectomy group (only open approach) were 1.10 (95% CI, 1.01-1.19), 1.49 (95% CI, 1.10-2.01), and 1.88 (95% CI, 1.23-2.87) times more likely to develop osteoporotic fracture, respectively. No significant difference of osteoporotic fracture risk was observed between open and laparoscopic cholecystectomy. The risk of osteoporotic fracture was significantly increased in females, patients aged ≥ 40 years old, and patients with some comorbidity.

CONCLUSIONS

Patients post cholecystectomy, hepatectomy, or pancreatectomy significantly increased risk of developing osteoporotic fracture, suggesting closer attention in post-operative care is needed.

Osteoporosis and the risk of temporomandibular disorder in chronic obstructive pulmonary disease

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a major cause of chronic morbidity and mortality worldwide. The coexistence of COPD and temporomandibular disorder (TMD) has been noted, and dysfunctional mastication resulting from TMD can worsen individuals' nutritional status. This association between COPD and TMD has been rarely discussed in previous studies. Therefore, this study aimed to determine whether osteoporosis increases the risk of TMD in COPD and whether anti-osteoporosis medications can prevent TMD.

MATERIALS AND METHODS

This retrospective nationwide population-based study utilized the Taiwan National Health Insurance Research Database. We enrolled 52,652 COPD patients between 2000 and 2015: 13,163 with osteoporosis and 39,489 without osteoporosis. Groups of COPD patients with and without osteoporosis were age- and sex-matched. A multivariable Cox proportional hazards regression model was used to evaluate the risk of TMD development in COPD patients with and without osteoporosis over 15 years.

RESULTS

There was a higher risk of TMD occurrence in COPD patients with osteoporosis than in those without osteoporosis (adjusted hazard ratio 2.564, P < 0.001) after adjusting for demographic variables and associative comorbidities. Osteoporosis, hypertension, vertebral compression fracture, and nonpsychotic mental disorders were risk factors contributing to TMD development in patients with COPD. Anti-osteoporosis medications were associated with the prevention of TMD development concomitant with osteoporosis and COPD (adjusted hazard ratio 0.617, P = 0.004).

CONCLUSIONS

Patients with COPD and osteoporosis are at a higher risk of developing TMD, and anti-osteoporosis medications can prevent the development of TMD in this context.

Osteoporosis and fracture risk associated with inhaled corticosteroid use among Swedish COPD patients: the ARCTIC study

The effect of inhaled corticosteroids (ICS) on the risk of osteoporosis and fracture in patients with chronic obstructive pulmonary disease (COPD) remains uncertain. The aim of this study was to assess this risk in patients with COPD.Electronic medical record data linked to National Health Registries were collected from COPD patients and matched reference controls at 52 Swedish primary care centres from 2000 to 2014. The outcomes analysed were the effect of ICS on all fractures, fractures typically related to osteoporosis, recorded osteoporosis diagnosis, prescriptions of drugs for osteoporosis and a combined measure of any osteoporosis-related event. The COPD patients were stratified by the level of ICS exposure.A total of 9651 patients with COPD and 59 454 matched reference controls were analysed. During the follow-up, 19.9% of COPD patients had at least one osteoporosis-related event compared with 12.9% of reference controls (p<0.0001). Multivariate analysis in the COPD population demonstrated a dose-effect relationship, with high-dose ICS being significantly associated with any osteoporosis-related event (risk ratio 1.52 (95% CI 1.24-1.62)), while the corresponding estimate for low-dose ICS was 1.27 (95% CI 1.13-1.56) compared with COPD patients not using ICS. A similar dose-related adverse effect was found for all four of the specific osteoporosis-related events: all fractures, fractures typically related to osteoporosis, prescriptions of drugs for osteoporosis and diagnosis of osteoporosis.We conclude that patients with COPD have a greater risk of bone fractures and osteoporosis, and high-dose ICS use increased this risk further.

Intercellular Communication by Vascular Endothelial Cell-Derived Extracellular Vesicles and Their MicroRNAs in Respiratory Diseases

Respiratory diseases and their comorbidities, such as cardiovascular disease and muscle atrophy, have been increasing in the world. Extracellular vesicles (EVs), which include exosomes and microvesicles, are released from almost all cell types and play crucial roles in intercellular communication, both in the regulation of homeostasis and the pathogenesis of various diseases. Exosomes are of endosomal origin and range in size from 50 to 150 nm in diameter, while microvesicles are generated by the direct outward budding of the plasma membrane in size ranges of 100-2,000 nm in diameter. EVs can contain various proteins, metabolites, and nucleic acids, such as mRNA, non-coding RNA species, and DNA fragments. In addition, these nucleic acids in EVs can be functional in recipient cells through EV cargo. The endothelium is a distributed organ of considerable biological importance, and disrupted endothelial function is involved in the pathogenesis of respiratory diseases such as chronic obstructive pulmonary disease, pulmonary hypertension, and acute respiratory distress syndrome. Endothelial cell-derived EVs (EC-EVs) play crucial roles in both physiological and pathological conditions by traveling to distant sites through systemic circulation. This review summarizes the pathological roles of vascular microRNAs contained in EC-EVs in respiratory diseases, mainly focusing on chronic obstructive pulmonary disease, pulmonary hypertension, and acute respiratory distress syndrome. Furthermore, this review discusses the potential clinical usefulness of EC-EVs as therapeutic agents in respiratory diseases.

CT Imaging and Comorbidities in COPD: Beyond Lung Cancer Screening

Comorbidities significantly contribute to morbidity, mortality, and health-care costs in individuals with COPD. Comorbidity prevalence does not always correlate with lung disease severity, and the elevated risk of certain comorbidities is often independent of shared risk factors such as tobacco burden. Although COPD management guidelines recognize the importance of identifying and treating comorbidities as part of the comprehensive management of COPD patients, little guidance is provided regarding best screening practices. Whereas universal comorbidity screening in COPD patients is likely not cost-effective, targeted early screening and treatment in those at highest risk may have a significant impact on COPD outcomes. Recent studies suggest that certain radiographic features on thoracic imaging may serve as surrogate markers of comorbidity in patients with COPD. This review evaluates these studies in the context of the growing availability of chest CT scans in the lung cancer screening era and discusses how chest CT imaging can be leveraged to identify those COPD patients at highest risk for comorbid disease.

Muscle-Bone Crosstalk in Chronic Obstructive Pulmonary Disease

Sarcopenia and osteoporosis are common musculoskeletal comorbidities of chronic obstructive pulmonary disease (COPD) that seriously affect the quality of life and prognosis of the patient. In addition to spatially mechanical interactions, muscle and bone can also serve as endocrine organs by producing myokines and osteokines to regulate muscle and bone functions, respectively. As positive and negative regulators of skeletal muscles, the myokines irisin and myostatin not only promote/inhibit the differentiation and growth of skeletal muscles, but also regulate bone metabolism. Both irisin and myostatin have been shown to be dysregulated and associated with exercise and skeletal muscle dysfunction in COPD. During exercise, skeletal muscles produce a large amount of IL-6 which acts as a myokine, exerting at least two different conflicting functions depending on physiological or pathological conditions. Remarkably, IL-6 is highly expressed in COPD, and considered to be a biomarker of systemic inflammation, which is associated with both sarcopenia and bone loss. For osteokines, receptor activator of nuclear factor kappa-B ligand (RANKL), a classical regulator of bone metabolism, was recently found to play a critical role in skeletal muscle atrophy induced by chronic cigarette smoke (CS) exposure. In this focused review, we described evidence for myokines and osteokines in the pathogenesis of skeletal muscle dysfunction/sarcopenia and osteoporosis in COPD, and proposed muscle-bone crosstalk as an important mechanism underlying the coexistence of muscle and bone diseases in COPD.

Bone mineral density and vitamin D levels in patients with group a COPD

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) is a chronic, inflammatory airway disease associated with osteoporosis. Reduced bone mineral density (BMD) and impaired bone quality were shown to cause increased bone fragility and fractures in COPD patients. The aim of this study was to evaluate vitamin D levels and BMDs in Group A COPD patients.

METHODS

This case-control study involved 33 males aged 50 or above diagnosed with Group A COPD and 44 age-matched healthy males. Participants' serum vitamin D and other indicators were evaluated as well as lumbar and hip BMD of COPD patients.

RESULTS

Vitamin D levels were significantly lower in COPD patients (15.13 ± 6.02 ng/L) than controls (21.89 ± 4.49 ng/L). Two patients had a history of thoracic vertebral fracture. Lumbar (L1-L4) T scores were normal in 16 patients (48.5%) and indicated osteopenia in 15 (45.5%) and osteoporosis in 2 (6%). Hip femur total T scores were normal in 19 patients (57.6%) and indicated osteopenia in 14 (42.4%).

CONCLUSION

Vitamin D deficiency/insufficiency is prevalent in COPD patients, and BMD decreases in the early period of the disease. Vitamin D and BMD should be evaluated in the early stages to prevent osteoporosis and its complications in COPD patients.

Personalising exacerbation prediction strategies in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality and morbidity worldwide. One of the most important features of this disease is exacerbations where a patient’s respiratory symptoms episodically worsen. Exacerbations accounted for over 140000 hospital admissions in 2012 in the United Kingdom with considerably more exacerbations being treated in primary care. Despite significant research in this area in recent years, treatment of acute exacerbations in the community remains limited to oral glucocorticoids, antibiotics and bronchodilators. One of the issues with unpicking the complexity of exacerbations is trying to find out the exact underlying cause and mechanism that leads to symptoms and lung destruction. Currently symptoms are initially guided by symptoms alone though multiple causes of exacerbations have common presentations. This includes viral and bacterial infections and episodes relating to environmental triggers such as pollen and pollution. There is also evidence that cardiovascular factors can contribute to symptoms of breathlessness that can mimic COPD exacerbations. In this editorial we discuss recent advances in the use of precision medicine to more accurately treat exacerbations of COPD. This includes identification of phenotypes that could help rationalise treatment and more importantly identify novel drug targets. We also consider the future role of precision medicine in preventing exacerbations and identifying COPD patients that are at increased risk of developing them.

Association between statin use and osteoporotic fracture in patients with chronic obstructive pulmonary disease: a population-based, matched case-control study

BACKGROUND

In the recent years, chronic obstructive pulmonary disease (COPD) has been found to be associated with a higher risk of new-onset osteoporotic fracture (NOF). However, the existence of such an association in the COPD patients receiving statin treatment remains unknown. The present study aimed to investigate the association between COPD and NOF in statin-treated patients.

METHODS

The present study was conducted over a period of 10 years (January 2004 to December 2013) in Taiwan. COPD patients receiving statin treatment were included in the statin user group, whereas the randomly selected statin non-users, with 1:1 matching for sex, age, index date, and Charlson Comorbidity Index, were included in the statin non-user group. The hazard ratio (HR) of NOFs in COPD patients was estimated between statin user and non-user groups.

RESULTS

A total of 86,188 cases were identified as the statin-treated patients, and 86,188 subjects were included in the control group of statin non-users. Initially, the risk of NOF was found to be higher among the statin users as compared to non-users [HR, 1.12; 95% confidence interval (CI), 1.01-1.25]. However, the calculation of risk for NOFs after the adjustment for age, sex, comorbidities, and concurrent medications indicated no association of NOF (HR, 0.81; 95% CI, 0.55-1.21) with COPD in patients receiving statin treatment as compared to statin non-users.

CONCLUSION

The results of the study provided first evidence for the absence of any association between COPD and NOFs in statin-treated patients during a follow-up period of 10 years. Thus, the findings of this study might support the hypothesis stating the potent pleiotropic effects of statins. In clinical practice, these drugs might prove beneficial for the patients with COPD.

Executive summary of clinical practice guide on fracture risk in lifestyle diseases

Accumulating evidence has shown that patients with lifestyle diseases such as type 2 diabetes mellitus, chronic kidney disease, and chronic obstructive pulmonary disease are at increased risk of osteoporotic fracture. Fractures deteriorate quality of life, activities of daily living, and mortality as well as a lifestyle disease. Therefore, preventing fracture is an important issue for those patients. Although the mechanism of the lifestyle diseases-induced bone fragility is still unclear, not only bone mineral density (BMD) reduction but also bone quality deterioration are involved in it. Because fracture predictive ability of BMD and FRAX^® is limited, especially for patients with lifestyle diseases, the optimal management strategy should be established. Thus, when the intervention of the lifestyle diseases-induced bone fragility is initiated, the deterioration of bone quality should be taken into account. We here review the association between lifestyle diseases and fracture risk and proposed an algorism of starting anti-osteoporosis drugs for patients with lifestyle diseases.

COPD and Osteoporosis: Associated Factors in Patients Treated with Inhaled Corticosteroids

Purpose

Osteoporosis is a systemic skeletal disease with a consequent increase in fractures rates. Osteoporosis may be primary which is related with normal aging, or secondary which occurs in the presence of an underlying disease or medication. Osteoporosis is one of the significant comorbidities in chronic obstructive pulmonary disease (COPD). In this study, we aimed to investigate the presence of osteoporosis and the influencing factors in COPD patients.

Patients and Methods

This is a two-group comparison study that was conducted among 30 COPD patients on inhaled corticosteroid (ICS) and 33 controls. It was conducted in the outpatient clinics at the Departments of Physical Medicine and Rehabilitation and Pulmonary Diseases in Bursa Uludag University Hospital, a tertiary reference center, in the northwest region of Turkey. For both groups, demographic variables, osteoporosis risk questioning, body mass index (BMI), bone mineral density (BMD), biochemical blood tests, vertebral fractures on lumbar and thoracic x-rays were recorded. COPD patients were also evaluated for lung functions via spirometry.

Results

Thirty patients with COPD (Group 1) and 33 controls (Group 2) were included in the study. Comparing the demographic and biochemical data, no difference was found between the groups except smoking (pack/year) (p<0.001) and erythrocyte sedimentation rate (p<0.001), which were significantly high in COPD group. BMD in the COPD group was significantly lower in both hip and lumbar regions compared with the controls. There were significant correlations between L2 BMD values and pulmonary function tests. BMI was significantly low in osteoporotic COPD patients when compared with the non-osteoporotic COPD patients (p=0.002).

Conclusion

In patients with COPD using inhaled corticosteroids, BMD was significantly low compared with the controls. Osteoporotic COPD patients had significantly lower BMI than non-osteoporotic. These findings suggest that pulmonary dysfunction and low BMI are associated with osteoporosis in COPD patients.

Parental cardiorespiratory conditions and offspring fracture: A population-based familial linkage study

BACKGROUND

The role of parental cardiorespiratory conditions on fracture risk is unclear. We examined the associations between parental cardiorespiratory conditions and offspring fracture risk.

METHODS

In this population-based retrospective cohort study, we identified 279,085 offspring aged≥40 years between April 1, 1997 and December 31, 2015 with successful linkage to 273,852 mothers and 254,622 fathers. Parental cardiorespiratory conditions, including cerebral vascular disease, congestive heart failure, hypertension, ischemic heart disease, myocardial infarction, chronic obstructive pulmonary disease (COPD) and peripheral vascular disease, were ascertained using physician and hospital records dating back to 1979. The outcome was offspring incident major osteoporotic fracture (MOF).

RESULTS

During an average of 11.8 years of offspring follow-up, we identified 8762 (3.1%) incident MOF. Either parent congestive heart failure (adjusted hazard ratio [HR]: 1.13; 95% confidence interval [CI] 1.07-1.19) and COPD (adjusted HR: 1.12; 95% CI 1.07-1.17) were independently associated with increased offspring MOF risk; all their false discovery rates were <0.001. Similar risk estimates were observed when analyses were performed for fathers only, mothers only or both parents, in multivariable models with and without adjustment for offspring cardiorespiratory conditions, and stratified by offspring sex and offspring incident fracture site. Parental cerebrovascular disease, hypertension, ischemic heart disease and myocardial infarction were not associated with offspring MOF.

CONCLUSIONS

Parental congestive heart failure and parental COPD are independent risk factors for offspring MOF.

Decreased Bone Type I Collagen in the Early Stages of Chronic Obstructive Pulmonary Disease (COPD)

Smoking is the main risk factor for the development of chronic obstructive pulmonary disease (COPD) and is known to have deleterious effects on bone metabolism. However, the effects on bone collagen matrix during the development of COPD are unclear. The aim of this study was to evaluate the temporal effect of cigarette smoke exposure on bone type I collagen during COPD development in a cigarette smoke-induced model. C57BL/6 mice were allocated to three groups: control (C), animals exposed to filtered air for 1, 3 and 6 months; cigarette smoke (S), animals exposed to cigarette smoke for 1, 3 and 6 months; provisional smoking (PS), animals exposed to cigarette smoke for 3 months, followed by another 3 months of filtered air exposure. Evaluation of the respiratory mechanics and alveolar enlargement were performed. Femoral and tibial extraction was also performed to evaluate the type I collagen by immunofluorescence and COL1A1 gene expression. Exposure to cigarette smoke led to an alveolar enlargement and progressive reduction in lung tissue resistance and elastance, progressive reduction of type I collagen and reduction in COL1A1 gene expression. Although we did not observe any improvement in the functional and histological parameters in the provisional smoking group, we detected an increase in COL1A1 gene expression. A worsening in bone collagen matrix is part of the initial physiopathological events during COPD development and the smoking cessation induced an evident recovery of COL1A1 expression, possibly to attempt at tissue repair.

Association of COPD with osteoporosis in male smokers: A case control study in a tertiary medical college hospital in Bangladesh

OBJECTIVES

Chronic obstructive pulmonary disease (COPD) may increase the risk of osteoporosis and resulting fractures can contribute to disability and mortality of patients. We intended to evaluate the frequency of osteoporosis in male smokers with and without COPD and study whether any correlation existed between osteoporosis and COPD.

MATERIALS AND METHODS

This case-control study was carried out in the Department of Medicine, Sylhet MAG Osmani Medical College Hospital, Sylhet, Bangladesh between July 2013 and June 2015. Seventy four male smokers with COPD and 66 age-matched male smokers without COPD were enrolled. All individuals underwent Bone Mass Densitometry (BMD) by Dual-Energy X-Ray Absorptiometry (DEXA).

RESULTS

COPD and non-COPD groups did not differ regarding age and smoking pack-years. Osteoporosis at femoral neck (48.6% versus 16.7%; p< 0.001) and lumbar spine (68.9% versus 37.9%; p< 0.01) was significantly higher in COPD compared to controls. Osteopenia did not differ significantly. Patients with COPD were 4.5 times more likely to develop osteoporosis than controls after adjusting age, smoking-pack years and BMI (adjusted OR = 4.5; 95% CI = 1.8-11.5).

CONCLUSIONS

Osteoporosis is more frequent in male smokers with COPD compared to smokers without COPD. COPD is a risk factor of osteoporosis independent of age, smoking and BMI.

The risk of osteoporosis in patients with asthma

It is well-known that use of continuous systemic corticosteroids (SG) affects bone metabolism, bone mineral density (BMD), and ultimately increases the risk of osteoporosis. In patients with asthma, on the other hand, the effects of long-term high-dose inhaled corticosteroids (ICS) on BMD and risk of osteoporotic fractures is controversial. The reasons for this inconsistency could be explained by the fact that only few long-term studies investigating the effect of ICS in patients with asthma exist. The studies are characterized by different study designs and duration of ICS exposure, small study populations, and differences between the used ICS. The aim of this article is to unravel which factors, if any, that contribute to an increased risk of osteoporosis in patients with asthma and to summarize the evidence regarding adverse effects of ICS on bone metabolism, BMD and osteoporotic fractures in patients with asthma.