The influence of hospitalizations due to exacerbations or spontaneous pneumothoraxes on the quality of life, mental function and symptoms of depression and anxiety in patients with COPD or asthma

Bioinformatics and systems-biology analysis to determine the effects of Coronavirus disease 2019 on patients with allergic asthma

Background

The coronavirus disease (COVID-19) pandemic has posed a significant challenge for global health systems. Increasing evidence shows that asthma phenotypes and comorbidities are major risk factors for COVID-19 symptom severity. However, the molecular mechanisms underlying the association between COVID-19 and asthma are poorly understood. Therefore, we conducted bioinformatics and systems biology analysis to identify common pathways and molecular biomarkers in patients with COVID-19 and asthma, as well as potential molecular mechanisms and candidate drugs for treating patients with both COVID-19 and asthma.

Methods

Two sets of differentially expressed genes (DEGs) from the GSE171110 and GSE143192 datasets were intersected to identify common hub genes, shared pathways, and candidate drugs. In addition, murine models were utilized to explore the expression levels and associations of the hub genes in asthma and lung inflammation/injury.

Results

We discovered 157 common DEGs between the asthma and COVID-19 datasets. A protein–protein-interaction network was built using various combinatorial statistical approaches and bioinformatics tools, which revealed several hub genes and critical modules. Six of the hub genes were markedly elevated in murine asthmatic lungs and were positively associated with IL-5, IL-13 and MUC5AC, which are the key mediators of allergic asthma. Gene Ontology and pathway analysis revealed common associations between asthma and COVID-19 progression. Finally, we identified transcription factor–gene interactions, DEG–microRNA coregulatory networks, and potential drug and chemical-compound interactions using the hub genes.

Conclusion

We identified the top 15 hub genes that can be used as novel biomarkers of COVID-19 and asthma and discovered several promising candidate drugs that might be helpful for treating patients with COVID-19 and asthma.

Clinical characteristics and burden of illness among adolescent and adult patients with severe asthma by asthma control: the IDEAL study

OBJECTIVES

Severe asthma (SA) can be uncontrolled despite guideline-directed treatment. We described SA characteristics and identified factors associated with uncontrolled disease and frequent exacerbations.

METHODS

Post hoc analysis of the observational IDEAL study (201722/NCT02293265) included patients with SA aged ≥12 years receiving high-dose inhaled corticosteroids plus additional controller(s) for ≥12 months. Uncontrolled SA was defined by Asthma Control Questionnaire (ACQ)-5 scores ≥1.5 or ≥1 exacerbations (prior year), and further stratified by exacerbation frequency (no/infrequent [0-1] vs frequent [≥2]; prior year); associated factors were determined using multivariate logistic regression.

RESULTS

Of 670 patients with SA, 540 (81%) were uncontrolled (ACQ-5 scores ≥1.5: 80%; ≥1 exacerbations [prior year]: 71%). Uncontrolled patients had lower lung function and worse health-related quality of life (HRQoL) than controlled patients; 197/540 (37%) experienced frequent exacerbations (prior year). Worse St George's Respiratory Questionnaire (SGRQ) total score, comorbid sinusitis, or eczema were significantly associated with uncontrolled SA; younger age, never smoker status, exacerbation requiring hospitalization (previous year), worse SGRQ symptom score, comorbid nasal polyps, COPD, or osteoporosis were significantly associated with uncontrolled SA with frequent exacerbations.

CONCLUSIONS

In IDEAL, one-fifth of patients with SA were controlled, based on symptoms. Uncontrolled, exacerbating SA was associated with specific comorbidities, frequent exacerbations, a lower lung function, and compromised HRQoL, although inference from this analysis is limited by the selective cross-sectional nature of the cohort. Nonetheless, these data highlight the need for more effective precision treatments in this population.

Impact of exacerbations on St George's Respiratory Questionnaire score in patients with severe asthma: post hoc analyses of two clinical trials and an observational study

Objective: To assess the effect of asthma exacerbations and mepolizumab treatment on health status of patients with severe asthma using the St George's Respiratory Questionnaire (SGRQ).Methods: Post hoc analyses were conducted using data from two randomized controlled trials in patients ≥12 years old with severe eosinophilic asthma randomized to receive placebo or mepolizumab 75 mg intravenously (32-week MENSA study) or 100 mg subcutaneously (MENSA/24-week MUSCA studies), and an observational single-visit study in patients with severe asthma (IDEAL). Linear regression models assessed the impact of historical exacerbations on baseline SGRQ total and domain scores (using data from each of the three studies), and within-study severe exacerbations and mepolizumab treatment on end-of-study SGRQ scores (using data from MENSA/MUSCA).Results: Overall, 1755 patients were included (MENSA, N = 540; MUSCA, N = 551; IDEAL, N = 664). In all studies, higher numbers of historical exacerbations were associated with worse baseline SGRQ total scores. Each additional historical exacerbation (beyond the second [MENSA/MUSCA]) or first [IDEAL] was associated with worsening mean total SGRQ scores of +1.5, +1.1 at baseline and +2.3 within the year prior to study enrollment. During MENSA and MUSCA, each within-study severe exacerbation was associated with a worsening in total SGRQ score of +2.4 and +3.4 points at study end. Independent of exacerbation reduction, mepolizumab accounted for an improvement in total SGRQ score of -5.3 points (MENSA) and -6.2 points (MUSCA).Conclusions: These findings support an association between a higher number of exacerbations and worse health status in patients with severe (eosinophilic) asthma.

Experience of Guilt and Strategies for Coping with Guilt in Patients with Severe Copd: A Qualitative Interview Study

Guilt is associated with an increased level of mood disturbance and a poorer quality of life. The aim of this study was to explore how patients with severe COPD view and experience guilt and the ways in which they cope with this guilt. A total of 31 COPD patients were interviewed about their perceptions and experiences of guilt. Qualitative content analysis was used to examine the interviews. In the descriptive (manifest) analysis, the categories “not feeling personal guilt” and “experiencing guilt” emerged; in the interpretative (latent) analysis, various strategies for dealing with guilt were identified — for example, acceptance or blaming others. Relatively few patients reported that they felt guilt on a conscious level, but those who did expressed anguish, and remorse before God; some felt blamed by others. It is important that healthcare providers acknowledge the guilt that their patients express, since guilt may have adverse effects on the patients’ overall health.

Evaluation of the psychometric properties of the St George's Respiratory Questionnaire in patients with severe asthma

PURPOSE

Limited data exist on the quantitative validity of the St George's Respiratory Questionnaire (SGRQ) in asthma populations. This study evaluated the psychometric properties of the SGRQ in patients with severe asthma.

METHODS

This was a post-hoc analysis of pooled data from MENSA (N = 576; NCT01691508) and SIRIUS (N = 135; NCT01691521), two randomized, placebo controlled trials of mepolizumab in patients with severe asthma. Patients completed the SGRQ at Baseline and Exit (MENSA Week 32; SIRIUS Week 24). Distributional characteristics, internal consistency reliability, test-retest reliability, convergent and discriminant validity, known-groups validity and responsiveness were assessed.

RESULTS

Internal consistency reliability was acceptable for the total and domain scores at Baseline and Exit (Cronbach's α was 0.92 and 0.94 at Baseline and Exit, respectively, for the total score). Test-retest reliability was demonstrated (intraclass correlation coefficients >0.7) for total score and the Activity and Impacts domains. Convergent and discriminant validity were demonstrated with measures associated or not associated with respiratory-related health status. Known groups validity based on baseline FEV₁% predicted, Asthma Control Questionnaire (ACQ)-5 score, exacerbations and eosinophil counts was demonstrated for the SGRQ total and domain scores. Responses to therapy based on clinician-rated response, patient-rated response, ACQ-5 change score and exacerbations generally correlated with improvements in SGRQ scores.

CONCLUSIONS

This analysis demonstrated that the SGRQ has acceptable psychometric properties in patients with severe asthma, exceeding the thresholds for adequate reliability, validity and responsiveness. The SGRQ appears to be a good instrument for identifying response to therapy in patients with severe asthma.

Comparative effectiveness of mepolizumab and omalizumab in severe asthma: An indirect treatment comparison

BACKGROUND

Severe asthma is a heterogeneous disease. Patients with both eosinophilic and allergic asthma phenotypes may be eligible for treatment with mepolizumab and omalizumab. Evidence on the relative effectiveness of these treatments in this 'overlap' population would be informative for clinical and payer decision making.

METHODS

A systematic literature review and indirect treatment comparison (Bayesian framework) were performed to assess the comparative effectiveness and tolerability of mepolizumab and omalizumab, as add-ons to standard of care. Studies included in the primary analysis were double-blind, randomized controlled trials, ≥12 weeks' duration enrolling patients with severe asthma with a documented exacerbation history and receiving high-dose inhaled corticosteroids plus ≥1 additional controller. Two populations were examined: patients potentially eligible for 1) both treatments (Overlap population) and 2) either treatment (Trial population).

RESULTS

In the Overlap population, no differences between treatments in clinically significant exacerbations and exacerbations requiring hospitalization were found, although trends favored mepolizumab (rate ratio [RR]:0.66 [95% credible intervals (Crl):0.37,1.19]; 0.19[0.02,2.32], respectively). In the Trial population, mepolizumab treatment produced greater reductions in clinically significant exacerbations (RR:0.63 [95% CrI:0.45,0.89]) but not exacerbations requiring hospitalization compared with omalizumab (RR:0.58 [95% Crl: 0.16,2.13]), although the trend favored mepolizumab. Both treatments had broadly comparable effects on lung function, and similar tolerability profiles.

CONCLUSIONS

Whilst this analysis has limitations due to a restricted evidence base and residual heterogeneity, it showed that in patients with severe asthma, mepolizumab seems to be at least as effective as omalizumab and that the tolerability profiles of the two treatments did not meaningfully differentiate.

[Quality of life and associated factors in asthma in a Primary Care Center. Application of the reduced version of the Asthma Quality of Life Questionnaire]

INTRODUCTION

Asthma is a highly prevalent disease that can affect the quality of life (QoL). The objective of this study is to determine the QoL in patients with asthma and its relationship with different factors in a Primary Care centre.

MATERIAL AND METHODS

A descriptive, cross-sectional study was conducted in an urban health centre. The study included a total of 243 patients between 17 to 70 years who had a diagnosis of asthma in their medical records. The QoL was measured using the Spanish version of the Mini-Asthma Quality of Life Questionnaire, with age, sex, smoking, anxiety, depression, severity and control of asthma as associated variables.

RESULTS

The mean age was 44.5 years and 71.2% were women. More than half (54.3%) had intermittent asthma, and 45.7% persistent asthma. The overall score in the Mini-Asthma Quality of Life Questionnaire was 5.4 out of 7. The scores by dimensions were: symptoms 5.4; limitation of activities 5.8; emotional function 5.7, and environmental stimuli 4.7. The variables with a worse QoL score that remained statistically significant (P<.05) in the multivariate analysis were poor control of asthma (in all dimensions), history of depression (in all except environmental stimuli), educated to less than secondary level (symptoms and emotional function), and patients admitted to hospital in the past 3 years (symptoms) and who used long-term beta-adrenergics (emotional function).

CONCLUSIONS

Patients with intermittent, mild and moderate asthma have a good QoL. Poor control of the asthma and a history of depression negatively affect the QoL.

Association of mental health disorders and Medicaid with ED admissions for ambulatory care-sensitive condition conditions

INTRODUCTION

Adult Medicaid enrollees are more likely to have mental health disorders (MHDs) than privately insured patients and also have high rates of emergency department (ED) visits for ambulatory care-sensitive conditions (ACSCs). We aimed to evaluate the association of MHD and insurance type with ED admissions for ACSC in the United States.

METHODS

We conducted a cross-sectional study of ED visits made by adults aged 18 to 64 years using the corrected 2011 National Emergency Department Survey. Using multivariable logistic regression analysis, we controlled for sociodemographics and clinical variables to determine the association between insurance type, MHD, Medicaid, and MHD (as an interaction variable) and ED admissions for ACSC.

RESULTS

There were 131 million ED visits in 2011; after exclusions, 1.4 million admissions were included in our study. Of all ED visits, 44.7% had an MHD, of which 49.9% were covered by Medicaid and 38.1% were covered by private insurance. A total of 32.6% (95% confidence interval, 32.5%-32.7%) of ED admissions were for an ACSC. Medicaid-covered ED visits were more likely to result in ACSC hospital admission (odds ratio, 1.32; 95% confidence interval, 1.30-1.35) compared with visits covered by private insurance. Among patients with MHD, those with Medicaid insurance had 1.6 times the odds of ACSC admission compared with those privately insured.

CONCLUSION

Among all ED admissions, patients covered by Medicaid are more likely to be admitted for an ACSC when compared with those covered by private insurance, with a larger association being present among patients with MHD comorbidities.

Impact of individualized care on readmissions after a hospitalization for acute exacerbation of COPD

BACKGROUND

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) increase COPD morbidity and mortality and impose a great burden on health care systems. Early readmission following a hospitalization for AECOPD remains an important clinical problem. We examined how individualized comprehensive care influences readmissions following an index hospital admission for AECOPD.

METHODS

We retrospectively reviewed data of patients admitted for AECOPD to two inner-city teaching hospitals to determine the impact of a comprehensive and individualized care management strategy on readmissions for AECOPD. The control group consisted of 271 patients whose index AECOPD occurred the year before the comprehensive program, and the experimental group consisted of 191 patients who received the comprehensive care. The primary outcome measure was the total number of readmissions in 30- and 90-day postindex hospitalizations. Secondary outcome measures included the length of time between the index admission and first readmission and all-cause mortality.

RESULTS

The two groups were similar in terms of age, sex, forced expiratory volume in 1 second, body mass index (BMI), pack-years, and the number and types of comorbidities. Comprehensive care significantly reduced 90-day readmission rates in females (P=0.0205, corrected for age, BMI, number of comorbidities, substance abuse, and mental illness) but not in males or in the whole group (P>0.05). The average times between index admission and first readmission were not different between the two groups. Post hoc multivariate analysis showed that substance abuse (P<0.01) increased 30- and 90-day readmissions (corrected for age, sex, BMI, number of comorbidities, and mental illness). The 90-day all-cause in-hospital mortality rates were significantly less in the care package group (2.67% versus 7.97%, P=0.0268).

CONCLUSION

Comprehensive individualized care for subjects admitted to hospital for AECOPD did not reduce 30- and 90-day readmission rates but did reduce 90-day total mortality. Interestingly, it reduced 90-day readmission rate in females. We speculate that an individualized care package could impact COPD morbidity and mortality after an acute exacerbation.

The impact of anxiety and depression on outpatients with asthma

BACKGROUND

Anxiety and depression may frequently affect patients with asthma. However, the findings of several studies are partially conflicting and conducted in selected cohorts.

OBJECTIVE

To investigate the effect of anxiety and depression in a group of outpatients with asthma.

METHODS

This cross-sectional, real-life study included 263 patients (109 males; mean age, 39.2 years) with asthma. Clinical examination, lung function, fractional exhaled nitric oxide measurement, Asthma Control Test (ACT) score, asthma control grade, perception of symptoms by visual analog scale, and Hospital Anxiety and Depression Scale (HADS) questionnaires were evaluated.

RESULTS

Globally, 97 patients (36.9%) had anxiety, and 29 (11%) had depression. Of these patients, 71 had combined anxiety and depression. Anxiety and depression were associated with poor asthma control (P =.007 and .02, respectively). Patients with depression had higher body mass indexes (P =.002). Anxiety and depression were associated with lower ACT scores (P < .001 for both). The scores on the anxiety and depression subscales of HADS were moderately related (r = 0.57).

CONCLUSIONS

The present real-life study indicates that anxiety and depression are common and relevant comorbidities in asthmatic outpatients and are associated with uncontrolled asthma and lower ACT scores. Thus, assessment of comorbid mental disorders should be performed in common practice.

Comorbidities and Chronic Obstructive Pulmonary Disease: Prevalence, Influence on Outcomes, and Management

Comorbidities impact a large proportion of patients with chronic obstructive pulmonary disease (COPD), with over 80% of patients with COPD estimated to have at least one comorbid chronic condition. Guidelines for the treatment of COPD are just now incorporating comorbidities to their management recommendations of COPD, and it is becoming increasingly clear that multimorbidity as well as specific comorbidities have strong associations with mortality and clinical outcomes in COPD, including dyspnea, exercise capacity, quality of life, healthcare utilization, and exacerbation risk. Appropriately, there has been an increased focus upon describing the burden of comorbidity in the COPD population and incorporating this information into existing efforts to better understand the clinical and phenotypic heterogeneity of this group. In this article, we summarize existing knowledge about comorbidity burden and specific comorbidities in COPD, focusing on prevalence estimates, association with outcomes, and existing knowledge about treatment strategies.

One-year prognosis and the role of brain natriuretic peptide levels in patients with chronic cor pulmonale

Data on the clinical outcomes and role of brain natriuretic peptide (BNP) levels in patients with chronic cor pulmonale are limited. A total of 69 patients with chronic cor pulmonale, admitted for dyspnea (January 2007 to September 2011) to three university hospitals, were retrospectively reviewed. All of the patients had right ventricular (RV) dysfunction on echocardiography. The median age was 70.0 yr, and chronic obstructive pulmonary disease (40.6%) and tuberculosis-destroyed lung (TDL, 27.5%) were the leading causes of chronic cor pulmonale. At the 1-yr follow-up, the mortality rate was 15.9%, and the readmission rate was 53.7%; patients with TDL had higher mortality (31.6% vs. 10.0%; P=0.059) and readmission rates (78.9% vs. 43.8%; P=0.009) than those with non-TDL diseases. The area under the receiver operating characteristic curve for admission BNP levels to predict readmission was 0.788 (95% confidence interval [CI], 0.673-0.904), and the sensitivity and specificity of the cut-off value were 80.6% and 77.4%, respectively. In multivariate analysis, high admission BNP levels were a significant risk factor for subsequent readmission (hazard ratio, 1.049; 95% CI, 1.005-1.094). Additionally, admission BNP levels were well correlated with cardiac troponin I (r=0.558), and delta BNP also correlated with delta RV systolic pressure (n=25; r=0.562). In conclusion, among hospitalized patients with chronic cor pulmonale, admission high BNP levels are a significant risk factor for subsequent readmission. Therefore, more intensive monitoring and treatment are needed in patients with higher BNP levels.

The role of macrolides in asthma: current evidence and future directions

Macrolides, such as clarithromycin and azithromycin, possess antimicrobial, immunomodulatory, and potential antiviral properties. They represent a potential therapeutic option for asthma, a chronic inflammatory disorder characterised by airway hyper-responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing. Results from clinical trials, however, have been contentious. The findings could be confounded by many factors, including the heterogeneity of asthma, treatment duration, dose, and differing outcome measures. Recent evidence suggests improved effectiveness of macrolides in patients with sub-optimally controlled severe neutrophilic asthma and in asthma exacerbations. We examine the evidence from clinical trials and discuss macrolide properties and their relevance to the pathophysiology of asthma. At present, the use of macrolides in chronic asthma or acute exacerbations is not justified. Further work, including proteomic, genomic, and microbiome studies, will advance our knowledge of asthma phenotypes, and help to identify a macrolide-responsive subgroup. Future clinical trials should target this subgroup and place emphasis on clinically relevant outcomes such as asthma exacerbations.