Gender and asthma-chronic obstructive pulmonary disease overlap syndrome

Urban-rural and socio-economic differences in inhaled corticosteroid treatment for chronic obstructive pulmonary disease: A nationwide register-based cross-sectional study

BACKGROUND

Urban-rural disparities within chronic obstructive pulmonary disease (COPD) have been documented in USA, but not in Europe. Inhaled corticosteroids (ICS) are widely used in COPD despite strict recommendations. We aimed to investigate urban-rural and socioeconomic differences in ICS treatment for COPD.

METHODS

A Danish nationwide register-based cross-sectional study. All patients alive on the December 31, 2018 with a J44 ICD-10 diagnosis code (COPD) were included (99,057 patients). Daily average ICS dose was calculated from the accumulated ICS use during 2018 based on redeemed prescriptions. Patients were divided into groups: No ICS, low dose ICS, medium dose ICS, high dose ICS. A multinomial logistic regression model including educational level, co-habitation status, age, and sex was performed with "No ICS" as reference group.

RESULTS

Compared to capital municipalities, living in other municipality types was associated with an increased probability of receiving medium and high dose ICS treatment, and increasing odds ratios (ORs) were seen with increasing ICS dose (medium dose ICS: ORs between 1.31 (95 % confidence interval (CI) 1.24-1.38) and 1.35 (95%CI 1.28-1.41), high dose ICS: ORs between 1.73 (95%CI 1.59-1.88) and 1.80 (95%CI 1.68-1.92)). Patients had increased probability of receiving ICS treatment if they were female, were co-habiting, or had completed only primary education.

CONCLUSION

Patients with a hospital-registered COPD diagnosis in non-capital municipalities receive more ICS, and in higher doses, compared to patients in capital municipalities. This is the first study to confirm that such urban-rural differences exist in Europe, and further research on this area is warranted.

Sex-Specific Genetic Determinants of Asthma-COPD Phenotype and COPD in Middle-Aged and Older Canadian Adults: An Analysis of CLSA Data

The etiology of sex differences in the risk of asthma-COPD phenotype and COPD is still not completely understood. Genetic and environmental risk factors are commonly believed to play an important role. This study aims to identify sex-specific genetic markers associated with asthma-COPD phenotype and COPD using the Canadian Longitudinal Study on Aging (CLSA) Baseline Comprehensive and Genomic data. There were a total of 1,415 COPD cases. Out of them, 504 asthma-COPD phenotype cases were identified. 20,524 participants without a diagnosis of asthma and COPD served as controls. We performed genome-wide SNP-by-sex interaction analysis. SNPs with an interaction p-value < 10^-5 were included in a sex-stratified multivariable logistic regression for asthma-COPD phenotype and COPD outcomes. 18 and 28 SNPs had a significant interaction term p-value < 10^-5 with sex in the regression analyses of asthma-COPD phenotype and COPD outcomes, respectively. Sex-stratified multivariable analysis of asthma-COPD phenotype showed that 7 SNPs in/near SMYD3, FHIT, ZNF608, RIMBP2, ZNF133, BPIFB1, and S100B loci were significant in males. Sex-stratified multivariable analysis of COPD showed that 8 SNPs in/near MAGI1, COX18, OSTC, ELOVL5, C7orf72 FGF14, and NKAIN4 were significant in males, and 4 SNPs in/near genes CAMTA1, SATB2, PDE10A, and LINC00908 were significant in females. An SNP in the ZPBP gene was associated with COPD in both males and females. Identification of sex-specific loci associated with asthma-COPD phenotype and COPD may offer valuable evidence toward a better understanding of the sex-specific differences in the pathophysiology of the diseases.

Asthma, chronic obstructive pulmonary disease, and asthma-COPD overlap among US working adults

BACKGROUND

Asthma-COPD overlap (ACO) is a respiratory condition with more severe respiratory symptoms, poorer quality of life, and increased hospital admissions compared with asthma or COPD alone.

OBJECTIVES

Estimate asthma, chronic obstructive pulmonary disease (COPD), and ACO prevalence among workers by industry and occupation and assess physical and mental health status, healthcare utilization, among workers with ACO.

METHODS

The 2014-2018 National Health Interview Survey (NHIS) data for working adults aged ≥18 years employed (sample n = 99,424) in the 12 months prior to the survey were analyzed. Age-adjusted ACO, COPD and asthma prevalence and prevalence ratios adjusted for age, sex, race and smoking status were estimated.

RESULTS

During 2014-2018, of the estimated 166 million (annual average) US workers, age-adjusted asthma, COPD, and ACO prevalence was 6.9%, 4.0%, and 1.1%, respectively. ACO prevalence was highest among workers aged ≥65 years (2.0%), females (1.6%), current smokers (1.9%), those living below the federal poverty level (2.3%), and workers in the accommodation and food services (1.6%) industry and personal care and service (2.3%) occupations. Workers with ACO had more frequent (p < 0.05) physician office visits, emergency department visits; and were more likely to be in poorer mental health, obese, have more lost workdays, more bed days, and comorbidities compared to workers with asthma alone and workers with COPD alone.Conclusion: Higher ACO prevalence among worker groups and increased healthcare utilization underscores the need for early identification of asthma and COPD, assessment of potential workplace exposures, and implementation of tailored interventions to reduce ACO among working adults.

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.

Examining Risk Factors Accelerating Time-to-Chronic Obstructive Pulmonary Disease (COPD) Diagnosis among Asthma Patients

Asthma patients may have an increased risk for diagnosis of chronic obstructive pulmonary disease (COPD). However, risk factors accelerating time-to-COPD diagnosis are unclear. This study aims to estimate risk factors associated with the incidence of COPD diagnosis in asthma patients. Canada's Population Data BC (PopData BC) was used to identify asthma patients without prior COPD diagnosis between January 1, 1998, to December 31, 1999. Patients were assessed for time-to-incidence of COPD diagnosis from January 1, 2000, to December 31, 2018. The study estimated the effects of several risk factors in predicting the incidence of COPD in asthma patients during the 18-year follow-up period. Patient factors such as Medication Adherence (MA) were assessed by the proportion of days covered (PDC) and the medication possession ratio (MPR). The log-logistic mixed-effects accelerated failure time model was used to estimate the adjusted failure time ratios (aFTR) and 95% Confidence Interval (95% CI) for factors predicting time-to-COPD diagnosis among asthma patients. We identified 68,211 asthma patients with a mean age of 48.2 years included in the analysis. Risk factors accelerating time-to-COPD diagnosis included: male sex (aFTR: 0.62, 95% CI:0.56-0.68), older adults (age > 40 years) [aFTR: 0.03, 95% CI: 0.02-0.04], history of tobacco smoking (aFTR: 0.29, 95% CI: 0.13-0.68), asthma exacerbations (aFTR: 0.81, 95%CI: 0.70, 0.94), frequent emergency admissions (aFTR:0.21, 95% CI: 0.17-0.25), longer hospital stay (aFTR:0.07, 95% CI: 0.06-0.09), patients with increased burden of comorbidities (aFTR:0.28, 95% CI: 0.22-0.34), obese male sex (aFTR:0.38, 95% CI: 0.15-0.99), SABA overuse (aFTR: 0.61, 95% CI: 0.44-0.84), moderate (aFTR:0.23, 95% CI: 0.21-0.26), and severe asthma (aFTR:0.10, 95% CI: 0.08-0.12). After adjustment, MA ≥0.80 was significantly associated with 83% delayed time-to-COPD diagnosis [i.e. aFTR =1.83, 95%CI: 1.54-2.17 for PDC]. However, asthma severity significantly modifies the effect of MA independent of tobacco smoking history. The targeted intervention aimed to mitigate early diagnosis of COPD may prioritize enhancing medication adherence among asthma patients to prevent frequent exacerbation during follow-up.

Concurrent asthma and chronic obstructive pulmonary disease in adult ED patients: A national perspective

OBJECTIVES

Emergency department (ED) visits for Asthma and Chronic Obstructive Pulmonary Disease (COPD) are common. The designation of Asthma-COPD overlap (ACO) has been used to describe patients with features of both diseases. Studies show that ACO patients may be at increased risk of poor outcomes relative to patients with either disease alone. We sought to characterize ED visits and ED-related outcomes of patients with ACO compared to patients with Asthma or COPD alone.

METHODS

We conducted a secondary analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS, 2005-2018) characterizing ED visits in patients ≥35 years of age with Asthma Only, COPD Only or ACO. We performed univariable and multivariable analyses adjusting for demographics to assess relevant ED outcome variables.

RESULTS

From 2005 to 2018, there were an estimated 8.15, 17.78 and 0.56 million ED visits for Asthma Only, COPD Only and ACO, respectively. ACO patients were younger than COPD Only patients (mean age 50.18 versus 61.79; p < 0.001). ACO patients differed in terms of sex, race and ethnicity from patients with either disease alone. When triaged, Asthma Only (adjusted odds ratio (aOR) = 11.45; 95% confidence interval (CI), 1.20-109.38) patients were more likely to require immediate care than ACO patients. Although admission rates were comparable between groups, ACO patients had a decreased mean length of ED visit compared to both Asthma Only (p < 0.001) and COPD Only (p < 0.05) patients. COPD Only patients were less likely than ACO patients to be seen in the ED in the last 72 h (aOR = 0.22; 95% CI, 0.056-0.89), receive nebulizer therapy (aOR = 0.55; 95% CI, 0.31-0.97), bronchodilators (aOR = 0.24; 95% CI, 0.12-0.48) and systemic corticosteroids (aOR = 0.18; 95% CI, 0.091-0.35). Asthma Only patients were less likely than ACO patients to undergo any imaging (aOR = 0.55; 95% CI, 0.31-0.96) and receive antibiotics (aOR = 0.46; 95% CI, 0.23-0.93).

CONCLUSIONS

ACO patients appear to differ demographically from patients with either disease alone in the ED. After adjustment for these demographic differences, ACO patients appear to differ with respect to several ED variables, notably respiratory therapies; however, clinical outcomes including admission and mortality rates appear to be comparable between groups.

Contemporary perspectives in COPD: Patient burden, the role of gender and trajectories of multimorbidity

An individual's experience of COPD is determined by many factors in addition to the pathological features of chronic bronchitis and emphysema and the symptoms that derive directly from them. Multimorbidity is the norm rather than the exception, so most people with COPD are living with a range of other medical problems which can decrease overall quality of life. COPD is caused by the inhalation of noxious particles or gases, in particular tobacco smoke, but also by early life disadvantage impairing lung development and by occupations where inhaled exposures are common (e.g. industrial, farming and cleaning work). Wealthy people are therefore relatively protected from developing COPD and people who do develop the condition may have reduced resources to cope. COPD is also no longer a condition that predominantly affects men. The prevalence of COPD among women has equalled that of men since 2008 in many high-income countries, due to increased exposure to tobacco, and in low-income countries due to biomass fuels. COPD is one of the leading causes of death in women in the USA, and death rates attributed to COPD in women in some countries are predicted to overtake those of men in the next decade. Many factors contribute to this phenomenon, but in addition to socioeconomic and occupational factors, there is increasing evidence of a higher susceptibility of females to smoking and pollutants. Quality of life is also more significantly impaired in women. Although most medications (bronchodilators and inhaled corticosteroids) used to treat COPD demonstrate similar trends for exacerbation prevention and lung function improvement in men and women, this is an understudied area and clinical trials frequently have a preponderance of males. A better understanding of gender-based predictors of efficacy of all therapeutic interventions is crucial for comprehensive patient care. There is an urgent need to recognize the increasing burden of COPD in women and to facilitate global improvements in disease prevention and management in this specific population. Many individuals with COPD follow a trajectory of both lung function decline and also multimorbidity. Unfavourable lung function trajectories throughout life have implications for later development of other chronic diseases. An enhanced understanding of the temporal associations underlying the development of coexisting diseases is a crucial first step in unravelling potential common disease pathways. Lessons can be learned from exploring disease trajectories of other NCD as well as multimorbidity development. Further research will be essential to explain how early life risk factors commonly influence trajectories of COPD and other diseases, how different diseases develop in relation to each other in a temporal way and how this ultimately leads to different multimorbidity patterns in COPD. This review integrates new knowledge and ideas pertaining to three broad themes (i) the overall burden of disease in COPD, (ii) an unappreciated high burden in women and (iii) the contrast of COPD trajectories and different multimorbidity patterns with trajectories of other NCD. The underlying pathology of COPD is largely irreversible, but many factors noted in the review are potentially amenable to intervention. Health and social care systems need to ensure that effective treatment is accessible to all people with the condition. Preventive strategies and treatments that alter the course of disease are crucial, particularly for patients with COPD as one of many problems.

Respiratory health, occupation and the healthy worker effect

BACKGROUND

Workers are exposed to physical, chemical and other hazards in the workplace, which may impact their respiratory health.

AIMS

To examine the healthy worker effect in the Canadian working population and to identify the association between occupation and respiratory health.

METHODS

Data from four cycles of the Canadian Health Measures Survey were utilized. The current occupation of employed participants was classified into 10 broad categories based on National Occupation Category 2011 codes. Data relating to 15 400 subjects were analysed.

RESULTS

A significantly lower proportion of those in current employment than those not in current employment reported respiratory symptoms or diseases or had airway obstruction. Similarly, those currently employed reported better general health and had greater mean values for percent-predicted forced vital capacity (FVC), forced expiratory volume in one second (FEV1), forced expiratory flow between 25% and 75% of FVC (FEF25-75%) and FEV1/FVC ratio. Among males, females and older age groups, significant differences were observed for almost all the respiratory outcomes for those in current employment. Those in 'Occupations unique to primary industry' had a significantly greater likelihood of regular cough with sputum and ever asthma and had lower mean values of percent-predicted FEV1/FVC and FEF25-75% than those in 'Management occupations'. Those in 'Health occupations' had the highest proportion of current asthma.

CONCLUSIONS

Participants in current employment were healthier than those not in current employment providing further support for the healthy worker effect. Those in 'Occupations unique to primary industry' had an increased risk of adverse respiratory outcomes and reducing workplace exposures in these occupations has the potential to improve their respiratory health.

Asthma-chronic obstructive pulmonary disease overlap syndrome

Overlap of asthma and chronic obstructive lung disease (ACO) in patients with obstructive lung disease is growing in recognition, though there is no consistent agreement on the diagnostic criteria for the disease process. Patients with ACO have distinct clinical characteristics and trajectories, which are representative of a heterogenous, multifactorial, and incompletely understood inflammatory pathophysiology. Current treatment strategies are focused on titration of inhaled therapies such as long-acting bronchodilators, with increasing interest in the use of targeted biologic therapies aimed at the underlying inflammatory mechanisms. Future directions for research will focus on elucidating the varied inflammatory signatures leading to ACO, the development of consistent diagnostic criteria and biomarkers of disease, and improving the clinical management with an eye toward targeted therapies.

Sex Differences in Veterans Admitted to the Hospital for Chronic Obstructive Pulmonary Disease Exacerbation

Rationale: As chronic obstructive pulmonary disease (COPD) prevalence in women has outpaced that in men, COPD-related hospitalization and mortality are now higher in women. Presentation, evaluation, and treatment of COPD differ between women and men. Despite higher smoking rates in Veterans, little work has characterized differences in Veterans with COPD by sex. Objectives: To determine risk factors for 30-day readmission among Veterans hospitalized for COPD exacerbations and how they differed by sex. Methods: We performed a retrospective observational analysis of Veterans receiving primary care in Veterans Health Affairs facilities. We included Veterans Administration-based hospitalizations for Veterans with a COPD exacerbation (identified by International Classification of Disease, Ninth Revision codes) who survived to discharge between fiscal years 2012 and 2015. Primary outcome was 30-day readmission. Predictors ascertained before hospitalization included smoking status (current, former, never), pulmonary function testing, pulmonary medication prescriptions, and medical and psychiatric comorbidities (identified by International Classification of Disease, ninth revision codes). We created combined and sex-stratified multivariate logistic regression models to identify associations with 30-day readmission. Results: Our sample included 48,888 Veterans (4% women). Compared with men, women Veterans were younger, more likely to be nonwhite, and differed in smoking status. Women were more likely to have asthma, drug use, and several psychiatric comorbidities. Before hospitalization, women were less likely to have pulmonary function testing (76% vs. 78%; P = 0.01) or be treated with antimuscarinic (43% vs. 48%) or combined long-acting bronchodilator/inhaled corticosteroid (61% vs. 64%) inhalers. Women were more likely to receive nicotine-replacement therapy (all P < 0.01). Women had shorter length of stay (median days, 2 vs. 3; P = 0.04) and lower 30-day readmission rate (20% vs. 22%; P = 0.01). In adjusted models including both sexes, age, antimuscarinic use, comorbidities, and diagnosis of drug or alcohol use were associated with readmission; there was no association with sex and readmission risk. In models stratified by sex, associations were similar between women and men. Conclusions: This study suggests differences between women and men hospitalized for COPD regarding presentation, evaluation, and management. Readmission is strongly influenced by comorbidities, suggesting individualized and comprehensive case management may reduce readmission risk for women and men with COPD.

Mortality Among Persons with Both Asthma and Chronic Obstructive Pulmonary Disease Aged ≥25 Years, by Industry and Occupation - United States, 1999-2016

Patients with asthma typically have chronic airway inflammation, variable airflow limitation, and intermittent respiratory symptoms; patients with chronic obstructive pulmonary disease (COPD) often have fixed airflow limitation and persistent respiratory symptoms. Some patients exhibit features suggesting that they have both conditions, which is termed asthma-COPD overlap. These patients have been reported to have worse health outcomes than do those with asthma or COPD alone (1). To describe mortality among persons aged ≥25 years with asthma-COPD overlap, CDC analyzed 1999-2016 National Vital Statistics multiple-cause-of-death mortality data* extracted from the National Occupational Mortality System (NOMS), which included industry and occupation^† information collected from 26 states^§ for the years 1999, 2003, 2004, and 2007-2014. Age-adjusted death rates per one million persons^¶ and proportionate mortality ratios (PMRs)** were calculated. During 1999-2016, 6,738 male decedents (age-adjusted rate per million = 4.30) and 12,028 female decedents (5.59) had both asthma and COPD assigned on their death certificate as the underlying or contributing cause of death. The annual age-adjusted death rate per million among decedents with asthma-COPD overlap declined from 6.70 in 1999 to 3.01 in 2016 (p<0.05) for men and from 7.71 in 1999 to 4.01 in 2016 (p<0.05) for women. Among adults aged 25-64 years, asthma-COPD overlap PMRs, by industry, were significantly elevated among nonpaid workers, nonworkers, and persons working at home for both men (1.72) and women (1.40) and among male food, beverage, and tobacco products workers (2.64). By occupation, asthma-COPD overlap PMRs were significantly elevated among both men (1.98) and women (1.79) who were unemployed, had never worked, or were disabled workers and among women bartenders (3.28) and homemakers (1.34). The association between asthma-COPD overlap mortality and nonworking status among adults aged 25-64 years suggests that asthma-COPD overlap might be associated with substantial morbidity. Increased risk for asthma-COPD overlap mortality among adults in certain industries and occupations suggests targets for public health interventions (e.g., elimination of or removal from exposures, engineering controls, and workplace smoke-free policies) to prevent asthma and COPD in and out of the workplace.

The many faces of asthma-chronic obstructive pulmonary disease overlap

PURPOSE OF REVIEW

Asthma and chronic obstructive pulmonary disease (COPD) are common diseases that often overlap. The term asthma-COPD overlap (ACO) has been used to define this entity but there remain several speculations on its exact definition, impact, pathophysiology, clinical features, and management. We reviewed recent publications on ACO to obtain more insight of current knowledge and outline future needs.

RECENT FINDINGS

Criteria for ACO vary from one publication to another and the many variable features of these patients underline the need to reconsider the evaluation and approach of patients with overlapping features based on clinical traits and underlying biological mechanisms. Epidemiological studies reveal that ACO patients have generally an increased burden of illness and healthcare use in addition to poorer quality of life (QoL) compared with asthma and higher or equal to COPD. However, their long-term outcome seems better than patients with COPD alone. Various methods have been proposed to evaluate these patients but their usefulness compared to 'classical' investigation of obstructive lung diseases remains speculative and needs further evaluation. Furthermore, there are no formal studies that examined and compared the different treatment strategies of well-characterized patients with ACO as such patients are usually excluded from clinical trials.

SUMMARY

ACO is a common condition with variable features and a high burden of disease. There is no consensus on its definition, diagnostic, and clinical features and more research should be done on its optimal management and long-term outcomes.

Clinical Characteristics of Chronic Obstructive Pulmonary Disease in Female Patients: Findings from a KOCOSS Cohort

PURPOSE

The prevalence of chronic obstructive pulmonary disease (COPD) in females has increased, changing the concept of COPD as a disease mostly limited to males. In this study, the clinical characteristics of COPD in females were investigated.

PATIENTS AND METHODS

The study was based on a multicenter cohort of COPD patients recruited from 54 medical centers in South Korea. Sex-based differences in general characteristics, exposure risk factors, depression scores, results of pulmonary function tests, COPD exacerbation, symptom scores, and radiologic findings were evaluated. Sex-related differences in the annual FEV₁ change over 5 years were analyzed in a linear mixed model.

RESULTS

Of the 2515 patients enrolled in this study, 8.1% were female. Female patients who had a higher BMI and a lower level of education were less likely to be smokers, were more exposed to passive smoking/biomass, and were more depressed compared to males. The rates of bronchiectasis, previous childhood respiratory infection, and asthma were higher in females. Female patients also had more symptoms and a poorer exercise capacity than males, but no significant differences were observed in terms of exacerbations. Radiologic findings revealed that male patients had worse emphysema, and female patients had worse bronchiectasis, as determined based on chest X-ray and computed tomography findings. On pulmonary function tests, female patients had less obstruction and less annual FEV₁ loss over 5 years.

CONCLUSION

This study revealed differences in the clinical parameters between male and female patients with COPD, including general characteristics, disease characteristics, and clinical outcomes.

Clinical Characteristics Of Patients With Asthma COPD Overlap (ACO) In Australian Primary Care

Purpose

Many older adults with a history of smoking and asthma develop clinical features of both asthma and COPD, an entity sometimes called asthma-COPD overlap (ACO). Patients with ACO may be at higher risk of poor health outcomes than those with asthma or COPD alone. However, understanding of ACO is limited in the primary care setting and more information is needed to better inform patient management. We aimed to compare the characteristics of patients with ACO or COPD in Australian general practices.

Patients and methods

Data were from the RADICALS (Review of Airway Dysfunction and Interdisciplinary Community-based care of Adult Long-term Smokers) trial, an intervention study of an interdisciplinary community-based model of care. Baseline demographic and clinical characteristics, pre- and post-bronchodilator spirometry, dyspnoea and St. George’s Respiratory Questionnaire scores were compared between 60 ACO patients and 212 with COPD alone.

Results

Pre-bronchodilator Forced Expiratory Volume in 1 second (mean±SD 58.4±14.3 vs 67.5±20.1% predicted) and Forced Vital Capacity (mean 82.1±16.9 v 91.9±17.2% predicted) were significantly lower in the ACO group (p<0.001), but no difference was found in post-bronchodilator spirometry. Demographic and clinical characteristics, dyspnoea, quality of life, comorbidities and treatment prescribed did not differ significantly between groups.

Conclusion

This is the first study describing the clinical characteristics of ACO patients in Australian general practices. Our finding of lower pre-bronchodilator lung function in the ACO group compared to those with COPD reinforces the importance of spirometry in primary care to inform management.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12614001155684.

Asthma and Chronic Obstructive Pulmonary Disease Overlap in Women. Incidence and Risk Factors

RATIONALE

Women with asthma are at a high risk of developing chronic obstructive pulmonary disease (COPD) or asthma and COPD overlap syndrome (ACOS) as they age, which is a condition associated with a high mortality rate, low quality of life, and high healthcare costs. However, factors influencing the development of ACOS remain unclear.

OBJECTIVES

To quantify the risk of developing COPD in women in Ontario with asthma and identify factors that are associated with increased risk.

METHODS

Data for women in Ontario with asthma who participated in the Canadian National Breast Screening Study from 1980 to 1985 were linked to health administrative databases, and participants were followed from 1992 to 2015. A competing risks survival model was used to measure the associations between sociodemographic, lifestyle, and environmental risk factors and time to COPD incidence, accounting for death as a competing risk.

RESULTS

A total of 4,051 women with asthma were included in the study, of whom 1,701 (42.0%) developed COPD. The mean age at the study end date was 79 years. Low education, high body mass index, rurality, and high levels of cigarette smoking were associated with ACOS incidence, whereas exposure to fine particulate matter, a major air pollutant, was not.

CONCLUSIONS

Individual risk factors appear to play a more significant role in the development of ACOS in women than environmental factors, such as air pollution. Prevention strategies targeting health promotion and education may have the potential to reduce ACOS incidence in this population.

Identification of Asthma-COPD Overlap, Asthma, and Chronic Obstructive Pulmonary Disease Phenotypes in Patients with Airway Obstruction: Influence on Treatment Approach

BACKGROUND

Many studies have described asthma-COPD overlap (ACO) among patients diagnosed with asthma or chronic obstructive pulmonary disease (COPD), but less so in broad populations of patients with chronic airway obstruction.

OBJECTIVE

This study aimed to (i) examine the prevalence of ACO, asthma, and COPD phenotypes among subjects referred for pulmonary function testing (PFT), who had airway obstruction in spirometry (forced expiratory volume in 1 s [FEV1]/forced vital capacity [FVC] <0.7); and (ii) delineate the therapeutic approach of each group.

METHODS

Cross-sectional study of patients who were referred for PFT at the Rokach Institute, in Jerusalem. Working definitions were as follows: (a) COPD: post-bronchodilator (BD) FEV1/FVC <0.70; (b) asthma: physician-diagnosed asthma before age 40 and/or minimum post-BD increase in FEV1 or FVC of 12% and 200 mL; and (c) ACO: the combination of the 2. Demographics, smoking habits, episodes of exacerbation, health-related quality of life (HRQL), and respiratory medication utilization were analyzed.

RESULTS

Of 3,669 referrals from January 1 to April 30, 2017, 1,220 had airway obstruction of which 215 were included. Of these, 82 (38.1%) had ACO, 49 (22.8%) asthma, and 84 (39.1%) COPD. ACO subjects tended to (a) be predominantly female; (b) be older than asthmatics, (c) be smokers; (d) have worse HRQL in the activity domain; and (d) have more exacerbations. Treatment of ACO and COPD patients differed from that of asthmatics, but not from each other, in the proportion of subjects on maintenance treatment, use of LABA, LAMA, and ICS, alone or in combination, and in the number of inhaler devices used by patients.

CONCLUSION

ACO represented >1/3 of patients referred for PFT. Despite a clearly identifiable phenotype, ACO patients received treatment similar to COPD patients, suggesting poor ACO identification. Our data emphasize the need to raise the awareness of ACO among clinicians, in order to guide better recognition and appropriate treatment in individual patients.

Clinical Features Of Women With COPD: Sex Differences In A Cross-Sectional Study In Spain ("The ESPIRAL-ES Study")

Aim

This cross-sectional multicenter study was performed aimed at describing the clinical characteristics of women with COPD attended in routine daily practice in Spain.

Methods and results

Of a total of 1610 consecutive patients diagnosed with COPD recruited in primary care centers and pneumology services throughout Spain over a 90-day period, 17.9% (n=286) were women, with a median age of 62 years. Differences in COPD phenotypes by sex were statistically significant (P = 0.002). Males as compared with females showed a higher prevalence of non-exacerbator (47.9% vs 42.2%) and exacerbator with chronic bronchitis (22.9% vs 18.8%) phenotypes, whereas the ACOS phenotype was more common among females (21.7% vs 12.9%). The mean (SD) CAT score was similar in men than in women (20.8 [9.0] vs 21.2 [8.7], P = 0.481), as well as the impact of the disease on the quality of life according to CAT scores of <5 (no impact), 5–9 (low), 10–20 (medium), >20 (high), and >30 (very high). Sex-related differences according to smoking status were statistically significant (P < 0.001), with a higher percentage of men as compared with women in the groups of current smokers and ex-smokers; never-smokers were higher in women (9.1%) than in men (0.6%). The mean number of comorbidities was 2.01 (1.43) (95% CI 1.93–2.09) in males and 1.99 (1.42) (95% CI 1.83–2.16) (P = 0.930) in females, but cardiovascular diseases (hypertension, ischemic heart disease, chronic heart failure) were more frequent in men, whereas metabolic disorders (osteoporosis) were more frequent in women.

Conclusion

This study highlights the impact of COPD in women and the importance of continuing sex-based research in tobacco-related respiratory diseases.

Do ethnic inequalities in multimorbidity reflect ethnic differences in socioeconomic status? The HELIUS study

BACKGROUND

The burden of multimorbidity is likely higher in ethnic minority populations, as most individual diseases are more prevalent in minority groups. However, information is scarce. We examined ethnic inequalities in multimorbidity, and investigated to what extent they reflect differences in socioeconomic status (SES).

METHODS

We included Healthy Life in an Urban Setting study participants of Dutch (N = 4582), South-Asian Surinamese (N = 3258), African Surinamese (N = 4267), Ghanaian (N = 2282), Turkish (N = 3879) and Moroccan (N = 4094) origin (aged 18-70 years). Educational level, employment status, income situation and multimorbidity were defined based on questionnaires. We described the prevalence and examined age-adjusted ethnic inequalities in multimorbidity with logistic regression analyses. To assess the contribution of SES, we added SES indicators to the age-adjusted model.

RESULTS

The prevalence of multimorbidity ranged from 27.1 to 53.4% in men and from 38.5 to 69.6% in women. The prevalence of multimorbidity in most ethnic minority groups was comparable to the prevalence among Dutch participants who were 1-3 decades older. After adjustment for SES, the odds of multimorbidity remained significantly higher in ethnic minority groups. For instance, age-adjusted OR for multimorbidity for the Turkish compared to the Dutch changed from 4.43 (3.84-5.13) to 2.34 (1.99-2.75) in men and from 5.35 (4.69-6.10) to 2.94 (2.54-3.41) in women after simultaneous adjustment for all SES indicators.

CONCLUSIONS

We found a significantly higher prevalence of multimorbidity in ethnic minority men and women compared to Dutch, and results pointed to an earlier onset of multimorbidity in ethnic minority groups. These inequalities in multimorbidity were not fully accounted for by differences in SES.

Sex Differences in Paediatric and Adult Asthma

Asthma is the most common chronic condition in Western countries. Affecting 1 in 7 children and 1 in 12 adults, asthma is responsible for >350,000 avoidable deaths every year. While most children who develop symptoms of asthma are <5 years of age, the disease is frequently misdiagnosed or not suspected in infants and toddlers. In addition, the prevalence of asthma is different in males and females throughout their lifespan. While boys are more likely to develop asthma than girls, this pattern is reversed after puberty. This indicates that sex-specific factors, such as fluctuations in hormone levels, play a role in the disease’s pathogenesis. In this review, the authors discuss recent advances in diagnostic tools for asthma in both adults and children, as well as the influences of BMI, environmental exposures, socioeconomic factors, and sex hormones in the disease’s pathogenesis. The review will show that both experimental and epidemiological evidence suggest that circulating sex hormone levels are important contributors to asthma symptoms in post-pubertal females, while their role in males and children has not been yet established. In addition, the mechanisms associated with these hormonal influences on airway inflammation and hyper-reactivity have not been yet elucidated. The authors conclude that different factors affect asthma rates and severity in children and adults, and that more research needs to be conducted to identify the specific contributions of sex hormones. These will allow the development of more personalised asthma treatment strategies for men and women at different stages of life.

Female-specific risk factors associated with risk of ACO (asthma COPD overlap) in aboriginal people

Objective: Sex differences in incidence, susceptibility and severity of many chronic respiratory diseases have been long recognized. Asthma-COPD Overlap (ACO) is newly recognized disease with its management guidelines reported in 2015. The objective of this analysis is to identify the female-specific risk factors associated with ACO in Aboriginal people.Methods: The Aboriginal Peoples Survey 2012 (N = 28,410) is the fourth cycle of a national cross-sectional survey representative of the First Nations living off reserve, Metis and Inuit. The 2012 APS collected information on employment, education, health status, housing, family background and income. Survey Logistic Regression was used to identify the significant risk factors for ACO in the multivariate analysis.Results: The prevalence of ACO was 1.65% and 3.53% in males and females, respectively. The following factors were significantly associated with increased risk of ACO in both males and females: increased age, living in Quebec, living in a rented dwelling and dwelling in need of major repairs. However, four factors including marital status (being widowed, separated, or divorced), smoking status (being a current daily smoker), having a diagnosis of diabetes and working 40 h and over a week were significantly associated with increased risk of ACO in females not males.Conclusion:The results of our study may offer useful evidence for future development of female-specific prevention and public health intervention programs in aboriginal communities to reduce the burden of ACO.

Sex Differences in Paediatric and Adult Asthma

Asthma is the most common chronic condition in Western countries. Affecting 1 in 7 children and 1 in 12 adults, asthma is responsible for >350,000 avoidable deaths every year. While most children who develop symptoms of asthma are <5 years of age, the disease is frequently misdiagnosed or not suspected in infants and toddlers. In addition, the prevalence of asthma is different in males and females throughout their lifespan. While boys are more likely to develop asthma than girls, this pattern is reversed after puberty. This indicates that sex-specific factors, such as fluctuations in hormone levels, play a role in the disease's pathogenesis. In this review, the authors discuss recent advances in diagnostic tools for asthma in both adults and children, as well as the influences of BMI, environmental exposures, socioeconomic factors, and sex hormones in the disease's pathogenesis. The review will show that both experimental and epidemiological evidence suggest that circulating sex hormone levels are important contributors to asthma symptoms in post-pubertal females, while their role in males and children has not been yet established. In addition, the mechanisms associated with these hormonal influences on airway inflammation and hyper-reactivity have not been yet elucidated. The authors conclude that different factors affect asthma rates and severity in children and adults, and that more research needs to be conducted to identify the specific contributions of sex hormones. These will allow the development of more personalised asthma treatment strategies for men and women at different stages of life.

Prevalence and features of asthma-COPD overlap in the United States 2007-2012

BACKGROUND

Perceived to be distinct, asthma and chronic obstructive pulmonary disease (COPD) can co-exist and potentially have a worse prognosis than the separate diseases. Yet, little is known about the exact prevalence and the characteristics of the Asthma-COPD overlap (ACO) in the US population.

AIMS

To determine ACO prevalence in the United States, identify ACO predictors, examine ACO association with asthma and COPD severity, and describe distinctive spirometry and laboratory features of ACO.

METHODS

Data on adult participants to the National Health and Nutrition Examination Surveys conducted from 2007 to 2012 was analyzed. ACO was defined as current asthma and post-bronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) <0.7.

RESULTS

Overall, 7,570 participants representing 98.58 million Americans were included in our study. From 2007 to 2012, the crude and age-standardized ACO prevalence were, respectively, 0.96% (95% CI: 0.65%-1.26%) and 1.05% (0.74%-1.37%). In asthma, ACO predictors included older age, male gender, and smoking. In COPD, ACO predictors were non-Hispanic Black race/ethnicity and obesity. ACO was associated with increased ER visits for asthma (OR = 3.46, 95% CI: 1.48-8.06]) and oxygen therapy in COPD (OR = 11.17, 95% CI: 5.17-24.12]). In spirometry, FEV1 and peak expiratory flow were lower in ACO than in asthma or COPD alone.

CONCLUSION

Age-adjusted prevalence of ACO in the United States was 1.05% in 2007-2012, representing 0.94 (95% CI: 0.62-1.26) million Americans. It is much lower than previously reported. The overlap was associated with higher asthma and COPD severity as well as decreased lung function compared with COPD or asthma alone.

Characteristics of asthma and COPD overlap syndrome (ACOS) in the Canadian population

Objective: Asthma is a chronic disease affecting both children and adults, whereas chronic obstructive pulmonary disease (COPD) is a respiratory disease most commonly related to smoking and is usually seen in adults. When the airway disease shares features of both asthma and COPD, the phenotype is referred to as asthma and COPD overlap syndrome (ACOS). The objective of this cross-sectional study is to characterize ACOS in the Canadian population. Methods: Data from the first three cycles of the Canadian Health Measures Survey (CHMS) were used in this study. The study included 9059 subjects aged 30 years and above. The CHMS included a detailed interviewer-administered questionnaire and spirometry measurements. Based on the self-report, subjects were categorized into control, ACOS, COPD only and asthma only groups. Results: The prevalence of ACOS, COPD and asthma groups was 1.59%, 2.21% and 6.65%, respectively. The proportion of females was significantly greater than males in the ACOS group. The proportion of wheeze was highest in the ACOS group (64.93%) whereas the prevalence of shortness of breath was the highest in the COPD group (46.25%). Heart disease, cancer, arthritis and liver disease were more prevalent in the ACOS group than in COPD, asthma and control groups. Severity of airway obstruction was the highest in the ACOS group and was followed by COPD, asthma and control groups, respectively. Conclusions: Characteristics of ACOS in the Canadian population were similar to those observed in the developed countries and longitudinal studies are required to determine the incidence and risk factors of ACOS.

Prevalence and features of asthma-chronic obstructive pulmonary disease overlap in Northern Italy general population

OBJECTIVE

There is controversy about the diagnostic criteria, prevalence, symptoms, and spirometry characteristics of asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO). Recent data indicate that the fixed method for diagnosing airway obstruction (AO) may overestimate ACO prevalence in the elderly, and a variable method may be more accurate. We aimed at estimating ACO prevalence in a general population sample and comparing patient and clinical features in subjects with ACO, COPD, and asthma.

METHODS

We analyzed data from a cross-sectional study estimating COPD prevalence in randomly selected adults aged 20-79 years in Verona, Italy, and estimated prevalence and analyzed characteristics of asthma, COPD, and ACO. ACO was defined as AO (Forced Expiratory Volume in one second-FEV₁/ Forced Vital Capacity-FVC < Lower Limit of Normal-LLN), highly positive bronchodilator test (≥15% increase in FEV₁ and FVC ≥400 mL), and personal self-reported history of physician diagnosed asthma and atopy.

RESULTS

One thousand two hundred and thirty-six patients were included; 207 (16.7%) had asthma, COPD, or ACO (mean ages: 61.2, 59.7, and 57.2 years, respectively). The 3 groups had similar clinical and demographic variables; however, spirometry revealed differences between ACO and COPD patients, particularly post-bronchodilator FEV₁ reversibility, which was detected in ACO and asthma patients but not in those with COPD.

CONCLUSION

ACO prevalence in Northern Italy was estimated at 2.1%, in the range of values reported by previous studies. Marked differences between ACO and COPD revealed by spirometry may have important clinical implications in terms of treatment for patients with ACO.

Asthma-chronic obstructive pulmonary disease overlap syndrome - Literature review and contributions towards a Portuguese consensus

INTRODUCTION

Phenotypic overlap between the two main chronic airway pulmonary diseases, asthma and chronic obstructive pulmonary disease (COPD), has been the subject of debate for decades, and recently the nomenclature of asthma-COPD overlap syndrome (ACOS) was adopted for this condition. The definition of this entity in the literature is, however, very heterogeneous, it is therefore important to define how it applies to Portugal.

METHODS

A literature review of ACOS was made in a first phase resulting in the drawing up of a document that was later submitted for discussion among a panel of chronic lung diseases experts, resulting in reflexions about diagnosis, treatment and clinical guidance for ACOS patients.

RESULTS

There was a consensus among the experts that the diagnosis of ACOS should be considered in the concomitant presence of: clinical manifestations characteristic of both asthma and COPD, persistent airway obstruction (post-bronchodilator FEV₁/FVC<0.7), positive response to bronchodilator test (increase in FEV₁ of ≥200mL and ≥12% from baseline) and current or past history of smoking or biomass exposure. In reaching diagnosis, the presence of peripheral eosinophilia (>300eosinophils/μL or >5% of leukocytes) and previous history of atopy should also be considered. The recommended first line pharmacological treatment in these patients is the ICS/LABA association; if symptomatic control is not achieved or in case of clinical severity, triple therapy with ICS/LABA/LAMA may be used. An effective control of the exposure to risk factors, vaccination, respiratory rehabilitation and treatment of comorbidities is also important.

CONCLUSIONS

The creation of initial guidelines on ACOS, which can be applied in the Portuguese context, has an important role in the generation of a broad nationwide consensus. This will give, in the near future, a far better clinical, functional and epidemiological characterization of ACOS patients, with the ultimate goal of achieving better therapeutic guidance.

The mediating effects of cognitive emotion regulation strategies on the relationship between alexithymia and physical symptoms: Evidence from Iranian asthmatic patients

Asthma is a chronic and episodic psychosomatic disease whose symptoms include coughing, wheezing, chest tightness, and shortness of breath. The present study aimed to investigate the effects of cognitive emotion regulation strategies (CERS) as mediators on the relationships between alexithymia subscales and physical symptoms (PS). 300 asthmatic patients (males=42.7%, females=57.3%, age _range=16-65, mean _age=29.40) and 100 normal controls participated in the study and completed the demographic questionnaire, the Cognitive Emotion Regulation Questionnaire (CERQ), the Persian version of the Toronto Alexithymia Scale (FTAS-20), and the Powell & Enright Physical Symptoms Inventory (PSI). Asthmatic patients showed higher scores on all three alexithymia subscales including difficulty in identifying feelings (DIF), difficulty in describing feelings (DDF), and externally oriented thinking (EOT) as well as non-adaptive CERS than normal controls. On the other hand, normal controls earned higher means in adaptive CERS. Results revealed that each of the three alexithymia subscales had indirect effects on PS through the non-adaptive cognitive emotion regulation strategy of catastrophizing. It is concluded that alexithymia can intensify PS through catastrophizing in asthmatic patients.